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THE 


LONDON 


MEDICAL  GAZETTE, 


Journal  of  practical  Jiflrtitrine. 


NEW  SERIES. 

VOL.  VII. 


LONDON : 

PRINTED  FOR 

LONGMAN,  BROWN,  GREEN,  AND  LONGMANS, 

PATERNOSTER  ROW. 


1848. 


I  v4 


I 

f 


LONDON: 

Printed  by  Wilson  and  Ogilvy, 
57,  Skinner  Street,  Snowliill. 


1,«  f 


•anntJon  mciucal  Cnuur.  /■'  1 


Ecfiurk. 


COURSE  OF  SURGERY, 
Delivered  in  the  years  1846  and .  1847, 

By  Bransby  B.  Cooper,  F.R.S. 

Surgeon,  and  Lecturer  on  Surgery  at  Guy’s 
Hospital. 


Lecture  XXXI. 

CONTINUATION  OF  THE  ORBITAL  REGION. 

Diseases  of  the  eyelids — tissues  entering  into 
their  composition.  Suppuration  in  the  eye¬ 
lids.  Obstruction  of  punctum  lachry- 
male.  Ecchymosis — treatment.  Entro¬ 
pium — its  effect.  Ectropium — compara¬ 
tive  inconvenience  and  danger  to  the  eye 
— operation  for  entropium  and  ectropium. 
Hordeola  or  styes.  Fncysted  tarsal 
tumors — treatment.  Wounds  of  the  eye¬ 
ball  —  treatment  —  intrusion  of  foreign 
bodies — mode  of  removal. 

Diseases  of  the  jaws.  Osteosarcoma  of  the 
jaw — malignant  character —  extirpation 
— mode  of  operating.  Tumors  from  the 
antrum  and  upper  jaw  not  always  malig¬ 
nant — operation  for  removal — mode  of 
proceeding — case. 

Region  of  the  neck.  Character  of  the  neck 
— anatomical  relations.  The  pharyngeal 
region — its  limits — the  pharynx  subject 
to  the  lodgment  of  fireign  bodies — their 
extraction— opening  the  trachea.  Ab¬ 
scesses — evacuation  of  the  pus — necessary 
precautions — case.  Ulcers  in  the  pha¬ 
rynx.  Anterior  region  of  the  neck — 
definition.  Supra  hyoid, eal  region  — 
“  cut  throat  ”  —  treatment  —  tumors. 
Laryngo  -pharyngeal  region.  Frequency 
of  wounds  in  attempt  at  suicide — wound 
of  lingual  artery — case.  Various  atten¬ 
dant  considerations ,  and  mode  of  treat¬ 
ment. 

Diseases  of  the  eyelids. — Before  we  begin 
to  treat  of  the  diseases  of  the  eyelids,  it  is 
proper  to  give  some  consideration  to  the  va¬ 
rious  structures  which  enter  into  the  compo¬ 
sition  of  these  parts,  as  it  is  evident  that  the 
eyelids  must  be  liable  to  the  diseases  incident 
to  each  of  their  tissues, — these  are,  skin, 
cellular  membrane,  muscular  fibre,  tendon, 
fibro-cartilage,  mucous  membrane,  and  the 
cilia. 

Of  the  skin  of  the  eyelids  there  is  little 
further  to  remark  than  that  it  is  subject  to 
the  eruptions  common  to  the  integuments  of 
the  other  parts  of  the  body ;  and  there  is 
nothing  peculiar  to  it  beyond  what  may 
arise  from  its  extreme  tenuity. 

The  cellular  membrane  is  remarkable  for 

xlii. — 1075.  June  7,  1848. 


the  freedom  of  the  connection  between  its 
cells.  The  muscular  apparatus  of  the  eye¬ 
lid,  in  common  with  the  muscular  system  of 
other  parts  of  the  body,  is  subject  to  no 
other  disease  than  that  arising  from  morbid 
irritability,  producing  a  constant  twitching 
or  “  winking”  of  the  eyelids.  The  tendon 
of  the  levator  palpebrse,  which  is  inserted 
into  the  fibro-cartilage,  constituting  the 
tarsus,  is,  like  all  tendinous  tissues,  as  well 
as  the  fibro-cartilage  into  which  it  is  inserted, 
from  its  slight  degree  of  vitality,  readily  dis¬ 
posed  to  slough  under  a  very  slight  degree 
of  inflammation.  When  the  tarsus  becomes 
affected  it  frequently  leads  to  great  interfe¬ 
rence  with  the  functions  of  the  lid.  The 
mucous  membrane  of  the  eyelids  is  also 
liable  to  the  peculiar  diseases  of  this  tissue, 
such  as  ophthalmia,  &c.  The  structures 
connected  with  the  hairs  of  the  cilia  some¬ 
times  become  diseased,  and  this  also  consti¬ 
tutes  one  of  the  morbid  conditions  to  which 
the  eyelids  are  liable. 

Suppuration  of  the  eyelids. — Owing  to 
the  loose  character  of  the  cellular  mem¬ 
brane  of  the  eyelids,  they  are  very  liable 
to  suppurate  under  inflammation,  whether  it 
proceed  from  disease  or  injury;  and  as  this 
affection  causes  great  swelling,  and  interferes 
with  the  motion  of  the  upper  lid,  it  is  neces¬ 
sary  that  the  matter  should  be  early  evacu¬ 
ated  ;  and  as  it  usually  attacks  persons  of  a 
weak  strumous  habit,  tonic  medicines  will 
also  be  requisite.  In  erysipelas  such  abscesses 
often  occur,  and  unless  the  matter  is  let  out 
sloughing  very  soon  results.  In  evacuating 
the  matter  the  incisions  should  be  curved, 
following  the  direction  of  the  fibres  of  the 
orbicularis  palpebrse  muscle,  so  that  the 
cicatrix  may  be  hidden  in  the  natural  folds 
of  the  skin  of  the  eyelid,  and  the  deformity 
avoided  that  would  result  if  the  incision  were 
at  right  angles  to  the  muscular  fibre.  Small 
circumscribed  tumors  frequently  obstruct 
the  punctum  lachrymale,  so  as  to  cause  a 
flowing  of  tears  over  the  cheek.  This  may  be 
mistaken  for  fistula  lachrymalis  ;  but  the 
comparatively  slight  pain  in  palpebral  ab¬ 
scess,  and  the  great  inconvenience  attendant 
upon  inflammation  of  the  lachrymal  sac, 
constitute  the  diagnostic  distinction  between 
them.  In  opening  the  abscess,  great  care 
must  be  taken  not  to  injure  the  punctum 
lachrymale,  as  permanent  disease  would  re¬ 
sult  from  its  obliteration. 

Ecchymosis.  —  Extravasation  of  blood 
into  the  eyelids,  technically  termed  ecchy¬ 
mosis,  frequently  results  from  external 
injury.  The  removal  of  this  coagulum 
by  incision  should  never  be  attempted, 
as  a  few  leeches,  and  poultices  composed 
of  the  bryony  root  scraped  and  mixed 
with  bread,  will  be  generally  found  suffi¬ 
cient  to  the  purpose. 


2 


ENTROPIUM.  ECTROPIUM.  ENCYSTED  TARSAL  TUMORS. 


1  am  of  opinion  that  in  all  cases  of  ecchy- 
mosis  more  injury  is  done  by  the  incision  to 
remove  the  coagulum  than  would  be  effected 
by  the  presence  of  the  blood  itself.  A  spon¬ 
taneous  ecchymosis,  or  effusion  of  blood  into 
the  eyelids,  sometimes  occurs,  and  is  charac¬ 
teristic  of  great  constitutional  deterioration, 
and  especially  of  an  impoverished  condition 
of  the  blood.  This  appearance  should  at 
once  create  considerable  alarm ;  and  the 
treatment  required  is  similar  to  that  neces¬ 
sary  in  the  haemorrhagic  tendencies — such  as 
acids,  bark,  and  generous  diet. 

'Entropium  or  inversion,  and  Ectropium 
or  eversion,  of  the  eyelids,  not  infrequently 
results  either  from  disease  or  injury  to  these 
organs,  but  more  particularly  to  their  fibro¬ 
cartilaginous  portions. 

In  Entropium,  the  free  edge  of  one  or  both 
of  the  eyelids  is  turned  inwards  upon  the 
globe  of  the  eye,  with  the  surface  of  which 
the  eyelashes  are  brought  in  contact.  Vio¬ 
lent  inflammation  results,  and  if  the  disease 
be  not  removed,  the  transparency  of  certain 
parts  of  the  organ  becomes  impaired  from  a 
deposition  of  lymph,  large  bloodvessels  from 
the  conjunctiva  shoot  across  the  cornea, 
ulceration  of  the  latter  membrane  soon  fol¬ 
lows,  and  the  eye  would  perish  unless  the 
disease  be  cured. 

Ectropium,  or  eversion  of  the  eyelid,  pro¬ 
duces  at  first  much  less  suffering,  as  in  this 
case  the  conjunctival  surface  of  the  eye  is 
not  subjected  to  the  irritative  action  of  the 
cilia  ;  but  if  the  disease  be  allowed  to  re¬ 
main,  the  tunica  conjunctiva  of  the  eyeball 
being  unprotected  by  the  affected  lid,  and 
losing  the  beneficial  lubricating  influence 
of  the  tears,  soon  becomes  inflamed  from  the 
action  of  the  air ;  and  by  the  lodgment  of 
extraneous  particles  of  matter,  the  inflam¬ 
mation  proceeds  to  opacity  of  the  cornea, 
and  ultimately  to  the  destruction  of  vision. 
The  deformity  in  this  disease  is  even  greater 
than  in  entropium  ; — in  consequence  of  the 
large  inflamed  mucous  surface  exposed  to 
view,  the  cornea  ulcerates,  the  anterior  cham¬ 
ber  of  the  eye  is  laid  open,  the  aqueous  tu¬ 
mor  escapes,  and  the  organ  is  very  soon 
completely  destroyed.  The  inferior  lid  is 
most  frequently  the  seat  of  this  affection. 

These  diseases  may  occur  from  an  altered 
condition  of  the  tunica  conjunctiva,  of  the 
skin  of  the  eyelid,  or  from  disease  of  the 
fibro-cartilage  which  constitutes  the  tarsus. 
Entropium  sometimes  results  from  a  relaxed 
state  of  the  skin  of  the  eyelid,  with  the 
exception  of  that  at  the  ciliary  edge,  so  that 
there  exists  an  unequal  degree  of  resistance 
to  the  orbicular  muscle  of  the  eyelids,  and  a 
tendency  to  inversion  is  established.  The 
deformity  arising  from  this  cause  may 
be  cured  by  taking  up  a  fold  of  the 
loose  skin,  and  cutting  out  a  longitudinal 


slip,  after  which  the  excised  edges  must 
be  perfectly  adapted,  and  kept  together 
by  uninterrupted  suture,  the  contraction  of 
the  cicatrix  removing  the  inversion.  Some 
surgeons  have  recommended  that  the  skin 
should  be  removed  by  strong  sulphuric 
acid,  but  I  consider  the  excision  of  a  portion 
of  the  integument  far  preferable.  When 
disease  of  the  tarsus  causes  either  entropium 
or  ectropium,  a  portion  of  that  structure 
must  be  removed  ;  this  is  best  effected  by 
passing  a  needle,  armed  with  silk,  through 
the  ciliary  edge  of  the  lid,  so  as  to  give  per¬ 
fect  command  of  this  moveable  part.  A 
triangular  portion  of  the  lid  is  now  to  be 
excised,  and  the  incised  edges  adapted  by 
suture.  The  surgeon  is  able  to  judge  of  the 
quantity  which  it  is  desirable  to  remove,  by 
examining  the  relation  of  the  lid  to  the  globe 
of  the  eye  before  he  operates.  When 
thickening  of  the  conjunctiva  produces  ectro¬ 
pium,  or  a  cicatrix  in  it,  entropium,  the 
operative  means  must  be  applied  to  this 
membrane. 

Tumors  of  the  palpebree  frequently  in¬ 
terfere  both  with  the  motions  of  the  eye¬ 
lid  and  with  the  conjunctival  surface  of 
the  eyeball :  the  most  common  of  these  are 
hordeola,  or  “  styes,”  which  require  little  or 
no  further  treatment  than  the  application  of 
cold,  or  a  poultice.  Sometimes,  however, 
the  matter  will  net  make  its  escape  by  the 
process  of  ulceration,  when  a  small  opening 
should  be  made,  the  pus  evacuated,  and  ni¬ 
trate  of  silver  applied  to  the  wound.  I  have 
lately  had  under  my  care  a  gentleman  from 
Cambridge,  with  so  obstinate  a  case  of  this 
disease  that  I  was  induced  to  call  in  the  aid 
of  Mr.  JDalrymple,  to  consult  with  him  on 
the  propriety  of  its  removal ;  but  as  the  stye 
was  placed  very  near  to  the  inferior  punc¬ 
tual  lachrymale,  he  recommended  merely  to 
lay  it  open,  and  touch  it  with  lunar  caustic 
more  completely  than  I  had  done ;  but  the 
tumor  is  not  yet,  however,  perfectly  re¬ 
moved. 

Encysted  tarsal  tumors  also  often  produce 
considerable  inconvenience  ;  the  tumor  give3 
the  sensation  as  if  it  were  placed  between 
the  skin  and  the  outer  surface  of  the  tarsus  ; 
but  if  their  extirpation  be  thought  necessary, 
they  should  be  removed  from  the  inner  side 
by  everting  the  lid  :  usually,  however,  merely 
puncturing  the  sac,  and  passing  a  small 
probe  into  its  interior  to  break  it  down,  will 
be  sufficient  to  cure  it.  Such  is  the  opera¬ 
tion  usually  recommended.  I  have,  however, 
frequently  removed  them  in  the  following 
manner :  everting  the  lid,  removing  a  por¬ 
tion  of  the  mucous  membrane  covering  the 
tumor,  and,  with  a  pair  of  bent-bladed  scis¬ 
sors  laid  flat  on  the  tarsus,  cut  off  the  whole 
tumor. 

In  cases  of  loss  of  portions  of  the  eyelids, 


WOUNDS  OF  THE  EYE-BALL.  TUMORS  GROWING  FROM  THE  ANTRUM.  3 


either  from  ulceration  or  wounds,  plastic 
operations,  for  the  purpose  of  forming  or 
restoring  a  covering  to  the  eyeball,  are 
sometimes  had  recourse  to. 

In  wounds  of  the  eyeball,  the  danger 
accruing  depends  upon  the  extent  and 
depth  of  the  lesion.  The  first  great  ob¬ 
ject,  in  case  of  such  an  accident,  is  to 
subdue  at  once  the  inflammation  by  strict 
antiphlogistic  means,  and  opening  the  tem¬ 
poral  artery  should  almost  always  be  had 
recourse  to ;  for,  if  the  inflammation  be  al¬ 
lowed  to  pass  into  a  chronic  state,  instead  of 
being  completely  subdued,  the  delicate  tis¬ 
sues  of  the  eye  are  almost  certain  to  become 
impaired,  and  the  power  of  vision  be  either 
wholly  lost  or  permanently  diminished.  It 
is  hardly  necessary  to  mention  that  the  pa¬ 
tient  should  be  kept  in  a  state  of  darkness, 
upon  low  diet,  and  the  bowels  freely  acted 
upon  during  the  progress  of  his  cure. 

Foreign  bodies  are  often  intruded  into  the 
eye,  more  especially  since  the  establishment 
of  railroads ;  they  are,  however,  easily  re¬ 
moved  by  everting  the  upper  lid  :  by  turning 
it  over  a  probe  pressed  just  above  the  tarsus, 
nearly  the  whole  of  the  conjunctival  surface 
may  be  thus  exposed,  and  any  small  particles 
may  be  easily  removed  by  the  corner  of  a  cam¬ 
bric  handkerchief;  if,  however,  a  particle  of 
iron,  or  such-like  substance,  should  become 
imbedded  in  the  cornea,  it  must  be  removed 
by  a  “couching  needle:”  cold  lotions,  or 
leeches,  may  afterwards  be  required  to  sub¬ 
due  inflammation. 

Diseases  of  the  jaws. — The  jaws  are  sub¬ 
ject  to  disease,  which  frequently  renders  their 
removal  necessary ;  they,  therefore,  occupy 
a  prominent  and  highly  important  position 
in  the  surgery  of  the  region  of  the  face. 

Osteo-sarcoma  sometimes  attacks  the  lower 
jaw. — (Vide  Fig.  1.)  The  malignant  cha¬ 
racter  of  this  disease,  which  is  indicated  by 
its  physical  characteristics  and  the  peculiar 
diathesis  of  the  patient,  renders  its  extirpa¬ 
tion  the  only  alternative  for  the  surgeon.  To 
remove  the  portion  of  the  lower  jaw  thus 
contaminated,  a  bold  and  extensive  incision 
must  be  made  through  the  soft  parts  cover¬ 
ing  the  bony  tumor,  the  course  of  the  knife 
following  the  curvature  of  the  jaw  close  to  its 
lower  margin.  An  incision  is  then  to  be 
made  at  either  end  of  the  first  incision, 
and  at  right  angles  to  it ;  one  portion  of 
the  integument  is  to  be  dissected  from 
the  jaw  upwards,  and  the  other  down¬ 
wards,  so  that  the  bony  tumor  is  com¬ 
pletely  exposed.  The  jaw  is  now  to  be  sawn 
through  at  the  extremities  of  the  first  incision; 
and  when  divided,  must  be  depressed  and 
everted,  so  that  the  soft  parts  adhering  to  the 
inside  may  be  dissected  off ;  the  muscles  at¬ 


tached  to  its  base  are  then  to  be  cut  through, 
and  the  bone,  thus  liberated,  removed.  The 
facial  artery  is  generally  divided  in  the  first  in¬ 
cision,  and  had  better  be  tied  immediately,  or 
the  haemorrhage  interferes  with  the  after 
steps.  It  is  necessary  to  extract  a  tooth  at 
the  point  where  the  jaw  is  to  be  cut 
through,  and  this  should  be  done  pi*e- 
vious  to  the  operation,  whether  the  chain 
or  common  saw  be  applied.  If  the  chain 
saw  is  adopted,  it  must  be  passed  behind 
the  jaw,  close  to  the  bone,  by  means  of 
a  needle  :  the  action  of  the  saw  being  from 
within  to  without.  After  the  removal  of  the 
bone  the  soft  parts  are  brought  together,  and 
retained  by  suture.  If  the  disease  be  situated 
so  near  to  the  condyle  as  to  preclude  the 
possibility  of  sawing  through  between  the 
diseased  part  and  the  articulation,  the  dis¬ 
articulation  of  the  jaw  must  be  resorted  to. 
In  this  case  the  saw  is  employed  only 
on  the  symphysis  side  of  the  disease ;  and 
when  the  soft  parts  are  dissected  off,  as 
in  the  former  case,  the  surgeon  takes  hold 
of  the  diseased  part  of  the  bone,  and 
directing  it  outwards  and  slightly  back¬ 
wards,  opens  the  front  part  of  the  tem- 
poro-maxillary  articulation,  continuing  the 
knife  backwards  so  as  to  divide  the  ligaments 
of  the  joint,  then  cutting  through  the  tempo¬ 
ral  and  pterygoideus  externus  muscles,  the 
diseased  part  is  extirpated.  Bleeding  vessels 
are  then  to  be  secured,  and  the  edges  of  the 
wound  neatly  approximated,  and  maintained 
in  coaptation  by  sutures.  If  there  be  any 
enlarged  glands,  or  other  signs  of  the  propa¬ 
gation  of  the  disease  to  the  surrounding  tis¬ 
sues,  it  would  be  equally  useless  and  cruel 
to  recommend  this  operation. 

Tumors  growing  from  the  antrum — 
(vide  Fig.  2) — frequently  lead  to  the  most 
dreadful  deformities,  interfering,  at  the 
same  time,  with  the  functions  of  the  eye, 
nose,  and  mouth ;  but  as  these  growths 
are  not  always  of  a  malignant  character, 
the  removal  of  large  portions  of  the  upper 
jaw  for  their  extirpation  may  be  regarded 
as  an  admissible  operation,  when  the  diag¬ 
nostic  marks  offer  a  just  hope  of  its  effec¬ 
tiveness.  The  mode  of  performing  this 
operation  is  as  follows : — An  incision  is  to 
be  made,  commencing  on  the  outer  side  of 
the  orbit,  and  carried  through  the  cheek  to 
the  angle  of  the  mouth  ;  a  second  incision  is 
to  be  made  through  the  commissure  of  the 
upper  lip,  extending  quite  to  the  septum  of 
the  nose,  and  continued  upwards  so  as  to 
separate  the  ala  from  the  cheek,  passing  also 
up  the  side  of  nose,  exposing  the  nasal  pro¬ 
cess  of  the  superior  maxillary  bone  ;  a  flap 
is  thus  formed,  which  may  be  turned  up¬ 
wards,  exposing  the  whole  of  the  tumor  ;  or 
if  it  be  so  large,  or  situated  so  far  back,  that 


4  TUMORS  GROWING  FROM  THE  ANTRUM.  REGION  OF  THE  NECK. 


this  flap  does  not  expose  the  whole,  another 
incision  may  be  made,  extending  backwards 
in  the  course  of  the  zygomatic  arch,  which 
will  afford  additional  exposure  of  the  parts. 
The  teeth  being,  as  in  the  former  case, 
drawn  at  the  point  where  the  bone  is  in¬ 
tended  to  be  cut  through,  the  jaw  is  to  be 
divided  by  the  cutting  forceps  through  the 
alveolar  processes,  the  palatine  processes, 
and  the  remaining  osseous  attachments  which 
prevent  the  extirpation  of  the  disease.  An 
able  assistant  is  required  during  this  opera¬ 
tion,  to  compress  the  bleeding  arteries  until 
it  is  completed,  when  they  must  be  secured 
by  ligature,  and  the  soft  parts  must  be 
carefully  adapted,  being  well  supported  by  a 
dossil  of  lint  or  a  piece  of  soft  sponge,  filling 
up  the  immense  cavity  which  has  been  made. 
It  is  impossible  to  describe,  in  this  general 
manner,  the  precise  parts  at  which  the  sec¬ 
tion  of  the  bone  may  require  to  be  made,  as 
it  depends  wholly  upon  the  extent  and  direc¬ 
tion  of  the  tumor.  Hence  it  is  most  essen¬ 
tial  that  any  surgeon,  however  bold  or  expert, 
should  thoroughly  make  himself  acquainted 
with  the  precise  attachments  of  the  diseased 
mass,  and  perfectly  make  up  his  mind  upon 
the  mode  of  procedure  he  intends  to  adopt, 
before  he  commences  the  operation.  I  have 
lately  removed  a  cartilaginous  tumor,  grow¬ 
ing  from  the  antrum  of  a  child  about  eleven 
years  of  age  ;  but,  as  it  had  not  acquired  a 
very  great  size,  of  course  the  extent  of  the 
incisions,  or  quantity  of  bone  to  be  removed, 
was  proportionately  smaller,  compared  with 
the  operation  I  have  just  before  described. 


Fig.  1. 


Osteo-sarcoma  of  the  lower  jaw.  The  dotted 
line  shews  the  direction  of  the  incision 
through  the  integuments,  which  are  dis¬ 
sected  off,  exposing  the  bony  excrescence. 


Fig.  2. 


Tumor  of  the  upper  jaw  exposed  by  the  re¬ 
moval  of  the  soft  parts.  The  dotted  line 
shews  the  direction  of  the  first  incision  ; 
one  of  the  teeth  is  drawn,  to  shew  the 
point  at  which  the  bone  is  to  be  cut  away 
by  the  bone-nippers. 

THE  REGION  OF  THE  NECK. 

The  neck  is  placed  between  the  thorax 
and  the  cranium,  and  constitutes  a  continua¬ 
tion  of  the  spine,  so  that  it  must  be  con¬ 
sidered  rather  as  an  appendix  to  the  trunk 
than  to  the  head,  although  Professor  Okie, 
and  some  other  physiologists,  consider  the 
bones  of  the  skull  as  mere  modifications 
of  the  form  of  the  vertebrae.  Seven  ver¬ 
tebrae  compose  the  osseous  portion  of  the 
neck  ;  and  it  is  worthy  of  remark,  that  all 
mammalia,  from  the  giraffe  to  the  mole, 
possess  the  same  number  of  cervical  verte¬ 
brae.  The  chain  of  bones  constituting  the 
neck  is  attached  above  to  the  cranium, 
posterior  to  the  centre  of  gravity  of  the  skull, 
leaving  a  large  space  between  the  four  upper 
cervical  vertebrae  and  the  lower  jaw  ;  this 
space  is  occupied  by  the  organs  of  mastica¬ 
tion,  deglutition,  and  respiration,  while  the 
three  lower  bones  of  the  cervical  spine  are 
curved  more  forward,  and  brought  within 
the  central  line  of  gravity  of  the  skull ;  but 
these  are  still  destined  to  support  por¬ 
tions  of  the  alimentary  and  respiratory  ap¬ 
paratus.  Thus  it  will  be  observed  that  the 
neck  is  not  only,  as  far  as  refers  to  bone,  the 
connecting  medium  between  the  trunk  and 
the  head,  but  that  all  the  organs  which  are 
situated  in  the  region  may  be  considered  as 
extrinsic  to  it,  and  forming  connecting 


REGION  OF  THE  NECK.  THE  PHARYNGEAL  REGION 


5 


media  between  the  commencement  of  the 
organs  ot  mastication,  and  stomach,  and 
the  respiratory  passages,  and  the  lungs. 
But  besides  these  organs,  the  natural  contour 
of  the  neck  is  made  up  of  various  muscles 
intrinsically  belonging  totheimportant  organs 
I  have  described,  as  well  as  of  those  muscles 
which  move  the  head  upon  the  spine,  and 
attach  the  cervical  region  to  the  trunk.  All 
of  these  structures,  as  well  as  the  head  itself, 
having  to  be  supplied  with  blood,  large 
arteries  and  veins  pass  through  the  neck 
to  maintain  the  circulation  ;  numerous 
nerves  also  traverse  this  region  in  their 
course  from  the  brain  to  the  organs  of  re¬ 
spiration  and  digestion,  and  the  cellular 
membrane  and  skin  make  up  its  remaining 
constituents. 

Although  the  length  of  the  neck  is  to  be 
attributed  to  its  osseous  development,  there 
is  still  a  great  variety  in  the  apparent  pro¬ 
portionable  length  of  this  region  in  different 
individuals  ;  but  this  is  more  to  be  attributed 
to  the  development  and  formation  of  the 
chest  than  to  the  construction  of  the  neck 
itself — a  short  narrow  thorax  giving  the  ap¬ 
pearance  of  an  elongated  neck,  pathologically 
indicative  of  a  pulmonic  diathesis,  while 
a  fully  developed,  deep  thorax,  encroaches 
on  the  cervical  region,  indicating  a  plethoric, 
if  not  an  apoplectic  tendency  :  this  inference 
would  almost  naturally  be  drawn  owing  to 
the  approximation  of  the  heart  to  the  brain. 

In  a  surgical  point  of  view  these  conside¬ 
rations  are  important,  inasmuch  as  opera¬ 
tions  in  the  region  of  the  neck,  such  as  the 
removal  of  tumors  and  tying  of  arteries,  are 
difficult  where  the  neck  is  short  and  stout, 
and  become  comparatively  easy  in  propor¬ 
tion  to  its  attenuation. 

The  pharyngeal  region. — The  pharynx 
must  be  considered  as  constituting  a  portion 
of  the  neck  ;  for  although  in  a  surgical  point 
of  view  the  neck  is  considered  as  being 
bounded  above  by  the  lower  jaw,  and  below 
by  the  sternum  and  clavicle,  still  the  pharynx, 
composed  of  a  layer  of  muscles,  is  placed 
behind  the  bones  of  the  face,  and  in  front  of 
the  four  superior  cervical  vertebrae.  It  is 
fixed  above  to  the  cuneiform  process  of  the 
occipital  bone  in  its  centre  to  the  maxil¬ 
lary  bones,  and  cornua  of  the  os  hyoides, 
and  below  to  the  thyroid  and  cricoid  car¬ 
tilages  ;  while  posteriorly  it  is  connected  by 
loose  cellular  membrane  to  the  muscles 
on  the  anterior  aspect  of  the  spine.  In 
front  it  communicates  with  the  posterior 
nares,  month,  eustachian  tubes,  and 
glottis ;  so  that  it  can  scarcely  be  considered 
as  possessing  any  anterior  parietes,  until 
below  the  level  of  the  glottis,  where  it  termi- 
na'es  in  the  oesophagus. 

The  pharynx  as  an  organ  of  deglutition, 
is  frequently  liable  to  the  lodgment  ot  foreign 


bodies,  and,  as  I  have  already  said,  is  so  in¬ 
timately  connected  with  other  important 
openings,  especially  with  that  of  the  respira¬ 
tory  canal,  that  so  great  an  inconvenience 
of  necessity  must  arise  from  any  obstruction 
as  to  render  imperative  the  immediate  re¬ 
moval  of  the  extraneous  matter  ;  and  in  con¬ 
sequence  of  the  communication  of  the  pha¬ 
rynx  with  the  mouth  and  fauces,  instruments 
can  be  readily  introduced  for  the  purpose  of 
their  extraction.  Instances  have  been  known, 
however,  of  suffocation  occurring  from  por¬ 
tions  of  meat  or  other  substances  sticking  in 
the  pharynx,  and  preventing  the  passage  of 
air  into  the  glottis,  producing  immediate  as¬ 
phyxia.  If  you  were  called  to  a  patient  under 
these  circumstances,  gentlemen,  and  had  no 
efficient  instruments  for  the  removal  of  the 
body,  you  should  immediately  open  the  tra¬ 
chea,  so  as  to  admit  air  to  the  lungs,  and  thus 
give  time  subsequently  to  remove  the  cause 
of  the  danger. 

Abscesses  sometimes  form  in  the  loose  cellu¬ 
lar  membrane,  between  the  pharynx  and  the 
spine :  the  pressure  of  these  gives  rise  to 
symptoms  very  similar  to  those  in  case  of  ob¬ 
struction  produced  by  the  presence  of  a  foreign 
body,  but  in  the  former  case  premonitory 
symptoms  form  sufficiently  clear  diagnostic 
works.  When,  therefore,  dysphagia  and  dysp¬ 
noea  result,  preceded  by  pain  in  swallowing, 
fibrile  action  and  rigors,  and  upon  examination 
a  tumor  presents  itself,  there  is  sufficient 
evidence  of  the  presence  of  an  abscess,  the 
evacuation  of  which  at  once  relieves  the 
urgency  of  the  symptoms. 

In  effecting  this,  some  little  caution  is 
necessary  ;  as,  for  instance,  the  tongue  should 
not  be  drawn  forward  for  the  purpose  of  ob¬ 
taining  the  best  view  of  the  abscess;  for, 
although  advantage  is  gained  by  this  pro¬ 
cedure,  it  is  more  than  counterbalanced  by 
the  liability  of  the  pus  to  flow  at  once  into  the 
glottis,  which  would  be  widely  opened  by  the 
protention  of  the  tongue.  The  pus  should  be 
early  evacuated,  as,  in  consequence  of  the  laxity 
of  the  cellular  membrane  between  the  pharynx 
and  the  anterior  muscle  of  the  spine,  there 
is  considerable  tendency  for  the  matter  to 
make  its  way  downwards  even  into  the  chest. 
Sometimes  the  abscess  is  so  far  down  the 
pharynx  as  to  be  beyond  ocular  detection. 
In  such  a  case  the  passage  of  an  oesophageal 
bougie  will  sometimes  not  only  detect  the 
seat  of  the  abscess,  but  also  cause  its  rupture, 
and  the  evacuation  of  the  matter. 

I  was  sent  for  to  a  lady  who  resided  in 
Westbourne  Terrace,  and  who,  after  an  attack 
of  cynanche  tonsillaris,  was  seized  with  diffi¬ 
culty  of  swallowing  and  breathing,  preceded 
by  distinct  rigor,  and  a  deep-seated  fixed 
pain  in  the  region  of  the  larynx.  I  ordered 
fomentations,  and  promised  to  call  again  in 
the  evening.  This  I  did,  taking  with  me  a 
bougie,  which  I  passed  down  the  oesophagus 


6  ANTERIOR  REGION  OF  THE  NECK.  THE  SUPRA-H YOIDE AL  REGION. 


and  my  patient  was  immediately  relieved  by 
the  evacuation  of  a  large  quantity  of  pus, 
which  she  brought  up  in  vomiting. 

An  abscess  may,  however,  result  from 
caries  of  the  bodies  of  the  vertebrae,  and  in¬ 
stances  have  been  known  of  portions  of  ex¬ 
foliated  bone  being  vomited  from  the 
stomach.  The  after-treatment  in  such  cases 
must  be  regulated  according  to  whether  the 
affection  results  from  strumous  diathesis,  or 
syphilitic  taint. 

Ulcers  on  the  pharynx  are  not  common, 
unless  they  proceed  from  secondary  or  ter¬ 
tiary  sores,  when  they  of  course  require  to 
be  treated  by  iodine,  and  other  alterative 
remedies. 

ANTERIOR  REGION  OF  THE  NECK. 

When  we  view  the  neck  on  its  anterior 
aspect,  several  important  projections  and  de¬ 
pressions  present  themselves,  occupying  an 
inverted  triangular  space  lying  between  the 
two  anterior  edges  of  the  sterno-cleido- 
mastoidei  muscles. 

Commencing  from  above,  the  symphysis  of 
the  lower  jaw  offers  the  most  prominent 
point  of  relief.  It  is  to  be  considered  w'hen 
the  jaw  is  closed,  and  forming  a  right  angle 
with  the  axis  of  the  body,  just  below,  and  an  ‘ 
inch  and  a  half  behind,  the  symphysis  may 
be  seen  (especially  in  thin  persons)  ;  a  second 
projection,  which  marks  the  situation  of  the 
os  hyoides  ;  a  quarter  of  an  inch  below  this, 
the  edge  of  the  thyroid  cartilage  presents 
itself,  forming  a  third  eminence,  from  whence 
the  larynx  takes  its  commencement,  termi¬ 
nating  at  the  lower  edge  of  the  cricoid  car¬ 
tilage,  its  vertical  length  being  about  two 
inches.  The  thyroid  gland  forms  the  next 
projection,  the  prominence  of  which  varies 
in  different  individuals.  From  the  lower 
edge  of  the  crycoid  cartilage  to  the  sternum 
measures  two  inches  and  a  half ;  and  in  tak¬ 
ing  the  dimensions  of  the  part,  it  is  better  to 
measure  from  the  cartilage  than  the  gland, 
as  the  latter  is  sometimes  difficult  to  define. 
Just  above  the  sternum,  the  supra- sternal 
cavity  is  placed  ;  this  space  is  formed  by  the 
peculiar  arrangement  of  the  cervical  fasciae. 
On  either  side  of  these  mesian  projections  a 
vertical  sulcus  is  distinguishable  :  it  runs 
along  the  inner  edge  of  the  sterno-cleido- 
mastoidei  muscles,  and  marks  the  situation 
of  the  carotid  arteries,  which  in  these  persons 
may  be  seen  pulsating  beneath  the  skin. 

The  whole  of  this  region  of  the  neck  is 
placed  anteriorly  to  the  cervical  vertebrae, 
and  as  it  contains  the  various  organs  I  have 
already  described  as  so  essential  to  life,  it 
offers  many  points  of  the  highest  interest  to 
the  surgeon ;  perhaps  one  of  the  most  im¬ 
portant  of  these  is  in  relation  to  the  mariner 
in  which  the  cervical  fascia  unites  all  the 
parts,  and  at  the  same  time  sub-divides 


them,  and  isolates  each  structure  by  form¬ 
ing  a  distinct  sheath  around  it. 

The  growth  of  tumors,  and  the  progress 
of  the  formation  of  abscess,  as  well  as  the 
effects  produced  upon  the  neighbouring 
organs,  are  modified  by  the  attachments  of 
the  fasciae:  these  processes  should,  therefore, 
be  most  scrutinously  studied  by  the  anato¬ 
mical  pupil,  in  order  that  he  may  become 
fully  acquainted  with  the  topography  of  the 
region. 

The  suprci-hyoidial  region. — It  is  in  this 
region  that  attempts  at  self-destruction  are 
most  frequently  made  by  what  is  termed 
“  cutting  the  throat"  :  if  such  an  attempt  be 
determinedly  made,  the  mouth  is  laid  open  : 
this  is  attended  by  a  discharge  of  mucus, 
mixed  with  more  or  less  blood,  and  saliva  ; 
if  the  sublingual  or  sub  maxillary  gland  be 
wounded,  a  flow  of  saliva  also  occurs;  the 
power  of  articulation  is  greatly  interrupted, 
although  the  voice  itself  is  unimpaired. 

In  these  cases  the  extent  of  the  haemor¬ 
rhage  is  the  most  alarming  feature  ;  it  de¬ 
pends  upon  the  division  of  the  submental  or 
lingual  artery,  which,  if  divided,  requires  a 
ligature  to  stop  the  bleeding :  the  former 
may  usually  be  at  once  secured  ;  but  with 
respect  to  the  lingual  artery,  it  is  more 
difficult,  from  its  being  so  deeply  seated, 
and  if  it  cannot  be  secured  at  the  wound 
the  trunk  itself  must  be  tied,  which  is 
effected  as  follows  : — A  piece  of  sponge  or 
lint  is  pressed  into  the  wound  to  check  the 
bleeding  during  the  operation,  and  an  incision 
is  made  through  the  skin  and  fascia  superfi- 
cialis,  commencing  a  quarter  of  an  inch  ante¬ 
rior  to  and  above  the  cornu  of  the  os  hyoides, 
and  extending  upwards  and  backwards  to¬ 
wards  the  anterior  edge  of  the  mastoid  mus¬ 
cle.  The  edges  of  this  wound  being  sepa¬ 
rated,  the  tendon  or  posterior  belly  of  the 
digastric  muscle  is  exposed,  and  immediately 
below  it  lie  the  lingual  nerve  and  artery, 
the  nerve  being  above,  and  somewhat  super¬ 
ficial  to  the  artery,  I  have  once  tied  this 
artery  myself  in  a  case  of  attempted  suicide 
by  a  person  in  St.  Martin’s  Lane,  and  I 
found  the  operation  extremely  difficult, 
although  on  the  dead  subject  you  will  find  it 
comparatively  easy  ;  which  depends  upon  the 
action  of  the  muscles  during  life  increasing 
the  depth  at  which  the  artery  is  situated. 
If  a  w;ound  in  the  side  of  the  throat  extend 
very  deeply  in  this  region,  the  instrument 
may  penetrate  into  the  inferior  part  of 
the  parotid  region  to  a  sufficient  depth  to 
injure  the  gland,  the  external  carotid 
artery,  or  perhaps  its  facial  branch.  If 
the  latter  only  be  wounded,  it  may  be  tied; 
but  if  the  carotid  itself  be  divided,  it  would 
generally  happen  that  the  patient  would  die 
before  the  necessary  assistance  could  be 
afforded.  I  remember,  however,  an  instance, 


S U FRA -HYO IDEAL  REGION.  LARYNGOPHARYNGEAL  REGION. 


7 


in  which  an  old  pupil  of  Guy’s  Hospital, 
a  Mr.  Tierman,  who  had  the  care  of  a 
lunatic,  succeeded  in  putting  a  ligature 
around  the  common  carotid,  and,  by  his  skill 
and  promptitude,  saved  the  life  of  the 
patient. 

Tumors  sometimes  occur  in  the  supra- 
hyoideal  region  :  the  degree  to  which  these 
project  externally  depends  upon  whether 
they  are  between  the  skin  and  the  muscles, 
or  the  muscles  and  the  mucous  membrane 
of  the  mouth  ;  in  the  last  case  they  would 
project  more  into  the  mouth,  and,  if  requir¬ 
ing  an  operation,  must  be  removed  through 
that  cavity. 

I  lately  removed  a  tumor  from  this  region: 
it  was  placed  between  the  superficial  fascia 
and  the  genio-hyoglossal  muscle ;  and 
although  from  its  projection  and  mobility  it 
appeared  very  superficial,  it  penetrated  so 
deeply  between  the  muscles  as  to  require 
careful  dissection  for  its  perfect  removal  ; 
the  tumor  was  composed  of  enlarged  and 
indurated  lymphatic  glands. 

The  glands  of  the  supra- hyoidial  region 
are  often  secondarily  affected  in  malignant 
disease  of  the  lower  jaw  and  tongue  ;  when 
this  is  the  case,  it  forcibly  indicates  the  im¬ 
propriety  of  resorting  to  operation  for  the 
removal  of  the  original  affection. 

The  central  region  of  the  neck  compre¬ 
hends  the  space  between  the  undersurface  of 
the  os  hyoides  and  the  inferior  edge  of  the 
cricoid  cartilage ;  I  shall  term  it  the 

Laryngo- pharyngeal  region. — Wounds  in 
this  part  are  also  not  infrequent  from  the 
hand  of  the  suicide,  and  the  cutting  instru¬ 
ment  may  divide  the  space  between  the  os 
hyoides  and  the  thyroid  cartilage,  between 
the  thyroid  and  cricoid  cartilages,  or  be¬ 
tween  the  cricoid  cartilage  and  the  trachea, 
or  it  may,  indeed,  divide  the  cartilages 
themselves  ;  in  either  case,  however,  the  re¬ 
sulting  phenomena  would  indicate  at  once 
the  nature  and  situation  of  the  inflicted  in¬ 
jury.  If,  for  instance,  the  wound  pene¬ 
trates  between  the  os  hyoides  and  thyroid 
cartilage,  the  thyro-hyoideal  ligament  will 
be  cut  through,  the  phalanx  laid  open,  and 
its  contents  probably  protruded.  Air  also 
passes  from  the  wound,  producing  often 
more  or  less  emphysema,  and  speech  is  also 
impaired,  if  not  destroyed.  The  bleeding  is 
here  usually  comparatively  slight,  as  the 
superior  thyroideal  artery  alone  is  liable  to 
be  wounded,  unless  the  incision  extends 
laterally  to  a  sufficient  degree  to  reach  the 
carotid  artery  and  jugular  vein ;  but  the 
superior  laryngeal  nerve  is  very  likely  to  be 
divided ;  and,  if  that  were  to  happen  on 
both  sides,  the  loss  of  sensation  in  the 
larynx  would  probably  lead  to  suffocation, 
owing  to  the  blood  passing  down  the  glottis  ; 


for,  as  the  presence  of  the  intruding  matter 
would  not  be  indicated  in  consequence  of  the 
loss  of  sensation,  there  would  be  no  effort  to 
expel  it  by  coughing.  Should  there  be  bleeding 
from  the  superior  thyroideal  artery,  and  an 
attempt  to  secure  its  truncated  extremity 
not  succeed,  the  trunk  of  the  artery  must  be 
tied ;  and,  with  this  object,  an  incision 
must  be  made  through  the  skin  and  fascia  of 
the  neck,  commencing  immediately  below 
the  cornu  of  the  os  hyoides,  and  extending 
outwards  and  downwards  for  an  inch  and  a 
half  towards  the  mastoid  muscle  :  the  artery 
is  thus  exposed,  several  small  veins  lying 
across  it,  and  the  superior  laryngeal  nerve 
behind  it.  I  have  seen  Sir  A'  tley  Cooper 
put  a  ligature  around  this  artery  for  the 
disease  of  the  thyroid  gland  termed  broncho- 
cele :  it  proved,  however,  ineffectual.  If 
the  carotid  artery  itself  be  divided  in  the 
laryngo- pharyngeal  region,  there  is  but  little 
chance  of  the  patient  surviving  until  surgical 
assistance  could  be  obtained.  If  the  cutting 
instrument  be  directed  deeply  backwards, 
and,  at  the  same  time,  takes  a  downward 
direction,  the  apex  of  the  epiglottis  may  be 
wounded.  In  such  a  case,  a  complicated 
train  of  symptoms  would  be  presented  by 
the  interruption  to  the  functions  of  respira¬ 
tion  and  deglutition.  If  the  wound  be  in¬ 
flicted  between  the  thyroid  and  cricoid 
cartilage,  the  vocal  cords  and  epiglottis  are 
almost  certain  to  be  injured,  and  the  voice 
greatly  impeded  or  totally  lost  ;  blood  and 
air  rush  out  of  the  wound  at  each  expira¬ 
tion,  while  every  time  the  air  is  drawn  into 
the  lungs,  cough  is  produced  by  the  blood 
passing  into  the  glottis. 

Should  the  incision  in  “  cut  throat”  be 
through  the  thyroid  or  cricoid  cartilage, 
the  danger  of  suffocation  is  increased,  as, 
owing  to  the  elasticity  of  the  tissue,  the 
wound  is  immediately  closed,  and  the  blood 
cannot  be  expelled  through  it.  The  object 
in  these  cases  is  to  secure  the  bleeding 
vessels  as  quickly  as  possible. 


SALUBRITY  OF  PHILADELPHIA. 

The  editors  of  the  Western  Journal  of 
Medicine  and  Surgery  infer,  from  the  fact 
that  but  two  medical  students,  in  a  class  of 
406,  have  died  there  during  the  last  session, 
that  Louisville  is  signally  healthy.  What 
then  must  be  the  healthfulness  of  Philadel¬ 
phia,  when  only  two  had  died  up  to  the  1st 
of  March  last,  in  about  1200.  The  Cata¬ 
logues  of  the  University  of  Pennsylvania  and 
the  Jefferson  Medical  College  have  alone 
been  published.  In  these  two  schools,  of 
the  five,  there  were  nearly  one  thousand 
students. — Philadelphia  Medical  Examiner, 
and  Record  of  Medical  Science,  April  1848. 


8 


mr  Phillips’s  clinical  remarks  on  hip  disease. 


CLINICAL  OBSERVATIONS  ON 

HIP  DISEASE. 

By  B.  Phillips,  F.R.S. 
Surgeon  to  the  Westminster  Hospital. 


Too  many  cases  of  hip  disease  occur  in  prac¬ 
tice  to  make  it  a  matter  of  indifference  that 
the  affection  should  be  rightly  understood  ; 
and  I  therefore  shall  beg  your  attention 
while  I  make  some  observations  on  it  to¬ 
day  :  the  more  so,  as  we  have  at  present  in 
the  hospital  several  cases  which  illustrate 
different  stages  in  the  existence  of  the  dis¬ 
ease. 

In  Henry  Hoare  ward  there  is  a  boy,  who, 
I  believe,  has  hip  disease,  but  there  is  no 
other  sign  of  the  disease  than  a  slight  limp 
in  walking  :  there  is  no  pain  upon  suddenly 
pressing  the  head  of  the  femur  into  the 
acetabulum,  nor  upon  rotation.  He  can 
stamp  upon  the  ground  vigorously  without 
flinching,  but  there  is  the  occasional  limp. 
In  Queen  Ann  ward  is  a  little  girl  who 
limps,  but  who  can  bear  a  hard  blow  upon 
the  heel  of  the  extended  leg  without  shrink¬ 
ing  ;  she  has,  however,  tenderness  in  the 
groin.  In  Sanctuary  ward  there  is  a  child 
in  whom  the  disease  has  been  more  acute, 
and  a  collection  of  fluid  exists,  I  believe, 
external  to  the  joint ;  but  the  symptoms 
have  now  become  very  chronic.  The  fluid 
was  a  kind  of  sero-pus,  as  shewn  by  the 
introduction  of  a  grooved  needle.  It  cer¬ 
tainly  has  greatly  lessened  in  bulk  under  the 
influence  of  repeated  blistering,  but  lias  not 
quite  disappeared.  In  Mark  ward  is  a  boy 
who  presented  the  disease  in  a  very  acute 
form  :  he  screamed  out  on  the  slightest 
motion  of  the  limb.  Leeches,  blisters,  and 
calomel  and  opium,  have  brought  it  into 
comparative  quiet.  Before  you  at  present 
are  two  cases :  one  of  dislocation  upon  the 
dorsum  of  the  ilium,  the  parts  being  in 
a  quiet  state  ;  the  other,  of  more  or  less 
complete  anchylosis.  Bear  in  mind,  with 
respect  to  anchylosis  at  the  hip-joint,  that 
errors  in  diagnosis  are  not  unfrequent.  The 
muscles  about  the  joint  sometimes  assume  a 
tetanic  rigidity,  which  prevents  for  a  time 
the  slightest  movement. 

Although  this  disease  is  so  common,  and 
although  it  often  terminates  by  wearing  out 
the  patient,  yet  the  opportunities  of  observ¬ 
ing  the  parts  in  the  early  stage  of  its  exist¬ 
ence  are  by  no  means  common.  This  is 
unfortunate,  because  it  leaves  room  for  dif¬ 
ference  of  opinion  at  a  time  when  curative 
agents  should  be  employed  with  most 
benefit. 

Some  persons  entertain  the  opinion  that 
in  this  early  stage  the  disease  is  external  to 
the  joint ;  others  maintain  that  the  disease, 


which  may  be  observed  external  to  the  joint, 
is  always  secondary — that  the  primary  dis¬ 
ease  is  usually  within  the  capsule.  Some 
think  the  disease  begins  in  one  tissue  of  the 
joint;  some  another.  It  would  surely  be 
well  that  we  were  all  agreed  on  this  point. 
If,  in  the  early  stage,  the  joint  were  com¬ 
paratively  free  from  disease,  it  might  explain 
the  alleged  success  of  those  who  allow  their 
patients  to  use  the  joints,  the  evils  of  con¬ 
finement  and  failing  health  being  averted. 
It  is  clear  that,  if  there  were  any  stage 
where  motion  could  be  permitted  with  im¬ 
punity,  the  patient’s  health  would  probably 
suffer  less  than  from  the  close  confinement 
to  which  the  motionless  limb  subjects  him. 

De  Haen,  and  especially  Dzondi,  main¬ 
tained  that  the  external  or  extra-capsular 
form  was  the  only  one  they  had  met  with  ; 
others  deny  its  separate  existence  altogether. 
As  far  as  the  demonstration  on  the  living 
can  avail,  we  have  had  many  instances  in 
this  hospital  in  proof  of  its  occasional  exist¬ 
ence.  Still,  the  preponderance  of  evidence 
favours  the  belief  that  the  intra-capsular 
form  of  the  disease  is  of  most  frequent 
occurrence  ;  and  until  comparatively  recent 
times, — even  from  that  of  the  Greeks,  the 
belief  was  universal,  that  the  soft  parts 
within  the  capsule  were  the  seat  of  the  dis¬ 
ease. 

There  was  a  boy  in  the  hospital  not  long 
ago  who  was  the  subject  of  fever  and  of 
acute  disease  affecting  several  joints,  parti¬ 
cularly  the  hips.  There  was  also  a  tumor, 
which  appeared  to  be  abscess,  in  the  left 
iliac  fossa.  He  died  ;  and,  upon  examina¬ 
tion  after  death,  the  results  of  most  acute 
inflammation  were  found  in  both  hip-joints. 
A  large  quantity  of  sanguineous  fluid  was 
found  there  ;  the  appendages  had  been  in 
the  highest  state  of  inflammation  ;  the  car¬ 
tilaginous  surfaces  were  partially  destroyed, 
and  the  fundus  of  one  acetabulum  had  given 
way,  so  as  to  allow  of  the  passage  of  a  por¬ 
tion  of  fluid  into  the  iliac  fossa,  and  of  the 
formation  of  the  tumor  which  was  felt. 
But  such  acute  forms  of  the  disease  are  by 
no  means  common  :  a  more  chronic  form  is 
the  more  usual.  In  the  lattter  stages  of  the 
disease,  accurate  post-mortem  inspections 
have  very  often  been  made,  and  the  appear¬ 
ances  are  similar  to  those  which  are  often 
observed  in  other  joints.  In  some  cases 
the  synovial  tissues  alone  have  suffered  ;  in 
others,  the  femur  alone ;  but  in  most  cases 
the  acetabulum  and  its  appendages  have 
undergone  great  change. 

Inflammation  within  this  joint  and  else¬ 
where  may  be  presented  under  different 
forms. — may  determine  the  formation  of 
different  products.  Those  products  may  be 
a  sero-mucous  fluid,  which,  when  the  accu¬ 
mulation  is  considerable,  constitutes  what  is 
known  as  dropsy  of  the  joint.  The  inflam- 


mr.  phillips’s  clinical  remarks  on  hip  disease. 


9 


mation  may  not  proceed  beyond  this  point 
to  the  formation  of  any  other  product.  I 
take  it,  the  cases  described  by  Mr.  Stanley  in 
the  Medico- Chirurgical  Transactions  are 
of  this  nature.  I  do  not,  however,  admit 
the  correctness  of  Petit’s  opinion,  that  it  is 
the  ordinary  first  stage  in  the  development  of 
the  disease.  The  inflammation  may  for  a 
time  he  confined  to  the  soft  parts,  which  be¬ 
come  tumid  and  painful  on  motion  ;  but  this 
condition,  in  the  absence  of  any  morbid 
product,  is  rare.  The  ligamentary  and  car¬ 
tilaginous  structures  are  soon  involved  in 
the  mischief  which  is  developed.  The  more 
common  state  is  that  in  which  the  inflam¬ 
mation  of  the  soft  parts  has  determined  the 
formation  of  pus  within  the  capsule,  and 
where  the  cartilages  have  undergone  ulcera¬ 
tion.  All  intra-capsular  disease  of  the  hip- 
joint  does  not,  however,  begin  in  the  soft 
parts,  though  many,  or,  according  to 
Brodie,  most  of  them,  begin  in  the  cartilagi¬ 
nous  structure.  But  certainly  the  osseous 
structures  of  the  head  of  the  femur,  or  of 
the  acetabulum,  are  often  the  first  to  suffer. 
Of  this  we  have  ample  proof  in  different  ccd- 
lections.  It  is  only  at  this  early  period  that 
we  can  obtain  proof  of  the  correctness  of  the 
positions  I  have  laid  down ;  at  a  later  time  the 
hard  and  the  soft  parts  alike  are  confounded 
in  the  disorganisation  which  is  determined. 
The  cartilaginous  surfaces  may  be  un¬ 
changed,  or  they  may  be  detached  at  points, 
ulcerated,  or  eburnated  ;  but  they  do  not 
always  suffer  altogether :  the  acetabulum 
may  be  destroyed  even  to  making  an  open¬ 
ing  into  the  pelvis,  while  the  surface  of  the 
head  of  the  femur  may  be  almost  unchanged, 
and  vice  versa.  The  fibrous  capsule  of  the 
joint  may  be  entire  amongst  the  most  re¬ 
markable  disorganisation  :  it  may  be  more 
or  less  completely  destroyed,  and  give  way. 
Such  great  changes,  however,  do  not  go  on 
long  within  the  capsule  without  exciting  dis¬ 
turbance  beyond  it.  (Edematous  or  puru¬ 
lent  infiltrations  may  occur,  and  may  make 
a  way  for  themselves  in  various  directions. 

What  is  singular  in  hip  disease  is  the 
uncertainty  of  what  may  happen  as  to  the 
relation  of  the  articular  surfaces.  Great 
destruction  of  the  soft  and  even  the  hard 
parts  will  happen,  while  the  head  of  the 
femur  will  remain  firm  or  even  anchvlosed 

r 

in  the  acetabulum ;  in  others,  the  disor¬ 
ganisation  may  be  even  less,  while  the  head 
of  the  femur  is  quickly  pushed  from  the 
cavity.  That  this  displacement  may  happen 
when  the  disorganisation  within  the  joint  is 
inconsiderable,  is  proved  by  Mr.  Stanley’s 
cases,  and  also  that  this  displacement  may 
occur  without  rupture  of  the  capsular  liga¬ 
ment  ;  but  usually  before  this  happens  there 
is  great  disorganisation  within  the  joint,  and 
the  capsule  is  ruptured.  When  displace¬ 
ment  occurs,  it  may  be  in  any  direction 


which  the  bone  takes  in  accidental  traumatic 
displacement.  In  any  case  it  may  make 
for  itself  a  resting  place,  and  a  kind  of  cap¬ 
sule  at  the  point  where  it  is  fixed. 

There  is  no  single  joint  oftener  the  seat 
of  disease  in  childhood  than  the  hip ;  and 
considering  how  much  it  is  protected,  this 
fact  is  not  easily  explained.  There  are, 
surgeons  —  Petit  was  one  of  them — who 
maintain  that  this  disease  is  always  set  up 
by  contusions — by  falls,  and  that,  as  they 
are  frequent  in  childhood,  a  ready  explana¬ 
tion  of  their  frequency  is  thus  furnished. 
Still,  however  carefully  you  interrogate  pa¬ 
tients,  you  are  often  unable  to  connect  the 
disease  with  a  contusion ;  but  this  by  no 
means  proves  that  such  contusions  have  not 
happened.  Considering,  too,  how  much 
children  fall  about,  it  is  reasonable  to  admit 
that  such  injuries  may  often  stand  in  the 
relation  of  an  exciting  cause  to  this  disease, 
although  we  may  be  unable  to  distinguish 
the  circumstances  of  the  connection.  At 
all  events,  it  seems  to  me  more  reasonable 
to  subscribe  to  this  opinion  than  to  that  of 
Dzondi,  who  asserts  that  there  is  only  one 
cause  capable  of  determining  coxalgia,  and 
that  he  calls  rheumatic  irritation.  He  says, 
“  Of  the  numerous  cases  I  have  seen  in 
thirty  years,  not  one  could  be  fairly  referred 
to  contusions  or  strains,  scrofula  or  syphilis.” 
He  does  not  deny  that  inflammation  may  be 
set  up  in  the  hip-joint  by  these  means,  but 
he  says  those  cases  do  not  end  in  sponta¬ 
neous  dislocation.  This  rheumatic  irrita¬ 
tion,  which  in  his  opinion  is  the  cause  of  so 
much  mischief,  he  describes  as  resulting 
from  a  suppression  of  the  cutaneous  trans¬ 
piration  at  a  time  when  that  function  is 
energetically  performed  ;  and  he  states  that 
it  usually  results  from  the  exposure  of  that 
region  of  the  body  to  cold  when  in  full  per¬ 
spiration.  He  attributes  it  mainly  to  the 
habit  which  nurses  have,  when  a  child  is 
tired,  of  causing  him  to  sit  down  anywhere 
on  a  cold  stone  or  cold  grass,  often  after  the 
part  has  been  supported  long  enough  on  the 
nurse's  arm  to  become  quite  warm.  In  the 
poor  man’s  house,  the  common  place  for  a 
child  to  sit  is  the  cold  stone  floor. 

Many  persons  regard  a  scrofulous  consti¬ 
tution  as  the  common  cause  of  the  disease; 
but  then  there  must  usually  be  something  to 
determine  the  mischief  on  the  hip-joint  :  it 
may  be  a  contusion.  Larrey  thought  scro¬ 
fula  the  cause  in  childhood  ;  rheumatism  in 
adult  life ;  but  in  adult  life  the  disease  is 
by  no  means  common ;  and  in  any  case,  if 
scrofula  be  a  cause,  it  is  a  remote  one.  No 
doubt  the  contusion,  which  might  prove 
harmless  in  a  vigorous  child,  might  set  up 
hip  disease  in  a  scrofulous  one. 

However  obscure  may  be  certain  points 
connected  with  the  pathology  and  with  the 
causes  of  hip  disease,  they  sink  into  insig- 


10 


MR.  phillips’s  clinical  remarks  on  hip  disease. 


nificance  compared  with  the  difficulty  of 
diagnosis  in  the  early,  and  therefore  most 
important,  period  of  the  disease.  Upon 
what  can  we  rely  for  proof  that  the  disease 
exists? — upon  pain? — upon  any  inter¬ 
ference  with  the  power  of  motion  ? — upon 
any  deformity  in  the  limb  ?  If  we  admit 
the  value  of  pain  as  a  symptom,  where  is 
the  point  at  which  it  is  most  characteric  ? — 
at  the  hip  ? — in  the  groin  ? — along  the  thigh  ? 
— at  the  knee  ? — down  to  the  foot  ?  The 
pain  at  the  knee,  as  a  characteristic  of  hip 
disease,  has  always  been  relied  cn :  it  may 
be  so  severe  as  to  mask  any  discomfort 
which  may  exist  at  the  hip  :  it  n.c.y  not  be 
present ;  and,  if  it  be,  it  may  be  c.  sign  of 
some  other  affection  than  hip  disease. 
When  it  is  a  symptom  of  hip  dise  :  it  has 
been  so  intense  as  to  be  treated  ."r  white 
swelling.  In  most  cases  the  pail  at  the 
knee  is  not  increased  by  pressure;,  but  in 
some  cases  the  slightest  pressure  upon  it 
cannot  be  borne  without  suffering  ;  however, 
this  is  more  particularly  the  case  in  hysterical 
patients.  With  respect  to  the  point  of  the 
knee  which  is  affected  in  these  cases,  some 
persons  have  sought  to  lay  down  rules'  by 
means  of  which  the  nature  of  the  hip  disease 
can  be  ascertained.  It  has  been  said,  that, 
where  the  hip  disease  is  of  rheumatic  origin, 
the  pain  will  take  the  course  of  those 
tendons  which  are  inserted  at  the  inner  side 
of  the  head  of  the  tibia ;  that  where  it  is 
scrofulous,  the  pain  is  referred  to  the  con¬ 
dyles  of  the  femur.  There  is  no  doubt  that, 
where  one  extremity  of  a  bone  is  thus  af¬ 
fected,  the  pain  will  often  extend  to  the 
other;  but,  in  my  opinion,  this  will  happen 
whether  the  disease  in  the  hip  be  set  up  by 
rheumatism  or  by  any  other  cause,  whether 
it  be  confined  to  the  acetabulum  or  extended 
to  the  femur  itself.  It  is  possibie  that  in 
some  cases  the  pain  at  the  inside  of  the 
knee  is  owing,  as  has  been  suggested,  to  a 
propagation  along  the  obturator  nerve.  In 
some  cases  the  pain  at  the  hip  or  the  knee 
may  be  very  severe  ;  in  others,  and  of  this 
we  have  had  many  examples,  it  is  so  slight 
that  there  is  little  interference  with  motion  ; 
occasionally  there  is  scarcely  any  limping, 
and  the  disease  often  continues  its  course 
comparatively  unobserved. 

It  will  frequently  happen  that  shocks  ap¬ 
plied  upon  the  trochanter,  or  knee,  or  heel, 
will  not  cause  any  pain  at  the  hip  ;  but 
there  is  a  manoeuvre  which  will  rarely  fail  to 
excite  it — that  is,  a  sudden  rotation  of  the 
limb  inwards.  Still,  you  have  seen  here 
cases  where  the  pain  has  been  so  severe  as 
to  oblige  us  to  take  blood,  to  blister,  to 
give  mercury,  and  the  slightest  motion  has 
caused  screams,  but  this  rarely  occurs  in  an 
early  period  of  the  disease.  A  watchful 
mother,  however,  has  her  attention  mos  * 
commonly  roused  at  an  early  period  by  ob 


serving  a  limp,  and  soon  she  ascertains  that 
there  is  fixed  uneasiness,  which  too  com¬ 
monly  goes  on  increasing.  The  pain  does 
not  always  seem  to  bear  any  very  exact  re¬ 
lation  to  the  amount  of  disease  set  up  in 
ihe  head  of  the  femur  or  in  the  acetabulum  : 
there  may  be  much  disease  there,  and  com¬ 
paratively  little  pain,  and  vice  versa ;  but 
generally  there  is  a  certain  relation  between 
the  twro.  Where  the  disease  is  slow  and 
chronic,  there  is  usually  not  severe  pain  ; 
where  the  disease  is  acute,  and  its  progress 
rapid,  the  pain  is  often  excruciating.  In 
bad  cases  it  often  happens  that  the  pain  is 
not  continuous — it  comes  on  in  paroxysms. 
In  milder  cases  it  is  usually  so;  but  in 
either  case  it  can  usually  be  determined  by 
sudden  shocks,  and  by  particular  positions. 

The  interference  with  motion  may  be  re¬ 
garded,  then,  as  an  important  sign  in  this 
affection  ;  and  may  be  observed  even  before 
attention  has  been  roused  by  the  existence 
of  pain.  A  child  may  continue  to  run  about, 
apparently  without  hesitation  —  without 
complaint,  but  the  eye  of  a  mother  may 
even  then  detect  the  limp  ;  although,  after  a 
careful  examination  by  a  surgeon,  no  other 
sign  of  hip  disease  can  be  detected.  Before 
a  child  begins  to  run  about,  this  sign  was  of 
course  of  no  value  ;  but  even  then,  if  doubts 
are  entertained,  they  will  be  strengthened  if 
there  be  any  rigidity  in  the  motions  of  the 
thigh.  The  disease  does  not  usually  con¬ 
tinue  long  before  the  power  of  extending  the 
limb,  as  well  as  the  lateral  motion,  is  inter¬ 
fered  with,  and  then  the  gait  becomes  al¬ 
tered  ;  what  is  wanting  in  motion  on  one 
side  is  borrowed  from  the  other,  or  from  the 
pelvis.  The  failure  of  motion  in  the  part  is 
owing  partly  to  the  pain  it  excites,  partly  to 
rigidity ;  the  muscles  will  not  voluntarily 
cause  a  movement  which  will  inflict  pain. 
Effusion  into  the  tissues  around  the  joint 
also  concurs  to  limit  motion  still  more  ;  and 
some  people  think  that  the  distension  of  the 
capsule  tends  to  the  same  end.  At  a  later 
period  all  these  causes  act  with  more  inten¬ 
sity,  and  the  limb  may  become  almost  fixed, 
even  before  the  articular  surfaces  are  de¬ 
stroyed  ;  when  that  has  occurred,  of  course 
complete  anchylosis  may  be  the  result.  But 
persons  are  often  deceived  as  to  the  actual 
extent  of  motion  at  the  part,  by  neglecting 
to  fix  the  pelvis. 

A  period  comes,  however,  when  the  form 
of  the  limb  is  a  most  important  point  in 
diagnosis.  At  an  early  period,  as  soon  as 
eructation  has  excited  decoction,  so  as  to 
distend  the  joint,  there  may  be  increased 
fulness  at  the  groin  or  upper  part  of  the 
‘thigh  ;  the  character  of  the  buttock  is 
changed :  it  is  flattened  and  flabby,  and 
looks  broader  than  its  fellows.  To  some 
extent,  as  is  observed  by  Sir  B.  Brodie,  this 
is  owing  to  the  constant  position  of  the  limb 


11 


mr.  phillips’s  clinical  remarks  on  hip  disease. 


— to  a  greater  extent  to  the  falling  away  of 
the  muscles.  This  falling  away  is  a  sign  to 
be  borne  in  mind,  but  not  a  certain  sign  of 
hip  disease.  It  may  happen  in  children  who 
have  the  limb  paralysed,  and  in  cases  of 
disease  of  the  femur.  When  the  disease  has 
proceeded  to  the  extent  of  purulent  infiltra¬ 
tion,  the  swelling  may  increase ;  it  may  be 
confined  or  diffused,  and  the  cellular  tissue 
over  it  becomes  oedematous ;  but  this 
oedema  is  usually  confined  to  the  upper  part 
of  the  thigh.  At  a  later  period,  if  to  the 
previous  mischief  be  added  displacement  of 
the  head  of  the  femur,  a  projection  will  be 
presented  at  the  point  corresponding  to  that 
where  the  head  of  the  bone  is  then  situated  ; 
but,  in  the  lower  part  of  the  thigh,  there  is 
observable  a  wasting,  dependent  on  muscular 
inaction. 

The  direction  of  the  limb  in  hip  disease 
undergoes  considerable  change :  it  may  be 
flexed,  abducted,  or  rotated  outwards  or  in¬ 
wards.  When,  during  the  erect  position, 
the  limbs  are  vertical  but  the  thigh  is  fixed, 
it  is  rather  the  pelvis  which  is  inclined  upon 
the  this'll,  than  the  thigh  upon  the  pelvis — 
the  trunk  being  inclined  forwards. 

Much  discussion  has  been  lavished  upon 
the  question  of  the  change  which  is  appa¬ 
rent  in  the  length  of  the  limb  :  it  may  be 
lengthened — it  may  be  shortened ;  and  the 
question  has  only  been  well  understood  in 
our  own  times.  The  shortening  has  been 
alluded  to  from  the  time  of  Hippocrates, 
but  the  lengthening  seems  to  have  been  first 
clearly  noticed  by  the  Arab  physicians.  It 
was,  however,  lost  sight  of,  until  again  al¬ 
luded  to,  but  not  satisfactorily  explained,  by 
Petit  and  by  Morgagni.  Paletta  conceived 
that  the  lengthening  was  owing  to  the  tume¬ 
faction  of  the  soft  parts  within  the  joint. 
Larrey  urged,  that  neither  was  lengthening 
nor  shortening  a  certain  sign  of  luxation,  for 
that  both  may  be  observed  without  disloca¬ 
tion  ;  the  lengthening  he  conceived  to  be 
owing  to  a  swelling  of  the  ligamentum  teres, 
causing  a  certain  projection  of  the  bone  ;  the 
shortening  to  destruction  of  the  articular 
surfaces.  In  either  case  it  would  be  hardly 
appreciable.  Hunter  was  accustomed  to 
explain  the  lengthening  by  means  of  the  de¬ 
pression  of  the  pelvis,  as  did  Morgagni  ;  but 
no  one  has  so  forcibly  insisted  on  this  as  an 
explanation  of  the  lengthening  or  shortening 
as  Brodie  ;  and  careful  admeasurement  will 
usually  shew  the  correctness  of  his  views. 
The  views  of  Fricke  on  this  subject,  although 
they  have  attracted  much  attention,  are 
manifestly  unsound  :  he  referred  the  elonga¬ 
tion  to  paralysis  of  muscles  ;  shortening  to 
contraction  of  m  uscles. 

There  is,  however,  no  doubt  that,  to  the 
eye,  apparent  elongation  or  shortening  of  the 
limb  is  a  common  symptom  of  hip  disease ; 
when  no  dislocation  has  taken  place,  it  is 


equally  true  that  careful  admeasurement 
between  two  fixed  points — the  anterior-supe¬ 
rior  spinous  process  of  the  ilium,  and  the 
superior  border  of  the  patella — will  shew 
that  in  most  cases  it  is  only  apparent.  There 
is,  therefore,  no  doubt  that  the  apparent 
elongation  is,  in  most  cases,  dependent  on  a 
lateral  depression  of  the  corresponding  side 
of  the  pelvis  ;  and  that  the  apparent  shorten¬ 
ing  is  due  to  a  similar  elevation,  which  is, 
however,  less  common  ;  and  the  abduction 
or  adduction  of  the  limb  must  depend  upon 
the  same  fact.  But,  in  making  the  necessary 
admeasurement,  one  thing  must  not  be  lost 
sightof :  the  position  whichisgiven  to  the  limb 
at  the  moment ;  for  the  difference  between 
the  two  points  may  be  influenced  by  it.  If 
we  measure,  between  the  anterior  and  supe¬ 
rior  iliac  spine  and  the  condyles  of  the  fe¬ 
mur,  the  superior  border  of  the  patella,  or 
the  ankles,  the  line  will  be  increased  in 
length  by  adduction  ;  it  will  be  decreased  by 
abduction  ;  and  the  greatest  elongation  will 
be  given  by  a  position  of  combined  adduc¬ 
tion  and  extension ;  the  greatest  shortening 
when  abduction  and  flexion  are  combined. 
It  is  clear,  therefore,  that  the  apparent 
lengthening  mainly  depends  upon  lateral  de¬ 
pression  of  the  pelvis  ;  that  apparent  short¬ 
ening  mainly  depends  on  lateral  elevation  of 
the  pelvis.  As  these  aj  parent  modifications 
in  length  depend  so  much  on  position,  it  is 
important  to  be  able  to  dissipate  them.  If 
by  dragging  upon  the  limb  we  could  bring  it 
into  its  proper  length,  there  might  be  less 
difficulty  in  diagnosis ;  but  frequently  this 
cannot  be  done  ;  the  affected  limb  is  fre¬ 
quently  fixed,  either  by  pain  or  by  some 
change  in  the  joint,  and  the  necessary  force 
cannot  be  prudently  applied ;  but  useful  in¬ 
formation  may  be  obtained  by  bringing  the 
sound  limb  into  the  same  position. 

Let  us  now  see  what  it  is  that  determines 
these  apparent  modifications.  Brodie  con¬ 
ceives  they  are  owing  to  the  predominant  ac¬ 
tion  of  certain  muscles,  and  the  vicious 
habit  into  which  the  patient  is  so  apt  to  get 
lor  the  purpose  of  saving  the  unsound  side  : 
he  rests  entirely  on  the  sound  limb  ;  hence 
the  tilting  of  the  pelvis, — the  forward  posi¬ 
tion  of  the  limb  of  the  other  side,  and  the  toe 
advanced;  the  spine  and  the  shoulder,  also, 
are  equally  affected  by  this  position.  Some 
surgeons  object  to  this  explanation.  It  is 
said,  for  instance,  that  the  position  is  owing 
to  an  instinctive  want  in  the  patient ;  it  is 
also  said  that  the  symptoms  have  equally 
place  in  those  who  have  been  kept  in  the 
horizontal  position  from  the  first  dawn  of 
the  disease  ;  but  this  is  not  correct.  It  has 
been  further  observed,  that  whenever  we  find 
a  patient  with  elongation  of  the  limb,  in  hip 
disease,  there  is  also  flexion  and  abduction  ; 
and  that  this  position  coincides  with  the 
habit  which  the  patient  has  contracted  of 


12 


MR.  philiips’s  clinical  remarks  on  hip  disease. 


lying  on  the  suffering  side  ;  and  a  similar 
explanation  has  been  given  as  to  the  appa¬ 
rent  shortening.  It  is  said  that  the  patients 
who  are  thus  affected  all  lie  on  the  sound 
side ;  the  diseased  limb  being  flexed  upon 
the  pelvis,  adducted  and  rotated  inwards. 
Bonnett  maintains  that  in  those  cases  where 
there  is  flexion  and  rotation  outwards  in  an 
early  period  of  the  disease,  it  is  owing  to  a 
distension  of  the  articular  cavity  by  some 
fluid.  That,  as  to  the  rotation  inwards  and 
flexion  which  are  observed  at  a  later  period, 
he  attributes  it  to  the  following  circum¬ 
stance, — that  the  articular  capsule,  softened 
or  destroyed,  no  longer  opposes  any  mecha¬ 
nical  obstacle  to  muscular  action  ;  adduction 
and  flexion  are  therefore  the  necessary 
results. 

There  is,  however,  a  state  of  elongation 
and  of  shortening  which  is  real ;  but  unless 
the  head  of  the  femur  has  left  the  articular 
cavity,  it  is  inconsiderable.  Whenever  a 
displacement  happens — the  head  of  the  femur 
leaving  the  cotyloid  cavity — the  marked 
change  in  the  length  of  the  limb  is  produced. 
There  are  authors  who  say  they  observed  a 
real  lengthening  of  the  limb  at  an  early 
period  of  disease,  though  many  persons  re¬ 
gard  it  as  only  apparent. 

Whatever  doubts  may  exist  on  this  sub¬ 
ject,  one  thing  is  certain — that  if  you  fix  the 
pelvis  of  a  dead  body  firmly  on  a  table,  the 
limbs  straight,  the  ankles  brought  together, 
and  incise  the  capsule  at  its  upper  part,  the 
head  of  the  femur  will  be  found  directed  out¬ 
wards,  so  as  to  be  firmly  pressed  against  the 
upper  'wall  of  the  cotyloid  cavity,  and  no 
longer  resting  against  the  floor  of  the  cavity; 
in  these  circumstances  there  will  be  length¬ 
ening,  but  to  only  a  trifling  extent.  If  a 
complete  section  of  the  capsule  be  made, 
the  ligamentum  teres  being  intact,  and  the 
head  of  the  bone  still  further  removed  from 
the  floor  of  the  cavity,  there  will  be  still 
more  lengthening  ;  but  even  now  it  will  be 
inconsiderable.  If  the  cartilaginous  coverings 
of  the  bones  be  removed,  and  the  same  ex¬ 
periment  be  made,  there  will  still  be  length¬ 
ening,  though  not  to  the  same  extent.  If 
those  facts  are  good,  they  may  help  to  ex¬ 
plain  what  would  otherwise  be  difficult — 
they  would  tend  to  shew  that  any  cause 
capable  of  projecting  the  head  of  the  femur 
from  the  floor  of  the  articular  cavity  would 
certainly  produce  a  real  lengthening. 

Lengthening,  trifling  though  it  be,  might 
also  result  from  the  tumefaction  of  the 
soft  parts  within  the  acetabulum,  or  from 
bony  or  other  deposits,  or  from  synovial  or 
other  fluid  accumulations.  This  elongation 
in  the  dead  subject,  while  the  head  of  the 
bone  is  in  the  acetabulum,  is  then  susceptible 
of  demonstration  ;  but  we  are  quite  justified  in 
assuming  that  the  same  effects  may  occur 
from  the  same  causes  in  the  living  ?  I  think 


so.  Whether,  as  some  have  supposed,  the 
occasionally  increased  bulk  of  the  head 
of  the  femur,  under  disease,  may  induce  an 
elongation  of  the  limb,  is  doubtful.  Rust 
strongly  insisted  that  it  does  : — he  says,  one 
of  two  things  indeed  happen  where  the  head 
of  the  femur  enlarges,  either  the  cavity  of  the 
acetabulum  must  enlarge  too,  or  the  head  of 
the  femur  must  be  displaced.  And  provided 
complete  extrusion  not  to  take  place,  a  cer¬ 
tain  amount  of  lengthening  must  be  pro¬ 
duced.  With  respect  to  shortening,  there  is 
no  doubt  it  may  be  brought  about  by  change 
in  the  volume  of  the  head  of  the  bone,  or  of 
the  acetabulum,  or  by  destruction  of  the 
cartilaginous  coverings  ;  still  this  must  be 
trifling;  but  for  the  most  part  real  shorten¬ 
ing  is  the  result  of  displacement.  1  am  not  of 
the  number  of  those  who  believe  that  mus¬ 
cular  contraction  can  produce  any  con¬ 
siderable  shortening ;  for  I  am  satisfied  that 
any  amount  of  pressure  of  the  head  of  the 
bone  against  the  superior  wall  of  the  ace¬ 
tabulum  will  not  produce  any  sensible 
shortening,  unless  there  be  some  change  in 
the  head,  or  other  parts  of  the  bone,  or  in 
the  acetabulum.  Where  the  head  of  the 
bone  is  pushed  out  upon  the  dorsum  of  the 
ilium,  the  extent  of  shortening  will,  of  course, 
depend  upon  the  point  where  the  head  of  the 
bone  rests. 

Hip  disease  may  commence  acutely,  or  it 
may  be  for  a  time  very  insidious,  and  the 
general  symptoms  will  vary  accordingly.  If 
it  be  acute,  the  general  excitement  may  be 
considerable,  but  commonly  it  is  not  so, 
and  no  great  constitutional  irritation  is  set 
up  until  suppuration  is  developed.  Then  the 
usual  signs  of  suppurative  action  are  mani¬ 
fested.  The  patienthas  fever,  he  loses  flesh  and 
strength,  and  the  face  is  pinched  ;  and  when 
large  collections  take  place  around  the  joint, 
hectic  too  frequently  sets  in. 

Different  surgeons  have  admitted  different 
stages  in  the  progress  of  the  disease  ;  one 
describes  a  period  of  inflammation,  and  one 
of  suppuration.  Another  distinguishes  a 
period  during  which  the  head  of  the  bone  re¬ 
mains  within  the  acetabulum  ;  another,  when 
it  has  left  it  ;  but  as  displacement  is  not  a 
necessary  stage  in  the  development  of  hip 
disease, — that  distinction  cannot  be  regarded 
as  good.  Though  it  may  be  apparently  less 
precise,  it  seems  to  be  more  natural  to  in¬ 
clude,  within  the  first  period,  the  mischief 
which  happens  up  to  the  destruction  of  the 
apparatus  of  the  cavity.  The  second,  what 
occurs  from  that  period  to  the  termination 
of  the  disease,  it  may  be  in  displacement,  it 
may  be  in  ankylosis,  it  may  be  in  death. 

In  most  cases  hip  disease  supervenes  spon¬ 
taneously,  and  the  symptoms  are  obscure, 
and  not  well  marked,  but  much  depends  on 
the  state  of  health  of  the  patient.  If  it  be 
spontaneously  developed  in  a  person  in 


mr.  Phillips’s  clinical  remarks  on  hip  disease 


13 


vigorous  health,  the  symptoms  maybe  severe 
and  unmistakeable,  but  usually  it  is  in  feeble 
persons  that  this  disease  is  observed,  and  in 
them  the  obscurity  of  the  symptoms  is  some¬ 
times  very  remarkable. 

In  some  cases  disease  seems  to  be  in¬ 
duced  by  injury,  and  then  the  symptoms  are 
often  acute  and  evident.  For  a  time  the 
pain  is  rather  wandering  than  fixed,  but 
before  long  it  begins  to  attract  attention  to 
the  joint  or  the  groin.  The  patient  can  often 
bear  pressure  at  this  time  without  wincing, 
and  sometimes  even  jolting  motion  ;  but, 
although  he  is  not  inconvenienced  at  the  hip, 
be  will  sometimes  complain  of  the  knee,  or 
the  ankles,  or  the  heel.  If  at  this  period 
there  be  any  change  apparent  in  the  limb, 
it  will  be  probably  only  a  certain  rigidity  ; — 
there  may  be  limping  ; — there  may  be  a 
change  in  form  or  direction.  There  is  usually 
some  amount  of  flexion,  with  abduction  or 
rotation  outwards,  and  apparent  lengthening. 
These  early  symptoms  are  rarely  accom¬ 
panied  by  any  trouble,  unless  indeed  there  be 
feeble  general  health  independently  of  the 
local  disease  ;  but  it  now  and  then  hap¬ 
pens  that  febrile  action  is  set  up  early. 
Brodie  thinks  that  the  occurrence  of  febrile 
symptoms  depends  entirely  upon  the  part 
first  affected.  That  when  the  synovial 
membrane  is  affected,  the  pain  is  less  intense 
at  first  than  subsequently  ;  —  that  it  never 
acquires  that  intensity  which  it  acquires  in 
the  case  where  the  bone  bcomes  affected  ; — 
that  the  pain  is  increased  by  motion,  but  not 
by  pressure  of  the  surfaces  aganst  each 
other  ;  and  that  the  weight  of  the  body  can 
be  often  supported  without  inconvenience,  on 
the  diseased  limb. 

When  the  bone  is  first  affected,  the  pain 
is  usually  slight  and  passing  :  later  it  becomes 
fixed  and  constant.  It  may  be  seated  at  a 
particular  point,  or  extended  to  different 
points  of  the  limb ;  further  on  it  becomes 
intense,  especially  at  night;  and  the  patient 
can  only  get  relief  in  some  particular  posi¬ 
tion,  and  screams  when  he  is  removed  from 
it.  In  many  cases  the  pain  is  more  intense 
at  the  knee  than  the  hip.  It  is  usually  most 
aggravated  when  the  diseased  surfaces  are 
pressed  against  each  other.  The  disease 
does  not  last  long  before  the  form  of  the 
buttock  changes  ;  it  loses  its  convexity,  it  be¬ 
comes  flattened  and  flabby.  When  the 
synovial  apparatus  is  first  implicated,  there 
is  often  swelling  in  the  groin,  as  well  as  the 
nates,  but  both  points  become  flattened  after 
a  time, 

You  have  seen  how  very  variable  is  the 
progress  of  this  disease  ;  it  may  end  in  death 
in  a  few  months  ;  it  may  continue  for  years  ; 
or  all  trouble  may  abate,  almost  disappear, 
and  be  again  suddenly  aggravated  without  ap¬ 
parent  cause.  It  may  terminate  in  cure, 
though  we  often  look  for  this  in  vain  ;  it  may, 


j  as  in  two  cases  now  in  this  hospital,  end  in 
luxation  ;  it  may,  as  in  the  specimen  before 
you,  end  in  anchylosis,  or  it  may  proceed 
further. 

It  is  laid  down  in  books  that  during  the 
first  period  of  the  disease  the  termination  in 
resolution  is  the  most  frequent ; — that 
gradually  the  lengthening  and  the  pain  dis¬ 
appear ;  the  pelvis  resuming  its  proper  posi¬ 
tion,  and  motion  becoming  unembarrassed. 
My  own  experience  is  in  melancholy  opposi¬ 
tion  to  that  conclusion.  Of  course  during 
that  period  any  displacement  of  the  head  of 
the  bone  is  very  uncommon,  though  not 
without  example.  In  most  cases,  however, 
probably  from  want  of  proper  care,  the 
disease  passes  on  to  the  next  period.  Then 
the  form  of  the  limb  becomes  changed — dur¬ 
ing  the  first  period  it  was  flexed,  abducted, 
rotated  outwards  ;  the  iliac  spine  of  the  dis¬ 
eased  side  somewhat  in  advance  of  the 
healthy  one  ;  the  limb  is  apparently  length¬ 
ened,  and  the  patient  for  the  most  part  con¬ 
tent  to  lie  on  the  unsound  side.  In  the  next 
period  these  features  are  changed  ;  the  thigh 
is  more  flexed,  abducted,  rotated  inwards; 
the  iliac  spine  is  less  advanced  than  that  of 
the  healthy  side,  and  the  patient  lies  on  the 
sound  side.  There  may  during  these  two 
periods  be  a  real  change  of  length,  brought 
about  by  an  accumulation  or  escape  of  fluid 
from  the  cavity.  There  may  come  abscesses 
around  the  joint,  varying  in  form,  in  volume, 
and  in  direction,  sometimes  passing  through 
pelvic  openings,  occasionally  penetrating  into 
hollow  organs,  more  commonly,  however, 
pointing  in  the  thigh.  In  some  cases  their 
progress  being  very  slow,  the  constitution 
gradually  breaking  down ;  in  others  most 
rapid. 

Death  is  a  very  common  termination  of 
hip  disease;  it  is  commonly  brought  about 
through  the  agency  of  extensive  abscesses 
and  profuse  and  continued  discharges,  which 
end  in  hectic  fever,  and  its  consequences. 

After  the  early  stages,  complete  cure, 
though  possible,  is  an  unfrequent  ter¬ 
mination  of  the  disease,  but  it  may  oc¬ 
cur  even  when  the  disease  has  arrived  at 
an  advanced  stage.  The  preservation  of 
life  at  the  expense  of  anchylosis  or  dislocation, 
is  by  no  means  uncommon.  When  it  occurs, 
however,  the  process  is  a  very  tedious  one. 

Where  there  is  dislocation  it  may  present 
every  variety  ; — the  head  of  the  bone  may  be 
within  the  pelvis,  having  passed  through  the 
acetabulum  ;  it  may  be  on  the  dorsum  of  the 
ilium  ;  the  thyroid  foramen  ;  upon  the  pubis, 
in  the  sciatic  notch  :  most  frequently,  how¬ 
ever,  it  is  found  in  the  dorsum  of  the  ilium, 
covered  by  the  glutaeus  medius,  and  minimus 
muscle.  In  some  cases  it  hollows  out  for 
itself  a  cavity  upon  the  part  where  it  rests, 
and  the  acetabulum  may  become  more  or 
less  completely  filled  up. 


14 


mr.  Phillips’s  clinical  remarks  on  hip  disease. 


As  we  have  already  seen,  there  is  no  uni¬ 
formity  in  the  method  by  which  the  head  of 
the  bone  is  displaced  :  in  some  cases  it  is 
owing  .to  an  accumulation  of  fluid  within  the 
acetabulum,  as  was  laid  down  as  a  general 
rule  by  Petit ;  in  some  instances  to  the  tume¬ 
faction  of  the  soft  parts  within  the  joint,  as 
was  laid  down  by  Boyer ;  in  others,  it  is 
owing  to  bony  or  other  products  developed 
there ;  in  others,  as  maintained  by  Rust,  it 
is  owing  to  disease  set  up  in  the  head  of  the 
femur.  In  either  case,  certain  circumstances 
are  necessary  ;  the  collection,  whether  fluid 
or  solid,  must  be  enough  to  push  the  head 
of  the  bone  out,  and  the  cotyloid  cavity 
must  be  entire ;  and  if  carious  action  has 
broken  down  the  edges,  the  displacement  is 
further  facilitated.  It  is,  however,  rai’ely 
accomplished  until  that  period  when  the 
limb  is  flexed,  adducted,  and  rotated  in¬ 
wards,  by  which  means  the  head  of  the  bone 
is  removed  from  the  fundus  of  the  cavity ;  if 
the  posterior  border  be  at  that  time  destroyed, 
the  displacement  is  of  course  facilitated. 
When  these  luxations  happen,  they  are  com¬ 
monly  well  marked ;  but  the  signs  are  not 
always  like  the  appearances  presented  in 
ordinary  luxations.  For  instance,  in  luxa¬ 
tion  upon  the  dorsum  of  the  ilium,  it  does 
not  always  happen  that  the  foot  is  inverted  ; 
but  it  may  be  everted,  as  in  fracture  of  the 
neck  of  the  femur. 

You  have  often  witnessed  the  difficulty  of 
diagnosis  at  an  early  period  of  hip  disease. 
Only  a  few  days  ago,  you  saw  how  obscure 
were  the  symptoms  in  a  case  in  Sanctuary 
ward  ;  but  that  is  a  circumstance  which 
attaches  to  an  early  period  of  many  diseases. 
You  have  seen  that,  among  the  early  symp¬ 
toms,  the  most  constant  are  pains  of  uncer¬ 
tain  seat,  and  often  wandering,  appearing 
one  day  at  the  hip,  another  at  the  groin, 
another  at  the  knee,  another  at  the  ankle. 
How  difficult  is  it,  in  many  of  these  cases, 
to  distinguish  them  from  rheumatism  !  At 
last  you  remain  in  doubt ;  but  if  your  sus¬ 
picions  are  excited,  you  direct  your  means 
to  the  hip.  Again,  the  knee  pain,  though 
characteristic,  is  by  no  means  to  be  relied 
on  ;  it  may  be  developed,  as  a  sympathetic 
pain,  in  other  cases  than  hip  disease  ;  we 
had  lately  a  case  where  it  was  a  marked 
symptom,  although  the  disease  under  which 
the  patient  laboured  was  psoas  abscess ; 
there  was  no  hip  trouble.  Again,  pain  along 
the  course  of  the  sciatic  nerve  is  by  no 
means  an  uncommon  cause  of  error,  pro¬ 
ducing,  as  it  does,  often  lameness  and  de¬ 
pression  of  the  pelvis. 

But  perhaps  there  is  nothing  more  difficult 
in  young  women,  in  cases  of  obscure  hip 
disease,  than  to  say  whether  the  pain  be 
hysterical,  or  owing  to  structural  disease  ; 
and  it  is  only  by  a  careful  consideration  of 
the  history  of  the  case,  and  the  general  con¬ 


dition  of  the  patient,  that  we  can  hope  to 
come  to  a  satisfactory  conclusion.  There  may 
be  pain  in  the  hip  and  the  knee, — it  may  be 
increased  by  motion  or  pressure ;  but  in 
most  cases  the  pain  has  no  fixed  seat  or  cha¬ 
racter  ;  and  in  many  instances,  on  pressure 
or  motion,  the  pain  complained  of  is  much 
more  severe  than  the  other  symptoms  would 
lead  one  to  expect ;  and  the  expression  of 
pain  can  frequently  be  elicited,  by  pressure 
made  at  a  point  where  no  influence  could  be 
exercised  on  the  hip-joint.  In  these  cases 
there  is  usually  no  emaciation, — no  sign  in 
the  face  of  articular  disease, — no  starting, 
or  pain  at  night, — no  sudden  waking  when 
once  asleep,  as  is  so  frequent  in  advanced 
disease  of  the  hip.  And  this  state  may  go 
on  for  months  or  years,  without  any  more 
decided  evidence  of  mischief  at  the  joint 
itself.  Sometimes  there  is  puffiness,  which 
may  cause  a  suspicion  of  abscess  ;  there 
may  even  be  a  notion  of  fluctuation  ;  a  tro¬ 
car  may  even  be  passed,  but  no  fluid  follows. 
There  may  be  deformity  of  the  spine  and 
tilting  of  the  pelvis,  which  may  give  an  ap¬ 
pearance  of  shortening,  so  as  to  induce  a 
suspicion  of  dislocation  ;  for  the  heel  may 
be  raised  from  the  ground,  but  still  the 
symptoms  are  illusory.  When  the  knee  is 
complained  of,  the  same  observations  will 
apply ;  there  are  the  same  pain,  the  same 
excessive  sensibility  upon  pressure  ;  while  it 
may  be  that  the  patient  can  support  herself 
on  that  limb  without  suffering.  Besides 
this,  it  will  happen  that  the  habitual  position 
of  the  limb  is  one  of  extension,  while  the 
ordinary  position  in  organic  disease  is  that 
of  flexion  ;  but,  again  I  repeat,  after  months 
of  suffering  in  the  hysterical  form  of  the 
disease,  there  will  be  a  total  absence  of  the 
ordinary  signs  of  organic  disease  at  the  part ; 
but  still  it  is  by  no  means  uncommon  for 
such  cases  to  be  locally  treated  by  blisters, 
issues,  cupping,  &c. ;  and  sometimes  with 
benefit.  In  most  of  these  cases  the  age  of 
the  patient  does  not  much  exceed  twenty ; 
the  general  appearance  is  fresh  coloured,  and 
the  circulation  languid  ;  but  in  many  of  these 
cases  the  general  features  of  hysteria  are 
sufficiently  marked.  The  local  symptoms 
often  follow  closely  upon  some  other  disease 
by  which  debility  has  been  induced  ;  or  they 
may  succeed  to  some  moral  shock  given  to 
the  system.  The  trembling  spasmodic  ac¬ 
tion  so  commonly  observed  when  caries 
exists  in  the  articular  surfaces,  is  rarely  pre¬ 
sent  in  the  condition  we  are  considering. 

When  all  pain  has  left  the  joint,  a  state  of 
feebleness  remains,  which  is  entirely  opposed 
to  the  use  of  such  exercise  as  then  becomes 
essential  for  the  cure. 

Affections  of  the  lower  part  of  the  spine, 
more  particularly  caries,  may,  as  you  see 
in  the  case  of  Maria  Bailey,  give  rise  to 
many  of  the  signs  of  hip  disease. 


SIMPLE  DIARRHCEA.  INFLAMMATORY  DIARRHCE A. 


15 


I  doubt  whether  the  symptoms  by  which 
Sir  B.  Brodie  has  sought  to  distinguish 
between  disease  affecting  the  several  struc¬ 
tures  entering  into  the  composition  of  the 
joint,  are  always  to  be  relied  on.  I  have 
known  the  uniform  swelling  of  the  hip,  and 
the  moderate  pain,  absent  in  synovial  inflam¬ 
mation  ;  I  have  known  the  agonizing  pain 
during  motion  wanting  where  there  was 
great  alteration  in  the  articular  surfaces.  I 
have  known  the  flattened  buttock  to  be  ab¬ 
sent  where  the  cartilages  were  ulcerated. 

Anchylosis  is  a  termination  of  hip  disease, 
which  we  occasionally  see,  though  not  fre¬ 
quently  ;  the  disease,  wrhen  it  arrives  at  the 
period  when  anchylosis  may  occuy,  often 
terminates  in  death.'  You  must  take  care 
to  avoid  mistake  when  examining  a  stiffened 
limb,  for  a  kind  of  tetanic  spasm  sometimes 
occurs,  which  leads  to  an  impression  that 
anchylosis  exists.  The  case  of  a  young  man 
in  Mark  ward  was  a  good  example  of  that 
state.  A  patient  at  present  under  Dr.  Roe’s 
treatment  is  a  good  example  of  false  anchy¬ 
losis.  The  specimens  on  the  table  are 
examples  of  the  complete  development  of 
that  state. 


LECTURES 

ON  THE 

DISEASES  OF  INFANCY  AND 
CHILDHOOD, 

Delivered  at  the  Middlesex  Hospital. 

By  Charles  West,  M.D. 

Physician-Accoucheur  to,  and  Lecturer  on  Mid¬ 
wifery  at,  the  Middlesex  Hospital,  and  Senior 
Physician  to  the  Royal  Infirmary  for  Children. 

Lecture  XXXIII. 

Diarrhoea — its  two  forms,  the  simple  and 
inflammatory — causes  of  the  affection — 
influence  of  age — of  process  of  dentition 
— of  temperature,  and  season  of  the  year. 

Sijmptoms  of  simple  diarrhoea — not  usually 
a  dangerous  affection — occasional  hazard 
from  great  exhaustion  that  it  produces — 
occasional  cessation  of  purging  indepen¬ 
dent  of  real  amendment  —  danger  of  se¬ 
condary  diarrhoea. 

Inflammatory  diarrhoea — occasional  want 
of  correspondence  between  the  symptoms 
and  morbid  appearances — chief  morbid 
appearances  in  large  intestine.  Close 
similarity  between  these  and  changes  in 
other  parts  to  those  in  dysentery  of  the 
adult. 

Symptoms — occasional  disturbance  of  ner¬ 
vous  system  at  the  outset — progress  of 
the  disease — its  tendency  to  a  chronic 
course.  Life  sometimes  cut  short  by  in¬ 
tercurrent  bronchitis — by  head  symptoms 
— by  relapse  after  temporary  amendment. 

In  a  systematic  course  of  lectures  like  the  pre¬ 
sent,  subjects  of  very  various  interest  and  im¬ 


portance  come  successively  before  us.  We 
were  engaged  yesterday  in  the  study  of  some 
affections  which  fortunately,are  of  very  rare 
occurrence;  butto-day  wepass  totheexamina- 
tion  of  one  of  the  most  common,  and  at  the 
same  time  one  of  the  most  serious,  disorders 
of  infancy  and  childhood.  The  importance  of 
diarrhoea  in  early  life,  indeed,  is  not  to  be 
estimated  merely  by  the  number  of  deaths 
which  our  tables  of  mortality  represent  it  to 
have  occasioned  ;  for  the  figures  th$t  they 
display  would  warrant  our  dismissing  it  with 
a  comparatively  short  notice.*  But  we  shall 
come  to  a  very  different  conclusion,  if  we 
consider  the  frequency  of  the  affection,  and 
the  slight  causes  which  often  suffice  to  in¬ 
duce  it  ;  the  dangers  to  health  which  result 
from  its  long  continuance ;  and  the  greatly 
increased  hazard  to  which  its  supervention 
in  the  course  of  some  other  disease  exposes 
the  patient. 

Under  the  common  name  of  diarrhoea, 
many  of  the  older  writers  on  the  diseases  of 
children  have  included  all  cases,  without  dis¬ 
tinction,  in  which  there  is  an  unnatural 
increase  of  the  alvine  discharges ;  while 
some  among  the  moderns,  rejecting  the  word 
diarrhoea  from  their  medical  nomenclature, 
have  treated  only  of  certain  inflammatory 
affections  of  the  intestines  of  which  they 
believe  the  flux  to  be  symptomatic.  Neither 
of  these  arrangements,  however,  is  free  from 
objection  ;  for  while  the  former  draws  no 
adequate  distinction  between  cases  in  which 
the  disorder  of  the  functions  of  the  bowels 
is  the  result  of  some  accidental  and  tempo¬ 
rary  cause,  and  others  in  which  it  is  the  con¬ 
sequence  of  organic  disease,  the  latter  in¬ 
volves  an  attempt  to  distinguish,  on  purely 
anatomical  grounds,  between  affections 
which  present  the  same  symptoms  and  re¬ 
quire  the  same  treatment. 

In  the  present  state  of  our  knowledge  it 
will  perhaps  be  the  safer  way  to  attempt  no 
further  subdivision  than  into  the  two  grand 
classes  of  simple  diarrhoea,  or  catarrhal 
diarrhoea,  as  it  has  been  termed  by  some 
writers,  and  inflammatory  diarrhoea  or 
dysentery.  Even  in  this  arrangement  it 
must  be  confessed  that  there  is  some¬ 
thing  arbitrary,  for  the  two  affections  are 
closely  allied  to  each  other.  In  the  child, 
as  in  the  adult,  they  often  prevail  at  the  same 
time, — they  are  to  a  considerable  degree  de¬ 
pendent  on  the  same  causes,  and  are  in  a 
measure  amenable  to  the  same  remedies ; 
while  the  milder  complaint  not  infrequently 


*  According  to  the  Fifth  Report  of  the  Regis¬ 
trar  General,  the  deaths  in  London  from  diar¬ 
rhoea,  dysentery,  and  cholera,  as  compared  with 
the  total  deaths  from  all  ascertained  causes,  were, 
in  children  under  one  year  old,  in  the  proportion 
of  3-9  per  cent. ;  between  one  and  three,  2  3  per 
cent. ;  from  three  to  five,  ‘6  per  cent. ;  from  five 
to  ten,  l’l  percent ;  and  from  ten  to  fifteen,  1‘  per 
cent. 


16 


DIARRHCEA — GREATEST  PREVALENCE  DURING  DENTITION. 


passes  into  the  more  severe.  Before  we 
proceed,  therefore,  to  the  study  of  the 
special  characters  of  either  affection,  it  may 
be  well  to  examine  into  some  of  those  con¬ 
ditions  which  arealike  favourable  to  the  pro¬ 
duction  of  both. 


You  will  observe  that  the  period  of  the 
greatest  prevalence  of  diarrhoea  coincides  ex¬ 
actly  with  that  time  during  which  the  pro¬ 
cess  of  dentition  is  going  on  most  actively, 
and  that  more  than  half  of  all  cases  of  diar¬ 
rhoea  occurred  in  children  between  the  ages 
of  six  months  and  two  years.  So  close,  in¬ 
deed,  is  the  connection  between  teething 
and  diarrhoea,  that  a  French  physician,  M. 
Bouchut,*  found  that  only  2G  out  of  110 
children  entirely  escaped  its  attack  during 
the  period  of  their  first  dentition,  while  46 
suffered  from  it  very  severely.  The  older 
writers  on  medicine,  whose  notice  this  fact 
did  not  escape,  attributed  the  disturbance  of 
the  bowels  to  a  sort  of  sympathy  between 
the  intestinal  canal  and  the  gums,  swollen 
and  irritated  by  the  approach  of  the  teeth  to 
their  surface.  The  frequent  observation  of 
cases  in  which  an  attack  of  diarrhoea  attends 
the  irruption  of  each  fresh  tooth,  and  ceases 
when  it  has  cut  through  the  gum,  shows 
that  such  a  hypothesis  is  not  altogether  with¬ 
out  foundation.  But  besides  the  influence 
of  nervous  irritation  in  quickening  for  a  time 
the  peristaltic  action  of  the  bowels,  and  thus 
inducing  diarrhoea  it  must  be  borne  in  mind 
that  there  exists  during  the  period  of  teeth¬ 
ing  a  more  abiding  cause,  which  strongly 
predisposes  to  its  occurrence.  All  parts  of  the 
digestive  canal,  and  of  its  dependencies,  are 
now  undergoing  an  active  evolution  to  fit 
them  for  the  proper  assimilation  of  the  varied 
food  on  which  the  young  being  will  soon  have 
to  subsist.  Just  as  the  salivary  glands  are 
now  developed,  and  pour  out  saliva  in  abun¬ 
dance,  so  the  whole  glandular  system  of  the 
intestines  presents  a  rapidity  of  growth,  and 
an  activity  of  function,  which,  under  the  in¬ 
fluence  of  comparatively  slight  exciting 
causes,  may  pass  the  just  limits  of  health. 


*  Manuel  Pratique  des  maladies  desNouveaux- 
N£s.  12rao,  Paris,  1845,  p.  196. 


The  following  table,  deduced  from  1344 
cases  of  diarrhoea  or  dysentery  that  came 
under  my  notice  at  the  Children’s  Infirmary, 
shows  that  the  age  of  the  child  has  much  to 
do  with  the  occurrence  of  the  affection. : — 


In  too  many  instances,  causes  fully  adequate 
to  excite  diarrhoea  are  abundantly  supplied 
in  the  excessive  quantity,  or  unsuitable 
quality,  of  the  food  with  which  the  infant  is 
furnished;  for  it  is  forgotten  that  its  con¬ 
dition  is  one  of  transition,  in  which  some¬ 
thing  more  than  ordinary  care  is  needed, 
while,  in  accordance  with  that  mistaken 
humoral  pathology,  so  popular  among  the 
vulgar,  the  profuse  secretion  from  the  irri¬ 
tated  glands  is  regarded  as  the  result  of  a 
kind  of  safety-valve  arrangement  whereby 
nature  seeks  to  moderate  the  constitutional 
excitement  attendant  upon  teething. 

Besides  those  causes  seated  within  the 
organism  of  the  child  which  predispose  it  to 
diarrhoea,  and  those  occasions  furnished 
from  without  by  the  food  with  which  it  is 
supplied,  atmospheric  influences  constitute 
a  third,  and  a  very  important  class  of  causes, 
which  at  one  time  render  diarrhoea  very  fre¬ 
quent,  and  at  another  greatly  check  its  pre¬ 
valence. 

On  a  comparison  of  the  results  of  five  years 
observation  at  the  Children’s  Infirmary,  I 
find  that 

In  the  three  months,  November,  Decem¬ 
ber,  and  January,  diarrhoea  formed  7'2  per 
cent,  of  all  cases  of  disease. 

In  the  three  months,  February,  March, 
and  April,  83  per  cent. 

In  the  three  months,  May,  June,  and 
July,  13’0  per  cent. 

In  the  three  months,  August,  September, 
and  October,  24*4  per  cent. 

The  above  mentioned  causes  dispose  alike 
to  diarrhoea  and  dysentery  ;  but  among  the 
dwellings  of  the  poor  in  the  metropolis,  and 
especially  in  that  district  of  it  where  most  of 
my  observations  have  been  made,  conditions 
abound  which  often  stamp  on  the  disease  the 
characters  of  the  more  serious  malady. 
Before  investigating  them,  however,  we  may 
first  study  the  symptoms  of  that  milder  affec- 


Cases  of  diarrhoea  in  children  a* 
the  following  ages  : — 

Were  to  all  cases  of  diarrhoea  in 
children  under  15,  in  the  pro¬ 
portion  of 

Were  to  all  other  diseases  at  the 
same  age,  in  the  proportion  of 

Undhr  6 

months. 

.  .  7-8 

per  cent.  . 

•  o 

126  per  cent. 

Between  6  and  12 

9  9 

.  .  16-6 

99  •  • 

•  9 

17-5  „ 

„  12  „  18 

9  f 

.  .  21-6 

99  •  • 

•  • 

23-2  „ 

„  18  „  2 

years. 

.  .  15-0 

9  9  •  o 

•  • 

23-7  „ 

,,  2  yrs.  3 

9  9 

.  .  12-0 

99  •  • 

•  • 

13-9  „ 

„  3  „  5 

99 

.  .  11-5 

99  • 

•  O 

8*6  „ 

,,  5  ,,  10 

99 

.  .  11-2 

99  •  • 

•  • 

•  7-0  „ 

„  10  „  15 

99 

.  .  4-8 

9  9  • 

•  • 

7-6  „ 

SYMPTOMS  OF  SIMPLE  DIARRHOSA. 


17 


tion,  which,  though  much  the  more  frequent, 
yet,  if  uncomplicated,  is  seldom  or  never 
fatal. 

When  the  attack  comes  on  in  perfectly 
healthy  children,  it  often  sets  in  quite  sud¬ 
denly,  with  vomiting  of  the  contents  of  the 
stomach,  and  afterwards  of  mucus,  which 
sometimes  has  a  yellow  or  greenish  colour. 
The  sickness  does  not  in  general  continue, 
though  exceptions  are  met  with  in  some  of 
the  more  severe  cases,  in  which  the  stomach 
remains  very  irritable  during  the  whole  pe¬ 
riod  that  the  affection  lasts.  In  either  case 
the  vomiting  is  almost  immediately  suc¬ 
ceeded  by  increased  action  of  the  bowels, 
the  matters  discharged  being  at  first  the 
healthy  faeces ;  but  they'  soon  assume  a 
bright  yellow  colour,  like  that  of  the  yolk  of 
egg,  and  are  often  intermix jd  with  slime,  or 
in  other  cases  present  a  frothy  appearance. 
The  bright  yellow  colour  of  the  evacuations 
often,  though  by  no  means  always,  changes 
to  green  under  exposure  to  the  air ;  while, 
if  the  diarrhoea  should  continue,  the  faeces 
when  voided  in  many  instances  present  a 
green  colour,  similar  to  that  which  is  fre¬ 
quently  produced  by  the  administration  of 
mercury.  In  other  cases  the  green  and 
yellow  colours  appear  intermixed  in  the 
evacuations,  while  the  presence  in  them  of 
numerous  white  specks,  the  caseum  of  the 
undigested  milk,  shows  that  the  function  of 
the  stomach  is  interfered  with  by  the  same 
cause  as  produces  the  over-action  of  the 
bowels.  The  source  of  the  green  colour  of 
the  evacuations  has  not  yet  been  quite  satis¬ 
factorily  determined.  In  some  cases  it  pro¬ 
bably  depends  on  the  action  of  the  acids  of 
the  alimentary  canal  upon  the  colouring 
matter  of  the  bile  ;  but  Dr.  Golding  Bird’s 
investigations  have  proved  it  not  to  be 
always  due  to  this  cause,  and  have  shown 
that,  in  many  instances,  it  results  from  the 
presence  of  altered  blood  in  the  evacuations. 
As  the  child  returns  to  health  the  faeces  be¬ 
come  less  watery ;  they  then  resume  their 
yellow  colour ;  or  stools  of  a  natural  cha¬ 
racter  alternate  with  others  of  a  green  colour 
and  unhealthy  aspect,  or  in  which  a  very 
large  quantity  of  mucus  is  present.  The 
action  of  the  bowels,  too,  becomes  less  fre¬ 
quent,  and  the  child  often  regains  its  usual 
health  in  four  or  five  days,  though  sometimes 
a  disposition  to  diarrhoea  is  left  behind,  and 
the  disorder  is  liable  to  be  re-excited  by  very 
slight  causes. 

In  the  majority  of  cases  this  over-action 
of  the  bowels  is  not  attended  with  much 
fever  or  constitutional  disturbance,  though, 
if  it  should  come  on  during  teething,  the 
general  feverishness  of  the  child  is  often 
somewhat  aggravated.  The  appetite  is 
usually  much  impaired,  while  the  thirst  is 
often  considerably  increased,-  and  the  child 
seems  very  desirous  of  cold  water.  The 


tmgue  is  moist,  in  general  thinly  coated 
with  mucus,  through  which  the  papillae  ap¬ 
pear  of  a  brighter  red  than  natural ;  but  the 
tongue  is  neither  very  red  nor  much  coated. 
The  abdomen  is  soft,  seldom  either  full  or 
painful ;  and  the  pain  which  attends  the 
diarrhoea  is  very  variable, — sometimes  it  is 
completely  absent,  the  stools  being  expelled 
without  either  effort  or  suffering ;  while  in 
other  cases  pain  comes  on  severely  at  in¬ 
tervals,  and  then  ceases  immediately,  so 
soon  as  the  bowels  have  acted.  Although 
there  is  seldom  much  tenesmus,  yet  a  si  ght 
degree  of  it  attend^  upon  simple  diarrhoea 
in  the  child  much  more  frequently  than  in 
the  adult.  There  is,  as  might  be  anticipated, 
a  loss  of  the  natural  look  of  health, — the  face 
grows  pale,  the  eyes  appear  sunken,  and  the 
child  becomes  fretful  and  languid, — while,  if 
the  attack  set  in  severely,  a  day  or  two  some¬ 
times  suffices  to  reduce  the  child  to  a  state  of 
extreme  weakness  and  exhaustion  ;  and  in 
young  infants  I  have  observed  all  the  symp¬ 
toms  of  spurious  hydrocephalus  make  their 
appearance. 

The  diarrhoea  that  occurs  in  connection 
with  the  irritation  occasioned  by  teething  is 
in  general  more  gradual  in  its  onset,  and 
slower  in  its  progress,  than  that  which 
depends  on  some  more  transient  source  of 
irritation.  It  is  likewise  often  associated 
with  catarrhal  symptoms  ;  and  both  the 
catarrh  and  diarrhoea  frequently  continue 
until  the  tooth,  having  pierced  the  gum,  the 
irritation  of  the  mucous  membranes  subsides, 
but  to  be  renewed  when  a  fresh  tooth 
approaches  the  surface. 

Although  the  dangers  attendant  on  simple 
diarrhoea,  especial  y  when  it  occurs  in  healthy 
children,  are  not  considerable,  yet  the  affec¬ 
tion  is  one  which  it  is  never  wise  to  make 
light  of.  On  more  than  one  occasion  I  have 
seen  an  infant  reduced  by  it  to  a  state  of 
such  extreme  exhaustion  as  seriously  to 
endanger  life.  Diarrhoea,  indeed,  is  the 
exciting  cause  of  the  greater  number  of  cases 
of  that  spurious  hydrocephalus,  described  in 
Lecture  X.,*  in  which  cerebral  disturbance 
from  debility  simulates  real  inflammatory 
disease  of  the  brain.  Under  such  cir¬ 
cumstances,  too,  the  diarrhoea  has  not  infre¬ 
quently  ceased  for  some  time  before  the  other 
more  alarming  symptoms  made  their  appear¬ 
ance.  The  cessation  of  diarrhoea  may  be 
due,  not  so  much  to  the  quieting  of  irrita¬ 
tion,  as  to  the  exhaustion  of  that  nervous 
energy  which  is  essential  to  the  performance 
of  their  secretory  function  by  the  glands  of 
the  intestines,  or  to  the  due  maintenance  of 
the  peristaltic  movements  of  the  bowels.  In. 
infants  prematurely  weaned,  or  improperly 
fed  after  being  taken  from  the  breast,  we 
often  see  this  exemplified  in  the  cessation, 


*  See  the  Gazette  for  September  10,  1848. 


18 


INFLAMMATORY  DIARRHOEA - MORBID  APPEARANCES 


some  twelve  or  twenty. four  hours  before 
death,  of  the  diarrhoea  from  which  they 
have  been  suffering  for  weeks  together.  Nor 
must  we  ever  make  too  sure  that,  because 
purging  has  ceased,  therefore  danger  is  over; 
or  venture  to  relax  our  watchful  care  until 
the  continuance  of  amendment,  for  twenty, 
four  hours  or  more,  shews  that  there  is  indeed 
no  longer  anything  to  fear. 

This,  however,  is  not  the  only  danger  to 
which  previously  healthy  children  are  exposed 
by  an  attack  of  simple  diarrhoea;  for  if  not 
quickly  checked,  it  sometimes  assumes  the 
more  serious  characters  of  dysentery,  and 
occasions  severe  and  long- continued  suffer¬ 
ing.  When  diarrhoea  supervenes  in  children 
who  are  recovering  from  some  disease,  such 
as  measles,  in  which  a  tendency  to  relaxation 
of  the  bowels  often  marks  the  period  of  con¬ 
valescence,  or  who  have  been  suffering  from 
some  protracted  ailment,  such  as  hooping- 
cough,  it  sometimes  occasions  the  patient’s 
death,  although  it  may  leave  behind  in  the 
intestinal  canal  no  traces  of  serious  mischief. 
Still  more  frequently  is  this  the  case  with 
infants  who  have  been  brought  up  by  hand, 
or  who  have  thriven  badly  at  the  breast.  A 
troublesome  purging,  continuing  for  weeks 
together,  exhausts  the  strength  of  such 
infants,  and  at  length  occasions  their  death  ; 
but  yet  the  intestinal  canal  in  many  in¬ 
stances  presents  no  trace  of  more  serious 
mischief  than  an  unusual  degree  of  distinct¬ 
ness  of  the  follicles  of  the  small  intestines, 
and  of  the  solitary  glands  of  the  colon  and 
rectum. 

In  proposing,  at  the  commencement  of 
this  lecture,  to  distinguish  between  simple 
and  inflammatory  diarrhoea,  I  yet  was  forced 
to  acknowledge  that  the  distinction  was 
one  rather  of  degree  than  of  kind  ;  or  perhaps 
it  would  be  more  correct  to  say  that  our  ob¬ 
servation  has  not  hitherto  been  minute 
enough  to  enable  us  to  draw  the  line  of 
demarcation  strictly  between  the  two  affec¬ 
tions.  Even  MM.  Rilliet  and  Barthez*, 
whose  opportunities  have  been  so  extensive, 
and  whose  industry  is  so  untiring,  confess 
their  inability  to  refer  the  symptoms  that 
attend  upon  the  different  varieties  of  diar¬ 
rhoea  to  any  distinct  and  invariable  anatomi¬ 
cal  lesions.  They  remark,  that  not  merely 
are  exceedingly  different  appearances  dis¬ 
covered  after  death  in  cases  where  the  same 
symptoms  have  been  observed  during  life, 
but  that  likewise  there  is  often  no  proportion 
between  the  intensity  of  the  two  ;  and  that 
sometimes  no  morbid  appearances  are  found, 
even  where  well-marked  symptoms  had  ex¬ 
isted.  Usually,  indeed,  the  symptoms  in 
such  cases  are  but  slight ;  but  sometimes 
they  are  severe, — the  diarrhoea  is  intense, 
the  pain  considerable,  the  abdomen  tense 


and  tympanitic.  They  state,  that  out  of  127 
children  who  died  of  different  diseases,  84 
had  presented  the  symptoms  of  inflammatory 
diarrhoea,  or  entero-colitis,  and  the  charac¬ 
teristic  appearances  of  that  affection  were 
manifest  on  an  examination  of  the  intestines 
after  death  :  in  24,  though  no  symptoms  had 
existed  during  life,  similar  changes  were  dis¬ 
covered  ;  while  in  19,  the  signs  of  disease 
were  present  during  life,  but  its  morbid  ap¬ 
pearances  were  absent.  It  is  true  that  these 
observations  refer  to  children  above  two  years 
of  age,  and  to  cases  in  which  the  diarrhoea 
had  occurred  as  a  secondary  affection  ;  but 
my  own  observation  would  lead  me  to  believe 
that  a  similar  statement  might  be  made  with 
reference  to  younger  children,  and  to  cases 
of  idiopathic  diarrhoea. 

These  circumstances  prevent  our  deducing 
from  the  results  of  anatomical  investigation 
those  practical  conclusions  which  we  should 
otherwise  be  inclined  to  draw  from  them  ; 
but  they  do  not  warrant  us  in  altogether 
omitting  to  inquire  what  changes  we  shall  be 
most  likely  to  meet  with  in  cases  of  fatal 
diarrhoea. 

These  changes  will  be  found  chiefly, 
though  not  exclusively,  in  the  large  intes¬ 
tine  ;  and  though  usually  much  less  serious 
than  those  which  are  observed  in  cases  of 
fatal  dysentery  in  the  adult,  they  yet  present 
very  similar  characters.  In  those  cases  in 
which  the  structural  alterations  have  been 
least  considerable,  the  attention  is  arrested 
less  by  any  great  increase  of  vascularity  in 
the  intestine,  than  by  the  remarkable  dis¬ 
tinctness  of  the  orifices  of  the  solitary  glands, 
which  appear  like  almost  innumerable  dark 
spots  upon  the  surface  of  the  mucous  mem¬ 
brane.  In  many  cases,  and  especially  in 
those  in  which  the  diarrhoea  was  profuse  at 
the  time  of  the  patient’s  death,  not  merely 
are  the  openings  of  these  follicles  unusually 
distinct,  but  the  glands  themselves  are  en¬ 
larged,  and  project  like  small  millet  seeds, 
or  small  pins’-heads,  beyond  the  level  of  the 
surrounding  tissue.  This  enlargement  of 
the  solitary  glands  is  usually  associated  with 
increased  vascularity  of  the  mucous  mem¬ 
brane,  which  does  not,  however,  assume  the 
characters  of  a  general  erythematous  redness, 
but  is  confined  to  that  part  of  the  membrane 
which  covers  each  gland,  or  which  surrounds 
its  base.  If  the  disease  advance  further, 
ulceration  succeeds  to  this  inflammation  of 
the  glands.  A  small  circular,  or  slightly 
oval  spot,  appears  upon  their  summit,  and 
increases  in  size  and  depth  until  it  has  de¬ 
stroyed  the  glandular  structure  and  the 
mucous  membrane,  and  has  produced  a  deep 
cup-like  depression  or  ulceration,  the  base 
of  which  is  formed  by  the  muscular  coat  of 
the  intestine.  On  one  occasion,  I  observed 
in  the  midst  of  enlarged  and  ulcerated  glands 
some  others  equally  large,  but  on  which  the 


*  Op.  cit.  tome  i.  p.  509-12. 


INFLAMMATORY  DIARRHCEA — CHANGES  LIKE  THOSE  OF  DYSENTERY. 


excavated  ulcer  had  not  yet  formed,  their 
summit  presenting  a  small  round  or  o^al 
spot,  of  a  yellowish  colour — most  probably 
a  minute  slough  not  yet  detached  from  the 
surface.  Besides  that  loss  of  substance 
which  results  from  the  ulceration  or  sloughing 
of  the  glands  themselves,  a  process  of  thin¬ 
ning  and  destruction  likewise  affects  other 
parts  of  the  mucous  membrane,  especially  in 
those  situations  which  correspond  to  the 
edges  of  the  intestinal  rugae.  In  some  parts 
the  membrane  appears  to  be  merely  attenu¬ 
ated,  while  in  others  it  seems  to  have  entirely 
disappeared,  though  the  limits  of  its  de¬ 
struction  are  not  marked  by  the  same  well- 
defined  edges  as  circumscribe  the  ulcers  of 
the  glands ;  nor  is  the  loss  of  substance  so 
deep.  On  the  inner  surface  of  an  intestine 
thus  affected  may  be  seen  a  number  of  nar¬ 
row  white  lines,  enclosing  between  them 
islets  of  mucous  membrane,  and  often  having 
such  an  arrangement  as  to  give  to  those  por¬ 
tions  of  the  membrane  the  form  of  irregular 
parallelograms.  This  superficial  destruction 
of  the  mucous  coat  of  the  intestine  is  often 
much  more  complete  in  the  rectum,  and  in 
the  sigmoid  flexure  of  the  colon,  than  else¬ 
where  ;  and  when  this  is  the  case,  the  sur¬ 
face  of  the  bowel  presents  an  uniformly 
rough  appearance.  It  is  also  in  the  lower 
part  of  the  large  intestine  that  the  ulcera¬ 
tive  process  is  most  frequent  and  most  ex¬ 
tensive  ;  and  if  care  be  not  taken  to  examine 
the  last  few  inches  of  the  rectum,  we  may 
come  to  the  mistaken  conclusion  that  ulce¬ 
ration  was  altogether  absent,  in  cases  where 
more  careful  investigation  would  have  easily 
convinced  us  of  its  existence.  On  one  occa¬ 
sion,  I  found  the  disease  in  the  lower  part 
of  the  large  intestine  to  be  so  far  advanced, 
that  the  interior  of  the  sigmoid  flexure  of 
the  colon  and  of  the  rectum  presented  an 
irregular  tuberculated  surface,  of  an  ash- 
grey  colour,  w'hich  appeared  eaten  into  holes 
by  a  number  of  small  circular  pits  or  ulcers, 
with  sharply  cut  edges.  Besides  these 
changes  in  the  interior  of  the  large  intestine, 
a  thickening  of  its  submucous  coat  is  almost 
always  observable  whenever  the  diarrhoea  has 
continued  for  any  considerable  length  of 
time.  It  is  in  the  rectum  and  sigmoid 
flexure  of  the  colon  that  this  thickening  is 
most  perceptible  ;  and  in  this  situation  a 
gelatinous-looking  matter  is  sometimes  de¬ 
posited  in  such  abundance  beneath  the  mu¬ 
cous  membrane,  as  to  prevent  the  intestine 
from  becoming  collapsed  when  it  is  divided. 

But  it  is  not  merely  in  the  morbid  ap¬ 
pearances  presented  by  the  large  intestines, 
but  also  in  the  subsidiary  changes  observed 
in  other  parts  of  the  intestinal  canal ,  that 
the  close  relation  between  the  diarrhoea  of 
the  infant,  and  dysentery  in  the  adult,  is 
manifested.  The  changes  in  the  small  intes¬ 
tine  are  almost  always  confined  to  the  lower 


part  of  the  ileum,  and  become  more  striking 
the  nearer  we  approach  to  the  ileo-coecal 
valve.  They  consist  in  a  more  or  less  in¬ 
tense  redness  of  the  mucous  membrane, 
which  sometimes  appears  thickened,  and 
presents  something  of  a  velvety  appearance, 
studded  over  with  numerous  dark  spots — 
the  orifices  of  the  solitary  glands.  In  other 
instances,  the  surface  of  the  reddened  mu¬ 
cous  membrane  appears  slightly  roughened, 
as  if  sprinkled  over  with  fine  sand ;  while 
near  to  the  coecurn  this  roughening  is  often 
greater,  the  membrane  appearing  elevated 
into  rough,  orange- coloured  prominences, 
separated  by  narrow  lines  of  a  dead  white 
colour,  which  mark  the  situations,  where, 
by  the  destruction  of  the  mucous  membrane, 
the  subjacent  tissue  is  exposed.  Both  of 
these  changes  are  well  represented  in  this 
drawing  of  the  intestine  of  an  infant,  six 
months  old,  who  died  of  a  relapse  of  diar¬ 
rhoea,  from  which  she  had  seemed  to  be  in 
course  of  recovery.  Besides  this  affection 
of  the  mucous  membrane  of  the  ileum, 
Peyer’s  glands  are  not  infrequently  very  well 
marked  in  the  lower  part  of  the  small  intes¬ 
tine  ;  and  their  surface  presents  a  punc¬ 
tated  appearance,  due  to  the  unusual  dis¬ 
tinctness  of  the  orifices  of  the  sacculi  which 
compose  each  gland.  Occasionally  a  few 
of  them  are  congested  and  swollen  ;  and 
once  or  twice  I  have  observed  one  or  two 
spots  of  ulceration  on  that  cluster  of  Peyer’s 
glands  which  is  situated  close  to  the  ileo- 
coecal  valve ;  but  in  every  instance,  the 
affection  of  the  small  intestine  has  appeared 
to  be  secondary,  and  quite  subsidiary,  to  the 
disease  in  the  colon.*  Lastly,  1  may  ob¬ 
serve  that  the  mesenteric  glands,  even  in  the 
vicinity  of  the  diseased  large  intestine,  de¬ 
viate  but  little  from  a  state  of  health,  being 
at  most  a  little  larger,  and  of  a  somewhat 


*  In  vol.  v.  of  the  Zeitschrift  fur  rationelle 
Medicin,  Heidelberg-,  1846,  is  a  very  interesting 
essay  by  MM.  Friedleben  and  Fleisch,  on  some 
points  in  the  pathology  of  the  intestinal  mucous 
membrane  in  infants.  Their  observations  are 
founded  on  fifteen  infants,  all  of  whom  were 
under  one  year  old,  who  were  brought  up  either 
exclusively,  or  in  great  measure,  on  artificial 
food,  and  who  died,  after  long  continued  illness, 
in  a  state  of  atrophy,  or  else  sank  rapidly  under 
profuse  watery  diarrhoea.  In  cases  of  the  former 
class,  a  state  regarded  by  them  as  the  result  of 
chronic  inflammation  of  Peyer’s  glands  was  the 
chief  morbid  appearance;  while,  in  those  instances 
where  death  took  place  l-apidly,  a  swollen  and 
congested  condition  of  the  same  bodies,  betoken¬ 
ing,  as  they  believe,  their  recent  inflammation, 
was  almost  always  present.  They  found,  too, 
that  in  all  these  cases  the  disease  of  the  colon 
was  comparatively  slight,  and  was  evidently  se¬ 
condary  to  the  more  serious  changes  in  the 
small  intestine. 

I  am  unacquainted  with  any  observations  of 
more  recent  date  on  this  very  important  subject ; 
and,  though  at  present  engaged  in  its  investiga¬ 
tion,  my  opportunities  have  not  yet  been  suffi¬ 
cient  to  enable  me  to  arrive  at  any  satisfactory 
conclusion  with  reference  to  it. 


20 


SYMPTOMS  ON  INFLAMMATORY  DIARRHCEA. 


redder  colour,  than  usual — a  condition  which 
contrasts  remarkably  with  their  serious 
affection  in  cases  of  typhoid  fever  in  child¬ 
hood,  where  yet  the  intestinal  lesion  is  often 
much  less  considerable. 

The  symptoms  of  inflammatory  diarrhoea 
sometimes  become  developed  very  gradually 
out  of  what  had  seemed  at  first  to  be  nothing 
more  than  a  simple  looseness  of  the  bowels  ; 
hut,  in  the  majority  of  cases,  they  present, 
almost  from  the  outset,  a  graver  character 
than  those  of  simple  diarrhoea,  and  are  asso¬ 
ciated  with  more  serious  constitutional  dis¬ 
turbance.  When  the  attack  comes  on  sud¬ 
denly,  it  often  commences  with  vomiting  ; 
and  though  in  many  instances  the  sickness 
does  not  recur  frequently,  yet  sometimes  the 
irritability  of  the  stomach  continues,  for 
twenty-four  or  forty-eight  hours,  to  be  so 
extreme,  that  every  drop  of  fluid  taken  is 
immediately  rejected  ;  and  that  frequent 
efforts  at  vomiting  are  made  even  when  the 
stomach  is  empty.  Violent  relaxation  of  the 
bowels  occurs  almost  simultaneously  with 
the  vomiting  ;  and  the  child  sometimes  has 
as  many  as  twenty  or  thirty  evacuations,  or 
even  more,  in  the  course  of  twenty-four 
hours.  The  motions  are  at  first  faecal  ;  but 
they  soon  lose  their  natural  character,  and 
become  intermixed  with  slime,  often  streaked 
■with  blood.  At  first  they  are  abundant,  and 
are  often  expelled  with  violence  ;  but  before 
long  they  become  scanty,  though  sometimes 
they  still  gush  out  without  much  effort  on 
the  part  of  the  child.  The  character  of  the 
evacuations  again  changes  :  in  the  severest 
cases,  they  not  only  lose  their  faecal  ap¬ 
pearance,  but  become  like  dirty-green  water, 
with  which  neither  blood  nor  intestinal  mu¬ 
cus  is  intermingled.  Usually,  however,  when 
the  first  violence  of  the  purging  has  a  little 
abated,  although  some  serous  stools  may 
Still  be  voided,  yet  the  evacuations  consist 
chiefly  of  intestinal  mucus,  intermixed  with 
a  little  faeces,  and  more  or  less  streaked  with 
blood.  These  scanty  mucous  stools  are 
generally  expelled  with  much  straining  and 
difficulty  ;  a  few  drops  of  blood  sometimes 
follow  them ;  and  once  or  twice,  at  an  early 
period  of  the  attack,  I  have  known  an  infant 
void  as  much  as  a  table-spoonful  of  pure 
blood. 

The  constitutional  symptoms  which  ac¬ 
company  an  attack  of  this  description  are 
usually  very  severe  :  the  skin  becomes  dry 
and  very  hot,  though  unequally  so  ;  the  pulse 
is  quickened,  often  very  much  so  ;  the  head 
is  heavy;  the  child,  fretful  and  irritable  if 
disturbed,  though  otherwise  it  lies  drowsily 
in  its  nurse's  lap,  with  its  eyes  half  open, 
and  scarcely  closing  the  lids  even  when  they 
are  touched  with  the  finger.  Now  and  then, 
too,  the  disturbance  of  the  nervous  system 
at  the  commencement  of  one  of  these  attacks 
of  diarrhoea  is  so  considerable,  that  a  state 


of  excitement  alternates  with  one  of  stupor, 
that  convulsions  seem  impending,  and  that 
there  are  distinct  carpo-pedal  contractions, 
or  startings  of  the  tendons  of  the  wrist  or 
forearm.  The  abdomen  is  usually  full,  and 
rather  tympanitic,  but  seldom  very  tender, 
nor  does  the  child  seem  to  suffer  much 
pain,  though  sometimes  a  degree  of  tormina 
appears  to  precede  each  action  of  the 
bowels.  The  tongue  at  first  is  moist, 
coated  slightly  with  mucous  fur  :  its  papillae 
are  often  of  a  bright  red,  as  are  also  its  tip 
and  edges  ^  while,  if  the  disease  continue, 
the  redness  becomes  more  general,  and  the 
tongue  grows  dry,  though  it  is  not  often 
much  coated.  The  thirst  is  generally  in¬ 
tense,  the  child  craving  for  cold  water,  and 
crying  out  for  more  the  moment  that  the 
cup  is  taken  from  its  lips  ;  and  the  thirst  is 
quite  as  urgent  even  in  those  cases  where 
the  stomach  is  so  irritable  that  it  imme¬ 
diately  rejects  whatever  is  swallowed. 

There  is  scarcely  any  affection  in  which 
the  loss  of  strength  and  of  flesh  is  so  rapid 
as  in  the  severer  forms  of  diarrhoea  ;  and  a 
period  of  twenty-four  hours  will  in  some 
cases  suffice  to  reduce  a  previously  healthy 
infant  to  a  condition  in  which  its  eyes  are 
sunken,  its  features  sharp, its  limbs  shrunken, 
and  its  strength  so  impaired,  that,  though  I 
have  never  seen  an  instance  of  it  myself,  I 
can  yet  well  understand  how  death  may 
take  place  in  the  course  of  a  few  hours  from 
the  commencement  of  the  attack  ;  and  this 
rapidly  fatal  termination  is  far  from  unusual 
in  some  of  the  Southern  States  of  America. 

A  rapidly  fatal  termination,  however,  is 
not  that  which  is  generally  observed  in  this 
country  ;  but,  how  urgent  soever  the  symp¬ 
toms  may  have  been,  there  is  in  most  in¬ 
stances  a  spontaneous  subsidence  of  them  in 
the  course  of  forty-eight  hours  at  furthest, 
or  a  measure  of  abatement  of  their  severity 
follows  the  use  of  remedies.  *The  sickness 
entirely  ceases  ;  the  bowels  act  much  less 
frequently,  probably  not  above  ten  or 
twelve  times  in  the  twenty -four  hours  ;  but 
they  act  irregularly,  five  or  six  evacuations 
taking  place  within  an  hour  or  two,  and 
then  no  action  of  the  bowels  recurring  for 
four  or  five  hours  together.  The  appearance 
of  the  motions  likewise  varies,  and  appa¬ 
rently  without  cause,  being  mucous,  green, 
watery,  intermingled  with  blood,  all  in  the 
course  of  a  single  day,  and  with  no  accom¬ 
panying  modification  in  the  infant’s  symp¬ 
toms.  The  tenesmus  in  general  continues  ; 
and  in  weakly  children,  or  in  those  who 
have  previously  suffered  from  diarrhoea, 
prolapsus  ani  not  infrequently  occurs ; 
though  this  accident  happens  less  commonly 
in  infants  than  in  children  of  two  or  three 
years  old. 

There  is  much  uncertainty  in  the  further 
course  of  the  affection,  and  in  the  way  in 


INFLAMMATORY  DIARRHCEA - CHRONIC  CASES. 


21 


which  it  tends  in  one  instance  towards  re¬ 
covery,  and  in  another  to  a  fatal  issue. 
Many  fluctuations  generally  interrupt  the 
progress  of  those  cases  which  terminate 
favourably ;  while,  when  it  eventually 
proves  fatal,  the  affection  generally  assumes 
a  chronic  character ,  and  does  not  end  in 
death  until  after  the  lapse  of  several  weeks. 

In  such  chronic  cases,  the  patient’s  con¬ 
dition,  though  progressively  tending  from 
bad  to  worse,  presents  but  little  difference 
from  day  to  day.  The  loss  of  flesh  goes  on 
until  the  child  is  reduced  to  a  degree  of 
emaciation  as  great  as  is  ever  witnessed 
even  in  the  most  advanced  stage  of  mesen¬ 
teric  disease  or  pulmonary  consumption, 
though  its  extreme  attenuation  is  sometimes 
concealed  by  the  anasarcous  swelling  of  its 
face  and  hands.  The  appetite  fails  com¬ 
pletely,  or  becomes  very  capricious,  and  the 
child  refuses  to-day  the  food  which  yester¬ 
day  it  took  with  eagerness.  In  course  of 
time,  the  desire  for  drink  is  lost,  too  ;  for 
though  there  may  be  no  return  of  vomiting, 
yet  nausea  is  excited  by  everything  which 
the  child  takes.  The  tongue  grows  red  and 
dry,  coated  with  brown  or  yellow  fur 
towards  its  root,  or  aphthae  appear  upon  its 
tip  and  edges,  or  the  whole  inside  of  the 
mouth  becomes  coated  with  muguet.  The 
diarrhoea  continues  much  as  it  was  before, 
except  that  the  action  of  the  bowels  is  now 
almost  immediately  excited  by  either  food 
or  drink.  The  evacuations  are  usually  of 
a  green  colour,  often  particoloured,  and 
though  generally  watery,  yetthey  vary  both  in 
their  consistence  and  in  their  other  charac¬ 
ters,  without  apparent  cause.  Slime,  blood, 
and  pus,  are  sometimes  present  in  the  stools, 
at  other  times  absent ;  and  it  does  not  often 
happen  that  purulent  matter  is  present  in 
large  quantity  in  the  evacuations,  or  for 
many  days  together,  thomgh  I  have  observed 
this  to  be  the  case  in  cases  that  recovered, 
as  well  as  in  those  which  had  a  fatal  termi¬ 
nation.  The  body  is  no  longer  able  to 
maintain  its  proper  temperature,  but  the 
extremities  are  almost  invariably  cold ; 
small  indolent  abscesses  occasionally  form 
about  the  buttocks ;  and  on  one  occasion  I 
saw  an  eruption  of  large  vesicles,  like  those 
of  pemphigus,  make  their  appearance  on  the 
hands,  arms,  and  neck  of  an  infant  eight 
months  old  about  ten  days  before  her  death. 
In  the  condition  of  weakness  to  which  the 
child  is  now  reduced,  a  slight  aggravation  of 
the  diarrhoea,  or  a  return  of  vomiting, 
suffices  to  put  out  its  feeble  life  ;  or,  even 
should  no  such  accident  occur,  death  takes 
place  from  pure  exhaustion. 

But  various  causes  may  abridge  this  pro¬ 
tracted  course  of  the  affection  ;  and  hence 
it  results  that  death  not  infrequently  takes 
place  before  the  mischief  in  the  intestines 
•has  become  so  serious  as  it  is  usually  found 


to  be  in  cases  of  fatal  dysentery  in  the 
adult.  Bronchitis  is  one  of  the  most  fre¬ 
quent  of  these  intercurrent  maladies,  while 
the  symptoms  that  attend  it  are  often  so 
slight  that  danger  to  the  patient  from  this 
source  is  very  frequently  overlooked.  It 
happens,  indeed,  in  many  cases,  that  almost 
from  the  outset  of  an  attack  of  diarrhoea, 
the  mucous  membrane  of  the  respiratory 
organs  appears  to  sympathise  with  the  irri¬ 
tation  of  the  intestinal  canal  :  hence  the 
child  has  slight  cough  from  the  very  com¬ 
mencement  of  its  illness,  and  the  con¬ 
tinuance  or  even  the  aggravation  of  this 
cough  attracts  but  little  notice  ;  and,  unless 
auscultation  is  carefully  practised,  and  often 
repeated,  there  is  little  to  call  attention  to 
the  state  of  the  respiratory  organs  until  the 
accumulated  secretions  in  the  bronchi  have 
already  seriously  interfered  with  the  entrance 
of  air  into  the  pulmonary  vesicles,  and  have 
occasioned  the  collapse  of  a  considerable 
extent  of  the  substance  of  the  lungs. 

There  are  other  causes  by  which  life  is 
sometimes  cut  short  in  the  course  of  infan¬ 
tile  diarrhoea.  The  disturbance  of  the 
nervous  system  that  attends  the  attack 
issues  now  and  then  in  convulsions,  and 
these  convulsions  end  in  a  state  of  stupor 
which  terminates  in  death — an  occurrence 
fortunately  rare,  but  of  which  instances 
may  be  observed  during  those  hot  seasons 
of  the  year  when  bowel  complaints  are 
usually  epidemic.  Less  rare  than  a  fatal 
termination  of  this  kind  is  the  infant’s 
death  under  symptoms  of  a  gradually  deep¬ 
ening  coma,  which  may  have  supervened  on 
the  suppression  of  the  diarrhoea,  or  its  great 
mitigation.  Many  of  the  symptoms  by 
which  this  condition  is  accompanied  are 
such  as  to  indicate  the  exhaustion  of  the 
infant’s  powers ;  but  it  happens  in  many 
instances  that  there  is  an  occasional  flush  of 
the  face,  or  a  temporary  heat  of  skin,  or 
some  other  passing  sign  of  an  attempt  at 
reaction,  just  sufficient  to  mislead  the  prac¬ 
titioner,  and  to  betray  him  into  a  vacillating 
line  of  practice  that  proves  fatal  to  his 
patient. 

Lastly,  there  are  cases,  and  these  by  no 
means  few,  in  which  the  onset  of  a  severe 
attack  of  diarrhoea  has  been  promptly  met 
and  judiciously  treated,  in  which  the  symp¬ 
toms  have  yielded,  and  the  child  has  ap¬ 
peared  convalescent.  Some  slight  error  in 
diet,  however,  a  variation  in  the  tempera¬ 
ture,  or  the  too  early  withdrawal  of  medi¬ 
cine,  is  followed  by  a  return  of  the  vomiting 
and  purging  ;  or  the  relapse  may  take  place 
without  our  being  able  to  assign  for  it  any 
adequate  cause.  The  active  symptoms 
which  attended  the  original  seizure  are  ab¬ 
sent  now' the  evacuations,  though  very 
watery,  generally  contain  neither  blood  nor 
slime  ;  but  medicine  is  often  wholly  unable 

i 


22 


MR.  SKEY  ON  THE  ACTION  OF  THE  OMO  HYOIDEDS. 


to  check  them.  The  vital  powers  fail 
speedily,  and  death  often  takes  place  in 
three  or  four  days  from  this  exacerbation  of 
the  symptoms,  while  an  examination  of  the 
body  after  death  shows  no  evidence  of  recent 
mischief  in  the  intestines,  but  only  the 
traces  left  by  the  first  attack,  and  these 
manifestly  in  course  of  disappearance. 

We  must  postpone  until  the  next  lecture 
the  very  important  subject  of  the  treatment 
appropriate  to  all  the  varieties  of  diarrhoea 
and  its  different  complications. 


Original  ©ommimtcationg. 


ON  THE 

ACTION  OF  THE  OMO  HYOIDEUS, 

&c. 

By  F.  C.  Skey,  F.R.S. 

Assistant  Surgeon  to  St. Bartholomew’s  Hospital. 


Although  the  action  of  the  muscles  of 
the  os  hyoides  may  be  supposed  to  have 
been  well  and  sufficiently  considered, 
forming  as  it  does  a  part  of  the  staple 
commodity  of  the  lectures  annually 
delivered  in  our  anatomical  schools, 
yet  I  think  we  may  extract  from  this 
hacknied  subject  material  for  further 
reflection,  and  form  deductions  which 
in  some  essential  respects  differ  from 
those  which  are  usually  received  by 
physiologists. 

The  muscles  in  question  are  the  re¬ 
puted  depressors  of  the  os  hyoides  and 
larynx — viz.  the  omo  hyoideus,  sterno 
hyoideus,  thvro  hyoideus,  and  sterno 
thyroideus ;  and  my  remarks  apply 
more  especially  to  the  first  of  this 
series.  The  uses  commonly  assigned 
to  them  by  authors  and  lecturers  is 
that  of  replacing  the  larynx  in  its  posi¬ 
tion  in  the  neck,  after  its  elevation  in 
the  act  of  swallowing,  by  drawing  down 
the  os  hyoides. 

Bell  says,  “  these  muscles  pull  the 
throat  down  ;  the  omo  hyoideus  draws 
it  directly  down,  and  braces  the  trachea 
a  little  backwards. 

Cloquet  assigns  to  the  omo  hyoideus, 
“  depression  of  the  os  hyoides  back¬ 
wards  to  the  sterno  hyoideus,  depres¬ 
sion  of  the  os  h)oides,  and  indirectly 
the  lower  jaw.” 

Quain. — “These  muscles  depress  the 
larynx,  for  they  draw  the  parts  down 
as  deglutition  is  being  performed. 


After  the  ascent  of  the  pharynx  and  os 
hyoides  has  been  effected,  the  parts  do 
not  return  to  their  original  position  by 
the  mere  relaxation  of  the  elevators, 
they  are  drawn  down  by  the  above 
muscles.” 

Cruveilhicr. — “They  all  concur  in 

* 

depressing  the  lower  jaw.”  “  If  the 
jaw  be  fixed,  they  produce  flexion  of 
the  head.”  “  When  the  omo  hyoidei  act 
together,  the  os  hyoides  is  forced  back¬ 
wards  against  the  vertebral  column.” 

Mechel. — “  The  omo  hyoideus  draws 
the  os  hyoides  downwards,  backwards, 
and  a  little  to  one  side.” 

The  larynx,  as  is  well  known,  is 
placed  on  the  summit  of  an  elastic 
pillar,  which  we  can  contract  or  elon¬ 
gate  at  will.  This  pillar  is  the  trachea, 
which  is  elongated  by  the  elevators,  and 
contracted  by  the  depressors.  On  the 
cessation  of  the  action  of  both,  the 
organ  recovers  its  natural  position  of 
rest,  which  corresponds  with  the  fourth 
and  fifth  cervical  vertebrae  ;  and  this 
holds  true  of  the  larynx  both  living 
and  dead,  being  dependent  on  a  mate¬ 
rial  whose  attributes  are  equally  per¬ 
fect  when  examined  in  the  dead  or  in 
the  living  subject — a  structure  indepen¬ 
dent  of  muscular  contraction. 

To  do  justice  to  the  action  of  these 
muscles,  we  must  assign  to  the  larynx 
and  os  hyoides  the  middle  place  between 
them,  and  conclude  the  organ  to  be 
raised  from  its  state  of  rest  by  one 
class,  (the  elevators),  and  to  be  carried 
down  from  that  state  by  the  other,  (the 
depressors.)  To  infer  that  the  depres¬ 
sors  possess  the  power  merely  of  re¬ 
placing  the  os  hyoides  and  larynx  after 
elevation,  is  to  deprive  them  of  their 
action  altogether,  because  these  parts 
are  replaced  by  their  own  elasticity, 
and  require  no  muscular  action  for  the 
purpose.  Their  action  will,  I  think,  be 
found  to  involve  a  highly  important, 
and  hitherto  unacknowledged  function 
— viz.  depression  of  the  os  hyoides,  &c. 
towards  the  sternum ,  by  which  action 
the  rings  of  the  trachea  are  made  to 
approximate,  and  the  whole  structure, 
consisting  of  the  os  hyoides,  larynx, 
and  tongue,  is  carried  forcibly  down¬ 
wards.  On  the  cessation  of  this  con¬ 
traction,  the  elastic  pillar  rises  to  its 
position  of  rest  in  the  neck.  There 
can  be  no  doubt,  I  conclude,  that  the 
important  office  assigned  to  these  mus¬ 
cles  is  that  of  imbibition  by  suction, 
effected  by  creating  a  vacuum,  and  en- 


MR.  SKEY  ON  THE  ACTION  OF  THE  OMO  HYOIDEUS 


23 


"aged  in  many  important  purposes. 
When  a  vessel,  a  tumbler  for  example, 
containing  fluid,  is  brought  into  con¬ 
tact  with  the  mouth  for  the  purpose  of 
drinking,  the  first  instinctive  act  con¬ 
sists  in  adapting  the  lips  to  the  surface 
of  the  vessel.  The  soft  palate  is  drawn 
down  to  touch  the  roof  of  the  tongue  ; 
prior  to  which  a  deep  inspiration  fills  the 
cavity  of  the  chest.  The  soft  structure 
of  the  lips  is  well  adapted  to  the  pur¬ 
pose  of  closing  in  upon  the  fluid,  and 
excluding  the  atmospheric  air.  A 
vacuum  is  then  attempted  by  the  de¬ 
pressors  of  the  os  hyoides,and  by  atmos¬ 
pheric  pressure  the  fluid  fills  the  closed 
cavity  of  the  mouth.  These  agents  ap¬ 
pear  to  be  the  omo  hyoid  primarily  and 
especially,  combined  with  the  sterno 
hvoid,  and  thyroid  muscles,  and  aided 
by  the  thyro  hyoid.  Of  these  muscles, 
the  three  latter  invariably  exist  in  man, 
and  in  a  large  majority  of  animals  ;  the 
omo  hyoid  by  no  means  so. 

In  examining  the  neck  of  such 
animals  as  drink  by  lapping,  in  which 
the  vacuum  of  the  mouth,  or  rather  the 
act  of  suction,  is  not  required  for  the 
purpose  of  drinking,  I  find  the  omo 
hyoid  invariably  absent.  Looking  at 
the  direction  of  this  muscle  in  its  entire 
course,  it  is  not  easy  to  comprehend  its 
supposed  action  bachwards,  for  the 
hyoid  portion  is  really  vertical,  and  not 
obliquely  forwards,  which  course  its 
fibres  would  have  taken,  had  it  been 
intended  to  act  in  this  direction. 
Nor  is  there  any  thing  eccentric  or  re¬ 
markable  in  its  remote  origin  from  the 
scapula,  when  we  consider  that  the 
first  rib  as  well  as  the  clavicle  are  dis¬ 
qualified  for  such  attachment,  the  rib 
being  entirely  occupied  by  the  origins 
of  the  scaleni,  and  the  subclavian  artery 
and  vein  ;  there  is  in  fact  no  room  for  it. 
To  the  clavicle,  indeed,  the  omo  hyoid 
is  extensively  connected  by  a  strong 
band  of  fascia,  by  which  the  action  of 
its  double  belly  identifies  its  two  por¬ 
tions  with  each  other,  as  in  the  case  of 
the  digastricus  and  superior  oblique 
muscle  of  the  orbit.  It  is  very  true 
that  the  origin  Nature  has  selected  is 
itself  so  far  an  objectionable  one  that 
the  action  of  the  omo  hyoid  may  be 
materially  impaired  by  approximating 
its  attachments  in  the  act  of  raising 
the  shoulders;  but  this  is  so  unnatural 
an  action,  and  requires  the  exercise  of 
so  large  and  powerful  muscles,  that  it 
cannot  frequently  interfere  with  the 


ordinary  function  of  the  muscle,  though 
I  shall  endeavour  to  shew  that  it  may 
do  so,  on  occasions’. 

That  the  omo  hyoid  muscle  is  the 
chief  agent  bv  which  the  act  of  suction 
is  effected  when  employed  for  the  pur¬ 
pose  of  drinking,  may  be  inferred  from 
its  total  absence  in  all  animals  that 
drink  by  lapping.  By  the  kindness  of 
the  Council  of  the  Zoological  Society,  I 
have  been  permitted  to  examine  a  large 
variety  of  animals  that  have  died  at  the 
gardens  of  the  Society  in  London,  in¬ 
cluding  most  of  the  large  carnivora, 
the  monkey  tribe,  lemurs,  porcupine, 
raccoon,  agouti,  coati  mundi,  jerboa, 
and  the  domestic  animals — dog,  ox, 
horse,  &c. ;  and  I  have  found  no  va¬ 
riety  in  the  law  I  have  referred  to, — the 
truth  of  which  will  acquire  some  de¬ 
gree  of  confirmation  from  the  result  of 
the  following  experiment.  It  is  ob¬ 
vious  that  the  origin  of  the  omo  hyoid 
muscle,  as  above  stated,  must  hold  a 
different  relation  to  the  os  hyoides, 
according  to  the  position  of  the  sca¬ 
pulae,  whether  at  rest  or  raised  by  the 
trapezius  muscle, — that  is  to  say,  if  the 
scapulae  be  raised  to  the  fullest  extent 
of  the  elevators  of  that  bone,  the  two 
extremities  of  the  omo  hyoid  muscles 
will  be  approximated,  and  the  power 
of  the  muscles  abridged  or  destroyed. 
If  the  mouth  be  filled  with  fluid  by 
the  greatest  effort  of  suction,  while 
the  shoulders  are  raised,  one  half  of 
each  omo  hyoid  are  paralysed,  and  the 
quantity  of  fluid  admitted  will  be 
limited.  The  shoulders  now  being 
brought  down  to  the  natural  level  of 
the  chest,  the  omo  hyoid  is  elongated, 
and,  in  fact,  placed  in  a  condition  to 
contract  on  the  os  hyoides  to  the  full 
extent  of  its  power,  a  much  larger  addi¬ 
tional  quantity  of  fluid  may  be  received 
by  the  mouth.  Now  there  is  but  one 
muscle  concerned  in  deglutition,  &c., 
the  condition  of  which  can  possibly  be 
affected  by  this  action  of  the  shoulders, 
and  that  is  obviously  the  omo  hyoid. 
The  omoid  portion,  or  origin  of  this 
muscle,  does  not  invariably  derive  its 
fixed  point  of  action  from  the  scapula; 
and  in  all  animals  the  name  omo 
hyoid  is  not  warranted  by  its  attach¬ 
ment.  In  the  ox  and  in  the  giraffe, 
and  probably  in  other  animals,  this 
muscle  consists  of  a  single  fasciculus, 
running  obliquely  backwards  towards 
the  transverse  processes  of  the  fifth 
and  sixth  cervical  vertebree ;  in  some, 


24 


MR.  SKEY  ON  THE  ACTION  OF  THE  OMO  HYOIDEUS. 


passing  behind  the  caroiid  sheath  ; 
and  in  others,  as  in  the  large  majority 
of  animals,  and  in  man,  being  super¬ 
ficial  to  them.  But,  so  far  as  I  have 
observed,  it  is  invariably  found  in  every 
adult  animal  that  drinks  by  suction. 

To  this  law  a  large  exception  must 
be  made  in  favour  of  the  young  ani¬ 
mal,  which,  in  the  whole  of  the  mam¬ 
malia,  drink  by  suction  — an  exception 
so  extensive,  that  it  would  appear  to 
invalidate  the  entire  law  of  action  of 
the  muscles  in  question.  But  it  ought 
not  really  to  do  so.  It  is  probable  that 
the  act  of  suction  of  the  young  mam¬ 
mal  is  a  process  effected  by  the  tongue 
itself  when  enclosed  around  the  nipple 
of  the  mother,  and  that  the  point  of  the 
organ  only  is  brought  into  action  when 
protruded  between  the  lips;  and  that 
the  action  of  the  entire  tongue  is  not 
involved. 

The  bony  scapula  would  therefore 
appear  the  only  point  by  which  an 
origin  could  be  afforded  it.  The  omoid 
portion  is  held  down  by  fascia  connect¬ 
ing  it  to  the  clavicle,  and  continuous 
with  that  of  the  axilla.  The  muscle 
becomes  tendinous  as  it  crosses  the 
large  vessels,  and  then  commences  its 
second  or  vertical  portion,  which  is 
inserted  above  into  the  os  hyoides  : 
and  it  is  necessary  to  observe  that  the 
connection  to  the  sterno  hyoid  muscle, 
along  the  outer  side  of  which  it 
ascends,  is  singularly  dense  and  un¬ 
yielding.  This  structure  is  very  unlike 
that  which,  under  the  term  of  general 
cellular  tissue,  connects  other  contigu¬ 
ous  muscles,  but  consists  of  well-cha¬ 
racterized  fascial  tissue.  Failing  such 
a  material,  the  depressing  action  of  the 
muscle  would  be  lost.  This  action  is 
of  course  vertical,  the  os  hyoides  being 
drawn  by  its  contraction  in  a  straight 
direction  downwards  in  the  mesial 
line. 

In  point  of  the  principle  of  their 
construction,  there  may  be  found  con¬ 
siderable  analogy  between  that  of  the 
mouth,  and  chest.  In  the  latter  we 
have  a  large  cavity,  operated  on 
through  the  medium  of  elastic  walls, 
and  a  large  moveable  base  occupied  by 
the  diaphragm.  The  ingress  of  air  is 
effected  and  regulated  by  this  muscle, 
by  the  contraction  of  which,  a  tendency 
to  a  vacuum  is  formed,  and  the  air 
rushes  into  the  lungs.  The  diaphragm 
then  ceases  to  act.  The  antagonist 
power  which  succeeds  is  the  elastic 


I  walls  of  the  thorax,  which,  contracting 
on  their  contents,  expel  the  air  by 
their  natural  recoil,  and  then  regain  a 
state  of  rest,  till  again  elevated  by  the 
intercostal  muscles  waiting  on  the  re¬ 
newed  action  of  the  diaphragm. 

Very  similar  to  the  above  well- 
known  operation  is  the  action  of  the 
agents  of  imbibition  by  the  mouth, 
which,  like  the  chest,  is  closed  on  all 
sides  during  the  act  which  fills  the 
cavity,  and  which  possesses  muscular 
walls  in  the  buccinators  contracting  on 
the  contents  when  admitted  in  larger 
than  ordinary  quantities  ;  and  to  these 
may  be  added  a  false  bottom  or  mus¬ 
cular  base  resembling  the  diaphragm, 
effecting  and  regulating  the  amount  of 
contents  admitted  into  the  cavity. 
Both  of  the*e  cavities  illustrate  the 
alternation  of  elasticity  with  muscular 
action,  the  antagonist  power  of  the 
diaphragm  being  situated  in  the  parietes 
of  the  chest,  the  antagonism  of  the 
depressors  of  the  tongue  being  effected 
even  more  directly  by  means  of  the 
recoil  of  the  trachea;  and  I  may  ven¬ 
ture  to  remark,  in  passing,  that  no  de¬ 
sign  could  have  been  more  perfect, 
and  no  precaution  more  absolute, 
against  the  fatal  effects  of  the  absence 
of  antagonism  to  the  depressors  of  the 
larynx  ,  during  the  action  of  which  the 
function  of  respiration  is  momentarily 
suspended. 

It  is  not  only  in  the  act  of  drinking 
in  the  adult  animal  that  the  action  of 
the  omo  hyoid, in  conjunction  probably 
with  the  other  depressors  of  the  os 
hyoides,  is  brought  into  play,  but  their 
contraction  will  be  found  the  cause  of 
every  act  by  which  a  limited  current  of 
any  fluid  is  admitted  into  the  cavity  of 
the  month  by  an  effort,  as  in  the  act  of 
smoking,  or  in  that  which,  regulated 
by  the  aperture  of  the  lips,  a  lesser 
current  of  air  is  forced  in  through  the 
teeth  to  remove  any  particle  of  food 
that  may  have  been  retained  there. 
Under  all  these  actions,  the  contrac¬ 
tion  of  the  outer  or  omoid  portion  may 
be  felt  by  the  finger  pressed  upon  the 
muscle  above  the  upper  border  of  the 
clavicle,  and  on  the  outer  side  of  the 
mastoid  muscle.  Even  in  the  slight 
action  of  kissing,  which  is  but  a  modi¬ 
fication  of  the  same  function,  the 
agency  of  the  omo  hyoid  will  be 
perceptible  to  the  finger  on  pressure. 
It  is  obvious  that  the  act  of  suction 
must  be  dependent  on  the  healthy 


MR.  NORMANS  CASE  OF  INFLAMMATION  OF  THE  LACHRYMAL  SAC.  25 


function  of  the  valve  or  flap  of  the  soft 
palate  or  some  substitute,  without 
which  the  tendency  to  a  vacuum  would 
be  transferred  from  the  mouth  to  the 
thorax.  The  omo  hyoid  cannot  be 
brought  into  action  until  the  soft 
palate  has  closed  the  posterior  opening 
of  the  mouth;  failing  which,  the  fluid 
carried  into  the  mouth  by  atmospheric 
pressure  would  pass  immediately  into 
the  larynx. 

Connected  with  this  arrangement  of 
the  muscles  of  the  tongue  and  os 
hyoides,  is  the  origin  and  distribution 
of  the  branch  of  hypoglossal  nerve 
called  the  “  descendens  noni.” 

In  man,  the  “descendens  noni”  is  a 
compound  nerve,  produced  conjointly 
by  the  hypoglossal  and  by  a  cervical 
nerve  ;  by  far  the  larger  portion  of  its 
filaments,  however,  being  derived  from 
the  former.  This  formation  of  the 
nerve  would  probably  in  itself  point  to 
the  identity  of  action,  or  rather  to  he 
mutual  dependence  of  action  subsist¬ 
ing  between  the  tongue  and  omo  hyoid 
muscle.  If  the  office  of  a  plexus  be 
that  of  harmonizing  the  functions  of 
parts  supplied  therefrom,  a  kind  of 
plexus  is  thus  formed  which  identifies 
the  action  of  the  omo  hyoid  muscle 
with  the  tongue  in  the  act  of  imbibi¬ 
tion. 

In  animals  deprived  of  the  omo 
hyoid,  the  nerve  commonly  known  as 
the  “descendens  noni”  has  a  similar 
communication  from  the  hypoglossal 
and  from  the  cervical,  but  with  this 
difference — that  by  far  the  greater 
number  of  its  filaments  is  obtained 
from  the  cervical,  from  which,  indeed, 
it  appears  to  originate.  It  then  de¬ 
scends  along  the  convex  arch  of  the 
hypoglossal,  and  receives  some  few  ad¬ 
ditional  filaments  from  that  nerve; 
whereas  in  the  other  examples  it  is 
almost  exclusively  formed  by  the  hypo¬ 
glossal  only. 

It  is  therefore  a  “ramus  descendens 
noni”  only  where  the  omo  hyoideus 
muscle  is  present — this  muscle  being 
found  in  such  animats  as  drink  by 
suction  :  at  least,  such  is  the  result  of 
my  limited  investigations  on  the  sub¬ 
ject. 

Grosvenor  Street, 

June  1848. 


A  CASE  OF 

CHRONIC  INFLAMMATION, 
with  RELAXATION  of  the 
LACHRYMAL  SAC  : 

WITH  FURTHER  CASES  AND  REMARKS 
ILLUSTRATING  SOME  POINTS  IN  THE 
PATHOLOGY  AND  TREATMENT  OF  SOME 
OF  THE  EXCRETING  LACHRYMAL  OR¬ 
GANS. 

By  H.  Burford  Norman,  F.R.C.S, 

Surgeon  to  the  Western  Ophthalmic  Institution, 
and  to  the  St.  Marylebone  and  Blenheim  Street 
Dispensaries. 


Mrs.  Halifax,  a  respectable  elderly 
female,  who  had  enjoyed  better  cir¬ 
cumstances  than  her  present  in  early 
life,  became  a  dispensary  patient, 
under  my  care,  Jan.  1,  1848  She  has 
all  the  appearance  of  perfect  health, 
which  she  says  she  enjoys,  never  re¬ 
quiring  any  medicine,  except  an  occa¬ 
sional  aperient  to  regulate  the  action 
of  the  bowels.  For  some  years  past  she 
has  been  troubled  with  a  “  watering”  of 
the  left  eye,  amounting  to  a  considera¬ 
ble  overflowing  of  the  tears  on  ex¬ 
posure  to  cold  air.  On  several  occa¬ 
sions  a  large  swelling  has  formed  near 
the  inner  canthus  on  the  side  of  the 
nose.  It  has  always  been  dispersed  by 
means  of  hot  fomentations.  About 
three  months  ago,  a  swelling  larger 
than  she  had  ever  known  it  before — as 
large  as  a  walnut — formed,  and  was 
dispersed  temporarily,  but  soon  re¬ 
appeared,  and  burst  upon  the  cheek, 
discharging  .its  fluid  contents.  The 
formation  of  these  swellings  has  always 
been  accompanied  by  much  pain  and 
throbbing,  and  by  a  dull  aching  down 
the  side  of  the  nose.  She  says  they 
have  never  been  accompanied  by  puru¬ 
lent  discharge  from  the  eyelid,  r.or,  on 
pressing  on  the  swelling  at  any  time, 
could  such  matter  be  made  to  flow 
back  through  the  puncta,  and  that  the 
discharge  on  the  last  occasion  was  quite 
clear.  At  present  there  is  no  appear¬ 
ance  of  swelling  on  the  lachrymal  sac, 
but  the  integument  covering  it  is  of  a 
dusky  red  colour,  much  indurated,  and 
a  scab  covers  the  point  at  which  the 
swelling  burst.  On  pressure,  there  is 
no  regurgitation  into  the  inner  canthus, 
nor  is  there  any  puriform  secretion 
from  the  lids  or  globe.  There  is  nei¬ 
ther  ectropium  nor  entropium.  The 
puncta  are  in  natural  position,  and  the 


26  MR.  NORMANS  CASE  OF  INFLAMMATION  OF  THE  LACHRYMAL  SAC. 


canals  quite  pervious ;  a  probe  was 
readily  passed  through  them  to  the 
lachrymal  sac.  The  caruncula  lachry- 
malis  and  conjunctiva  only  a  little 
redder  than  natural ;  yet  the  stillici- 
dium  lachrymum  is  constant,  and,  on 
exposure  to  a  cold  draught,  it  is  most 
uncomfortably  augmented. 

Treatment. — Let  the  affected  part  be 
frequently  fomented  with  hot  decoc¬ 
tion  of  poppy-heads  and  chamomile 
flowers.  Let  one  leech  be  applied  to 
the  discoloured  integument;  and  every 
evening  let  a  soft  warm  bread- and- 
water  poultice  be  applied  on  the  same 
part,  and  worn  through  the  night.  The 
bowels  to  be  regulated  by  a  dose  of 
blue-pill  and  colocynth  on  alternate 
nights. 

4th. — Since  the  last  visit  a  swelling 
has  recurred  in  the  sac,  and  its  con¬ 
tents  were  discharged  through  the 
nose.  The  dusky  redness  of  the  skin 
has  increased,  and  extends  along  the 
edge  of  the  orbit.  There  is  more  in¬ 
duration  also.  No  regurgitation  by 
pressure  on  the  sac.  A  drop  of  solu¬ 
tion  of  nitrate  of  silver  placed  in  the 
inner  canthus  was  immediately  taken 
up  by  the  puncta.  The  same  treat¬ 
ment  to  be  continued. — ^  Argent. 
Nit.  gr.  i.;  Aquae  Destill,  f~j.;  F.  Sol. 
Instill.  Gutt.  in  canth.  oculi  intern, 
nocte  maneque.  ]^>  Unguent.  Hydrarg. 
Mitior,  5>ij. ;  Camphoree,  3j.  tere  simul 
ut  F.  Ung.  cujus  infricetur  paululum 
in  cutem  induratum  nocte  maneque. 

11th. — The  dusky  redness  of  the 
skin  much  lessened  ;  two  whitish  hard 
elevated  spots  mark  the  position  of  the 
leech-bite,  andof  the  ulceration  through 
the  sac,  which  is  cicatrized.  Con¬ 
junctiva  paler ;  less  stillicidium.  She 
only  finds  the  eye  “  water”  on  exposure 
to  cold.  Directions  have  been  care¬ 
fully  followed,  and  to  be  persevered  in. 

25th.  — No  induration  over  the  sac, 
and  scarcely  any  discolouration  ;  the 
tears  never  overflow,  except  on  sudden 
exposure  to  cold.  She  feels  much 
comfort  in  her  improved  condition. — 
Treatment  to  be  continued. 

Feb.  8th. — There  is  no  sign  of  dis¬ 
ease  left,  and  the  eye  is  never  watery, 
except  very  slightly  on  sudden  exposure 
to  a  cold  draught  of  air,  and  then  much 
less  than  it  was  wont  to  be.  She  was 
discharged  as  cured,  but  recommended 
to  continue  to  use  the  ointment  and 
fomentation,  and  cautioned  particularly 
not  to  neglect  the  state  of  her  bowels. 


May  31st. — I  have  not  seen  or  heard 
of  the  patient  up  to  this  date,  and  have 
every, reason  for  believing  that  I  should 
have  done  so  had  there  been  a  relapse. 

In  reflecting  upon  the  foregoing  case, 
one  is  led  to  inquire — What  was  the 
condition  of  the  lachrymal  passages 
which  occasioned  or  existed  in  those 
frequent  distensions  to  which  the  sac 
appears  undoubtedly  to  have  been 
subject?  And,  in  replying  to  the 
question,  it  is  necessary  to  bear  in 
mind  the  different  conditions  under 
which  such  a  state  of  distension  may 
arise.  First,  the  lining  membrane  of 
the  lachrymal  sac,  like  other  portions 
of  the  mucous  membrane,  is  liable, 
under  the  influence  of  common  causes, 
to  acute  inflammatory  attacks.  In 
such  the  ordinary  secretion  of  healthy 
mucus,  sufficient  only  to  lubricate  the 
surface  (or,  if  redundant,  still  quickly 
removed  by  its  ordinary  channels  as 
fast  as  secreted),  is  suspended,  and,  in 
its  stead,  a  muco-purulent  or  decidedly 
purulent  secretion  takes  place  in  very 
unnatural  and  excessive  quantity.  If 
such  disease  occur  on  a  free  mucous 
surface,  as  that  of  the  palpebra,  or  in 
one  like  that  of  the  vagina,  from  which 
the  abnormal  secretion  can  readily 
find  escape,  the  local  suffering  may  be 
restricted  to  a  slight  itching  or  smart¬ 
ing  of  the  part,  or  there  may  be  also  a 
degree  of  general  pyrexia;  but  if  the 
secreting  surface  be  bound  down,  so  to 
speak,  by  dense  structures,  and  be  so 
formed  or  situate  that  its  morbid  secre¬ 
tion  mustaccumulate,the  symptomsand 
signs  of  an  acute  abscess,  throbbing, 
aching,  and  great  local  tenderness,  toge¬ 
ther  with  swelling,  heat,  and  redness  of 
the  superjacent  integument,  are  added. 
Of  this,  a  very  striking  illustration  oc¬ 
curs  in  the  acute  abscesses  which  form 
in  certain  bursse,  though  the  membrane 
lining  such  cavities  possesses  a  some¬ 
what  different  anatomical  structure 
from  that  of  the  mucous  surfaces. 
But  in  such  acute  attacks,  the  cavity 
now  under  consideration — the  lachry¬ 
mal  sac — is  potentially  in  the  same 
condition  with  a  synovial  bursa  not 
possessing  an  outlet.  Its  lining  mem¬ 
brane  is  not  alone  the  seat  of  vascular 
turgescence;  the  nasal  duct  partici¬ 
pates  most  commonly,  if  not  always,  in 
the  diseased  action:  its  calibre  is  either 
annihilated  by  the  turgescence  of  its 
walls,  or  so  nearly  so,  that  the  morbid 


MR.  NORMAN’S  CASE  OF  INFLAMMATION  OF  THE  LACHRYMAL  SAC.  27 


secretion  of  the  sac  cannot  pass  down 
into  the  nose  ;  its  dense  fibrous  walls 
become  distended  ;  the  resistance  which 
they  and  the  surrounding  bony  struc¬ 
tures  afford  to  the  distending  force 
within,  augments  the  local  irritation, 
and  a  very  painful  throbbing  exists  in 
the  seat  of  disease  ;  the  pain  extends 
down  the  nose  and  cheek,  the  external 
surface  becomes  extremely  sensitive, 
and  much  irritative  fever  co-exists. 
It  rarely  happens  that  the  disease, 
arrived  at  such  a  state,  subsides  with¬ 
out  the  formation  of  an  opening 
through  the  integuments,  by  ulcera¬ 
tion  or  by  the  surgeon’s  knife  ;  for  the 
calibre  of  the  lachrymal  canals  is  at 
the  same  time  so  much  diminished  also 
by  participation  in  the  disease  of  the 
sac,  that  they  afford  no  backward 
course  to  the  accumulated  secretions, 
nor  way  of  escape  for  the  secretions  of 
the  conjunctiva  and  lachrymal  gland. 
These,  therefore,  increased,  and  gene¬ 
rally  vitiated  also,  escape  by  overflow- 
ingthe  lids,  andconstitutingstillicidium 
or  epiphora.  Now  this  affection  is  as 
little  liable  to  frequent  repetitions  as  it 
is  to  spontaneous  subsidence  ;  nor  do  I 
think  the  degree  of  suffering  to  which 
the  present  patient  was  subject,  was 
such  as  this  acute  affection  would  have 
occasioned. 

Again,  the  lining  membrane  of  the 
lachrymal  sac  and  nasal  duct  may  be 
the  seat  of  a  lower  form  of  inflamma¬ 
tory  action,  leading  to  a  certain  amount 
of  obstruction  to  the  due  passage  of  its 
own  secretions,  and  those  from  the  lids 
to  the  nose.  The  secretion  of  these 
parts  may  also  be  augmented  and 
changed  in  character,  and  a  swelling 
form  in  the  site  of  the  sac.  This  chro¬ 
nic  affection  may  originate  in  the  sac 
or  nasal  duct,  as  a  consequence  of  a 
cachectic  condition  of  the  system  at 
large,  or  of  disease  affecting  their  bony 
protections ;  or  it  may  be  occasioned 
by  the  extension  of  similar  disease  from 
the  conjunctiva  of  the  eyelids.  It  is 
altogether  chronic  and  indolent,  liable 
to  increase  and  diminution  from 
variations  in  the  general  health — in  the 
dryness  or  moisture  of  the  atmosphere, 
&c.  The  distension  of  the  sac  is  seldom 
great;  its  contents  consist  either  of  a 
clear  fluid,  (tears  probably),  inter¬ 
spersed  with  small  white  flakes,  or  of  a 
thin  muco-pus,  resembling  that  dis¬ 
charged  from  chroi\ic  abscess,  and  they 
can  be  forced  by  a  little  pressure  either 


into  the  nose  or  into  the  inner  canthus 
of  the  eye,  in  most  cases.  Of  this  the 
patient  is  often  aware  experimentally, 
and  without  teaching.  In  other  in¬ 
stances,  when  the  swelling  is  very  slight, 
he  is  not  conscious  of  any  disease  ex¬ 
isting,  except  from  the  occasional  over¬ 
flowing  of  the  tears,  and  sometimes 
from  the  agglutination  of  the  lids  on 
awaking  from  sleep.  Often,  too,  a  few 
white  shreds  or  flakes  may  also  be 
seen  floating  in  the  tears  retained  be¬ 
tween  the  lower  lid  and  the  globe. 
This  affection  sometimes  ceases  spon¬ 
taneously,  and  recurs  at  uncertain 
periods  ;  but  seldom  is  the  natural  sub¬ 
sidence  so  complete,  as  for  the  patient 
to  lose  altogether  the  “  watery  eye.” 
It  affects  both  the  young  and  the  old, 
but  chiefly  those  of  either  state  of  life, 
who  present  a  general  state  of  health 
that  might  be  called  lou ;,  or  a  constitu¬ 
tion  decidedly  strumous. 

3rdly.  There  is  a  state  termed  re¬ 
laxation  of  the  lachrymal  sac,  in  which 
that  organ  is  subject  to  very  considera¬ 
ble  distension.  In  this  form  of  disease 
a  tumor  forms  on  the  site  of  the  lach¬ 
rymal  sac,  and  consists,  indeed,  of  the 
sac,  whose  natural  dimensions  are  by 
reason  of  a  state  of  laxity  readily  dis¬ 
tended  by  the  secretions  of  its  own  lin¬ 
ing  membrane,  and  those  which  enter 
it  by  the  lachrymal  canals.  It  is  an 
affection  accompanied  by  little  pain  or 
suffering,  as  compared  with  that  felt  in 
the  acute  cases,  though  the  tumor 
attains  a  large  size;  it  produces,  like  all 
these  impediments  between  the  eye  and 
the  nose,  a  stillicidium  lachrymurum, 
is  relieved  from  time  to  time  by  pres¬ 
sure,  which  propels  its  contents  either 
into  the  nose  or  eyelds,  and  is  due, 
perhaps,  not  only  to  a  laxity  of  the 
lachrymal  sac,  but  also  to  a  chronic  in¬ 
flammation  of  its  lining  membrane,  and 
to  a  slight  thickening  of  the  membrane 
of  the  nasal  duct.  It  perhaps  deserves 
not  a  separate  name,  but  may,  I  think, 
be  considered  as  a  more  chronic  form 
still  of  inflammation  or  blenorrhoea, 
accompanied  by  a  lax  and  easily  dis¬ 
tended  state  of  the  sac  from  frequent 
attacks.  The  secretions  are  in  this  class 
of  cases  somewhat  changed  and 
opaque.  The  application  of  a  compress 
over  the  lachrymal  sac,  with  due  at¬ 
tention  to  the  general  health,  and  the 
use  of  such  means  as  improve  the 
secretions  of  the  eyelids,  and  can  reach 
the  sac  itself,  will  be  often  attended 


28  mr.  norman’s  case  of  inflammation  of  the  lachrymal  sac. 


with  a  complete  and  permanent  cure  of 
the  disease.  It  is  seldom  necessary  to 
open  the  sac. 

4thly.  A  far  less  frequent  form  of 
disease  attended  with  a  tumor  of  the 
lachrymal  sac  is  that  termed  mucocele 
— a  tumor  occasioned  by  a  collection 
of  mucus  in  the  sac,  the  ducts  com¬ 
municating  with  which,  and  the  lids 
and  nose,  being  impervious,  the  con¬ 
tents  can  neither  be  made  to  regurgitate 
upon  the  eyelids  nor  into  the  nose ; 
and  can  therefore  only  escape  by  some 
opening  either  artifically  made  or 
occasioned  by  ulceration.  It  is  obvious 
that  no  permanent  relief  can  be  given 
in  this  state  of  things,  by  any  means 
that  fall  short  of  suppressing  the  secret¬ 
ing  power  of  the  sac,  and  that  even 
such  means  will  fail  of  removing  that 
which  is  the  great  source  of  annoyance 
to  the  patient — the  overflowing  of  the 
tears  upon  the  cheek. 

Of  the  affections  thus  briefly  described, 
I  should  be  inclined  to  refer  the  case 
which  has  been  detailed  at  the  com¬ 
mencement  of  this  paper  to  the  second 
and  third  varieties — or  in  other  words, 
should  describe  it  as  a  case  of  chronic 
inflammation  of  the  lachrymal  sac 
with  relaxation.  It  had  not  the  active 
character  of  acute  inflammation,  though 
subject  to  occasional  accessions,  and 
though  the  induration  and  discoloura¬ 
tion  of  the  integuments  prove  the  in¬ 
flammatory  character  of  the  disease. 
The  occasional  complete  subsidence  of 
the  tumor  by  discharge  through  the 
nose,  and  its  final  subsidence  under  the 
means  used,  shew  that  the  nasal  duct 
was  not  obliterated.  The  absorption 
of  fluids  by  the  puncta  lachrvmalia 
proves  that  both  those  and  the  canals 
to  which  they  lead  were  still  patent. 
It  was  not,  therefore,  a  mucocele.  It 
was  just  one  of  those  cases  which  one 
engaged  in  much  ophthalmic  practice 
meets  with  from  time  to  time,  and 
which  confirms  him  in  the  propriety 
of  resorting  to  other  measures  than 
those  of  an  operative  and  mechanical 
character.  I  am  confident  that  the 
opening  of  the  sac,  and  the  introduc¬ 
tion  of  tubes  and  styles,  is  yet  far  too 
indiscriminately  resorted  to  in  slight 
obstructions  of  the  lachrymal  passages, 
and  I  have  quoted  the  preceding  case, 
not  because  it  is  unique,  but  as  a  text, 
and  with  a  view  of  confirming  by 
further  observations  that  which  has 
been  so  ably  stated  on  this  subject  by 


more  experienced  observers  again  and 
again  before.  I  have  met  in  the  course 
of  my  practice  in  the  last  few  years 
with  many  cases,  both  acute  and 
chronic,  which  have  yielded  so  com¬ 
pletely  to  the  steady  use  of  local  and 
general  medical  treatment,  that  I  very 
rarely  resort  to  insirumental  means,  re¬ 
serving  these  for  very  obstinate  chronic 
cases,  in  which  the  nasal  duct  seems 
to  be  so  much  contracted  and  so  per¬ 
manently  obstructed,  that  other  means 
prove  futile  ;  and  for  very  acute  cases 
in  which  a  considerable  collection  of 
matter  has  formed  in  the  sac,  before  I 
have  had  the  opportunity  of  using 
antiphlogistic  treatment,  and  there  is 
danger  of  its  bursting  upon  the  cheek 
in  such  a  manner  as  to  occasion  a  true 
fistula  lachrymalis.  In  the  former 
cases  l  introduce  a  style  at  once;  in 
the  latter  I  content  myself  wdth  open¬ 
ing  the  sac,  which  being  thus  enabled 
to  discharge  its  contents,  the  functions 
of  the  parts  frequently  recover  their 
natural  condiiion  under  ordinary  treat¬ 
ment,  though  it  becomes  sometimes 
necessary  after  a  time  to  introduce  a 
style  or  tube. 

I  had  a  young  woman  under  my 
care  about  a  year  and  a  half  ago, 
suffering  from  partial  amaurosis  of  the 
left  eye,  and  stilhcidium  lachrymum. 
She  was  in  a  very  cachectic  si  ate  of 
constitution,  from  vicious  habits  and 
want, — there  were  reasons  for  believ¬ 
ing  that  she  had  been  the  subject  of 
secondary  syphilis,  but  no  history  of 
the  primary  disease  could  be  obtained. 
The  lachrymal  sac  was  but  little  dis¬ 
tended,  but  a  muco-purulent  matter 
could  be  pressed  out  through  the 
puncta  upon  the  lids  ;  the  bridge  of  the 
nose  w7as  somewhat  fallen  in.  Her 
general  health  improved  under  the  use 
of  sarsaparilla,  &c.,  but  various  local 
means,  perseveringly  tried,  were  un¬ 
availing  to  cure  the  obstruction  of  the 
nasal  duct :  under  these  circumstances 
I  attempted  to  pass  a  style  after  open¬ 
ing  the  sac,  but  the  passage  of  the  in¬ 
strument  was  prevented,  apparently  by 
a  piece  of  diseased  bone.  Some  "time 
after,  a  piece  of  carious  bone  escaped 
from  the  nostril,  and  a  cure  quickly 
followed,  whilst  the  amendment  of  the 
general  health  was  sustained  by  im¬ 
proved  circumstances  and  better  habits 
of  life;  the  eye  recovered  its  functions 
perfectly  on  the  restoration  of  the 
health. 


I 


MR.  NORMAN'S  CASE  OF  INFLAMMATION  OF  THE  LACHRYMAL  SAC.  29 


A  very  similar  case  has  occurred 
much  more  recently  in  my  practice,  in 
the  person  of  an  Irishman,  about  tnirty 
years  of  age.  In  this  patient,  however, 
the  habit  of  body  was  much  more  de¬ 
bilitated,  the  nose  was  much  more  flat¬ 
tened,  and  a  profuse  foetid  discharge 
from  the  nostrils  accompanied  the  dis¬ 
ease.  The  introduction  of  the  style 
was  attempted,  after  a  long  trial  of 
other  means,  but  was  prevented  by  a 
similar  obstruction  to  that  which  ex¬ 
isted  in  the  preceding  case.  Several 
pieces  of  bone  have  come  from  the 
nostrils  at  different  times  since,  but  the 
blenorrhoea  of  the  sac  has  not  entirely 
ceased.  The  patient  has  also  suffered 
very  severely  from  sloughing  and  ulce¬ 
ration  of  the  palate  and  fauces,  from 
which  he  is  only  now,  after  some 
months  of  treatment,  recovering ;  and 
as  extensive  disease  of  the  bones  of  the 
nose  exists,  I  have  not  thought  it 
right  to  irritate  the  parts  by  any  re¬ 
currence  to  instrumental  means.  In 
this  determination  1  am  actuated  by 
the  conviction  that  those  means  would 
be  unavailing  at  present ;  by  the  fact 
that  the  disease  affecting  the  nostrils, 
and  the  general  state  of  cachexia,  are 
diminishing  under  general  treatment; 
and  by  the  check  that  is  maintained 
upon  the  stillicidium  by  occasionally 
pressing  out  the  secretions  of  the  sac 
upon  the  lids,  and  by  the  use  of  astrin¬ 
gent  lotions. 

In  these  cases  the  disease  of  the  nasal 
bones  caused  that  of  the  lachrymal  pas¬ 
sage.  One  of  the  worst  cases  of  ble¬ 
norrhoea  of  the  lachrymal  sac  that  I 
have  seen,  unaccompanied  with  fistula 
lachrymalis,  or  disease  of  the  adjacent 
bones,  was  that  of  a  little  boy  about 
five  years  old.  Both  lachrymal  sacs 
were  involved,  but  neither  of  them  was 
much  distended,  though  from  both  one 
could  always  press  out  a  considerable 
quantity  of  opaque  fluid  upon  the  eye¬ 
lids.  These  parts  were  also  slightly 
inflamed,  and  their  secretions  both  in¬ 
creased  in  quantity  and  changed  in 
quality.  The  skin  of  the  cheeks  was 
dry,  hard,  red,  and  scaly,  from  the 
overflowing  of  the  tears.  The  upper 
lip  was  swollen  and  thick ;  the  orifices 
of  the  nostrils  excoriated;  the  Schnei¬ 
derian  membrane  dry,  hard,  and  skin¬ 
like  ;  and  the  meatus  so  contracted  by 
thickening  of  the  parietes  that  a  com¬ 
mon  probe  could  not  be  passed  through 
one  of  them,  and  the  other  would  not 


admit  anything  much  larger.  He  was 
slightly  deaf,  and  his  tonsils  weremuch 
enlarged.  His  constitution  was  most 
decidedly  strumous,  and  the  intestinal 
secretions  were  much  disordered. 

Here  the  cause  of  the  local  malady 
was  clearly  constitutional. 

By  the  exhibition  of  alterative  medi¬ 
cines  and  steel, — by  the  introduction, 
of  small  greased  bougies  into  the  nos¬ 
trils, — by  systematically  and  regularly 
emptying  the  lachrymal  sacs,  and 
dropping  into  the  inner  commissures  of 
the  eyelids  weak  solutions  of  nitrate  of 
silver,  &c., — by  careful  attention  to 
diet,  clothing,  and  cleanliness,  much 
benefit  was  derived  to  the  general 
health,  and  the  state  of  the  eyelids  and 
lachrymal  sac  wTere  improved.  I  had 
reason  to  expect  a  cure,  but  the  parents 
became  impatient,  and  I  lost  sight  of 
the  case.  Whether  the  use  of  styles 
would  have  hastened  the  cure  I  do  not 
feel  certain,  but  should  have  given 
them  a  trial,  had  not  a  fair  perseve¬ 
rance  in  the  constitutional  and  local 
treatment  already  indicated  have  proved 
effectual  alone. 

But  as  I  have  already  said,  I  prefer 
what  seems  to  me  the  more  rational 
treatment — by  medicines,  &c. — so  long 
as  there  are  constitutional  .defects  to  be 
remedied,  and  a  fair  hope  of  their  suc¬ 
cess  exists. 

Experience  convinces  me  of  the  fre¬ 
quency  with  which  disease  of  the 
lachrymal  sac  is  to  be  traced  to  an  in¬ 
flammatory  condition  of  the  conjunc- 
tivse  of  the  eyelids,  which  is  pro¬ 
pagated  by  continuity  of  structure 
along  the  lachrymal  canals  to  the 
sac,  as  was  long  ago  insisted  on  by 
the  late  Mr.  Ware;  and  of  the  fre¬ 
quency,  also,  with  which  the  disease  of 
the  sac  may  be  successfully  managed 
by  the  means  in  ordinary  use  for  chro¬ 
nic  inflammation  of  the  conjunctival,  as 
also  urged  by  that  experienced  oculist. 
It  may  seem  out  of  place  and  uncalled 
for  to  insist  at  any  length  upon  this 
doctrine,  which  is  now  more  generally 
admitted  than  it  was  in  former  times; 
but  I  believe  that  however  generally 
admitted  as  a  doctrine ,  it  is  not  suffi¬ 
ciently  acted  on  as  a  principle .  The 
local  malady  may  in  so  many  instances, 
and  so  speedily,  be  remedied  by  ope¬ 
rative  treatment,  that  it  has  many  ad¬ 
vocates.  The  idea,  too,  that  one  line 
of  treatment  will  suit  almost  all  cases, 
has  its  attractiveness.  Operations  have 


30 


MR.  HINTON  ON  THE  APPLICATION  OF  THE 


their  charms,  also,  in  the  direct  cha¬ 
racter  of  their  results  ;  whilst  a  long, 
and  it  may  he  a  tedious,  medical 
treatment,  has  its  demerit.  Its  re¬ 
sults  are  less  direct  and  less  obvious. 
But  the  question  is— which  is  most 
consistent  with  scientific  principles; 
which  is  most  truly  beneficial  to  our 
patients?  I  would  answer  for  myself, 
that  which  aims  at  the  root  of  the  evil 
first — the  constitutional  and  local  medi¬ 
cal  general  means;  these  may  be  judi¬ 
ciously  aided  by  the  surgical  and  me¬ 
chanical,  as  auxiliary  to  them;  but 
when  the  latter  are  placed  first,  I  think 
they  generally  take  the  wrong  place, 
and  are  likely  to  lead  to  the  neglect  of 
the  former,  for  very  few  of  these  cases, 
if  any,  are  unaccompanied  with  some 
more  general  derangement  of  the  system. 

In  the  foregoing  remarks  I  have  not 
alluded  to  cases  of  no  unfrequent  oc¬ 
currence,  in  which  one  does  not  see  the 
patient  until  fistula  lachrymalis  has 
occurred.  In  most  of  these  cases  the 
fistula  cannot  be  cured  without  surgical 
treatment;  and  to  avoid  further  mis¬ 
chief,  it  is  well  immediately  to  enlarge 
the  fistulous  aperture,  making  at  the 
same  time  a  more  direct  opening  into 
the  sac,  and  to  introduce  some  dilating 
instrument  through  the  nasal  duct  into 
the  nose.  Even  in  such  cases,  how¬ 
ever,  recovery  does  occasionally  take 
place,  as  I  have  seen,  under  topical 
and  general  medical  treatment,  where 
it  has  been  fairly  tried,  in  consequence 
of  operative  measures  having  been  re¬ 
fused  by  the  patient.  But  I  should  not 
counsel  the  delay  of  an  operation  here, 
as  I  should  in  those  cases  before  al¬ 
luded  to,  in  which  the  lachrymal  sac 
has  not  burst,  and  can  be  emptied  by 
pressure.  The  circumstances  are 
widely  different:  and  whilst  in  the  one 
case  nothing  is  to  be  feared  from  delay, 
in  the  other  the  structures  of  the  lach¬ 
rymal  sac  may  be  so  injured  by  the 
extension  of  the  ulcerative  process 
which  has  already  occasioned  the  fis¬ 
tula,  that  its  functions  may  be  perma¬ 
nently  and  irrecoverably  destroyed. 

It  is  no  part  of  my  object  on  the  pre¬ 
sent  occasion  to  discussother  methods  of 
restoring  the  functions  of  the  lachrymal 
passages  by  the  introduction  of  instru¬ 
ments  into  the  nasal  duct,  either  from 
the  nostrils  or  through  the  lachrymal 
canals.  These,  with  the  system  of 
treatment  by  injections  into  the  sac, 
will  form  another  subject  for  inquiry. 


OX  THE  APPLICATION  OF 

THE  GALVANIC  PLATES  AND 
“  ELECTRIC  MOXA.” 

( Read  before  the  Pupils’  Physical  Society 
of  Guy’s  on  the  2Dth  Nov.  1847.) 

By  Joseph  Hinton, 

One  of  the  Presidents  of  the  Society. 


Among  the  numerous  remedies  which 
from  time  to  time  have  occupied  the 
attention  of  medical  men,  few  have 
been  brought  into  notice  without  ex¬ 
citing  various  opinions  regarding  their 
utility  :  being  on  the  one  hand  con¬ 
sidered  indispensable  —  the  sine  qua 
non  of  successful  practice ;  while,  on 
the  other  hand,  others  have  scarcely 
deigned  to  inquire  into  their  method  of 
action,  much  less  to  make  any  practi¬ 
cal  use  of  the  discovery.  Valuable 
remedies  have  shared  the  fate  of 
the  quackeries  of  a  day,  and  have 
been  laid  aside,  to  be  again  brought 
forward  more  prudently,  and  ulti¬ 
mately  with  better  success,  by  suc¬ 
ceeding  generations.  Such  has  been 
the  lot  of  an  agent  which  is  now  justly 
considered  a  most  important  remedy — 

I  allude  to  electricity.  When  first  in¬ 
troduced  it  attracted  great  attention, 
and  was  soon  considered  infallible  ; 
experience,  however,  proved  that  this 
title  had  been  unmerited,  and  in  a 
short  time  this  useful  and  valuable 
agent  fell  into  disuse.  But  as  the 
means  of  employing  this  important  re¬ 
medy  were  improved,  it  gradually  crept 
out  of  that  obscurity  into  which  it  had 
so  undeservedly  fallen,  and  being 
placed  on  the  safer  foundation  of  care¬ 
ful  experience,  it  again  advanced,  and 
from  that  time  the  benefit  resulting 
from  its  employment  has  steadily  in¬ 
creased  ;  numerous  cases  of  recovery 
from  paralysis,  and  nervous  affections 
of  various  kinds,  have  been  greatly  ex¬ 
pedited  by  its  application.  The  special 
employment  of  this  remedy  to  which  I 
wish  to  draw  attention  is  its  use  as  a 
counter-irritant,  a  stimulant  to  the  ner¬ 
vous  system,  and  even  as  a  caustic. 

For  this  valuable  application  of  elec¬ 
tricity  we  are,  I  may  say,  wholly  in¬ 
debted  to  the  researches  of  Dr.  Golding 
Bird. 

I  will  first  lay  before  the  Society  a 
short  account  of  the  case  in  which  it 
was  employed  as  an  experiment,  and 


GALVANIC  PLATES  AND  C(  ELECTRIC  MOXA.” 


31 


during  the  recital  of  the  case  the 
method  of  applying  this  apparatus  will 
be  fully  shewn;  following  up  the  re¬ 
port  with  a  few  remarks  on  the  case 
itself,  which  was  of  peculiar  interest, 
and  then  briefly  touch  upon  the  practi¬ 
cal  application  of  the  Electric  Moxa . 

Case. — Thos.  M - ,  aged  32  years, 

was  admitted  Dec.  30,  1847,  into  No. 

5,  Naaman  ward,  with  hemiplegia  of 
the  right  side,  under  the  care  of  Dr. 
Golding  Bird.  He  is  married,  by  trade 
a  tanner,  and  has  always  enjoyed  good 
health  ;  habits  temperate ;  no  heredi¬ 
tary  tendency  discoverable.  The  fol¬ 
lowing  history  was  obtained  : — On  the 
12th  of  this  month  he  retired  to  bed 
in  apparently  good  health,  but  during 
the  night  his  wife  was  disturbed  by  his 
making  a  peculiar  noise  with  his 
mouth  ;  on  obtaining  a  light,  however, 
he  appeared  to  be  asleep,  and  when 
roused,  said  there  was  nothing  the 
matter.  Some  incoherency  of  speech 
was  noticed,  but  attributed  to  sleep. 
He  was  restless  during  the  remainder 
of  the  night,  and  in  the  morning  it  j 
was  discovered  that  the  right  side  was  j 
completely  paralyzed,  the  speech  very 
imperfect,  and  the  face  considerably 
drawn  to  the  left  side.  He  was  at¬ 
tended  by  a  medical  practitioner ;  and 
the  more  alarming  symptoms  subsided 
under  antiphlogistic  treatment,  the  leg 
rapidly  regaining  power ;  so  that  when 
admitted  he  could  walk  tolerably.  The 
following  were  his  symptoms  on  admis¬ 
sion  :  occasional  pain  over  the  forehead, 
with  some  degree  of  vertigo ;  no  loss  of 
memory  ;  constant  tendency  to  laugh 
when  spoken  to;  paralysis  of  the  right 
facial  nerve  ;  both  pupils  dilated,  espe¬ 
cially  the  left;  both  acting  freely.  The 
arm  is  perfectly  motionless,  but  when 
he  gapes,  it  rises  involuntarily  ;  the  leg 
drags  slightly  ;  sensation  is  somewhat 
deficient  over  the  upper  extremity.  The 
tongue  turns  to  the  paralyzed  side,  and 
has  a  tolerably  thick  fur  on  that  side 
only.  Heart’s  action  normal;  pulse 
60,  full,  labouring,  firm;  bowels  regu¬ 
lar;  the  urine  acid,  and  remaining  un¬ 
altered  on  the  application  of  heat.  The 
head  is  rather  narrow  and  long,  but 
the  forehead  is  well  formed. 

After  the  bowels  had  been  well  acted 
on,  electricity  wTas  used  daily  in  the 
form  of  sparks  drawn  from  the  spine, 
and  he  certainly  improved;  on  the  8th 


of  January  the  sulphate  of  zinc  was 
ordered  in  grain  doses,  three  times  a 
day. 

Jan.  15th.  —  Feels  much  better; 
countenance  improved  ;  twisting  of  face 
scarcely  noticed ;  pupils  equally  di¬ 
lated  ;  tendency  to  laughing  continues. 
He  can  now  walk  without  a  stick. 
Power  of  motion  increases;  he  can. 
partially  throw  out  the  arm,  and  in  the 
morning  can  clasp  the  fingers  a  little; 
this  power,  however,  is  soon  lost.  He 
sleeps  badly. 

From  this  date  little  alteration  took 
place  until  the  18th,  when  Dr.  Bird 
ordered  the  following  plan  to  be 
adopted.  Two  blisters  having  been 
formed,  one  about  the  insertion  of  the 
deltoid,  and  the  other  over  the  poste¬ 
rior  part  of  the  wrist-joint,  a  zinc  plate, 
the  size  of  half  a-crown,  with  copper 
wire  attached,  was  applied  to  the  upper 
and  a  silver  plate  to  the  lower.  Over 
each  plate,  water  dressing  was  applied, 


82 


MR.  HINTON  ON  THE  APPLICATION  OF  THE 


and  above  this,  oiled  silk  (merely  for 
the  purpose  of  retaining'  the  moisture), 
which  was  secured  by  strapping.  The 
arm  was  then  enveloped  in  a  loose 
roller,  through  the  folds  of  which  the 
wires  connected  with  the  plates  pro¬ 
truded,  and  on  contact  being  made, 
the  patient  experienced  a  tingling 
sensation  at  the  silver  plate  alone. 

19th. — About  3  a.m.  he  experienced 
severe  pain  in  the  arm,  which  soon 
wore  off.  Motion  very  much  im¬ 
proved  ;  the  arm  can  be  raised  to  a 
level  with  the  shoulder,  and  power 
over  the  fingers  is  greatly  increased. 
The  patient  was  quite  delighted  at  the 
sudden  progress  which  he  had  made. 
Tingling  sensation  still  experienced. 
The  apparatus  was  taken  off  in  the 
evening  ;  the  surface  of  the  upper  sore 
(zinc)  wras  coated  with  a  firm  whitish 
matter,  like  lymph.  Nothing  peculiar 
about  the  lower  sore  ;  the  plates  were 
again  applied.  For  the  next  few  nights 
he  experienced  severe  pain  and  spasm 
of  the  muscles  of  the  arm,  but  this  did 
not  last  long.  On  the  20th  and  21st, 
he  thought  that  there  was  less  motion, 
but  on  trial  he  could  still  lift  the  arm 
on  a  level  with  the  shoulder.  On  the 
22nd,  he  lifted  it  above  the  level  of  the 
shoulder,  and  could  clasp  slightly.  On 
the  23rd,  he  could  lift  his  arm  on  to  his 
head.  The  slough  forming  on  the  zinc 
sore,  appears  to  increase  in  thickness 
Before  taking  off  the  apparatus,  I  tried 
whether  any  current  was  passing,  but 
failed  in  obtaining  any  decided  effect 
on  the  galvanometer.  With  another 
patient,  who  was  then  in  the  house,  by 
constantly  breaking  and  reforming  the 
current,  the  needle  moved  over  an  arc 
of  30°. 

On  the  29th  the  slough  was  found 
to  be  separating:,  and  exuding  a  thin 
sanious  pus.  The  apparatus  was  or¬ 
dered  to  be  discontinued,  and  a  bread 
poultice  to  be  applied.  A  faint  blush 
is  all  that  remains  of  the  sore  above 
the  wrist. 

31st. — The  slough  has  separated, 
leaving  a  most  perfect-  specimen  of  a 
healthy  granulating  sore. 

The  sore  began  to  heal  rapidly,  its 
healthy  character  continuing — the  pus 
poured  out  being  perfectly  healthy. 
PouTer  over  the  arm  increases. 

He  continued  to  improve  up  to  Feb. 
11th.  The  dose  of  zinc  was  then  in¬ 
creased,  and  gradually  reached  seven 


grains  three  times  a  day  ;  but  for  the 
next  fortnight  the  powder  of  motion,  if 
anything,  decreased.  He  again  went  to 
the  electrifying  room,  and  again  he  im¬ 
proved.  The  sore  had  now  nearly  dis¬ 
appeared,  maintaining  a  healthy  cha¬ 
racter,  until  nearly  healed.  The 
granulations  then  became  rather  flabby. 
On  the  27th,  he  was  made  an  out¬ 
patient. 

As  connected  with  this  case  of  he¬ 
miplegia,  there  are  several  points  of 
great  physiological  interest. 

1st.  Emotional  tendency. 

Dr.  Watson,  in  his  Lectures,  says, 
“after  the  coma  has  passed  off,  there 
are  two  ways  in  which  the  patient  may 
be  affected  — 1st,  defective  memory, 
more  or  less  partial ;  and  2nd,  a  pecu¬ 
liar  tendency  to  emotion,  especially 
emotions  of  grief ;  the  patient  will  weep 
from  slight  causes  long  after  the  attack 
of  apoplexy  has  passed  off.”  Now,  here, 
the  loss  of  memory,  if  present  at  the  on¬ 
set,  shortly  disappeared;  theemotional 
tendency,  howTever,  was  well  marked, 
but  it  was  of  quite  a  different  character 
from  that  usually  observed,  being  here 
characterized  by  a  desire  to  laugh.  The 
patient  himself  was  perfectly  aware  of 
it,  but  was  quite  unable  to  prevent  it, 
often  remarking  that  it  was  very  silly; 
when  last  I  saw  him  in  the  summer,  it 
was  still  present.  These  tendencies  to 
various  emotions  may  in  some  cases 
materially  assist  the  diagnosis,  as  they 
are  frequently  present  before  the  attack. 
Dr.  Watson  mentions  several  cases,  and 
remarking  on  them,  adds,  “  these  and 
many  other  signs  indicate  a  disposition 
to  the  disease.  They  show,  that,  even 
before  the  stroke  descends,  there  is 
some  morbid  process  going  on  within 
the  skull.”  On  this  account,  then, 
these  symptoms  are  of  importance,  as 
they  may  enable  us  to  ward  off  an  ap¬ 
proaching  attack  by  appropriate  treat¬ 
ment. 

2ndly.  As  regards  sensation*  and 
motion.  The  law  in  cerebral  paralysis 
is,  that  motion  is  more  affected  than 
sensation.  When  we  meet  with  cases, 
in  which  the  opposite  is  shewn,  we 
must  look  for  some  functional  distur¬ 
bance,  some  poison  circulating  :n  the 
blood,  rather  than  to  the  existence  of  a 
clot.  The  influence  of  the  inhalation 
of  ether  is  a  case  in  point,  motion 
being  little  affected.  Dr.  Gull  has 
offered  the  following  explanation  of  the 


GALVANIC  PLATES  AND  “  ELECTRIC  MOXA.” 


33 


cause  : — he  says,  “the  law  of  lesion  is 
this — any  given  injury  to  the  fibres  di- 
•m’nishesthe  power  of  motion  more  than 
that  of  sensation,  whether  the  lesion  be 
in  the  fibres  passing  from  the  corpus 
striatum,  or  from  the  optic  thalamus 
to  the  convolutions.”  Two  conditions 
arise  from  this — 1st,  the  fibres  of  the 
sensory  nerves  are  much  more,  say 
one- third,  more  numerous  than  the 
motor,  if  we  may  judge  from  the  size 
of  the  posterior  roots,  as  the  ultimate 
fibrils  have  the  same  diameter.  The 
ultimate  stimuli,  also,  to  the  sensory 
nerves,  are  more  numerous  than  those 
of  the  motor. 

“2dly.  In  seusatioji,  the  seat  of  per¬ 
ception  is  to  a  degree  passive  ;  in  mo¬ 
tion,  it  is  an  origin  of  power.  It  is 
evident  that  in  the  former  a  less  vital 
condition  is  required  than  in  the 
latter:  hence  a  priori  we  should  have 
concluded  that  a  given  injury  would 
have  destroyed  volition  more  than 
sensation  ;  and  we  should  also  have 
concluded  that  injury  would  first  de¬ 
prive  us  of  directive  influence,  and 
then  of  the  power  altogether.  These 
remarks  are  made,  as  bearing  upon  the 
received  theory  of  their  being  distinct 
centres  for  sensation  and  motion,  which 
hypothesis  seems  to  have  been  unwar¬ 
rantably  built  upon  the  great  discovery 
of  Bell  on  the  double  function  of 
nerves,  which  discovery  is  by  no 
means  opposed  to  the  idea  of  sensa¬ 
tion  and  volition  being  in  the  same 
centre.” 

3dly.  The  more  rapid  recovery  of 
the  leg.  This  is  important,  inasmuch 
as  it  may  mislead  the  inexperienced  to 
suppose  that  the  arm  will  also  recover. 
Unfortunately  this  is  too  frequently 
found  to  be  a  false  hope;  hence  the 
prognosis  as  regards  the  arm  should  be 
guarded.  The  reason  for  this  Mr. 
Mayo  supposed  to  be,  that  some  shock 
was  transmitted  from  the  injured  brain, 
and  that  in  consequence  it  affected  the 
nearest  part  most.  Dr.  Watson  re¬ 
marks,  that  if  this  were  the  case,  we 
ought  to  have  it  always  present;  but, 
out  of  75  cases  collected  by  Andral,  12 
were  of  the  leg  alone.  Dr.  Gull  offers 
the  following  explanation  :  —  “  The 
spinal  covd,  the  nerves  arising  from  it, 
and  the  muscles  to  which  they  are 
distributed,  form  a  mechanism  for  mo¬ 
tion,  which  acts  according  to  laws  in¬ 
cluded  in  its  formation,  and  which  can 
be  modified  by  habit,  becoming  part  of 


the  law  of  the  machine,  and  termed 
automatic.  The  volition,  having  its 
origin  in  the  encephalon,  can  direct* 
and  move  the  machine.  From  observa¬ 
tion  we  find  that  the  voluntary  in¬ 
fluence  can  be  directed  with  the 
greatest  precision  and  force  upon  the 
upper  extremity.  We  also  find, 'from 
observation,  that,  the  spinal  cord  being 
separated  from  the  direct  influence  of 
the  encephalon,  the  arm  reacts  less  on 
an  impulse  being  given  to  its  nerves, 
than  the  lower  extremity,  from  which, 
we  may  infer  that  the  original  auto¬ 
matic  power  of  the  arm  (excito- motor 
power)  is  less  than  that  of  the  leg. 
Hence,  if  only  a  certain  influence  passes 
to  the  spinal  system  from  the  encepha¬ 
lon,  the  leg  will  be  more  affected  than 
the  arm  ;  that  is  to  say,  in  other  words, 
volition  will  be  more  marked  in  the 
lower  than  in  the  upper  extremity  in 
recovery.  Another  circumstance  must 
be  taken  into  account  in  considering 
the  phenomena  of  recovery  from  a 
clot — viz.  that  as  the  nervous  centres 
are  everywhere  continuous,  and  that 
each  part  is  readily  affected  by  injury 
to  those  adjacent  ;  so  any  given  injury 
to  the  encephalon  will  react  most  on 
that  part  of  the  spine  which  is  nearest, 
cceteris  paribus. 

The  twelve  cases  noticed  by  Andral 
may  appear  to  negative  this  view;  but 
it  remains  to  be  proved  by  further  obser¬ 
vation  whether  these  cases  were  really 
genuine  cases  of  hemiplegia  from  cere¬ 
bral  haemorrhage,  or  whether  they  may 
not  be  more  correctly  attributed  to 
spinal  affection.  Two  cases  have  lately 
come  under  Dr.  Gull’s  notice,  in  both 
of  which,  on  careful  examination,  the 
spine  was  found  to  be  implicated.  One 
of  these  is  an  out-patient ;  the  other  is 
at  present  in  No.  3,  Charity  ward.  In 
the  latter  case  it  appears  doubtful  whe¬ 
ther  any  cerebral  hmmorrhage  took 
place  at  all,  and  whether  the  cerebral 
symptoms  may  not  be  referred  to  in¬ 
creased  vascularity  alone. 

4thly.  The  involuntary  raising  of 
the  arm  during  the  act  of  yawning . 
This  fact  is  mentioned  by  Carpenter, 
but  no  attempt  is  made  to  offer  any 
explanation.  Here  also  I  may  state 
an  explanation  proposed  by  Dr.  Gull : 
— “  This  may  be  explained  by  the  fact 
that  injury  to  any  of  the  fibres  going 
from  the  corpus  striatum  or  thalamus 
opticus  to  the  convolutions,  diminishes 
the  power  over  the  extremities.  Thus, 


34  MR.  HINTON  ON  THE  APPLICATION  OF  GALVANIC  PLATES,  ETC. 


A  if  the  line  of  continuity  from 
A  to  B  be  interrupted,  no  force 
can  pass  from  A  to  B;  but  if 
the  force  originates  in  B,  it 
may  pass  on  to  C  below  it. 

B  Now,  if  we  let  A  represent  the 
cerebral  hemispheres,  and  B  the 
medulla  oblongata,  C  the  bra¬ 
chial  plexus,  the  explanation  is 
tolerably  clear. 

5thly.  Irregularity  of  pupil. —  The 
third  nerve  arising  above  the  bifurca¬ 
tion  ought  to  be  affected  on  the  same 
side ;  and  so  it  was  in  this  case  :  the 
left  pupil  was  considerably  larger  than 
the  right. 

6thly,  and  lastly,  the  stale  of  the 
tongue. — This  I  have  not  seen  noticed 
in  any  book  :  it  is  frequently  connected 
with  local  irritation  on  one  or  other 
side  of  the  mouth,  such  as  cynanche 
tonsillaris  or  diseased  teeth  ;  but  there 
was  nothing  of  the  kind  to  account  for 
it  here.  Might  it  not  arise  from  the 
want  of  motion  on  that  side  of  the 
tongue  ;  so  that,  being  less  subject  to 
friction  than  the  sound  side,  the  mucus, 
&c.,  collects  upon  it,  and  remains  there 
while  the  other  side  is  less  free  P  In 
this  case  it  varied  from  time  to  time, 
being  occasionally  absent,  but  most 
frequently  it  was  well  marked. 

As  regards  the  employment  of  elec¬ 
tricity  this  appeared  to  be  a  favoura¬ 
ble  case.  The  patient  had  com¬ 
pletely  passed  the  dangerous  period 
of  reaction,  and  was  perfectly  free  from 
all  appearance  of  fever,  and  accord¬ 
ingly  he  was  electrified  three  times 
during  the  week.  Some  progress  was 
made,  and  it  then  occurred  to  Dr. 
Bird  that  a  continuous  feeble  current 
might  prove  more  beneficial,  and  he 
determined  to  try  the  plates.  To  my 
mind  the  result  was  most  satisfactory 
for  the  time ;  and  1  think  that  greater 
progress  was  made  during  the  few  days 
that  the  apparatus  was  applied,  than 
at  any  previous  or  subsequent  period. 
We  were  not,  however,  prepared  to  see 
a  large  slough  separate  from  the  sore 
to  which  the  zinc  had  been  placed; 
and  when  the  slough  had  separated, 
the  use  of  the  plates  was  discontinued. 
Some  practical  results,  however,  were 
further  to  be  obtained  from  its  applica¬ 
tion,  and  to  these  I  will  briefly  allude. 

1st.  Seeing  that  a  large  suppurating 
surface  was  exposed,  with  compara¬ 


tively  little  pain,  Dr.  Bird  determined 
to  employ  it  as  a  moxa;  and,  from  its 
action,  he  named  it  the  “  Electric 
Moxa.”*  Following  out  this  idea,  it 
was  used  in  several  cases  in  this  hos¬ 
pital,  with  unvaried  success.  In  the 
case  of  a  little  girl,  who  was  admitted 
into  Miriam  ward,  with  commencing 
degeneration  of  the  apex  of  the  left 
lung,  the  effect  was  produced  without 
the  slightest  complaint  of  pain.  I  am 
sorry  to  find,  however,  that  this  freedom 
from  pain  is  not  an  invariable  accom¬ 
paniment.  Dr.  Gull  used  it  in  a  case 
in  private,  and  the  patient  said  he  had 
never  suffered  such  torment :  but  there 
appears  to  have  been  a  reason  for  this — - 
the  disease  under  which  the  patient 
laboured  was  spinal;  and  this  system 
was  in  an  extreme  state  of  sensibility, — 
this,  in  some  measure,  if  not  wholly, 
accounts  for  it.  There  is,  however,  as 
a  general  rule,  more  pain,  with  some 
spasm  of  the  muscles,  when  the  current 
from  the  plates  passes  in  the  direction 
of  the  ramifications  of  a  spinal  nerve; 
and  this  pain  appears  to  recur  chiefly 
at  night — of  course,  if  the  contact  is 
destroyed,  the  pain  and  spasm  cease. 
If  applied  on  the  chest,  the  plates 
should  be  placed  as  much  below  the 
dress  as  possible  ;  the  cicatrix  (so  far  as 
I  have  seen)  has  a  very  uneven  surface, 
and  in  case  of  recovery,  some  of  our 
fair  friends  might  feel  inclined,  and 
with  great  propriety,  to  disagree  with 
their  medical  attendant,  for  leaving 
them  so  marked  a  legacy. 

The  plates  were  subsequently  tried 
in  a  case  of  dropped  hands,  the  zinc 
plate  being  placed  over  the  extensor 
muscles  :  it  produced  a  slough,  but  I 
do  not  think  that  the  paralysis  was  les¬ 
sened. 

On  observing  that  the  blister  upon 
which  the  negative  plate  was  placed 
healed  so  rapidly,  Dr.  Bird  suggested 
its  application  to  old  indolent  ulcers, 
and,  accordingly,  when  I  became 
dresser  for  Mr.  Bransby  Cooper,  it  was 
several  times  put  to  the  test,  and  with 
varied  results,  but  on  the  whole,  satis¬ 
factory.  The  cases  in  which  it  seemed 
to  produce  an  extraordinary  effect 
were  those  of  tertiary  sores  ;  one  of 
these  cases  had  previously  resisted  all 
kinds  of  treatment.  It  is  in  these  cases, 

*  Lectures  on  the  Therapeutical  Application  of 
Electricity,  delivered  at  the  Royal  College  of 
Physicians,  May  1847  ;  in  Medical  Gazette, 
vol.  iv.  New  Series,  page  981. 


HYGIENE  IN  THE  NAVY. 


35 


I  imagine,  that  it  acts  as  an  alterative, 
setting  up  a  fresh  action.  It  was  also 
tried  in  a  case  in  Stephen  ward :  here 
the  character  of  the  ulcer  was  very 
much  altered :  it  assumed  a  remarkably 
congested  appearance,  and  the  dis¬ 
charge  became  sanguinolent :  yet  even 
in  this  case,  (in  my  opinion),  the  most 
unfavourable  that  I  witnessed,  the  size 
of  the  ulcer  diminished,  and  cicatriza¬ 
tion  commenced  at  the  lower  part. 

Seeing  that  the  formation  of  the 
slough  depended  on  the  action  of  the 
chloride  of  zinc,  and  knowing  how 
exquisitely  painful  the  common  appli¬ 
cation  of  this  remedy  proves,  I  sug¬ 
gested  to  Mr.  Cooper  that  its  applica¬ 
tion  might  be  successful  in  destroying 
small  scirrhous  masses,  where  from 
various  circumstances  the  surgeon  does 
not  feel  justified  in  using  the  knife; 
this  was  put  to  the  test  in  a  case  of 
open  scirrhous  breast  in  Dorcas  ward ; 
in  this  case  there  was  a  large,  deep, 
irregularly  excavated  sore,  with  hard¬ 
ened  ba^e,  and  often  excessively  ten¬ 
der.  After  the  slough  had  separated, 
the  negative  plate  was  applied,  and  in 
some  points  cicatrization  commenced — 
the  great  tenderness  was  much  relieved. 
From  the  great  irregularity  of  the  sur¬ 
face  of  the  sore,  it  was  difficult  to 
apply  it  very  effectually,  yet  the  hard¬ 
ness  at  the  base  of  the  sore  was  mate¬ 
rially  lessened. 

I  may  state  here  that  in  subsequent 
trials,  it  was  found,  that  in  forming  a 
slough,  one  blister,  placed  where  the 
slough  was  to  be  formed,  in  general 
proved  sufficient,  providing  the  surface 
of  the  skin  to  which  the  silver  plate 
wras  applied  were  previously  bathed 
with  a  little  salt  and  water,  so  as  to  make 
it  a  good  conductor. 


CHLOROFORM  IN  THE  UNITED  STATES. 

The  anaesthetic  excitement  which  prevailed 
a  short  time  since,  has  rapidly  subsided,  as 
we  anticipated  it  would.  The  occurrence  of 
fatal  consequences  in  several  instances  in 
which  ether  and  chloroform  were  admini¬ 
stered,  particularly  the  latter,  has  cast  a 
dark  shade  over  the  use  of  these  agents. 
The  danger  now  is,  that  we  shall  run  into 
the  opposite  extreme,  and  instead  of  having 
recourse  to  these  remedies  for  pain  in  trifling 
cases,  decline  to  employ  them  in  those  in 
which  they  may  be  most  necessary  and 
proper. — Phil.  Med.  Exam.  May,  1848. 


MEDICAL  GAZETTE. 


FRIDAY,  JULY  7,  1848. 

Although  there  remains  nothing 
more  to  be  said  on  the  subject  of  the 
“  Eclair”  and  the  Boa  Yista  fever,  yet 
the  late  report  of  Dr.  King  brings  to 
light  a  scandalous  piece  of  neglect  in 
relation  to  the  sanitary  condition  of 
Government  steam-vessels.  It  was 
reasonable  to  suppose  that  a  vessel  in 
which  there  had  been  such  a  large 
amount  of  mortality,  would  either  have 
been  abandoned  altogether,  or  at  any 
rate,  in  these  days,  when  “  disinfect¬ 
ants”  abound,  so  cleansed  and  purified 
that  no  risk  would  have  been  incurred 
by  refitting  her  for  service.  Dr.  King’s 
report,  however,  clearly  shews  that  the 
authorities  allowed  matters  to  take 
their  course ;  and,  but  for  the  fact 
that  the  local  origin  of  fever  appa¬ 
rently  received  some  support  from  the 
admission,  the  public  would  probably 
have  heard  nothing  of  the  mode  in 
which  pest-ships  are  dealt  with. 

In  the  first  place,  the  name  was 
changed,  and,  in  November,  1846,  the 
Eclair  was  commissioned  at  Wool¬ 
wich  as  the  “  Rosamond.”  The  vessel 
was  ordered  to  the  Cape  ;  but  it  is 
rather  significant  of  her  suspected 
condition,  that  not  one  of  the  former 
crew  would  rejoin  her.  We  shall 
now  allow  Dr.  King  to  state  the 
facts : — 

“During  the  time  of  fitting  out,  four 
cases  of  typhus  fever  occurred,  and 
were  sent  to  the  hospital,  where  two 
of  them  died ;  but  it  is  necessary  to 
mention  that  typhus  was  prevalent  at 
Woolwich  at  the  time.  The  steamer 
left  England,  for  the  Cape,  on  the  23d 
of  February,  1847.  Three  days  after 
sailing,  one  of  the  men  was  affected 
with  slight  febrile  symptoms,  and  he 
continued  more  or  less  indisposed  for 
a  number  of  days,  but  occasionally  felt 
so  well  that  he  returned  to  his  work. 


36 


HYGIENE  IN  THE  NAVY. 


After  the  ship  entered  the  tropics, 
however,  the  disease  began  to  assume 
a  new  and  alarming  character;  and 
when  off  the  island  of  St.  Nicholas, 
and  almost  in  sight  of  Boa  Vista,  the 
man  died,  having  had,  for  two  days 
previous,  black  vomit  and  other  cha¬ 
racteristic  symptoms  of  the  yellow 
fever.  Within  a  few  days  afterwards 
the  “  Rosamond”  arrived  at  Ascension, 
where  I  was  then  stationed ;  and 
Commander  Foot  having  communi¬ 
cated  to  Captain  Hutton,  the  super¬ 
intendent  of  the  island,  every  parti¬ 
cular  respecting  the  illness  and  death 
of  the  seaman,  I  was  ordered,  with 
Hr.  Sloan,  the  surgeon  of  the  hospital, 
to  make  a  report  on  the  case,  and,  at 
the  same  time,  to  suggest  measures 
for  the  benefit  of  the  ship,  without  en¬ 
dangering  the  health  of  the  people  on 
the  island.  Having  obtained  from 
Dr.  Slight,  surgeon  of  the  “  Rosa¬ 
mond,”  every  information  relative  to 
his  late  patient,  we  stated  our  opinion 
that  the  disease  the  man  died  from 
was  sporadic  yellow  fever  ;  and  as  the 
weather  was  then  extremely  sultry, 
and  the  hottest  month  in  the  year 
(April)  approaching,  and  the  hospital 
being  full  of  patients,  we  recommended 
that  the  necessary  supplies  should  be 
furnished  without  delay,  and  the  ship 
hastened  on  to  her  destination,  the 
Cape  of  Good  Hope. 

“  On  the  following  morning  I  went 
on  board,  with  the  view  of  learning 
something  to  enable  me  to  form  an 
opinion  as  to  the  sanitary  condition  of 
the  ship,  and  for  the  purpose  also  of 
inspecting  the  sick,  as  the  surgeon  in¬ 
formed  me  he  had  then  a  suspicious 
case,  with  symptoms  of  a  low  kind  of 
fever.  I  had  barely  time  to  take  a 
cursory  view  of  the  after  parts  of  the 
ship,  when  my  attention  was  called  to 
the  patients,  whov  were  all  mustered 
in  the  steerage  ;  and  I  found  the  man 
the  doctor  had  alluded  to  in  such  a 
state  that  I  recommended  him  to  be 
sent  on  shore  immediately.  The  only 
other  severe  case  was  that  of  a  super¬ 
numerary  lad,  who  was  taken  ill  the 
same  morning,  but  the  indications  of  a 
low  malignant  fever  were  so  apparent 
even  at  that  early  stage  as  to  induce 
me  to  express  my  opinion  to  the  sur¬ 
geon  that  he  would  not  probably  sur¬ 
vive  twenty-four  hours.  As  it  was 
most  desirable  to  prevent  a  panic 
amongst  the  ship’s  company,  1  went 


on  shore  to  consult  with  Captain 
Hutton,  and  make  arrangements  for 
their  reception.  The  point  was  settled 
very  soon :  I  was  to  take  them,  and 
two  other  ladswho  slept  in  thesame  part 
of  the  ship  (and  who  were  found  to 
have*incipient  fever),  to  the  sick  quar¬ 
ters  on  the  Green  Mountain.  The  ar¬ 
rangement  was  quite  agreeable  to  my 
wishes  as  I  was  most  anxious  to  avoid 
the  risk  of  again  complicating  an  im¬ 
portant  question,  which  has  been  al¬ 
ready  sufficiently  mystified  ;  viz.,  the 
contagious  or  non-contagious  nature  of 
the  disease.  Before  we  had  half  ac¬ 
complished  our  short  journey  to  the 
Green  Mountain,  the  poor  boy  became 
delirious,  and,  without  having  had  one 
favourable  symptom  from  the  com¬ 
mencement  of  the  attack,  he  died  at 
the  sick  quarters,  after  an  illness  of 
thirty-six  hours.  Had  wre  made  a  post¬ 
mortem  examination,  I  have  no  doubt 
that  the  matter  of  black  vomit  would 
have  been  found  in  the  stomach  or 
intestines;  but  unfortunately  the  assis¬ 
tant-surgeon,  Dr.  Andrews,  had  for¬ 
gotten  his  instruments  in  the  hurry  of 
leaving  the  garrison.  The  body,  how¬ 
ever,  soon  after  death,  assumed  a  dark 
and  motley  appearance,  especially  the 
abdomen,  buttocks,  and  the  lower  ex¬ 
tremities.  The  other  three  patients 
recovered  slowly,  but  were  at  length 
cured,  and  discharged  to  Her  Majesty’s 
ship  ‘  Tortoise.’  None  of  the  marines 
who  attended  them  as  nurses,  nor  the 
assistant-surgeon,  caught  the  fever ; 
nor  was  it  communicated  to  any  one  in 
the  island. 

“  The  patients  themselves  attributed 
their  illness  to  foul  air  in  the  fore  part 
of  the  ship;  one  of  them  said  he  suf¬ 
fered  so  much  from  an  abominable 
stench  in  the  boatswain’s  storeyoora 
that  he  represented  the  circumstance, 
and  obtained  permission  to  cut  a  hole 
in  the  floor,  which  exposed  to  view  a 
considerable  quantity  of  soft  mud  ;  and 
five  or  six  buckets  full  of  it ,  mixed  with 
decayed  shavings ,  and  emitting  an  offen¬ 
sive  odour,  were  removed  at  the  lime. 

“  It  appears,  then,  that  besides  an 
unusual  number  sleeping  in  the  fore¬ 
cockpit,  some  of  them  at  least  had  been 
exposed  to  a  morbific  miasma  exhaled 
from  a  festering  mass  of  filth  in  the 
bottom  oj  that  part  of  the  ship.  The 
quantity  of  mud,  no  doubt,  was  small 
in  comparison  with  what  had  accumu¬ 
lated  when  the  vessel  arrived  at  Spit- 


HYGIENE  IN  THE  NAVY 


37 


head  from  the  coast  of  Africa  ;  yet  the 
malaria  eliminated  from  that  small  and 
circumscribed  focus  was  equally  viru¬ 
lent  in  its  operation,  and  produced  the 
same  disease  in  a  few  who  were  placed 
within  the  sphere  of  its  influence.” 

The  inquiry  naturally  suggests  itself, 
why  a  crew,  thrown  off  their  guard  by 
the  alteration  in  the  name  of  this  ship, 
were  allowed  to  embark,  and  live 
in  the  midst  of  a  “  festering  mass  of 
filth.” 

We  quite  agree  with  the  Govern¬ 
ment  reporter  that  a  ship  which  is 
sickly  may  be  pronounced  to  be  clean, 
from  a  loose  and  careless  examination 
of  the  hold  ;  and  we  cannot  help  think¬ 
ing  that  the  cleansing,  if  it  had  here 
taken  place  at  all,  had  been  carried  out 
in  a  most  imperfect  manner.  It  is 
otherwise  impossible  to  suppose,  that, 
only  three  days  after  sailing,  one 
of  the  crew  should  have  been  attacked 
with  febrile  symptoms ;  and  that,  when 
the  ship  reached  the  latitude  of  the  Cape 
de  Yerd  islands,  the  disease  assumed 
the  alarming  characters  of  yellow 
fever,  and  the  man  died.  Four  other 
cases  occurred,  one  of  which  proved 
fatal ;  and  some  management  was  re¬ 
quired,  in  order  to  prevent  a  panic 
amongst  the  crew.  These  facts  are 
quite  inconsistent  with  the  idea  that 
the  ship  was  in  a  proper  condition  for 
a  voyage  when  she  left  this  country  ; 
for  among  the  many  hundreds  of  ves¬ 
sels  sailing  through  the  same  latitudes, 
we  do  not  find  the  same  alarming  and 
fatal  attacks  of  the  so-called  sporadic 
yellow  fever,  although  the  vessels  and 
the  crews  are  exposed  to  similar  atmos¬ 
pheric  and  marine  influences.  The 
subject  may  not  have  attracted  the  at¬ 
tention  of  Government;  but  it  appears 
to  us  that  the  sanitary  condition  of  our 
ships  should  be  as  much  an  object  of 
superintendence  and  care,  as  that  of  the 
streets  and  alleys  of  our  populous  cities. 
This  is  especially  necessary  in  steam¬ 
ships,  in  which  from  the  high  tempe¬ 


rature  that  always  prevails,  the  causes 
most  favourable  to  decomposition  are 
constantly  in  action.*  We  care  little 
about  “  disinfectants,”  as  they  are 
absurdly  called.  They  can  be  of  no 
possible  service  where  cleanliness  is 
not  observed,  or  where  a  ship  is  so 
badly  constructed,  that  her  hold  be¬ 
comes  foul,  and  a  source  of  morbific 
miasmata  in  the  course  of  a  few 
weeks’  voyage  on  the  open  Atlantic. 
We  therefore  advise  sanitary  refor¬ 
mers,  so  soon  as  the  Public  Health  Bill 
has  received  the  royal  assent,  to 
direct  their  attention  to  the  state  of  our 
navy.  The  revelations  made  in  Dr. 
King’s  report,  show  that  hygiene  is 
not  sufficiently  attended  to  in  this 
department  ;  and  that  our  Govern¬ 
ment  ships  may  in  consequence  either 
be  the  means  of  engendering,  or  of 
importing,  a  most  malignant  and  in¬ 
tractable  disease. 


Mcbtefos. 


Practical  Observations  on  Midwifery , 
and  the  Diseases  incident  to  the  Puer¬ 
peral  State .  By  A.  H.  M‘Cuntock, 
M.D.,  and  Samuel  Hardy,  M.D., 
Ex-assistants  of  the  Dublin  Lying-in 
Hospital.  8vo.  pp.  368.  Hodges 
and  Smith,  Dublin.  1848. 

This  volume  may  be  regarded  as  a 
valuable  compendium  of  practical  mid¬ 
wifery.  It.  consists  of  a  series  of  clinical 
and  statistical  reports,  drawn  up  by 
the  authors  from  the  cases  which  pre¬ 
sented  themselves  at  the  Dublin  Lying- 
in  Hospital  during  the  three  years  that 
they  were  connected  with  that  institu¬ 
tion.  We  have  therefore  in  it  the 
results  of  a  large  share  of  experience  in 
clinical  midwifery,  in  a  form  conve¬ 
nient  for  reference.  The  subjects  are 
treated  by  the  authors  in  the  following 
order: — Saturn l  Labour ,  Tedious  and 
Difficult  Labours,  Preternatural  La¬ 
bours,  Complex  Labours ,  Convulsions , 


*  The  temperature  of  the  hold  of  a  Government 
steam  vessel  on  the  West  India  station,  has  been 
known  to  be  as  high  as  154°  F. ! 


38 


PRACTICAL  OBSERVATIONS  ON  MIDWIFERY,  AND  THE 


Rupture  of  the  Uterus ,  Funis  Presen¬ 
tations,  Ophthalmia  Neonatorum,  and 
the  Management  of  Stilt- horn  Children. 
The  whole  of  these  subjects  are  illus¬ 
trated  by  numerous  cases,  in  which  the 
plan  of  treatment  pursued  and  the 
autopsy,  when  the  case  was  fatal,  are 
given ;  and  to  each  section  are  ap¬ 
pended  some  judicious  practical  re¬ 
marks.  In  order  that  our  readers  may 
judge  of  the  character  of  the  work,  we 
shall  proceed  to  make  a  few  extracts; 
and  first,  in  reference  to  Puerperal  In¬ 
sanity.  After  detailing  the  particulars 
of  a  case  in  which  the  attack  was  very 
sudden,  the  authors  observe  : — 

“  In  the  majority  of  cases,  however,  it 
does  not  come  on  in  this  abrupt  way,  but  is 
preceded  for  a  few  days  by  certain  symptoms, 
which  the  watchful  practitioner  will  scarcely 
fail  to  observe  and  to  profit  by.  The  most 
common  of  these  premonitory  symptoms  are 
a  disposition  to  find  fault  or  quarrel  with 
her  nurse,  loss  of  sleep,  and  quickness  of 
pulse.  On  other  occasions  suspicion  will  be 
first  excited  by  some  deviation  in  the 
patient’s  manner  or  language  from  what  is 
■usual  or  natural  to  her ;  thus  she  will  be 
peevish  or  fretful,  or  sullen  and  discontented. 
When,  from  the  concurrence  of  two  or  more 
of  these,  an  attack  of  mania  is  apprehended, 
orders  should  be  immediately  given  to  keep 
the  patient  as  quiet  and  undisturbed  as 
possible  ;  and  further,  it  is  necessary  to  have 
her  closely  and  unremittingly  watched  by  a 
vigilant  attendant,  as  well  to  prevent  her 
doing  harm  to  the  infant  as  to  herself.  This 
disposition  to  injure  themselves  or  their 
offspring  is  a  striking  feature  in  puerperal 
insanity,  and  one  which  it  is  most  important 
to  bear  in  mind  throughout  the  entire  treat¬ 
ment.  After  a  patient  has  become  decidedly 
maniacal,  she  will  often  prove  refractory, 
and  obstinately  refuse  taking  her  medicine 
or  submitting  to  rule,  and  the  contest  will 
he  whether  she  or  the  doctor  is  to  have  the 
ascendancy.  Under  these  circumstances  it 
is  requisite  for  the  physician  to  exercise 
much  tact  and  resolution  in  his  language 
and  conduct  towards  the  patient.  If  he 
does  not  succeed  in  enforcing  his  directions 
by  mild  expostulation,  he  must  show  himself 
to  be  determined,  and,  without  harshness, 
insist  on  his  orders  being  obeyed  ;  for  if, 
through  vacillation  or  want  of  resolution,  he 
now  fail  to  establish  his  authority,  he  will 
lose  all  control  or  restraint  over  the  patient ; 
whereas,  on  the  other  hand,  if  he  carry  his 
point,  and  bring  her  into  compliance,  it  will 
have  a  lasting  effect,  and  she  will  probably 
stand  in  awe  of  him  during  the  remainder  of 
her  illness. 

“  A  striking  example  of  this  occurred  in  the 


Hospital.  A  patient  in  a  ward  with  five 
others  became  maniacal,  and  at  the  same 
time  so  violent,  that  it  was  thought  neces¬ 
sary  to  separate  her  from  the  rest,  and  to 
put  her  into  a  room  by  herself.  When  they 
came  to  remove  her,  however,  she  appeared 
resolved  not  to  go,  and  maintained  her  posi¬ 
tion  with  such  strength  and  obstinacy,  as 
to  set  at  defiance  all  the  efforts  of  the  nurse 
to  effect  her  transportation.  In  this  di¬ 
lemma  Dr.  Hardy  (being  the  assistant  on 
duty)  was  sent  for,  and,  seeing  how  the 
matter  was,  quietly  lifted  the  patient  up  in 
his  arms,  and  carried  her  bodily  into  the 
ward  appropriated  for  her  reception.  From 
being  extremely  boisterous  and  unmanage¬ 
able,  she  immediately  calmed  down  into  a 
state  of  perfect  submission,  and  seemed  as  it 
were  quite  awe-stricken  by  the  unexpected 
suddenness  of  the  act.  She  did  not  again 
give  any  trouble.  Until  she  was  quite 
recovered,  the  presence  of  Dr.  H.  always 
put  her  into  a  state  of  trepidation  and  alarm, 
and  any  command  of  his  she  promptly  and 
implicitly  obeyed” — (pp.  67-68). 

The  authors  refer  to  a  fact  of  some 
practical  interest  connected  with  this 
disorder,  namely,  that  abdominal  in¬ 
flammation  sometimes  alternates  with 
the  alienation  of  reason,  and  this  at  a 
period  after  delivery  when  a  patient  is 
usually  considered  free  from  the  liabi¬ 
lity  to  such  attacks.  An  instance  is 
quoted  in  which  a  female  some  days 
after  delivery  became  maniacal,  and  in 
this  state  continued  for  a  week,  when 
she  regained  the  possession  of  her  in¬ 
tellect  ;  but  to  this  immediately  suc¬ 
ceeded  violent  peritonitis,  which  car¬ 
ried  her  off  (p.  71.)  This  should  be 
taken  into  consideration  in  forming  a 
prognosis. 

On  the  use  of  the  Ergot  in  tedious 
labours  the  following  observations  are 
made  : — 

“  When  the  ergot  acts  at  all,  we  have 
usually  remarked  that  it  does  so  within 
fifteen  minutes  from  the  time  of  its  admini¬ 
stration.  If  a  bad  description  of  ergot  be 
used,  it  may  naturally  be  expected  that  it 
will  produce  little  or  no  effect.  This,  we 
believe,  is  the  most  common  cause  of  its 
failure ;  but  there  is  another,  not  generally 
known  or  recognised,  namely,  where  it  is 
given  at  a  very  advanced  period  of  a  difficult 
labour,  when  the  pains  have  nearly  entirely 
ceased,  and  the  vaginal  discharge  has  be¬ 
come  fetid  and  olive-coloured.  Under  these 
circumstances  the  drug  rarely  exerts  any 
influence  in  bringing  about  a  return  of  the 
pains ;  in  fact  it  would  seem  as  if  the  muscu¬ 
lar  irritability  of  the  uterus  had  been  com- 


DISEASES  INCIDENT  TO  THE  PUERPERAL  STATE. 


39 


pletely  exhausted.  It  by  no  means  follows 
as  a  consequence  that  the  ergot  will  not  act  on 
the  child  because  it  does  not  act  on  the 
uterus,  for  we  have  seen  numerous  instances 
where  the  child  was  unquestionably  affected 
by  it,  although  the  uterus  was  wholly  un¬ 
affected,  or  nearly  so.  We  have  on  many 
occasions  observed  the  ergot  of  rye  to  ex¬ 
ercise  a  very  depressing  influence  upon  the 
maternal  circulation,  lowering  the  rapidity 
of  the  pulse  ten  or  twenty  beats  per  minute. 
In  some  few  instances  this  effect  lasted  for 
two  or  three  days” — (pp.  83-84). 

The  ergot  was  employed  in  the  In¬ 
stitution  in  the  form  of  infusion.  Half 
a  drachm  of  the  fresh  powder  was 
infused  in  half  a  small  cupful  of  boiling 
water  for  ten  or  fifteen  minutes,  when 
it  was  strained.  To  the  infusion  ten 
or  fifteen  grains  more  of  the  powder 
were  added,  with  some  sugar  to  make 
it  palatable.  This  constituted  the  or¬ 
dinary  dose,  and  it  was  repeated  in 
about  twenty-five  minutes  if  thought 
requisite :  a  third  dose  was  seldom 
given.  We  learn  from  another  part  of 
the  work,  that  the  ergot  was  found  to 
be  a  valuable  remedy  in  the  treatment 
of  secondary  haemorrhage.  It  was 
usually  given  in  six- grain  doses  three 
times  a  day  ;  but  where  the  discharge 
had  been  profuse,  fifteen  or  twenty 
grains  were  administered  at  once  (p. 
235.)  The  results  were  very  satisfac¬ 
tory.  This  bears  out  the  view  taken 
by  Mr.  C.  A.  Aikin,  of  the  utility  of 
this  drug  in  the  suppression  of  haemorr¬ 
hage.* 

The  authors  concur  with  Dr.  Beatty, 
in  the  opinion  that  dangerous  effects 
may  be  produced  by  ergot  on  the  child,  - 
and  they  consider  its  safe  administra¬ 
tion  in  tedious  labours^  to  be  restricted 
to  those  “  cases  of  arrest,”  in  which 
delivery  may  be  effected  at  any  time 
by  the  vectis  or  forceps,  should  the 
resort  to  instruments  become  neces¬ 
sary,  in  order  to  save  the  child. 

“  It  is  with  extreme  reluctance,  and  only 
when  impelled  by  unavoidable  necessity,  that 
the  secale  is  ever  given  here  in  any  other 
cases  than  these  ;  for,  independent  of  con¬ 
siderations  towards  the  mother’s  safety,  ex¬ 
perience  has  amply  proved  that  the  child 
will  undoubtedly  perish  unless  delivery  be 
accomplished  within  a  limited  time  after 
having  exhibited  the  ergot,  and  therefore  it 
is  an  important  desideratum  that  the  use  of 
the  forceps  be  feasible  before  resorting  to 


*  See  Medical  Gazette,  March  31,  1848,  p. 
532. 


the  administration  of  this  remedy.  Thus, 
to  use  the  words  of  Dr.  Johnson,  *  when 
ergot  is  given  it  brings  matters  to  a  crisis  ; 
for  if  the  child  be  not  delivered  within  a 
certain  time,  it  will,  in  all  probability,  be 
destroyed/  The  period  during  which  it  is 
safe  to  wait,  and  beyond  which  delay  cannot 
be  permitted  with  impunity  to  the  life  of  the 
foetus,  varies  in  every  case,  and  can  only  be 
known  by  carefully  observing  with  the 
stethoscope,  the  changes  that  take  place  in 
the  foetal  cardiac  sounds.  As  long  as  they 
remain  unaffected  there  is  no  necessity  for 
hastening  the  delivery ;  but  if  they  become 
diminished  in  frequency,  and  depressed  in 
strength,  and  if  at  the  same  time  there 
should  be  any  irregularity  or  intermission  in 
the  beats,  then  no  time  is  to  be  lost  in  ter¬ 
minating  the  labour,  as  the  delay  of  a  few 
minutes,  under  these  circumstances,  will 
decide  the  child’s  fate.  Dr.  Beatty  states, 
that  ‘  he  is  inclined  to  place  two  hours  as 
the  limit  of  safety,  and  to  consider  a  pro¬ 
longation  of  labour  beyond  that  period  as 
perilous  to  the  infant/  Dr.  Hardy,  in  his 
paper  on  the  effects  of  ergot,  writes,  ‘  that 
to  this  rule’  (of  Dr.  Beatty’s)  ‘  he  has  met 
with  but  three  exceptions.  It  by  no  means 
follows  from  this/  he  continues,  *  that  a 
period  of  two  hours  should  elapse  from  the 
exhibition  of  ergot  until  the  expulsion  of  the 
child.  In  two  instances  the  children  were 
lost,  although  only  twenty  minutes  in  one, 
and  twenty-five  in  the  other,  had  passed 
from  the  administration  of  the  ergot  to  their 
expulsion’  ” — (pp.  79-80). 

Out  of  259  tedious  and  difficult 
labours,  173  females  were  delivered 
without  any  instrumental  assistance. 
Of  this  number,  it  appears  30  had  ergot 
administered  to  them,  to  overcome 
inertia  in  the  second  stage  of  labour  ; 
and  only  ten  out  of  the  thirty  children 
were  born  alive.  “  This,”  observe  the 
authors,  “  furnishes  strong  proof,  were 
any  such  required,  of  the  deleterious 
influence  of  ergot  upon  the  foetus,  as  in 
nearly  every  one  of  the  above  instances 
there  was  unequivocal  evidence  of  the 
child’s  vitality  when  the  ergot  was 
given,  and  in  the  great  majority  of 
them  delivery  took  place  within  two 
or  three  hours  after  the  administration 
of  the  medicine.”  (p.  95.) 

In  reference  to  the  treatment  of 
hcemorrhage  before  delivery,  the 
authors  dissent  from  the  new  views 
which  have  been  recently  promulgated 
on  this  subject. 

“  The  operation  of  turning  should  not  be 
performed  until  the  mouth  of  the  womb  be 
so  far  dilated,  or  in  such  a  condition  as  to 
offer  no  material  resistance  to  the  passage  of 


40 


PRACTICAL  OBSERVATIONS  ON  MIDWIFERY. 


the  hand.  The  best  practitioners  are  una¬ 
nimous  in  condemning  all  attempts  at 
rudely  forcing  the  hand  through  the  uterine 
orifice,  as  the  very  worst  results  are  to  be 
apprehended  from  such  a  proceeding, — one 
which  is  in  any  case  dangerous,  but  in  these  of 
placenta  prsevia,  peculiarly  so.  ‘It  is  seldom 
safe,’  writes  Dr.  Lee,  ‘  to  attempt  to  deliver 
by  turning  before  the  os  uteri  is  so  far 
dilated  that  you  can  easily  introduce  the 
points  of  the  four  fingers  and  thumb  within 
it :  however  soft  and  relaxed  it  may  be,  until 
dilatation  has  commenced  and  proceeded  so 
far,  I  am  convinced  there  are  very  few  cases 
in  which  the  operation  of  turning  will  be  re¬ 
quired,  or  completed  without  the  risk  of 
inflicting  some  injury  on  the  os  uteri.  This 
is  a  point  of  the  greatest  practical  import¬ 
ance,  but  I  do  not  know  in  what  manner  to 
communicate  to  you,  in  words,  a  more  clear 
and  definite  idea  of  the  grounds  upon  which 
you  ought  to  proceed’  ” — (pp.  197-198). 

“  Of  the  plan  lately  recommended  by 
Drs.  Simpson  and  Radford,  for  extracting 
the  placenta  before  the  child  in  certain  cases 
of  haemorrhage,  we  cannot  speak  from  ex¬ 
perience  ;  and  the  mere  expression  of  our 
opinion  upon  its  merits  would  not  carry 
much  weight.  Dr.  Johnson  entertains  very 
strong  objections  to  the  practice,  not  only 
because  it  necessarily  destroys  the  child,  but 
also  from  a  conviction  of  its  inapplicability 
to  cases  of  rigid  os  uteri,  which  is  the  chief 
or  almost  only  obstacle  to  the  performance 
of  turning  in  placenta  prsevia  cases.  With¬ 
out  entering  into  any  analytical  examination 
of  the  ingenious  arguments  brought  forward 
by  Dr.  Simpson  in  support  of  this  novel 
mode  of  treatment,  we  would  venture  to 
make  a  few  casual  remarks  upon  one  or  two 
of  his  positions.  In  the  first  place,  as  re¬ 
gards  the  source  of  the  haemorrhage,  he 
writes  :  *  I  know  of  no  reason,  anatomical  or 
otherwise,  for  alleging  that  the  open  pla¬ 
cental  orifices  do  not  bleed ;  and  on  the 
contrary,  I  believe  with  Dr.  Hamilton  and 
others,  that  the  discharge  issues  principally 
or  entirely  from  the  vascular  openings  which 
exist  on  the  exposed  placental  surface ;’  and 
again  he  observes  :  *  in  proportion  as  we 
approach  nearer  and  nearer  a  total  separation 
of  the  placenta,  the  number  of  its  different 
utero-placental  vessels  are  diminished,  till 
at  last  we  find,  that  when  the  one  organ  is 
once  completely  separated  from  the  other, 
the  flooding  is  instantly  moderated  or  entirely 
arrested.’  Now  if  this  doctrine  were  correct, 
the  conclusion  might  legitimately  be  drawn, 
that  haemorrhage  after  the  birth  of  the  child 
and  expulsion  of  the  placenta  ought  to  be  an 
exceedingly  rare  occurrence :  but  unfor¬ 
tunately  such  is  not  the  case,  as  every  one 
knows.  We  do  not  at  all  deny  the  possi¬ 
bility  of  haemorrhagic  discharge  taking  place 
from  the  detached  portion  of  a  partially 


separated  placenta,  for  there  is  no  physio¬ 
logical  reason  why  this  should  not  happen  ; 
but  we  cannot  persuade  ourselves  that  the 
great  amount  of  the  haemorrhage  does  not 
proceed  from  the  uterine  vascular  orifices” — ■ 
(pp.  198-199). 

Drs.  M‘Clintock  and  Hardy  object 
to  the  tables  of  mortality  drawn  up  by 
Dr.  Simpson,  because  they  compare 
cases  which  do  not  admit  of  a  fair  com¬ 
parison  . 

“Lastly,  we  must,  with  a  very  recent 
writer,  express  our  surprise  that  Dr.  Simpson 
should,  in  his  tables  of  mortality,  have  in¬ 
cluded  cases  of  the  spontaneous  separation 
and  expulsion  of  the  placenta,  with  those 
cases  where  artificial  separation  had  been 
resorted  to  ;  the  former  being  examples  of 
an  entirely  natural  process,  carrying  along 
with  them  self-evident  proof  that  most 
energetic  and  'powerful  uterine  action  must 
have  been  present,  which  satisfactorily  ex¬ 
plains  why  the  haemorrhage  ceased  upon  the 
expulsion  of  the  placenta” — (p.  200). 

Our  space  will  not  allow  us  to  go 
further  into  an  analysis  of  this  work, 
and  we  shall  close  our  notice  by  an  ex¬ 
tract  from  the  first  page.  We  are  there 
informed,  that  the  report  extends  from 
1842  to  1845,  and  during  this  period 
6(534  women  were  delivered  in  the 
Institution,  and  gave  birth  to  6702 
children.  The  primiparse  amounted  to 
2125,  being  nearly  one  third  of  the 
whole  number.  The  total  deaths  were 
65,  giving  an  average  mortality  of  1  in 
102  cases  ;  and  35  of  these  deaths  were 
amongst  the  primiparee.  Of  the 
children  there  were — 


Males 

t3551  :  of  whom 

Females  \ 
3151  :  of  whom  ^ 


198  were  born  dead, 
and 
62  putrid. 

127  were  born  dead, 
and 
80  putrid. 


These  facts  corroborate  the  common 
opinion,  that  a  greater  number  of  male 
children  are  lost  during  labour  than  of 
female  children ;  while  the  greater 
number  of  those  which  die  in  utero 
are  females. 

We  quote  this  statistical  summary, 
in  order  that  our  readers  may  perceive 
that  the  authors  have  had  an  ample 
field  for  collecting  their  practical  ob¬ 
servations.  That  they  have  made  good 
use  of  the  opportunity  thus  afforded 
them,  is  manifest  from  the  work  now 
before  us.  We  recommend  it  as  a 
valuable  addition  to  our  obstetric  lite- 


STOMACH  AND  RENAL  DISEASES.  CANCER  OF  THE  LIP. 


41 


rature.  It  has  this  advantage  over  sys¬ 
tematic  treatises,  that  we  can  watch 
the  progress  of  treatment,  and  are  able 
to  form  a  judgment  of  the  inferences 
drawn  by  the  authors.  To  all  who  are 
engaged  in  the  practice  of  midwifery, 
it  will  prove  an  excellent  guide. 


On  the  Nature  and  Treatment  of 
Stomach  and  Renal  Diseases.  By 
William  Prout,  M.D.  F.R.S.,  Fel¬ 
low  of  the  Royal  College  of  Physi¬ 
cians,  &c.  The  fifth  edition  revised, 
pp.  585.  London:  Churchill,  1848. 

After  an  interval  of  nearly  five  years, 
we  have  to  announce  the  appearance  of 
a  fifth  edition  of  this  excellent  treatise, 
on  the  chemical  pathology  of  a  most 
important  class  of  diseases.  The 
favourable  reception  which  it  has  met 
with  in  the  profession,  is  a  satisfactory 
proof  of  the  value  attached  to  the 
author’s  labours  by  men  engaged  in 
practice,  for  it  is  to  them  that  this  work 
is  chiefly  addressed.  The  fact  that  the 
treatise  has  reached  its  fifth  edition  also 
proves  that  English  chemistry  has  not 
been  quite  swept  away  in  the  flood  of 
German  hypotheses  with  which  we 
have  been  of  late  overwhelmed,  in  rela¬ 
tion  to  diseases  of  the  urinary  organs. 
The  fact  is,  as  the  authorpithily  observes 
in  his  preface,  “  before  the  truth  can  be 
known,  chemists  must  work  more,  and 
speculate  less.”  At  present  the  plan  is 
to  speculate  first,  and  work  afterwards. 
There  is  no  objection  to  this,  provided 
we  do  not  become  so  wedded  to  our 
speculations,  as  to  mistake  them  for 
facts.  The  contests  into  which  Liebig 
has  been  drawn  with  Mulder,  Laurent, 
Gerhardt,  and  others,  has  laid  bare 
some  strange  secrets  regarding  the 
manufacture  of  chemical  formulas,  and 
the  mode  in  which  figures  and  symbols 
are  shifted  and  transposed  in  order  to 
suit  particular  views.  The  struggles 
of  the  Edinburgh  and  Quarterly  Re¬ 
views,  (we  mean  our  non-medical  con¬ 
temporaries),  to  maintain  in  their  full 
ascendancy  the  new  chemical  doctrines, 
have  ended  in  failure.  Men  may  be 
dazzled  by  what  is  beautiful,  but  they 
will  insist  upon  looking  below  the  sur¬ 
face;  and  in  matters  of  science  they 
will  in  the  end  only  yield  their  judg¬ 
ment  to  that  which  is  demonstrable. 
We  do  not  agree  with  Dr.  Prout  in 
thinking  that  formulae,  when  properly 
employed,  are  to  be  regarded  as  clumsy 


and  unphilosophical  expedients;  bu 
we  think  he  is  quite  justified  in  saying 
that  few  of  them  represent  the  true  con¬ 
stitution  of  organised  substances:  and 
it  is  in  our  view  questionable,  whether 
chemical  science  lias  not  lost  more  than 
it  has  gained  by  the  very  free  introduc¬ 
tion  of  empirical  formulae. 

To  give  an  analysis  of  the  contents  of 
a  book  which  has  been  so  long  before 
the  profession  as  that  before  us,  would 
be  a  work  of  supererogation.  Dr. 
Prout’s  treatise  has  for  some  years 
deservedly  found  a  place  among  those 
which  are  referred  to  and  consulted  as 
works  of  authority.  The  present  edi¬ 
tion  appears  to  have  been  most  care¬ 
fully  revised,  and  its  value  is  increased 
by  the  addition  of  many  well-executed 
illustrations,  some  of  which,  as  the 
author  duly  acknowledges,  have  been 
derived  from  the  researches  of  Dr.  Gold¬ 
ing  Bird.  We  can  recommend  this 
volume  to  all  who  are  engaged  in  prac¬ 
tice.  It  will  be  found  a  most  useful 
guide  in  cases  requiring  a  careful 
diagnosis. 


(£oi‘vegpon  hence. 


ON  CANCER  OF  THE  LIP. 

Sir, — Your  report,  in  the  last  number  of 
the  Gazette  (June  23),  of  Mr.  Bransby 
Cooper’s  Lecture  on  Regional  Surgery, 
has,  in  reference  to  cancer  of  the  lip,  these 
words : — 

“  Sir  Astley  Cooper  states  that  he  had 
seen  upwards  of  two  hundred  cases,  in  only 
one  of  which  the  upper  lip  was  the  seat  of 
the  disease.”  And  again,  “  It  generally 
attacks  men  after  the  middle  age,  females 
being  seldom  the  subjects  of  the  complaint. 
I  have,  indeed,  never  seen  a  case  in  a  fe¬ 
male.” 

Now,  a  surgeon  of  Sir  Astley’s  extensive 
experience  having  seen  only  one  case  of 
cancer  in  the  upper  lip ;  and  so  excellent  a 
practical  surgeon  as  Mr.  Bransby  Cooper 
having  never  seen  a  case  of  cancer  of  the  lip 
in  the  female ,  it  must  be  inferred  that  such 
cases  are  of  extremely  rare  occurrence. 

I  cannot,  therefore,  but  deem  it  a  singular 
coincidence,  that  a  case  of  each  kind  fell  to 
my  lot,  on  the  same  day,  about  three  weeks 
since.  Two  old  women,  very  near  neigh¬ 
bours,  came  from  a  very  considerable  distance 
out  of  Wales,  and  presented  themselves  at 
our  Infirmary.  One  of  them,  76,  with 
cancer  in  the  upper ,  and  the  other,  80  years 
i  of  age,  with  cancer  in  the  lower  lip.  I  ope- 


42  ACTION  FOR  ILLEGAL  PRACTICE  OF  MEDICINE  IN  CANADA. 


rated  upon  both  on  the  same  day.  Both 
cases  did  well,  and  both  went  home  together. 
They  were  both  well-marked  cases  of  cancer, 
of  some  standing.  The  one  in  the  upper 
lip  encroached  on  the  right  nostril ;  and,  as 
it  occupied  some  extent  of  the  substance  of 
the  lip,  it  was  necessary  to  remove  it  by  the 
V-shaped  incision.  The  lower,  having  oc¬ 
cupied  only  a  superficial  extent  of  the  border 
of  the  lip,  was  removed  by  the  horizontal 
incision. 

Should  you  deem  the  above  cases  worthy, 
from  their  singularity,  of  a  place  in  your 
next  number,  you  will  perhaps  give  insertion 
to  this  brief  notice  of  them. — I  am,  sir, 
Yours  very  respectfully, 

John  Dickin. 

Shrewsbury,  June  2S,  1848. 


#tetucal  Intelligence. 


THE  PROFESSORSHIP  OF  CLINICAL  SURGERY 
IN  EDINBURGH. 

Professor  Syme  has  been  allowed  by  the 
Crown  to  withdraw  his  resignation  of  the 
Chair  of  Clinical  Surgery  in  the  University 
of  Edinburgh,  and  he  will  accordingly  resume 
his  duties  in  that  seminary  next  session. 

RESIGNATION  OF  MEDICAL  OFFICERS  AT 
THE  YARMOUTH  HOSPITAL. 

At  the  Yarmouth  Hospital  the  Governors 
have  taken  upon  themselves  to  appoint  a 
consulting-surgeon.  A  vacancy  having  oc¬ 
curred  by  the  death  of  the  late  holder  of  the 
office,  a  meeting  was  held  on  the  28th  June 
to  make  the  appointment  It  was  protested 
against  by  the  medical  men,  as  creating  an 
invidious  distinction  ;  and  it  was  contended 
by  them  that  it  ought  only  to  be  given  as  a 
•compliment  when  one  of  the  old  surgeons, 
from  age  or  a  wish  to  retire  from  active 
practice,  resigned  his  appointment ;  but  the 
meeting  thought  otherwise,  and  refused  to 
listen  to  the  remonstrances  of  the  medical 
staff.  They  have  appointed  as  consulting- 
surgeon  a  personal  friend  of  one  of  the 
leading  members  of  the  committee.  The 
whole  of  the  medical  men  attached  to  the 
hospital  then  tendered  their  resignations,  in 
which  they  were  supported  by  all  the  re¬ 
spectable  practitioners  of  the  town.  A  most 
unfair  prejudice  was  raised  against  the  staff, 
by  stating  that  they  wished  to  rule  the  in¬ 
stitution.  If  medical  men  will  now  act 
consistently,  there  is  an  opportunity  of  show¬ 
ing  to  the  Governors  that,  in  the  management 
of  an  hospital,  the  medical  officers  have  a 
right  to  be  treated  with  courtesy,  and  some 
weight  given  to  their  opinions.* 

*  Communicated  by  a  correspondent,  who  has 
forwarded  his  name. 


THE  WOUNDED  IN  PARIS. 

The  number  of  wounded  admitted  into  the 
civil  hospitals  of  Paris  during  the  23d,  24th, 
25th,  26th,  27th,  and  28th  ult.,  amounted 
to  1,61 9,  namely,  773  civilians,  813  military, 
and  33  women.  The  dead  carried  to  these 
hospitals  during  the  same  interval,  were  162 
in  number,  namely,  127  civilians,  33  mili¬ 
tary,  and  2  women.  195  died  in  the  hos¬ 
pitals  within  the  same  period,  namely,  115 
civilians,  77  military,  and  3  women. 

ACTION  FOR  THE  ILLEGAL  PRACTICE  OF 
MEDICINE  IN  CANADA. 

The  College  of  Physicians  and  Surgeons  of 

Lower  Canada  v.  Silas  Gregory. 

This  was  an  action  professing  to  be  based 
upon  the  10th  and  11th  Viet.  c.  26,  to  re¬ 
cover  a  penalty  of  ten  pounds  from  the  de¬ 
fendant,  for  having,  as  the  information 
alleged,  practised  physic  on  two  several  oc¬ 
casions.  Mr.  Johnson,  Q.C.,  appeared  for 
the  defendant,  and  demurred  to  the  infor¬ 
mation  on  the  following  grounds  : — 

The  section  imposing  a  penalty  is  worded 
as  follows : — “  And  be  it  enacted,”  &c.  &c. 
“  that  no  person  shall  practise  physic  or  sur¬ 
gery  in  Lower  Canada,  unless  he  be  a  per¬ 
son  duly  licensed  so  to  practise,  under  a 
penalty  of  five  pounds  currency  for  each  day 
on  which  any  person  shall  so  practise  ;  and 
such  penalty  shall  be  recoverable,  on  the 
oath  of  any  two  credible  witnesses,  before 
any  Justice  of  the  Peace,”  &c. 

These  words  do  three  things — first,  they 
create  an  offence  ;  secondly,  they  enact  a 
penalty  for  its  commission;  and  thirdly, 
they  create  a  jurisdiction  to  enforce  that 
penalty.  A  penalty  created  in  such  a  ge¬ 
neral  way  may  be  admitted  to  be  recoverable 
by  the  Crown,  but  not  at  the  suit  of  the 
present  plaintiffs,  to  whom  no  authority  to 
sue  qui  tam,  or  in  any  other  way,  is  given 
by  the  statute.  The  prayer  of  the  informa¬ 
tion  is,  that  “  the  defendant  be  adjudged  to 
have  forfeited  ten  pounds  to  Her  Majesty, 
and  that  he  be  condemned  to  pay  the  same 
to  Her  Majesty,  her  heirs  and  successors,” 
&c.  &c.  This  prayer,  of  course,  could  not 
be  granted  except  at  the  suit  of  the  Crown, 
which  is  not  made  a  party  to  the  action  ! 
The  present  suit,  therefore,  by  the  “  College 
of  Physicians  and  Surgeons,”  demands  no¬ 
thing  which  they  have  any  right  to  demand 
for  themselves,  but  something  alleged  to  be 
due  to  the  Crown,  which  does  not  demand  it. 

The  case  was  taken  en  delihere  by  Mr. 
Amiot,  before  whom  it  was  tried,  and,  on 
the  12th  inst.,  he  gave  judgment,  dismissing 
it. — Brit.  Amer.  Journal ,  June. 

MONTREAL  GENERAL  HOSPITAL. 

The  late  Chief  Justice  Reid,  one  of  the 
warmest  and  oldest  friends  of  this  institution, 
bequeathed  a  large  sum  of  money,  sufficient 


NEW  SYSTEM  OF  PRACTICE.  FATAL  EFFECTS  OF  CHLOROFORM.  43 


for  the  building  of  another  wing  to  the  hos¬ 
pital,  to  be  erected  after  the  decease  of  his 
widow.  This  lady,  largely  partaking  of  the 
liberality  which  prompted  the  act  of  her 
lamented  husband,  has  determined  upon  its 
immediate  erection,  and  has  already  ordered 
the  necessary  preparatory  excavation.  This 
additional  structure  will  in  all  probability  be 
completed  this  summer,  and  will  be  desig¬ 
nated  the  “  Reid  wing,”  as  the  other  has 
been  the  “  Richardson  wing.”  This  valua¬ 
ble  institution,  one  of  the  finest  hospitals  on 
this  continent,  has  been  singularly  favoured 
within  the  last  few  years.  The  late  Dr. 
Skakel  bequeathed  a  valuable  property  to  it. 
in  reversion,  estimated  at  about  .£3000  in 
value. — British  American  Journal. 

THE  INCORPORATED  SCHOOL  OF  MEDICINE, 
QUEBEC. 

The  circular  of  this  school  announces  that 
the  Marine  Hospital  contains  250  beds  ;  that 
during  the  season  about  1500  cases  are  ad¬ 
mitted,  of  which  from  400  to  500  are  of  the 
most  instructive  and  important  surgical 
kind.  During  the  summer  of  1846,  there 
were  admitted  72  cases  of  fractures,  among 
which  were — fracture  of  the  thigh,  10  ;  of 
the  leg,  16  ;  of  the  pelvis,  2  ;  of  the  skull, 
13;  and  of  other  minor  descriptions,  31. 
The  operations  performed  during  that  season 
were  those  of  amputation,  lithotomy,  hernia, 
trephine,  ligatures  of  arteries,  removal  of 
head  of  the  humerus,  and  of  various  tumors, 
&c.  Besides  which,  clinical  instruction  is 
given,  and  access  afforded  to  a  library  of  the 
best  standard  works. 

'As  far  as  this  province  is  now  concerned, 
students  of  medicine  have  no  lack  of  means 
of  professional  information,  and  they  ought 
not  to  slight  them.  We  earnestly  call  their 
attention,  as  well  as  that  of  medical  .men 
generally,  having  the  control  of  their  studies, 
to  the  facilities  afforded  in  our  sister  city  ; 
and  we  do  not  think  we  exaggerate  in  the 
least  in  stating,  that  between  the  schools  of 
Montreal  and  Quebec,  a  means  is  afforded 
to  students  of  acquiring  a  practical  knowledge 
of  their  profession,  both  medical  and  surgi¬ 
cal,  which  is  unequalled  on  this  continent, 
bidding  fair  for  successful  competition  with 
those  of  any  of  the  most  favoured  cities  of 
the  American  Union. —  British  American 
Journal. 

a  new  system  of  practice. 

The  St.  Louis  Medical  and  Surgical  Journal 
for  November  states,  that  in  Arkansas  there 
is  a  man  who  practises  medicine  on  a  system 
which  he  calls  the  te-to-tum  system.  He 
uses  an  instrument  having  eight  sides,  simi¬ 
lar  to  the  toy  of  the  same  name  used  by 
children.  On  each  side  of  the  octagon  is  a 
letter  of  the  alphabet,  corresponding  with  a 
precise  indication ;  e.  g.  V  for  vomit,  G  for 
glister,  P  for  purge,  C  for  calomel,  and  so 


on.  When  called  to  see  a  patient,  the  sage 
takes  his  instrument,  and,  without  examining 
pulse  or  tongue,  or  asking  a  question,  spins 
it  before  the  patient,  and  administers  accord¬ 
ing  to  its  revelations.  His  success  is  great, 
and  his  reputation  unbounded  ;  so  much  so, 
as  to  throw  into  the  shade  Thompsonianism, 
Homoeopathy,  Hydropathy,  and  the  Uri- 
no  scopists.  What  the  next  humbug  may  be, 
time  will  tell. — British  American  Journal. 

apothecaries’  hall. 

Names  of  Gentlemen  who  passed  their  ex¬ 
amination  in  the  science  and  practice  of 
medicine,  and  received  certificates  to  prac¬ 
tise,  on  Thursday,  29th  June,  1848  : — 
Augustus  Robert  Henry  Padmore,  Pilton, 
near  Barnstaple— Thomas  Rhys,  Penlline, 
Glamorganshire— Samuel  Nathaniel  Squire, 
Pakefield,  Suffolk— Eade  Sewell,  St.  Oakely 
Hall,  Essex— Alfred  Drew  Dunstan,  Wade- 
bridge,  Cornwall — James  Kingdon  Luke, 
Week  St.  Mary,  Cornwall — John  Lacy  Lyle, 
Launceston  —  Hugh  Cuolahan  —  Blackall 
Mansack,  Barnstaple,  Devon. 


THE  USE  OF  NITRATE  OF  ATROPIA  FOR 

PRODUCING  DILATATION  OF  THE  PUPIL. 

Dr.  Jacob  remarks  that,  for  application  to 
the  conjunctiva,  the  solution  of  atropia,  or 
some  of  its  salts,  is  much  more  effective  and 
convenient  than  any  extract  or  tincture  of 
belladonna.  He  has  found  that  a  single 
drop  of  a  solution,  made  by  dissolving  two 
grains  of  nitrate  of  atropia  in  an  ounce  of 
water,  dilated  the  pupil  as  perfectly,  if  not 
more  perfectly,  than  the  best  extract  of 
belladonna.  It  produced  less  pain  and  irri¬ 
tation,  and  was  not  attended  with  the  in¬ 
convenience  of  leaving  a  string  of  green 
coagulum  between  the  lids.— Dublin  Medical 
Press. 

FATAL  EFFECTS  OF  CHLOROFORM. 

A  fatal  case  of  the  use  of  chloroform 
occurred  in  Cincinnati,  Ohio.  A  Mrs.  Sim¬ 
mons  inhaled  the  vapour  before  an  operation 
on  her  teeth.  Death  occurred  within  five 
minutes.  The  patient  was  put,  in  accordance 
with  Dr.  Simpson’s  suggestion,  as  speedily 
as  possible  under  its  influence,  to  which 
Mr.  Murray,  who  reports  the  case  in  the 
Boston  Journal,  refers  the  fatal  issue*. 

Dr. Sabin,  ofWilliamstown,  Massachusetts, 
has  administered  successfully  the  vapour  of 
chloroform  in  a  case  of  convulsions  in  an 
infant  aged  five  months.  The  effect  was 
markedly  beneficial. — A  young  man  in  New 
Bedford  inhaled  the  chloroform  for  amuse¬ 
ment.  Convulsions  supervened,  lasting  16 
hours. — A  student  of  medicine  in  Baltimore, 
from  the  same  cause,  became  insensible,  and 
remained  so  for  an  hour  and  a  half. — At  the 
Baltimore  Almshouse  it  was  recently  given 

*  We  shall  shortly  give  a  full  report  of  this 
case. 


44 


BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY,  ETC 


to  a  patient  furiously  maniacal :  in  a  minute 
he  was  calmed. — British  American  Journal. 

THE  PLEA  OF  INSANITY. 

An  individual  possessing  a  healthy  moral 
constitution  can  choose  whether  he  will  or 
will  not  commit  a  crime.  But  it  is  the 
leading  feature  of  insane  impulse  that  the 
power  of  choice  is  in  abeyance,  and  the 
unhappy  being  commits  crime  from  necessity. 
The  Code  of  the  French  exhibits  a  degree  of 
scientific  and  humane  accuracy  and  compre¬ 
hensiveness  in  this  matter,  which  our  own 
legislators  would  do  well  to  study.  It  im¬ 
peratively  demands,  in  order  to  establish  the 
charge  of  criminality  in  any  case,  that  the 
accused  be  in  possession  of  a  perfect  moral 
constitution ;  and  should  he  labour  under 
any  mental  defect  or  alienation  involving 
the  suspension  of  the  freedom  of  the  will , 
and  proved  to  exist  at  the  moment  the 
crime  was  committed,  punishment  cannot  be 
inflicted. — Dublin  Quarterly  Journal. 


BIRTHS  &  DEATHS  in  the  Metropolis 


During  the  week  ending  Saturday ,  July  1. 


Births. 
Males....  783 
Females..  789 


1552 


Deaths. 
Males....  548 
Females. .  552 

1100 


Av.  of  5  Spr. 
Males....  485 
Females..  458 

943 


Deaths  indifferent  Districts. 
West — Kensington;  Chelsea;  St.  George, 
Han  over  Square;  Westminster;  St.  Martin 
in  the  Fields;  St.  James  ..  (Pop.  301,326) 
North— St.  Marylebone  ;  St.  Pancras  ; 

Islington  ;  Hackney . (Pop.  386,303) 

Central— St.  Giles  and  St.  George;  Strand; 
Holborn;  Clerkenwell ;  St.  Luke;  East 
London  ;  West  London ;  the  City  of 

London  . . (Pop.  374,7.59) 

ast — Shoreditch  ;  Bethnal  Green  ;  White¬ 
chapel  ;  St.  George  in  the  East ;  Stepney ; 

Poplar . (Pop.  393,247) 

South  — St.  Saviour;  St.  Olave ;  Ber¬ 
mondsey  ;  St.  George,  Southwark ; 
Newington;  Lambeth;  Wandsworth  and 
Clapham  ;  Camberwell  ;  Rotherhithe  ; 
Greenwich . (Pop.  479,469) 


165 

215 

188 

24S 

284 


Total .  H00 


Causes  of  Death- 

All  Causes . 

Specified  Causes . . 

1.  Zy»«o(ic(orEpidemic,Endemic, 

Contagious)  Diseases .. 
Sporadic  Diseases,  viz. — 

2.  Dropsy,  Cancer,  &c.  of  uncer¬ 

tain  seat  . 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  . 

4.  Lungs  and  other  Organs  of 

Respiration . 

5.  Heart  and  Bloodvessels . 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion  . 

7.  Diseases  of  the  Kidneys,  &c... 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c . 

9.  Rhematism,  Diseases  of  the 
Bones,  Joints,  &c . 

10.  Skin,  Cellular  Tissue,  & c . 

11.  Old  Age . 

12.  Violence,  Privation,  Cold,  and 

Intemperance . 


1100 

1096; 

347 


53 

125 

76 

27 

70 

7 

12 

1 

2 

34 

92 


Av.  of 
5  Spr. 

943 

939 

176 


50 

122 

129 

33 

62 

10 

12 

9 

I 

55 

29 


The  following  is  a  selection  of  the  numbers  of 
Deaths  from  the  most  important  special  causes : 


Small-pox  .  28 

Measles  .  23 

Scarlatina  .  86 

Hooping-cough..  37 

Diarrhoea  .  42 

Cholera  .  3 

Typhus  .  73 

Dropsy .  15 

Sudden  deaths  . .  12 

Hydrocephalus . .  24 
Apoplexy .  20 


Paralysis .  22 

Convulsion .  38 

Bronchitis .  21 

Pneumonia .  26 

Phthisis . 129 

Dis.  of  Lungs,  &c.  II 

Teething .  8 

Dis.  Stomach,  &c.  8 
Dis.  of  Liver,  &c.  It 


Childbirth .  5 

Dis. of UteruSj&c.  7 


Remarks. — The  total  number  of  deaths  was 
157  above  the  weekly  average.  This  is  a  very 
sudden  increase  of  mortality.  Scarlatina  appears 
to  be  specially  fatal,  the  deaths  being  nearly 
quadruple  ot'  the  average. 


METEOROLOGICAL  SUMMARY. 

Mean  Height  of  Barometer .  29'64 

“  “  Thermometer1  .  57*4 

Self-registering  do.b _ max.  87'6  min.  33* 

“  in  the  Thames  water  —  65’  —  61 -8 

a  From  12  observations  daily.  b  Sun. 

Rain,  in  inches,  0  46 :  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological.—' The  mean  temperature  of  the 
week  was  3’6°  below  the  mean  of  the  month. 


BOOKS  RECEIVED  DURING  THE  WEEK. 

Wood’s  Practice  of  Medicine,  2  vols. 

Dr.  Rigby’s  Obstetric  Memoranda,  2d  edition. 

Water-Cure  Journal,  No.  12,  July  1848. 

Journal  of  Public  Health,  July  1848. 

Remarks  on  the  Employment  of  Anaesthetic 
Agents  in  Midwifery,  by  G  T.  Gream,  Medical 
Officer  of  Queen  Charlotte’s  Lying-in  Hospital. 

Ethnological  Journal,  No.  2,  July  1848. 

Edinburgh  Monthly  Journal,  July. 

Philosophical  Magazine,  July. 

Journal  de  Pharmacie  et  de  Chimie. 

Veterinary  Record,  July. 

The  Journal  of  Psychological  Medicine,  July. 

Edinburgh  Medical  and  Surgical  Journal,  July. 

Ranking’s  Half-Yearly  Abstract  of  the  Medical 
Sciences,  Jan.  to  June  1848. 

Dublin  Medical  Press,  July  5. 

British  and  Foreign  Medico-Chirurgical  Review, 
Julv  1848. 

Braithwaite’s  Retrospect  of  Medicine.  Vol.  17, 
January  to  June  1848. 

Remarks  on  Deodorization  ar.d  Disinfection,  and 
on  Dr.  Sir  Wm.  Burnett’s  Disinfecting  Fluid. 
By  T.  Stratton,  M.D.  Royal  Navy,  Particular 
Service.  Montreal. 


NOTICES  to  CORRESPONDENTS. 

The  following  communications  have  been  re¬ 
ceived  and  will  be  inserted  as  early  as  our  space 
will  permit :— Mr  Hunt  on  the  Use  of  Tar  in 
Cutaneous  Diseases. —  Mr.  C.  W.  Turner  on 
Gastric  or  Gastro-Enteritic  Fever.— On  Injuries 
to  the  Eye,  by  Dr.  T.  O.  Ward. 

Contributions  to  Pathology,  by  Mr.  W.  Robbs. 

Mr.  E.  Canton’s  request  shall  be  attended  to. 

Dr.  Simpson’s  communication  on  Local  Anaes* 
thesia  is  unavoidably  postponed  until  next 
week. 

Received. — Philologist.— A  Third  Year’s  Man. 


45 


Conboit  iHdatcal  ©alette. 


Settures. 


LECTURES 

ON  THE 

DISEASES  OF  INFANCY  AND 
CHILDHOOD, 

Delivered  at  the  Middlesex  Hospital. 

By  Charles  West,  M.D. 

Physician-Accoucheur  to,  and  Lecturer  on  Mid¬ 
wifery  at,  the  Middlesex  Hospital,  and  Senior 
Physician  to  the  Royal  Infirmary  for  Children. 


Lecture  XXXITI. 

Diarrhoea  —  continued .  Close  resemblance 
between  inflammatory  diarrhoea  and  the 
dysentery  of  the  adult — local  conditions 
favouring  its  occurrence ,  as  damp,  want 
of  drainage,  fyc. 

Treatment  of  simple  diarrhoea — of  diarrhoea 
in  connection  with  teething  —  use  of 
astringents. 

Treatment  of  the  inflammatory  diarrhoea — 
in  its  acute  stage — treatment  of  certain 
symptoms — as  the  irritability  of  the  sto¬ 
mach — the  cerebral  symptoms — indica¬ 
tion  for  the  use  of  stimulants — of  astrin¬ 
gents — management  of  the  chronic  stage 
— use  of  enemata — diet  in  this  stage. 
Management  of  intertrigo  excited  by  diar¬ 
rhoea — and  of  prolapsus  ani. 

Gentlemen,  —  Those  of  you  who  were 
present  at  yesterday’s  lecture,  could  hardly 
fail  to  be  struck  by  the  close  resemblance 
which  exists  between  the  severer  forms  of  in¬ 
fantile  diarrhoea  and  the  true  dysentery  of 
the  adult.  In  both  cases  similar  morbid  ap¬ 
pearances  are  discovered,  occupying  the  same 
parts  of  the  intestinal  canal ;  in  both  the 
symptoms  during  life  are  almost  identical, 
their  resemblance  being  disturbed  mainly  by 
the  greater  excitability  of  the  nervous  system 
in  early  life  :  whence  it  arises  that  convul¬ 
sions  and  other  signs  of  serious  cerebral  dis¬ 
turbance  are  often  observed  in  the  infant 
affected  with  diarrhoea,  while  they  are  but 
seldom  noticed  in  the  adult  suffering  even 
from  severe  dysentery.  But  this  difference 
is  one  of  degree  rather  than  of  kind,  since 
the  morbid  poison,  whatever  be  its  nature, 
to  which  dysentery  is  due  in  the  adult,  pro¬ 
duces  under  favourable  circumstances  dis¬ 
orders  of  the  nervous  system  analogous  to 
those  which  we  may  have  frequent  oppor¬ 
tunities  of  observing  in  the  infant.  If  dysen¬ 
tery,  for  instance,  break  out  epidemically 
in  a  large  prison,  the  inmates  of  which  have 
had  the  excitability  of  their  nervous  system 
increased  by  the  debilitating  influence  of 
long  confinement,  tremors,  cramps,  spasms, 
xlii. — 10/6.  July  14,  1848. 


convulsions  or  stupor,  may  attend  upon  the 
affection,  and  death  may  take  place  under 
symptoms  that  betoken  disorder  of  the  brain 
or  spinal  cord.  You  will  find  ample  proof  of 
this  in  Dr.  Latham’s  account  of  the  Disease 
at  the  Penitentiary  in  the  year  1823  ;  and 
in  Dr.  Baly’s  Gulstonian  Lectures  on  Dysen¬ 
tery,  which  are  based  on  observations  at  the 
same  establishment.  Among  the  striking 
examples  of  this  complication  related  by 
those  writers,  some  are  recorded  in  which, 
though  death  took  place,  neither  the  brain 
nor  the  spinal  cord  presented  any  sign 
of  disease.  Just  of  the  same  kind,  and 
equally  independent  of  any  appreciable 
change  of  structure,  are  the  nervous  symp¬ 
toms  that  often  come  on  in  the  course  of 
infantile  diarrhoea.  I  shall  have  presently 
to  refer  to  the  important  practical  bearings 
of  this  fact,  when  we  come  to  consider  the 
treatment  of  diarrhoea  and  its  complications. 

Before  we  pass  to  that  subject,  however, 
we  must  inquire  whether  there  are  any  spe¬ 
cial  conditions  that  tend  to  engender  the 
severer  forms  of  bowel  complaint  in  child¬ 
hood,  over  and  above  those  general  causes 
of  diarrhoea  to  which  your  attention  was 
directed  in  the  last  lecture.  I  believe  that 
such  special  conditions  do  exist — that  they 
abound  in  the  locality  where  most  of  my  ob¬ 
servations  have  been  made — and  that  they 
are  precisely  the  same  as  prevailed  far  more 
extensively  in  this  metropolis  at  the  time 
when  the  bloody  flux  annually  carried  off 
large  numbers  of  its  inhabitants. 

In  almost  every  country  and  climate,  and 
under  circumstances  in  many  respects  very 
different,  dysentery  has  been  known  to  occur, 
but  in  each  instance  it  has  been  possible  to 
connect  the  prevalence  of  the  disease  with 
some  source  or  other  of  malaria.  Although 
while  I  was  physician  to  the  Finsbury  Dis¬ 
pensary,  a  large  amount  of  disease  among 
children  as  well  as  among  adults  came  under 
my  notice,  yet  my  acquaintance  with  those 
severer  forms  of  infantile  diarrhoea  which 
approach  to  the  characters  of  dysentery,  and 
which  give  rise  to  similar  lesions,  has  been 
derived  almost  exclusively  from  observations 
made  in  Lambeth  and  the  adjoining  parishes. 
The  children  in  both  districts  are  alike  sub¬ 
jected  to  the  evils  of  improper  and  insuffi¬ 
cient  food,  and  of  close  and  ill-ventilated 
dwellings  ;  but  in  the  latter  there  are  super- 
added  certain  very  important  influences  of  a 
local  character.  A  considerable  portion  of 
the  district  on  the  Surrey  side  of  the  Thames 
lies  below  high-water  mark  ;  and  the  kitchens 
and  cellars  of  some  of  the  houses  near  the 
river  become  flooded  at  unusually  high  tides. 
The  sewerage  throughout  is  very  defective  ; 
in  many  parts  it  is  effected  entirely  by  open 
drains,  while  in  some  places  there  are  mere 
cesspools,  which  have  no  communication 
with  any  drain  whatever.  Cases  of  infantile 


46 


TREATMENT  OF  SIMPLE  DTARKHCEA. 


dysentery  do  not  occur  with  the  same  fre¬ 
quency  in  all  parts  of  this  district,  but  they 
are  most  numerous  and  most  severe  where- 
ever  these  noxious  influences  are  most  abun¬ 
dant.  Proof,  too,  of  the  intimate  connec¬ 
tion  that  subsists  between  these  conditions 
and  the  occurrence  of  infantile  dysentery,  is 
afforded  by  cases  such  as  the  following  : — 
With  the  return  of  every  spring,  a  poor 
woman  brought  to  me  her  younger  children 
suffering  from  diarrhoea,  which  they  seemed 
to  outgrow  when  about  three  years  old. 
This  diarrhoea  was  always  obstinate,  very  apt 
to  assume  a  dysenteric  character,  and  was 
almost  sure  to  return  if  medicines  were  dis¬ 
continued  before  the  return  of  the  cold 
season.  On  one  occasion,  her  infant,  aged 
about  fifteen  months,  who  had  had  diarrhoea 
severely  in  the  previous  autumn,  suffered  a 
return  of  it  with  the  returning  warmth  of 
spring.  The  infant’s  symptoms  were  very 
alarming,  and  the  child  had  frequent  convul¬ 
sions,  on  which  account  I  visited  her  at 
home.  I  then  found  that  the  infant  spent 
the  whole  of  the  day  in  a  back  room  on  the 
ground  floor,  which  looked  out  upon  a  little 
yard,  at  the  bottom  of  which  there  was  a 
large  cesspool,  whence  there  came  a  most 
offensive  smell  during  the  whole  of  the  wrarm 
weather.  I  urged  the  mother  to  remove  her 
infant  from  this  room,  and  to  occupy  instead 
a  front  room  on  the  first  floor  in  the  same 
house,  which  looked  upon  the  street.  When 
this  had  been  done  the  convulsions  ceased 
almost  at  once,  and  the  diarrhoea  was  not 
long  before  it  disappeared.  I  have  attended 
this  woman’s  children  since  for  other  affec¬ 
tions,  but  it  is  now  nearly  eighteen  months 
that  they  have  occupied  the  more  wholesome 
room,  and  during  this  time  I  have  heard 
nothing  of  their  suffering  from  diarrhoea.  I 
may  just  add,  that,  under  similar  circum¬ 
stances,  I  have  met  with  a  few  instances  of 
the  sudden  and  apparently  causeless  occur¬ 
rence  of  convulsions  in  two  or  three  children 
of  the  same  family.  It  is  not  long  since  a 
little  girl,  five  years  old,  was  seized  with  con¬ 
vulsions,  which  recurred  frequently  for 
between  two  and  three  days,  leaving  her  in 
a  state  of  stupor.  By  degrees  the  symptoms 
of  very  severe  typhoid  fever  developed  them¬ 
selves  out  of  this  disturbance  of  the  nervous 
system.  The  disease  during  the  whole  of  its 
course  presented  an  adynamic  character,  and 
required  the  free  employment  of  wine  and 
stimulants.  While  she  was  convalescent  the 
health  of  her  elder  sister,  who  was  eight 
years  old,  began  to  fail,  and  before  long  she 
experienced  convulsive  attacks  of  an  anoma¬ 
lous  character  not  unlike  fits  of  hysteria, 
which  returned  at  intervals  of  two  or  three 
days  for  several  weeks  together, — three  Or 
four  fits  sometimes  occurring  in  the  cours 
of  a  single  day.  These  seizures  were  accom 
panied  with  much  debility,  and  they  disap¬ 


peared  by  degrees  under  the  use  of  prepara¬ 
tions  of  iron,  and  a  generally  tonic  plan  of 
treatment. 

In  studying  the  treatment  of  diarrhoea  and 
dysentery  in  early  life,  we  will  pass  succes¬ 
sively  in  review  the  different  forms  of  the 
disease  ;  beginning  with  the  simplest  and 
least  dangerous,  and  passing  to  the  more 
formidable  varieties  of  the  affection,  and  to 
those  complications  which  add  so  greatly  to 
its  hazard. 

In  a  large  proportion  of  cases  of  simple 
infantile  diarrhoea ,  the  ailment  tends  to 
subside  in  a  day  or  two,  and  finally  to  cease 
of  its  own  accord.  While,  therefore,  in  con¬ 
sideration  of  the  tender  years  of  the  patient, 
no  such  case  can  he  regarded  as  altogether 
trivial,  yet  in  many  instances  but  little  medi¬ 
cal  interference  is  needed.  Great  care, 
hov/ever,  is  required  in  this,  as  well  as  in  the 
more  serious  forms  of  diarrhoea,  to  prevent 
the  affection  being  aggravated  by  any  error 
of  diet,  or  even  by  the  infant  being  allowed 
to  partake  too  freely  of  food  otherwise  suit¬ 
able  for  it.  If,  therefore,  the  sickness  with 
which  the  attack  sets  in  have  not  altogether 
subsided,  the  child  should  be  taken  com¬ 
pletely  from  the  breast  for  a  few  hours,  and 
should  have  nothing  more  than  a  few  spoon¬ 
fuls  of  water  or  barley-water,  till  the  irrita¬ 
bility  of  the  stomach  has  abated.  If  the 
disposition  to  vomit  have  completely  ceased, 
it  will  yet  be  right  to  put  the  infant  less 
frequently  to  the  breast ;  while  it  is  supplied , 
if  thirsty,  with  water  or  barley-water,  in 
small  quantities  at  a  time.  In  children 
already  weaned,  a  similar  plan  must  be  car¬ 
ried  out  ;  solid  food  being  for  a  time  with¬ 
drawn,  and  thin  arrow--root,  or  barley- wjater 
and  milk,  in  equal  parts,  being  substituted 
for  it.  If  the  attack  be  clearly  traceable  to 
some  improper  article  of  food,  a  dose  of 
castor  oil  will  sometimes  get  rid  of  the  irri¬ 
tant  cause  and  of  the  diarrhoea  together. 
Unless  this  be  the  case,  however,  it  is  better 
not  to  give  the  aperient,  since  its  action, 
under  these  circumstances,  is  somewhat  un¬ 
certain  ;  and  it  may  aggravate,  instead  of  re¬ 
lieve,  the  diarrhoea.  Provided  there  be 
neither  much  pain  nor  much  tenesmus,  and 
the  evacuations,  though  wratery,  are  faecal, 
and  contain  little  mucus  and  no  blood,  very 
small  doses  of  the  sulphate  of  magnesia  and 
tincture  of  rhubarb  have  seemed  to  me  more 
useful  than  any  other  remedy.  To  a  child 
of  a  year  old  I  am  accustomed  to  give,  every 
eight  or  every  six  hours,  a  teaspoonful  of  an 
ounce  and  a  half  mixture,  containing  one 
drachm  of  the  sulphate  of  magnesia,  and  two 
drachms  of  the  tincture  of  rhubarb,  diffused 
in  caraway  water ;  and  I  seldom  fail  to 
observe  from  it  a  speedy  diminution  in  the 
frequency  of  the  action  of  the  bowels,  and  a 
return  of  the  natural  character  of  the  eva¬ 
cuations. 


DIARRHOEA  IN  CONNECTION  WITH  TEETHING — USE  OF  ASTRINGENTS.  47 


In  the  diarrhoea  that  comes  on  in  con¬ 
nection  vnth  teething ,  it  has  seemed  to  be 
better  to  pursue  a  somewhat  different  plan. 
There  is  in  them,  usually,  a  greater  amount 
of  constitutional  disturbance,  and  some  de¬ 
gree  of  febrile  excitement;  and  to  abate  this, 
the  use  of  the  tepid  bath,  once  or  twice  in 
the  twenty-four  hours,  will  be  found  very 
serviceable.  There  is,  likewise,  in  many 
instances  a  considerable  disposition  to  catar¬ 
rhal  affection  of  the  respiratory  mucous  mem¬ 
brane  ;  and  this  needs  to  be  carefully 
watched,  lest  by  its  increase  it  should  be¬ 
come  a  source  of  serious  danger  to  the  child. 
The  diarrhoea  in  the  majority  of  these  cases 
comes  on  gradually,  and  its  subsidence  takes 
place  gradually  too.  Now  and  then  the 
gum  may  appear  at  one  spot  so  tense  and 
swollen  as  to  induce  us  to  scarify  it ;  and  if 
the  tooth  had  been  very  near  the  surface,  the 
effect  of  so  doing  may  sometimes  be  greatly 
to  diminish  the  diarrhoea,  by  relieving  the 
irritation  which  excited  it.  Any  such 
marked  benefit,  however,  is  quite  an  excep¬ 
tional  occurrence ;  and  unless  the  state  of 
the  gums  were  such  as  of  itself  to  indicate 
the  propriety  of  scarifying  them,  it  would 
be  a  rather  cruel  piece  of  empiricism  to  sub¬ 
ject  the  child  to  the  distress  of  the  operation. 
Instead  of  the  saline  and  rhubarb  mixture 
which  I  have  just  mentioned,  I  usually  em¬ 
ploy  in  these  cases  small  doses  of  ipeca¬ 
cuanha  in  combination  with  an  alkali ;  and 
think  that  I  have  found  great  benefit  from 
this  plan.  Three  or  four  drops  of  liquor 
potassae  and  the  same  quantity  of  vinum 
ipecacuanha:  mixed  with  mucilage,  and 
given  in  a  little  milk  about  every  four  hours, 
is  the  dose  for  an  infant  a  twelvemonth  old. 
At  the  same  time  a  powder  of  one  grain  of 
Dover’s  powder,  and  one  of  mercury  and 
chalk,  may  be  given  every  night,  after  the 
child  is  taken  out  of  the  warm  bath,  and 
will  often  be  found  to  procure  for  the  litttle 
patient,  previously  restless  and  fretful, 
some  hours  of  quiet  repose.  If  the  child 
should  appear  much  exhausted,  a  slight 
stimulant,  such  as  four  or  five  drops  of  the  ' 
spirit  of  nitrous  ether,  may  be  advanta¬ 
geously  combined  with  each  dose  of  the  mix¬ 
ture  ;  and  in  all  cases  of  simple  diarrhoea  it 
behoves  us  to  watch  most  carefully  against 
the  powers  becoming  too  much  depressed, 
either  by  the  profuseness  of  the  purging  or 
by  its  continuance. 

Supposing  in  any  case  that  a  considerable 
degree  of  looseness  of  the  bowels  were  to 
continue  after  the  lapse  of  two  or  three  days, 
astringents  must  be  resorted  to  ;  and  I  know 
of  none  better  than  the  extract  of  logwood, 
in  combination  with  tincture  of  catechu. 
Five  grains  of  the  former  and  ten  minims  of 
the  latter,  three  times  a  day,  in  some  sweet¬ 
ened  aromatic  water,  is  a  suitable  dose  for 
an  infant  a  year  old.  The  logwood,  more¬ 


over,  is  something  besides  a  mere  astrin¬ 
gent  :  it  is  a  very  valuable  tonic  in  all  cases 
where  gastro-intestinal  disorder  has  existed  ; 
and  it  is  one  which  children  take  readily.  It 
is,  however,  not  very  popular  in  the  nursery, 
because  it  imparts  to  the  evacuations  a  deep 
pink  colour,  which  leaves  an  indelible  stain 
upon  the  napkins  :  a  circumstance  which  it 
is  as  well  to  mention  when  you  prescribe 
the  medicine.  The  mercury  and  chalk  and 
Dover’s  powder  may  be  still  continued  at 
bed-time,  if  the  evacuations,  though  less 
frequent,  be  still  slimy  and  unhealthy.  If 
either  the  evacuations  or  the  infant’s  breath 
have  a  sour  smell,  three  grains  of  the  sesqui- 
carbonate  of  soda  may  be  added  to  each 
dose  of  the  mixture  ;  or,  if  the  child  be  not 
wholly  fed  at  the  breast,  a  drachm  of  pre¬ 
pared  chalk  may  be  stirred  up  with  each 
pint  of  milk  given  to  it,  and  after  the  powder 
has  been  allowed  to  settle,  enough  will  still 
remain  suspended  in  the  fluid  to  counteract 
any  slight  acidity  in  the  alimentary  canal. 
If,  after  the  bowels  have  become  quite  regu¬ 
lar,  some  tonic  should  still  be  required,  the 
extract  of  bark,  with  small  doses  of  the  tinc¬ 
ture,  will  be  one  of  the  best  that  could  be 
given.  You  will  observe  that  all  the  remedies 
mentioned  occupy  but  a  very  small  compass: 
a  point  the  importance  of  which  is  never  to 
be  forgotten  in  prescribing  for  children. 

But  there  are  cases  which  wear  a  much 
more  serious  aspect  than  those  the  treat¬ 
ment  of  which  we  have  hitherto  considered. 
Even  in  true  inflammatory  diarrhoea ,  how¬ 
ever,  depletion  is  but  seldom  needed,  for 
either  the  abdominal  tenderness  is  inconside¬ 
rable,  or,  if  the  attack  set  in  with  great  se¬ 
verity,  it  will  be  generally  found  to  have 
occasioned  so  much  depression  of  the  powers 
of  the  system  as  to  contraindicate  the  ab¬ 
straction  of  blood.  Still,  in  cases  of  recent 
date,  when  the  abdominal  tenderness  is  con¬ 
siderable,  and  when  it  is  associated  with 
much  heat  of  skin  and  febrile  disturbance,  a 
few  leeches  may  be  applied  in  either  iliac 
region.  The  child  should  be  carefully 
watched  for  some  hours  afterwards,  in  order 
to  prevent  any  excessive  loss  of  blood;  since 
considerable  haemorrhage  not  infrequently 
follows  the  application  of  leeches  to  the  ab¬ 
domen,  and  it  is  not  always  very  easily 
arrested.  In  the  majority  of  instances  the 
pain  and  tenderness  of  the  abdomen  are 
much  relieved  by  the  application  of  a  large 
hot  bran  poultice ;  the  frequent  renewal  of 
which  often  affords  great  comfort  to  the 
child. 

If  the  irritability  of  the  stomach  be  not  so 
great  as  to  prevent  its  administration,  no 
medicine  is  of  such  general  application,  or 
of  such  essential  service  in  these  cases,  as  a 
mixture  containing  a  small  quantity  of  castor 
oil  diffused  in  mucilage,  with  the  addition  of 
a  few  drops  of  tincture  of  opium.  I  was  lecb 


4ft 


TREATMENT  OF  INFLAMMATORY  DIARRHCEA. 


to  use  this  medicine  in  the  inflammatory 
diarrhoea  of  children  from  observing  the 
great  benefit  which  followed  its  employment 
by  my  friend  Dr.  Baly  in  the  treatment  of 
dysentery  among  the  prisoners  in  Millbank 
Penitentiary.  The  following  is  the  form  in 
which  I  should  prescribe  it  for  an  infant  a 
year  old,  and  in  which  it  is  taken  by  most 
children  very  readily  : — 

p)  Ol.  Ricini,  3j.  ;  Pulv.  Acaciae,  3j. ; 

Syrupi  Simpl.  3j*  5  Trae.  Opii,  !T[iv.  ; 

Aquae  Flor.  Aurant.  5vij.  M.  ft.  mist. 

A  tea-spoonful  to  be  given  every  four 

hours. 

Although  this  medicine  may  relieve  all  the 
symptoms  considerably,  and  although  the 
general  state  of  the  child  may  be  much  im¬ 
proved,  yet  it  sometimes  happens  that  a 
considerable  degree  both  of  tenesmus  and  of 
purging  continue.  These  symptoms  will 
now  be  more  effectually  relieved  by  an  opiate 
enema  than  by  any  other  means.  Four 
drops  of  laudanum  will  form  an  enema  of 
sufficient  strength  for  an  infant  a  year  old  ; 
and  this  should  be  given  suspended  in  half 
an  ounce  of  mucilage,  since  a  more  bulky 
injection  is  almost  sure  to  be  immediately 
expelled.  Supposing  the  symptoms  not  to 
yield  to  these  means,  or  that  the  case  pre¬ 
sented  from  the  first  a  great  degree  of  se¬ 
verity,  small  doses  of  Hyd.  c.  Creta  and 
Dover’s  powder  may  be  given  every  four 
hours,  in  addition  to  the  castor  oil  mixture, 
which,  however,  should  now  be  given  with¬ 
out  the  laudanum. 

In  some  cases  the  irritability  of  the  sto¬ 
mach  is  so  great,  that  almost  every  thing 
taken  is  speedily  rejected  ;  and  when  this 
condition  is  present,  none  of  the  medicines 
already  mentioned  can  be  borne.  Under 
these  circumstances  a  small  mustard  poultice 
should  at  once  be  applied  to  the  epigastrium, 
the  child  should  be  taken  from  the  breast,  a 
tea-spoonful  of  cold  water,  or  cold  barley- 
water,  should  be  given  at  intervals,  and  a 
powder  of  a  third  of  a  grain  of  calomel,  and 
a  twelfth  of  a  grain  of  opium,  should  be  laid 
upon  its  tongue  every  three  hours.  The 
sickness  will  generally  subside  in  four  or  five 
hours,  though  the  stomach  often  remains  too 
irritable  to  bear  any  change  in  the  remedies, 
and  the  greatest  caution  will  be  needed  in 
restoring  the  infant  to  the  breast.  It  may 
be  necessary,  indeed,  to  confine  the  child  for 
twenty-four  or  thirty-six  hours  to  cold 
barley-water,  cold  water  thickened  with 
isinglass,  the  white  decoction  of  Sydenham, 
or  equal  parts  of  cold  milk  and  water ;  and 
when  the  child  has  been  seen  early  in  the 
disease,  I  have  never  observed  any  evil  to 
follow  the  perseverance  for  this  short  period 
in  a  rigorous  diet. 

The  tepid  bath,  employed  twice  a  day,  or 
even  more  frequently,  will  be  found  of  great 


service  in  soothing  that  general  irritability 
of  the  nervous  system  which  often  continues 
through  the  whole  course  of  the  affection, 
and  which  sometimes  issues  in  convulsive 
seizures,  or  in  other  symptoms  that  are  oc¬ 
casionally  mistaken  for  the  indications  of 
real  cerebral  disease.  It  cannot  be  neces¬ 
sary  to  reiterate  here  the  often- repeated 
caution  against  regarding  the  symptoms  of 
disturbance  of  the  nervous  system  as  always 
the  signs  of  active  cerebral  disorder,  calling 
for  depletion  to  relieve  the  congestion  of  the 
vessels  of  the  brain,  and  for  antiphlogistic 
measures  to  moderate  the  excited  state  of 
the  circulation.  In  the  second  lecture*  I 
endeavoured  to  set  before  you  the  very  va¬ 
rious  circumstances  under  which  convulsions 
come  on  in  early  life  ;  and  in  the  tenthf  I 
tried  to  delineate  the  characteristic  features 
of  spurious  hydrocephalus.  On  that  occa¬ 
sion  I  related  the  history  of  two  children, 
both  of  whom  had  been  attacked  by  severe 
diarrhoea.  In  one  case  the  child  passed 
every  few  minutes  from  a  state  of  listless 
drowsiness  to  a  condition  of  extreme  rest¬ 
lessness  and  alarm ;  the  tendons  of  the  fore¬ 
arm  were  in  a  state  of  subsultus,  and  general 
convulsions  seemed  impending.  In  the 
other  case,  the  irritability  of  the  nervous 
system  was  rapidly  subsiding  under  the 
general  exhaustion  of  the  vital  powrers,  and 
probably  in  a  few  hours  more  the  infant 
would  have  sunk  into  a  profound  coma,  from 
which  no  means  would  have  been  adequate 
to  rouse  it.  The  tepid  bath  and  an  opiate 
enema  in  the  first-mentioned  case,  and  the 
free  employment  of  stimulants  in  combina¬ 
tion  with  small  doses  of  Dover’s  powder  in 
the  second,  speedily  averted  dangers  that 
had  seemed  so  threatening.  I  need  not, 
however,  go  again  over  all  the  ground  we 
have  already  passed  over,  but  will  content 
myself  with  repeating  the  remark  I  then 
made, — that  if,  in  cases  of  this  kind,  you 
fall  into  the  error  of  regarding  the  cerebral 
symptoms  as  the  signs  of  active  disease,  and 
withhold  the  Dover’s  powder  or  the  opiate 
enema,  that  might  have  checked  the  diarrhoea 
and  soothed  the  irritability,  while  you  apply 
cold  lotions  to  the  head,  and  give  the  child 
nothing  more  nutritious  than  barley-water  in 
small  quantities,  because  the  irritability  of 
the  stomach  which  results  from  weakness 
seems  to  you  to  be  the  indication  of  disease 
in  the  brain,  the  restlessness  will  before  long 
alternate  with  coma,  and  the  child  will  die 
either  comatose  or  in  convulsions. 

As  to  the  time  when  stimulants  are  to  be 
given,  or  the  quantity  in  which  they  are  to 
be  employed,  no  definite  rule  can  be  laid 
down.  Each  case  must  be  treated  for  itself; 
and  to  be  treated  successfully  it  must  be 


*  Med.  Gaz.  vol.  xxxix.  p.  883. 
f  Ibid.  vol.  xl.  p.  439. 


MANAGEMENT  OF  THE  CHRONIC  STAGE - USE  OF  ENEMATA.  49 


watched  most  closely.  The  necessity  for 
stimulants  may  arise  suddenly,  or  the  need 
of  their  administration  may  be  but  tempo¬ 
rary  ;  while  the  infant’s  state  in  the  morning 
affords,  in  cases  of  severe  diarrhoea.,  no  sure 
criterion  by  which  to  judge  what  its  condi¬ 
tion  will  be  at  night.  In  general  it  is  not 
until  the  active  symptoms  have  begun  to 
decline  that  stimulants  are  needed,  nor  even 
then  are  they  required  in  a  large  number  of 
instances.  I  have,  however,  met  with  some 
instances  in  which  they  were  absolutely  ne¬ 
cessary  as  early  as  the  second  or  third  day 
of  the  disease.  This  has  occurred  in  cases 
in  which  there  was  great  irritability  of  the 
stomach,  as  well  as  violent  action  of  the 
bowels;  in  which  no  medicine  could  be 
borne  except  the  calomel  and  opium  powders, 
nor  any  drinks  except  such  as  were  given 
cold.  Under  such  circumstances  a  state  of 
extreme  debility  is  sometimes  very  rapidly 
induced,  and  the  vomiting,  which  at  first  was 
a  sign  of  the  gastric  disorder,  continues 
when  it  is  nothing  else  than  an  effect  of  the 
general  exhaustion.  About  half  a  drachm  of 
brandy  given  every  two  or  three  hours,  to  a 
child  of  a  year  old,  in  a  quantity  of  a  few 
drops  at  a  time,  mixed  wfith  the  cold  milk 
and  water,  or  the  thin  arrow-root  with 
which  it  is  fed,  will  often  have  the  effect  of 
arresting  the  sickness,  as  well  as  of  rallying 
the  sunken  energies  of  the  system.  No  sti¬ 
mulant  has  appeared  to  answer  the  required 
ends  better  than  brandy  ;  and,  when  suffi¬ 
ciently  diluted,  children  take  it  very  readily. 
Sometimes,  however,  when  it  has  been  ne¬ 
cessary  to  continue  it  for  some  time,  it  has 
seemed  to  occasion  pain  in  the  stomach,  and 
even  to  nauseate  the  child  ;  and  in  this  case 
the  compound  tincture  of  bark,  or  the  aro¬ 
matic  spirits  of  ammonia,  or  the  two  together, 
may  be  substituted  for  it ;  and  there  is  sel¬ 
dom  much  difficulty  in  administering  them, 
if  they  be  mixed  with  milk  and  sufficiently 
sweetened. 

The  proper  time  for  the  employment  of 
aromatics  and  astringents  is  not  during  the 
acute  stage  of  the  affection ;  but  when  the 
disease  has  already  begun  to  decline,  these 
remedies  will  be  found  of  most  essential  ser¬ 
vice  in  checking  that  looseness  of  the  bowels 
which  otherwise  is  very  apt  to  degenerate 
into  a  state  of  chronic  diarrhoea.  Under 
these  circumstances  the  logwood  and  cate¬ 
chu  mixture,  mentioned  at  an  earlier  part 
of  this  lecture,  is  a  very  valuable  medicine. 
If,  notwithstanding  its  employment,  the 
bowels  still  continue  to  act  with  excessive 
frequency,  small  doses  of  the  compound 
powder  of  chalk  and  opium  may  be  given 
twice  a  day,  or  the  use  of  the  opiate  enema 
may  be  continued  if  there  be  much  tenesmus. 
By  these  means,  coupled  with  the  most  se¬ 
dulous  attention  to  the  child’s  diet,  and  the 
greatest  care  in  allowing  either  animal  broths, 


or  meat  or  other  solid  food,  a  complete  cure 
will  usually  be  brought  about  in  the  course 
of  two,  or  at  latest  of  three  weeks. 

There  are  some  cases  id  which,  after  the 
disease  has  passed  its  acute  stage,  it  still 
retains  much  of  its  dysenteric  character ; 
the  bowels  not  merely  acting  with  undue 
frequency,  but  the  evacuations  containing 
mucus,  pus,  or  blood,  and  their  expulsion 
being  attended  with  very  considerable  tenes¬ 
mus.  The  strength  in  such  chronic  cases 
is  very  greatly  reduced,  and  emaciation  goes 
on  to  a  greater  degree  than  in  almost  any 
other  affection,  with  the  exception  of  phthisis 
and  mesenteric  disease ;  while  the  bowels 
are  excited  to  almost  immediate  action  by 
even  the  simplest  food.  The  treatment  of 
these  cases  is  attended  with  considerable 
difficulty  ;  recovery,  when  it  does  take  place 
(and  it  is  consolatory  to  know  that  it  often 
does,  even  from  a  condition  apparently 
desperate),  is  brought  about  very  slowly, 
and  each  remedy  employed  seems  speedily 
to  become  ineffectual.  Throughout  their 
course  two  objects  are  to  be  borne  in  mind  : 
one  being  to  check  the  diarrhoea  ;  the  other 
to  support  the  child’s  strength  during  the 
time  required  for  nature  to  effect  the  cica¬ 
trization  of  the  ulcerated  mucous  membrane, 
and  to  restore  it  to  a  state  of  health.  The 
utility  of  mercurial  preparations  has  ap¬ 
peared  to  me  to  be  almost  exclusively  con¬ 
fined  to  the  early  stage  of  dysentery,  and  to 
cease  when  the  disease  has  passed  into  the 
chronic  form.  On  the  other  hand,  astrin¬ 
gents  may  now  be  employed  with  the  most 
marked  benefit,  and,  when  one  fails,  another 
may  be  substituted  for  it.  In  cases  where 
the  stomach  has  been  very  irritable,  so  that 
almost  everything  taken  has  been  speedily 
rejected,  I  have  sometimes  employed  the 
gallic  acid  in  combination  with  laudanum, 
and  have  seen  much  benefit  follow  from  its 
use.  At  other  times  I  have  given  the  ace¬ 
tate  of  lead  likewise  with  opium — a  com¬ 
bination  which,  notwithstanding  that  decom¬ 
position  takes  place,  yet  retains  its  efficacy 
when  given  in  the  form  of  mixture.  The 
sulphate  of  iron  combined  with  opium  is 
another  highly  useful  remedy  in  these  cases, 
and  appears  to  have  this  advantage  over  the 
sulphate  of  zinc,  which  has  likewise  been 
used  in  similar  cases — that  it  does  not  excite 
the  same  irritability  of  the  stomach. 

Our  remedies  are  not  to  be  confined  to 
those  administered  by  the  mouth  ;  for  much 
may  be  done  towards  relieving  the  symp¬ 
toms  and  curing  the  disease  by  suitable 
enemata.  In  some  cases  of  unmanageable 
diarrhoea,  M.  Trousseau  employs  an  enema 
of  nitrate  of  silver  in  the  proportion  of  a 
grain  to  an  ounce  of  distilled  water,  with 
very  good  effect.  I  have  never  employed 
it,  but  have  sometimes  used  the  gallic  acid 
as  an  enema,  though  not  sufficiently  often 


50 


MANAGEMENT  OF  INTERTRIGO,  AND  OF  PROLAPSUS  ANI. 


to  be  able  to  form  any  very  decided  opinion 
as  to  its  efficacy.  In  the  majority  of  in¬ 
stances  I  have  been  content  with  glysters  of 
laudanum  diffused  in  mucilage,  or  in  a  small 
quantity  of  starch;  occasionally  in  protracted 
cases,  where  the  tenesmus  was  very  distress¬ 
ing,  I  have  used  the  black  wash  as  a  vehicle 
for  the  laudanum  ;  and,  on  one  occasion,  in 
which  a  copious  discharge  of  pus  continued 
from  the  lower  bowel  for  several  days  in  a 
little  boy  two  years  old,  this  symptom 
was  greatly  relieved  by  the  administration, 
twice  a  day,  of  an  enema  containing  two 
grains  of  sulphate  of  zinc. 

The  support  of  the  child’s  strength  is  a 
matter  of  no  less  importance  in  chronic 
dysentery  than  the  suppression  of  the  diar¬ 
rhoea.  The  great  weakness  of  the  patient, 
and  the  manifest  distaste  for  nourishment  of 
all  kinds,  often  render  it  necessary  to  con¬ 
tinue  the  use  of  brandy  for  several  days,  or 
even  for  several  weeks.  For  an  infant  not 
weaned,  there  can  be  no  better  food  than 
that  which  is  furnished  by  the  breast  of  a 
healthy  nurse.  In  the  majority  of  cases, 
however,  the  child  has  been  either  in  great 
measure  or  altogether  weaned  before  the 
affection  came  on,  and  consequently  it  is  a 
less  easy  matter  to  supply  it  with  suitable 
food.  Farinaceous  articles,  such  as  arrow- 
root,  sago,  &c.  are  less  easily  assimilated  in 
early  life  than  in  adult  age,  and  not  infre¬ 
quently  they  pass  in  cases  of  this  kind 
through  the  alimentary  canal  unchanged. 
Milk,  too,  does  not  always  agree,  and  is 
sometimes  rejected  almost  at  once,  unless  it 
be  given  in  a  state  of  extreme  dilution. 
Under  these  circumstances  we  must  not 
hesitate  to  give  strong  beef  or  veal  tea  in 
small  quantities,  but  at  short  intervals,  to 
the  patient ;  for  though  it  be  true  that  the 
bowels  are  often  excited  to  increased  action 
in  cases  of  chronic  diarrhoea  or  dysentery  by 
animal  broths,  yet  this  is  a  smaller  hazard 
than  that  of  the  child  dying  for  want  of 
sufficient  nutriment.  I  may  add,  that, 
when  prepared  with  care,  and  quite  free 
from  salt  or  any  seasoning,  and  when  given 
cold,  I  have  seldom  observed  any  serious  in¬ 
crease  of  the  diarrhoea  to  follow  their  use. 

Two  accidents  are  occasionally  met  with 
in  connection  with  protracted  diarrhoea  in 
infants  and  young  children,  concerning  each 
of  which  a  few  words  must  be  said.  It  is 
not  unusual  to  observe  a  general  erythema¬ 
tous  redness  of  the  buttocks  and  nates  in 
infants  suffering  from  severe  diarrhoea,  and 
sometimes  the  irritation  of  the  acrid  faeces 
produces  an  attack  of  intertrigo,  and  a 
serous  fluid  exudes  abundantly  from  the 
inflamed  skin.  This  condition,  which  is  the 
occasion  of  very  considerable  suffering  to 
the  child,  almost  always  depends  upon  a 
neglect  of  that  most  scrupulous  cleanliness 
which  is  of  such  essential  importance  in 


early  life.  In  order  to  prevent  its  occur¬ 
rence,  the  nates  and  buttocks  must  be 
sponged  with  warm  water  immediately  after 
each  evacuation ;  the  surface  may  after¬ 
wards  be  smeared  with  a  little  Ung.  Zinci, 
while  any  part  at  which  the  skin  seems  dis¬ 
posed  to  crack  should  be  dusted  over  with 
the  oxide  of  zinc  in  powder.  These  simple 
precautions  will  usually  suffice  to  prevent  a 
condition  which,  in  some  of  the  hospitals  of 
Paris,  where  such  sedulous  care  is  almost 
impossible,  degenerates  into  a  state  of  un¬ 
healthy  ulceration  that  exhausts  the  infant’s 
power,  and  sometimes  contributes  to  its 
destruction  quite  as  much  as  the  diarrhoea 
in  the  course  of  which  it  came  on. 

Prolapsus  of  the  anus  is  another  rather 
troublesome  accident  which  sometimes  takes 
place  in  the  course  of  protracted  diarrhoea. 
It  abates,  however,  almost  always  as  the  diar¬ 
rhoea  diminishes,  and  generally  ceases  alto¬ 
gether  as  the  child  regains  its  strength. 
When  there  is  a  disposition  to  it  during  the 
acute  stage  of  the  affection,  this  may  often 
be  controlled  if  the  nurse  be  instructed  to 
support  the  margin  of  the  anus  during  each 
evacuation,  and  thus  to  prevent  the  descent 
of  the  bowel,  while  the  opiate  enema  which 
relieves  the  tenesmus  is  of  most  essential 
service  by  thus  removing  the  cause  of  the 
prolapse.  The  child’s  attendant  should  also 
be  taught  how  to  return  the  bowel  if  it 
should  come  down,  and  this  is  best  effected 
by  means  of  gentle  pressure  with  a  napkin 
wrung  out  of  cold  water.  If,  as  the  diar¬ 
rhoea  abates,  the  prolapse  should  still  con¬ 
tinue,  and  especially  if  the  gut  should  come 
down  independent  of  efforts  at  defecation,  it 
may  be  necessary  to  make  the  child  wear  a 
compress  and  bandage  to  prevent  its  descent. 
In  such  cases,  too,  an  enema  consisting  of  a 
small  quantity  of  some  astringent,  such  as 
the  decoction  of  tormentilla,  should  be  ad¬ 
ministered  cold  once  or  twice  a  day,  and  no 
instance  has  come  under  my  notice  in  which 
these  measures,  persevered  in  for  a  few 
weeks,  have  not  sufficed  to  remove  this 
troublesome  ailment. 


ELECTION  OF  MEMBERS  OF  COUNCIL  AT  THE 
ROYAL  COLLEGE  OF  SURGEONS. 

At  a  meeting  of  the  Fellows  of  the  College, 
held  on  Thursday,  July  6th,  three  new 
members  of  Council  were  elected  to  fill 
up  the  vacancies  occasioned  by  the  decease 
of  Messrs.  Briggs,  Liston,  and  Morgan. 
The  gentlemen  present  having  been  addressed 
by  the  President,  proceeded  to  ballot  for 
members,  when  Messrs.  Bransby  Cooper, 
Skey,  and  Stafford,  were  elected ;  after 
which  the  party  dined  together  at  the  Free¬ 
masons’  Tavern.  Many  gentlemen  attended 
the  election  from  distant  parts  of  the  king¬ 
dom. 


dr.  r.  b.  todd’s  clinical  lecture  on  paralysis. 


51 


CLINICAL  lecture 

ON 

PARALYS  I  S, 

Delivered  at  King's  College  Hospital , 

By  R.  B.  Todd,  M.D.  F.R.S. 

Physician  to  the  Hospital. 

(Reported  by  Mr.  S.  I.  A.  Salter,  A.Iy.C.) 

Gentlemen, — I  beg  to-day  to  call  your 
attention  to  the  subject  of  Paralysis.  I  have 
at  present  five  cases  in  the  hospital,  which 
exemplify  different  forms  of  palsy  ;  so  that  I 
shall  be  able  to  illustrate  my  observations  on 
these  diseases  by  reference  to  cases  which 
have  been  under  our  immediate  inspection. 

Let  me,  however,  first  make  some  general 
observations  on  the  conditions  which  give 
rise  to  and  attend  paralysis.  I  must  ask 
you  to  receive  my  statements  on  these 
points  as  so  many  postulates;  for  it  would 
occupy  too  much  time  to  enter  into  the 
proofs  which  could  be  adduced  to  demon¬ 
strate  the  correctness  of  my  propositions. 

In  the  first  place,  then,  you  must  not  look 
upon  paralysis  as  a  disease  of  itself :  it  is 
not  a  disease,  but  a  symptom  of  a  disease. 
Non-medical  people,  and  sometimes  even 
medical  men,  are  apt  to  speak  as  if  the  palsy 
constituted  the  whole  essence  of  the  malady; 
but  this  is  not  the  case.  Paralysis  is  an 
effect  due  to  a  cause,  which  cause  itself  is 
not  always  the'essential  disease. 

What  are  the  causes  which  may  give  rise 
to  paralysis  ?  These  are,  either  an  affection 
of  the  nerve  or  nerves,  whose  power  is  de¬ 
stroyed,  in  some  part  of  their  course,  or  a 
morbid  state  of  the  centre  in  which  the  nerve 
or  nerves  are  implanted,  or  with  which  they 
may  be  less  directly  connected.  The  ner¬ 
vous  trunks  themselves  may  be  impaired  in 
their  nutrition,  the  centre  being  healthy,  or 
they  may  have  suffered  some  mechanical 
injury  from  violence  or  pressure  ;  thus 
either  they  become  imperfect  conductors  of 
the  nervous  force,  or  they  are  rendered  alto¬ 
gether  incapable  of  propagating  it ;  or  some 
portion  of  the  centre  of  volition  is  the  seat 
of  a  morbid  process,  whereby  the  influence 
of  the  will  over  certain  parts  is  suspended, 
and  thus  the  nerves  of  those  parts  receive 
no  impulse  at  all  from  that  centre,  whether 
mental  or  physical ;  and,  although  perfectly 
healthy  in  themselves,  are  incapable  of  taking 
part  in  voluntary  acts. 

I  would  say  that  the  centre  of  volition  is 
of  very  great  extent :  it  extends  from  the 
corpora  striata  in  the  brain  down  the  entire 
length  of  the  anterior  horns  of  the  grey 
matter  of  the  spinal  cord,  including  also  the 


locus  niger  in  the  crus  cerebri,  and  much  of 
the  vesicular  matter  of  the  mesocephale  and 
of  the  medulla  oblongata.  A  morbid  state 
of  any  part  of  this  centre  is  capable  of  pro¬ 
ducing  paralysis ;  but  as  the  intracranial 
portion  of  it  exercises  the  greatest  and  most 
extended  influence  in  the  production  of  vo¬ 
luntary  movements,  so  disease  of  this  por¬ 
tion  gives  rise  to  the  most  extended  and 
complete  paralysis. 

Another  fact  which  I  would  impress  upon 
you  is  one  which  anatomy  in  a  great  degree 
demonstrates,  and  which  pathological  re¬ 
search  confirms — that  the  centre  of  volition 
for  either  side  of  the  body  is  not  altogether 
on  the  same  side  of  the  body.  Of  the  centre 
for  the  left  side,  for  instance,  the  intra¬ 
cranial  portion  is  on  the  right  side,  and  the 
intraspinal  portion  on  the  left  side,  and  these 
two  portions  are  brought  into  connection 
with  each  other  through  certain  oblique 
fibres  from  the  anterior  pyramids  which 
cross  from  right  to  left,  decussating  with 
similar  fibres  proceeding  from  left  to  right, 
and  belonging  to  the  centre  of  volition  of 
the  right  side. 

Having  made  these  introductory  observa¬ 
tions,  gentlemen,  I  will  now  pass  on  to  the 
consideration  of  the  cases  ;  and  the  first  we 
shall  take  is  that  of  Halliday,  in  Sutherland 
ward,  as  affording  a  good  example  of  a  very 
serious  form  of  paralysis,  of  very  com¬ 
mon  occurrence  in  the  London  hospitals — 

I  mean  paralysis  from  the  poison  of  lead. 
The  patient  is  30  years  of  age,  by  occupation 
a  house-painter,  of  temperate  habits.  It 
appears  that  he  was  never  obliged  to  desist 
from  work  on  account  of  illness  until  about 
three  years  ago,  when  he  had  an  attack  of 
colic,  for  which  he  was  treated  in  a  hospital 
in  town,  and  perfectly  recovered.  He  has 
since  had  several  slight  attacks.  About 
three  weeks  ago  he  first  noticed  that  his 
wrists  became  weak,  and  began  to  drop, 
and  that  he  became  very  nervous  and  irrita¬ 
ble.  About  this  time,  or  rather  later,  he 
had  two  paroxysms  of  general  convulsions, 
fits  of  epilepsy,  during  which  he  suddenly 
fell  down,  lost  his  consciousness,  and  strug¬ 
gled  violently,  but  he  did  not  bite  his  tongue. 
These  attacks  occurred  once  daily  on  two 
succeeding  days,  came  on  without  any  warn¬ 
ing,  and  lasted  about  ten  minutes.  He  has 
frequently  had  cramps  in  the  arms  and  legs, 
but  no  other  pain  in  the  limbs.  For  some 
weeks  past  he  has  noticed  a  blue  line  on 
his  gums  :  bowels  generally  confined. 

I  have  on  many  occasions  pointed  out  to 
you  the  remarkable  and  peculiar  condition 
of  this  man’s  arms.  When  they  are  held 
out,  the  hands  drop,  from  his  inability  to 
maintain  them  in  the  state  of  extension ; 
nor  can  he,  by  the  utmost  effort,  bring 
them  into  the  state  of  extension.  His 
power  of  extending  the  fingers  is  also  im- 


52 


DR.  R.  B.  TODD’S  CLINICAL  LECTURE  ON  PARALYSIS. 


paired,  but  to  a  less  degree.  If  you  exa¬ 
mine  the  posterior  surface  of  the  forearm  I 
where  the  extensor  muscles  are  situate,  you  . 
will  find  that  space  rendered  quite  concave, 
from  the  atrophy  and  consequent  shrinking 
of  the  muscles.  The  forearm  has  lost  its 
plumpness  in  this  region,  and,  by  pres¬ 
sure,  you  can  feel  the  interosseous  mem¬ 
brane.  These  are  not  the  only  muscles 
affected  :  those  of  the  ball  of  the  thumb  are 
also  wasted,  and  the  movements  of  the 
thumb  are  much  weakened,  especially  those 
of  opposition.  But  in  this  case  the  wasting 
of  these  thumb  muscles  has  by  no  means 
gone  to  so  great  an  extent  as  you  may  often  J 
find  in  extreme  cases.  The  flexor  muscles 
of  the  forearm  have  suffered  slightly  in  their 
nutrition,  and  have  lost  much  of  their  firm¬ 
ness  ;  their  power  is  consequently  much 
affected  ;  and,  although  the  patient  can  flex 
liis  wrist  with  sufficient  power,  he  cannot 
grasp  with  full  force.  The  general  move¬ 
ments  of  the  arm  are  accompanied  with  that 
kind  of  tremulousness  which  so  frequently 
accompanies  enfeebled  states  of  nutrition  of 
the  muscles.  The  deltoid  muscles  are  quite 
paralysed,  so  that  the  patient  has  no  power 
to  raise  his  arm  or  maintain  it  at  right  angles 
with  his  trunk.  The  lower  extremities  are 
not  paralysed,  but  they  participate  slightly 
in  the  general  weakness. 

In  addition  to  the  symptoms  above  de¬ 
tailed,  we  find  in  this  patient  that  curious  sign 
of  the  presence  of  lead  in  the  system  first 
pointed  out  by  Dr.  Burton — namely,  the 
blue  line  or  margin  of  the  gums  surround¬ 
ing  ;  the  necks  of  the  teeth,  present  only 
where  the  teeth  or  their  stumps  are  in  the 
alveoli,  and  ceasing  where  a  tooth  is  wanting. 
There  is  no  indication  of  any  affection  of 
the  central  organs  of  the  nervous  system, 
although  those  organs  cannot  be  regarded  as 
sound  ;  the  digestive  organs  are  natural,  as 
also  those  of  circulation  and  respiration  ;  the 
pulse  is  09,  and  feeble  ;  and  the  secretions 
healthy. 

It  is  not  very  common  to  see  the  muscles 
above  the  elbow  much  weakened  in  lead- 
palsy  ;  in  this  case,  however,  that  condition 
existed  in  a  very  marked  degree  ;  and  not 
only  were  the  biceps  and  triceps  thus  affected, 
but  the  deltoid  was  so  much  paralysed  that 
the  man  could  scarcely  raise  his  arm,  much 
less  extend  it  at  right  angles  to  his  body.  He 
still  has,  although  some  time  under  treat¬ 
ment,  a  symptom  which  wras  much  more  ob¬ 
vious  at  first — namely,  a  trembling  agitated 
manner,  like  that  of  an  intemperate  man  in 
a  state  of  incipient  delirium  tremens.  It  is 
not  improbable  that  this,  to  a  certain  extent, 
did  arise  from  intemperance,  for  although  he 
did  not  call  himself  intemperate,  he  was  fond 
of  his  glass,  and  intemperance  is  a  very 
common  vice  among  those  of  his  trade.  I 
believe,  however,  that  it  mainly  depended 


upon  a  general  diffusion  of  the  lead  poison 
through  his  muscular  and  nervous  systems. 
Again,  you  will  remember  that  he  had  epi¬ 
lepsy,  and  evidently  in  connection  with  the 
same  causes  which  produced  paralysis  ;  the 
fits  were  slight,  but  still  they  were  distinctly 
epileptic  ;  they  had  all  the  essential  charac¬ 
ters  of  that  disease  :  there  was  the  sudden 
fall,  the  loss  of  consciousness,  the  convul¬ 
sion.  He  has  had,  moreover,  cramps  in  the 
arms  and  legs. 

The  question  here  arises — what  is  the 
particular  tissue  or  organ  affected  in  the 
paralysis  of  house-painters  and  others  ex¬ 
posed  to  the  influence  of  lead  ?  I  believe 
that  the  muscles  and  nerves  are  early  affected, 
and  that,  at  a  subsequent  period,  the.  ner¬ 
vous  centres  become  implicated.  The  ner¬ 
vous  system  is  affected  at  the  periphery  of 
the  nerves  first,  obviously,  and  the  poisonous 
influence  continuing,  the  contamination  gra¬ 
dually  advances  to  the  centres,  as  is  suffi¬ 
ciently  shewn  by  the  fact  that  the  local  para¬ 
lysis  always  precedes,  and  generally  for  some 
considerable  time,  the  epileptic  convulsions 
and  other  symptoms  of  centric  disease.  In 
this  case  the  epilepsy  shewed  itself  unusually 
early. 

Another  question  suggests  itself  to  us  here 
■ — what  is  it  that  thus  contaminates  the  mus¬ 
cular  and  nervous  tissues,  and  impairs  their 
functions  ?  To  this  we  answer,  without  hesi¬ 
tation,  it  is  lead,  existing  materially  in  the 
affected  tissues.  If  you  examine  the  gums 
of  patients  suffering  from  lead-palsy,  you 
will  perceive  a  bluish  areola  on,  or  rather  in, 
the  gum,  close  to  the  neck  of  each  tooth; 
and  this  is  produced  by  lead  existing  there 
in  some  unknown  combination  with  the 
tissue ;  and  you  may  produce  precisely  the 
same  effect  by  giving  acetate  of  lead  in. 
small  doses  to  patients  for  some  time.  The 
most  positive  evidence,  however,  is  given  us 
by  the  post-mortem  examination  of  patients 
who  have  died  from  lead-poisoning ;  for 
from  their  muscles  and  brains  chemists  are 
able  to  extract  lead  in  notable  quantity. 

People  whose  bodies  thus  become  impreg¬ 
nated  with  lead,  are  those  whose  employ¬ 
ments  require  them  to  use  that  material  in 
large  quantity  ;  and,  in  our  London  hospitals, 
house-painters  are  those  whom  we  have  most 
frequently  to  treat  for  this  malady.  These 
men  get  the  lead  paint  upon  their  skin, 
where  it  may  become  absorbed,  or  inhale  it 
into  their  lungs  in  the  form  of  small  par¬ 
ticles  of  the  powder  with  which  the  paint  is 
made,  floating  in  the  air ;  or  it  may  be 
mixed  with  the  saliva,  and  so  get  into  the 
stomach.  From  one  or  all  of  these  sources 
the  lead  gets  into  the  circulation,  and  during 
its  course  through  the  body  becomes  depo¬ 
sited  in  the  affected  organs,  or  combined 
with  their  constituents  in  some  way  or 
other.  But  why,  it  will  be  asked,  does  it 


dr.  R.  b.  todd’s  clinical  lecture  on  paralysis. 


58 


alight  upon  the  muscular  and  nervous  tissues 
chiefly  ?  why  upon  the  muscles  of  the  ex 
tremities,  rather  than  those  of  the  trunk  ? 
and  why  upon  the  extensor  muscles  in  pre¬ 
ference  to  the  flexors  ?  The  answer  which 
appears  to  me  most  satisfactory,  and  which 
offers  the  best  explanation  of  the  phenome¬ 
non,  is  this — that  those  tissues  in  which  the 
nutrient  changes  are  most  active  receive  the 
largest  supply  of  blood,  and  that  blood, 
being  loaded  by  a  poisonous  material,  would 
impregnate  them  with  it  to  a  greater  degree 
than  other  tissues  in  which  the  circulation 
is  less  active ;  that,  for  this  reason,  such 
highly-nourished  structures  as  muscle  and 
nerve  become  poisoned  early  ;  that,  as  the 
muscles  of  the  upper  extremities  are  used 
more,  and  probably  on  that  account  expe¬ 
rience  more  active  nutrient  changes  than 
those  of  the  trunk  and  lower  extremities, 
they  are  poisoned  sooner  than  those  muscles. 
Moreover,  in  painters,  the  extensor  muscles 
of  the  arm,  as  well  as  the  muscles  constitut¬ 
ing  the  ball  of  the  thumb,  become  princi¬ 
pally  paralysed,  because  they  are  most  exer¬ 
cised  during  the  practice  of  painting  ;  and 
as  they  are  more  exercised,  are  consequently 
more  supplied  with  blood — poisoned  blood 
— to  repair  the  waste  that  is  going  on  in 
them. 

Patients  who  die  of  lead -poisoning  are 
generally  such  as  have  been  long  exposed  to 
its  influence,  or  have  addicted  themselves  to 
intemperate  habits.  The  morbid  appearances 
in  the  brain  and  spinal  cord  are  such  as  de¬ 
note  imperfect  nutrition  of  those  centres, 
and  are  frequently  associated  wjth  marks  of 
chronic  irritation  of  the  membranes,  such  as 
frequently  accompany  intemperance  ;  these 
changes  are  doubtless  also  due  to  the  pre¬ 
sence  of  lead.  The  brain  especially  presents 
the  appearance  of  an  ill- nourished  organ  : 
pale,  soft ;  its  convolutions  wasted  ;  the 
sulci  between  them  wide  ;  and  sometimes 
patches  of  white  softening  are  seen  in  the 
hemispheres.  I  have  seen  this  condition  in 
patients  who  have  experienced  several  parox¬ 
ysms  of  epilepsy  before  death,  or  who  may 
have  died  in  one. 

Treatment. — In  the  treatment  of  lead- 
palsy,  the  great  object  is,  if  possible,  to 
eliminate  the  poison  from  the  body,  and  to 
prevent  the  introduction  of  further  supplies 

of  it. 

The  patient  should  be  kept  clean,  should 
wash  much,  and  use  such  means  as  friction, 
exercise,  & c.,  to  stimulate  the  excreting 
power  of  the  skin. 

It  has  been  thought  that  sulphur,  when 
introduced  into  the  system,  has  the  power  of 
neutralizing  the  effects  of  lead,  by  forming 
some  innocuous  compound  with  it ;  whether 
or  not  any  such  compound  is  formed  I 
cannot  say,  but  I  have  certainly  found  sul¬ 
phur  a  very  useful  remedy,  in  the  form  of  a 


sulphur-bath.  The  bath  which  I  order  for 
my  patients  consists  of  one,  two,  or  three 
ounces  of  sulphuret  of  potassium,  mixed 
with  as  many  gallons  of  water.  I  give  this 
to  my  patients  empirically  ;  but  I  am  quite 
sure  they  derive  much  benefit  from  its  em¬ 
ployment. 

Galvanism,  as  a  local  stimulant  to  the 
nerves,  should  not  be  neglected ;  I  am  cer¬ 
tain  it  is  of  service.  Our  patient  Halliday 
was  much  improved  by  it  ;  and  I  mainly  at¬ 
tribute  the  recovery  of  his  power  of  moving 
his  deltoid  muscle,  which  he  has  now  done, 
to  its  use. 

In  the  use  of  galvanism,  you  must  take 
care  not  to  continue  its  employment  too 
long  each  time.  Half  an  hour  each  day,  or 
still  better  ten  minutes  or  fifteen  minutes 
at  three  different  periods  of  the  day,  will  be 
found  quite  sufficient. 

Added  to  this,  the  subjects  of  lead  palsy 
should  breathe  pure  air,  and  have  good  sus¬ 
taining  food. 

The  next  case,  gentlemen,  is  one  of 
paralysis  of  the  arm  produced  by  a  bandage 
improperly  applied  to  a  man  who  had 
suffered  fracture  of  the  clavicle  ;  and  I  hope 
that  from  it  you  will  not  only  learn  an  im¬ 
portant  lesson  in  pathology — namely,  that 
pressure  on  a  nerve  is  capable  of  producing 
paralysis  of  the  parts  supplied  by  it,  and 
likewise  the  particular  treatment  which 
paralysis  so  produced  requires ;  but  I  hope 
that  you  will  also  deduce  a  moral  from  it, — 
that  a  surgeon  cannot  be  too  careful  in  daily 
watching  cases  that  are  under  his  care,  and 
in  noticing  every  symptom  which  may  in¬ 
dicate  that  his  patient  is  not  progressing 
favourably  ;  for  had  that  been  done  in  the 
present  instance,  this  man  would  not  have 
come  to  our  hospital  with  paralysis  of  his 
arm.  I  am  happy  to  say  that  the  bandage 
was  not  applied  at  King’s  College  Hospital, 
and  indeed,  from  the  character  of  the  gentle¬ 
men  who  have  filled  the  office  of  house-sur¬ 
geon  here,  1  believe  such  an  accident  could 
never  have  happened  among  us. 

The  patient  who  is  the  subject  of  this 
case  has  been  in  the  hospital  before  under 
my  care,  for  some  pectoral  complaint,  when 
a  full  report  of  his  history — his  former 
health  and  habits,  were  taken;  the  notes 
made  at  his  admission  for  his  present  illness 
are,  therefore,  rather  brief :  I  will  read 
read  them  to  you. 

“Timothy  Sullivan,  admitted  into  Rose 
ward,  November  18th.  This  patient  is  23 
years  of  age,  a  native  of  Cork  ;  has  lived  in 
London  for  about  a  year;  in  occupation,  a 
labourer.  Last  June  he  was  admitted  into 
this  hospital,  suffering  from  pain  in  the  side, 
and  cough  both  these  symptoms  were  re¬ 
lieved,  and  he  went  out.  Shortly  after  leav¬ 
ing  the  house,  his  right  clavicle  was  broken 

i 


54 


DR.  R.  B.  TODD’S  CLINICAL  LECTURE  ON  PARALYSIS. 


by  an  old  wall  falling  upon  him.  He  went 
to  an  hospital,  and  the  ordinary  figure-of- 
eight  bandage  was  applied.  After  a  time, 
the  patient  found  that  his  right  hand  and 
arm  were  numb ;  and  soon  after  this  he 
noticed  a  great  loss  of  power  of  the  extensors 
of  the  hand.  Notwithstanding  these  symp¬ 
toms,  the  bandage  was  allowed  to  remain, 
and  both  the  paralysis  of  sensation  and  mus¬ 
cular  motion  have  continued  up  to  the  pre¬ 
sent  time. 

Nov.  19th. — At  present  there  are  numb¬ 
ness  of  the  hand  and  arm,  and  entire  loss  of 
power  in  the  extensors  of  the  hand,  which 
is  completely  flexed  when  the  arm  is  raised. 
All  the  muscles  of  the  arm  have  less  power 
than  natural. 

This  case  was  treated  with  galvanism,  and 
the  patient  left  the  hospital  better,  having 
gained  some  power  of  the  extensors,  and 
that  of  the  flexors  being  nearly  restored  to 
their  healthy  state.  It  was  some  time,  how¬ 
ever,  before  the  improvement  became  mani¬ 
fest.  In  the  reports  of  the  22nd  and  26th 
of  November,  it  is  stated  that  no  change  had 
taken  place,  and  he  first  began  to  mend  on 
the  28th. 

Paralysis  produced  by  pressure  on  the 
axillary  plexus  of  nerves  is  not  of  uncom¬ 
mon  occurrence ;  I  have  seen  some  cases 
in  which  it  was  produced  in  the  following 
way  : — A  man  gets  intoxicated,  and  falls 
asleep  with  his  arm  over  the  back  of  a  chair  ; 
his  sleep  under  the  influence  of  his  potations 
is  so  heavy,  that  he  is  not  roused  by  any 
feelings  of  pain  or  uneasiness,  and  when  at 
length  he  awakes,  perhaps  at  the  expiration 
of  some  hours,  he  finds  the  arm  benumbed 
and  paralysed.  It  generally  happens  that 
the  sensibdity  is  restored  after  a  short  time, 
but  the  palsy  of  motion  continues :  galvanism 
should  be  employed  in  these  cases,  but  if  the 
pressure,  which  caused  the  paralysis,  had 
been  very  long  continued,  these  cases  seldom 
come  to  a  favourable  termination.  Nerve 
tissue  is  one  which  does  not  regenerate 
quickly  or  completely,  so  that  any  great  or 
long  continued  lesion  of  its  structure  is 
likely  to  become  a  permanent  condition. 

I  shall  next  call  your  attention  to  a  case 
illustrative  of  another  form  of  paralysis — 
namely,  hysterical  paralysis. 

The  following  is  the  report  of  the  case  : — 
Mary  Leigh,  set.  42  years,  was  admitted 
into  Lonsdale  ward  on  October  28th  :  states 
that  she  is  a  native  of  London,  where  she 
has  resided  all  her  lifetime  ;  she  lived  in 
occupation  as  a  housemaid  for  twelve  years, 
when  she  was  married ;  has  been  a  widow 
for  seven  years  ;  had  an  attack  of  rheumatic 
fever  when  she  was  15  years  of  age,  and  a 
second  about  nine  years  ago;  three  years 
since  she  had  erysipelas  in  the  left  ankle ; 
and  twelve  months  back  she  suffered  from 
typhus  fever. 


About  six  weeks  ago  she  worked  hard  for 
several  succeeding  days,  during  which  time 
she  suffered  from  headache,  and  going  to  bed 
tired  on  a  Saturday  night,  fell  asleep  almost 
immediately.  About  five  o’clock  on  the 
following  morning,  she  woke  up  with  pain 
and  loss  of  powder  in  the  right  arm.  For 
this  she  applied  to  a  druggist,  who  purged 
her  and  gave  her  a  liniment  for  the  arm. 
About  three  weeks  after  this,  she  became  an 
out-patient  at  this  hospital :  took  mineral 
and  saline  purgatives  for  a  fortnight,  when 
the  leg  also  became  affected  like  the  arm, 
with  pain  and  loss  of  power ;  she  also 
suffered  from  pain  in  the  head,  and  dimness 
of  sight. 

In  this  case  the  most  important  points  to 
be  remembered  are  these :  —  In  the  first 
place  the  invasion  was  very  sudden,  and 
occurred  after  hard  work,  and  it  was  ac¬ 
companied  by  no  loss  of  sensibility,  and  no 
impairment  of  intellect.  The  face  is  quite 
free  from  paralysis  ;  and  this,  considering 
the  extent  of  the  paralysis  elsewhere,  is  a 
remarkable  circumstance.  I  was  at  first, 
however,  disposed  to  think  that  there  was  a 
small  amount  of  facial  paralysis ;  but  I  am 
now  quite  sure  that  that  is  not  the  case,  and 
that  what  I  took  for  palsy  is  nothing  more 
than  that  want  of  symmetry  on  the  opposite 
sides  of  her  countenance,  which  the  majority 
of  people  present.  Examine  the  faces  of  a 
number  of  persons  collected  together,  as  I, 
with  a  numerous  class  before  me,  have  now 
an  opportunity  of  doing,  and  I  will  venture 
to  say  that,  without  any  disparagement  to 
the  good  expression  of  the  countenance,  you 
will  find  but  few  which  exhibit  perfect  sym¬ 
metry.  The  tongue,  too,  at  first  sight, 
appeared  to  be  paralysed  ;  but  we  soon  dis¬ 
covered  that  the  obliquity  in  the  direction  in 
which  the  tongue  was  protruded  was  due  to 
a  cause  which  will  be  very  apt  to  mislead 
you  if  you  are  not  prepared  for  it,  namely, 
an  undue  projection  of  two  or  more  of  the 
teeth  in  the  lower  jaw,  which  gave  an  oblique 
direction  to  the  movement  of  the  tongue. 

Now  in  this  case  there  is  no  evidence  of 
brain  disease  ;  all  the  symptoms  under  which 
the  patient  labours  may  have  occurred  inde¬ 
pendently  of  disease  of  that  organ.  There 
was  no  injury,  no  suspension  of  intellect  ; 
the  function  of  deglutition  was  unimpaired  ; 
there  is  no  tongue  or  face  paralysis  ;  pain  of 
the  head  there  was,  but  this  was  not  fixed  in 
its  position.  All  this  militates  against  the 
idea  that  these  symptoms  were  caused  by 
any  lesion  of  the  brain.  What,  then,  it  will 
be  asked,  did  cause  them  ?  We  know  that 
there  are  certain  conditions  of  the  svstem — 

v 

hysterical — in  which  organic  diseases  are 
simulated  by  mere  functional  disturbance, 
and  that  even  the  gravest  diseases  are  occa¬ 
sionally  imitated  with  great  accuracy,  and 
among  these  paralysis.  Hysterical  paralysis, 


DR.  C.  H.  JONES  ON  THE  NERVES  OF  THE  LfVER. 


55 


however,  generally  affects  only  one  limb,  or 
a  portion  of  one  limb,  as  a  joint  or  a  finger. 
The  case  of  Mary  Leigh,  which  we  have  just 
been  considering,  I  believe  to  be  one  of 
hysterical  paralysis  in  its  least  common 
form,  being  far  more  general  than  usual, 
and  nearly  amounting  to  hemiplegia.  Added 
to  the  negative  evidence  which  I  have  already 
adduced,  there  is  much  positive  evidence  to 
show  that  the  malady  is  an  hysterical  affec¬ 
tion  ;  the  patient’s  physiognomy  is  hysteri¬ 
cal,  as  well  as  her  general  constitution  ;  the 
catamenia  have  been  irregular  ;  she  has  had 
decided  globus  hystericus,  and  is  in  the 
habit  of  voiding  large  quantities  of  very  pale 
urine  of  low  specific  gravity.  Again,  the 
great  extent  of  the  paralysis  in  the  limbs, 
and  the  total  absence  of  it  in  the  face  and 
tongue,  are  certainly  evidence  in  favour  of 
its  hysterical  character  ;  for  although  hyste¬ 
rical  paralysis  occurs  in  all  parts  of  the 
trunk  and  extremities,  it  very  rarely,  if  ever, 
attacks  the  face.  But  I  would  particularly 
call  your  attention  to  the  peculiar  character 
of  the  movement  of  the  paralysed  leg  when 
the  patient  walks,  which,  in  my  opinion,  is 
quite  pathognomonic  of  the  hysterical  affec¬ 
tion.  If  you  look  at  a  person  labouring 
under  ordinary  hemiplegia  from  some  oi’ga- 
nic  lesion  of  the  brain,  when  he  walks  you 
will  see  that  he  uses  a  particular  gait 
to  bring  forward  the  palsied  leg  :  he  first 
throws  the  trunk  to  the  opposite  side,  and 
rests  its  entire  weight  on  the  sound  limb  ; 
and  then,  by  an  action  of  circumduction,  he 
throws  forward  the  paralysed  leg,  making 
the  foot  describe  an  arc  of  a  circle.  Our 
patient,  however,  does  not  walk  in  this  way  ; 
she  drags  the  palsied  limb  after  her,  as  if  it 
were  a  piece  of  inanimate  matter.;  and  uses 
no  act  of  circumduction,  nor  efforts  of  any 
kind  to  lift  it  from  the  ground  ;  the  foot 
sweeps  the  ground  as  she  walks.  This  I 
believe  to  be  characteristic  of  the  hysterical 
form  of  paralysis. 

Were  I  to  enter  into  the  pathology  of  this 
case  at  full  length,  I  should  have  to  discuss 
the  whole  subject  of  hysteria,  which  alone 
would  occupy  more  than  one  lecture  to  do 
it  justice  ;  I  must  at  present  content  myself 
by  stating,  that  I  believe  hysterical  paralysis 
is  caused  by  a  depraved  nutrition  of  the 
nerves  of  the  limb  affected,  or  of  some  part 
of  the  centre  of  volition.  Moral  causes  no 
doubt  exercise  an  important  influence  in  the 
production  of  this  state,  and  the  power  of 
the  will  becomes  impaired  ;  but  that  a  de¬ 
praved  state  of  general  nutrition,  which  tells 
chiefly  upon  the  nervous  system,  or  upon 
parts  of  it,  is  at  the  foundation  of  the  ma¬ 
lady,  I  think  no  one  can  doubt  who  consi¬ 
ders  fairly  its  natural  history. 

In  the  treatment  of  these  affections  you 
must  direct  your  attention  chiefly  to  the 
improvement  of  the  general  constitutional 


state  of  your  patient,  by  diet,  by  good  air 
and  exercise  when  they  can  be  obtained,  by 
cold  bathing  and  improving  the  condition  of 
the  skin,  by  the  use  of  such  vegetable  or  mine¬ 
ral  tonics  as  may  be  suitable  to  her  digestive 
organs,  and  by  regulating  the  action  of  the 
bowels,  and  promoting  the  renal,  uterine,  and 
other  excretions.  Many  cases  are  perfectly 
curable  by  these  means  only  ;  and  all  cases 
should  be  treated  in  this  way  at  first.  The 
mind  should  be  diverted  as  much  as  possible 
from  the  paralysed  limb  or  part,  and  its  ex¬ 
ercise,  by  indirect  means,  promoted  as  much 
as  possible. 

If  these  means  fail,  then  local  treatment 
may  be  had  recourse  to.  And  for  this  pur¬ 
pose  galvanism  is,  I  think,  very  useful :  it 
must  be  employed  gently,  so  as  not  to  alarm 
the  patient,  and  its  intensity  may  be  gra¬ 
dually  increased  and  varied,  according  to 
circumstances.  The  galvanic  trough  may  be 
used  at  first,  and  afterwards  the  coil  machine, 
which,  however,  admits  of  easy  variations  of 
intensity,  from  shocks  scarcely  to  be  felt  up 
to  those  of  such  intensity  as  to  be  beyond 
endurance.  Such  violent  shocks  you  will 
not,  of  course,  have  recourse  to  ;  their  in¬ 
fluence  extends  beyond  the  affected  parts, 
and  is  calculated  to  disturb  the  healthy  ac¬ 
tion  of  the  nervous  centres.  Mild  shocks 
applied  for  short  periods,  two  or  three  times 
in  the  day,  varying  the  direction  of  the  cur¬ 
rent,  allowing  it  to  pass  at  one  time  from 
centre  to  circumference  (direct),  and  at  ano¬ 
ther  time  from  circumference  to  centre ; 
this  mode  of  applying  electricity  you  will 
find  most  successful  in  restoring  the  healthy 
action  of  the  paralysed  parts. 


©ngmad  ©cmmumcationsb 

ON 

THE  NERVES  OF  THE  LIVER. 

By  C.  H.  Jones,  M.B.  Cantab. 
Physician  to  Chelsea  Dispensary. 

The  liver  receives  a  pretty  ample  sup¬ 
ply  of  nerves  from  various  sources  : 
branches  of  the  left  pneumogastric, 
branches  from  the  semi-lunar  ganglia, 
and  some  from  the  right  phrenic,  are 
usually  described  as  entering  the  organ 
at  the  transverse  fissure.  Having 
entered  the  portal  canals,  they  run  in 
the  areolar  tissue  which  surrounds  the 
vessels,  and  may  be  seen  distinctly  in 
great  numbers  when  the  coats  of  the 
vein  are  dissected  off.  By  ordinary 
dissection  they  may  be  followed  some 
distance  along  the  portal  canals,  but 


56 


DR.  C.  H.  JONES  ON  THE  NERVES  OF  THE  LIVER. 


nothing  satisfactory  can  in  this  way  be 
determined  respecting  their  distribu¬ 
tion  and  arrangement.  In  endeavouring 
to  ascertain  something  more  precise 
respecting  these  points,  I  adopted  the 
following  mode  of  proceeding : — Hav¬ 
ing  slit  up  a  portal  canal  throughout 
the  greater  part  of  its  extent,  I  selected 
a  part  where  the  lining  membrane  of 
the  vein  wTas  of  sufficient  tenuity,  and 
yet  still  separated  by  an  areolar  invest¬ 
ment  from  the  parenchyma  of  the  pa¬ 
rietal  lobules  ;  the  coats  of  the  vein 
were  then  carefully  dissected  off,  laid 
on  a  slip  of  glass  with  the  outer  surface 
uppermost,  and  rendered  transparent 
by  acetic  acid  ;  when  the  specimen  was 
now  moderately  compressed,  it  could 
be  conveniently  examined  with  a  power 
of  200  linear,  which  was  quite  sufficient 
to  enable  the  eye  to  recognise  the  small¬ 
est  filaments  of  the  nerves.  The  exami¬ 
nation  of  such  a  preparation  shews  that 
a  very  large  number  of  nerves  are  dis¬ 
tributed  to  the  coats  of  the  divisions  of 
the  portal  vein ;  they  form  trunks  of 
various  size,  which  continually  divide 
and  unite  with  other  branches,  so  as 
to  constitute  a  plexus  with  elongated 
meshes;  this  arrangement  obtains  so 
completely,  that  it  is  often  by  no  means 
easy  to  determine  what  is  the  general  I 

Fig. 


direction  which  the  stream  is  taking,  or 
whether  what  appears  to  be  a  division 
of  a  branch  is  not  really  an  anastomo¬ 
sis.  In  following  further  the  course 
of  the  smaller  branches,  one  is  soon 
led  to  remark  the  very  great  length  of 
the  distances  they  run  :  very  often  a 
small  branch,  say  in.  diam.,  sepa¬ 
rates  from  a  trunk,  and  runs  along  the 
surface  of  the  coats  of  the  vessel  for 
a  distance  too  great  for  measurement; 
after  thus  wandering,  as  it  were,  for  a 
long  way,  it  often  joins  with  another 
filament,  and  the  resulting  one  again 
pursues  a  like  course ;  perhaps  soon 
dividing  again,  and  uniting  with  others, 
or  proceeding  to  join  some  distant 
trunk.  This  plexiform  disposition  is 
certainly  the  most  frequent ;  but  in 
several  instances  it  may  be  observed 
that,  during  a  long  course,  the  structure 
of  the  nerve  filament  becomes  gradu¬ 
ally  less  marked,  the  nuclei  fewer  and 
more  widely  “  espaces,”  and  the 
fibrous  striatum  more  faint,  until  at  last 
it  can  be  no  longer  discerned ;  this 
mode  of  termination  I  think  really  oc¬ 
curs,  though  there  is  risk  of  being  de¬ 
ceived  by  the  nerves  having  suffered 
injury  in  the  preparation  of  the  speci¬ 
men. 

1. 


A  small  artery,  with  organic  nerves  accompanying  it ;  the  smaller  filaments  are  seen 
passing  across  the  vessel.  At  a,  two  branches  decussate  each  other. 


Fig.  2. 


The  supply  of  nerves  to  the  hepatic 
artery  is  extremely  abundant,  more  so, 
even,  than  that  which  belongs  to  the 
portal  veins;  one  of  its  branches,  re¬ 
moved  from  a  portal  canal  and  treated 
with  acetic  acid,  is  generally  found  to 
be  surrounded  with  nerves.  The  larger 
trunks  mostly  run  parallel  to  the  ves¬ 
sel,  sometimes  they  cross,  and  form 
communications  upon  it ;  from  these, 
small  branches  and  filaments  separate, 
which  run  often  a  long  way,  dividing 
and  communicating  with  each  other, 


A  small  organic  nerve ;  at  a  is  seen  a  small 
portion  of  a  tubular  fibre. 


DR.  C.  H.  JONES  ON  THE  NERVES  OF  THE  LIVER. 


57 


much  in  the  same  way  as  upon  the 
coats  of  the  portal  veins.  In  some  of 
these  anastomoses,  where  a  branch 
joined  another  nearly  at  right  angles 
to  its  course,  I  have  remarked  that 
the  nerve  beyond  the  point  of  junc¬ 
tion  was  little,  if  at  all,  larger  than 
before  it;  and  further,  that  the  uniting 
branch  did  not  pass  simply  in  one  di¬ 
rection,  and  blend  with  the  receiving 
one,  but  that  the  filaments  of  the  for¬ 
mer  passed  in  both  directions,  towards 
and  from  the  periphery;  this  was  ren- 
pered  clearly  manifest  by  the  elongated 
nuclei  at  the  line  of  union  being 
curved  in  a  corresponding  manner. 
As  the  supply  of  nerves  to  these  arteries 
is  so  abundant,  and  as  they  are  fa¬ 
vourable  objects  for  examination,  it 
seems  probable  that  the  question  of 
the  mode  of  termination  of  the  organic 
nerves  may  be  solved  by  a  careful  ex¬ 
amination  of  the  minute  filaments  in 
this  situation.  In  endeavouring  to  as¬ 
certain  this  point,  it  has  appeared  to 
me,  that  most  commonly  the  minute 
branches,  after  running  a  long  course 
upon  the  coats  of  the  vessel,  either 
unite  with  some  other  filament,  which 
again  runs  on  in  a  similar  manner,  or 
enter  some  neighbouring  trunk  ;  some¬ 
times,  however,  the  filament  which  one 
is  tracing,  cannot  be  followed  to  a  junc¬ 
tion  with  any  other,  but  is  lost,  its  struc¬ 
ture  gradually  becoming  indiscernible. 
In  this  way,  I  believe,  some  of  the 
minute  branches  terminate ;  but  I  do 
not  think  there  is  any  blending  of  the 
nerve  filaments  with  the  fibrous  or 
arterial  tissues  ;  they  appear  to  me  to 
retain  their  distinctness,  even  when  re¬ 
duced  to  their  minutest  size.  The  very 
circumstance  of  the  small  branches 
running  so  long  a  course  as  they  do, 
seems  to  indicate  pretty  certainly  that 
the  influence  which  they  convey  pro¬ 
duces  its  effects,  not  at  any  terminal 
point,  but  wherever  the  conducting 
filament  is  in  contact  with  the  arterial 
tissue.  This  view  is  supported  and 
illustrated  by  the  following  observa¬ 
tion: — A  nerve  of  some  size  was  seen 
running  parallel  to  an  artery,  and,  close 
to  its  margin,  it  gave  off  a  filament, 
which  inclined  so  as  to  get  upon  the 
coats  of  the  vessel,  then  turned  and  ran 
for  some  distance  upon  them,  forming 
a  gentle  curve,  and  returning  at  last  to 
its  parent  trunk,  with  which  it  subse¬ 
quently  proceeded  in  the  peripheral 
direction.  Now  it  cannot  be  supposed 


that  this  filament  should  thus  have 
deviated  from  its  original  course,  had 
it  not  been  thereby  enabled  to  exert  a 
more  effectual  influence  upon  the 
vessel  with  which  it  came  into  relation. 
Another  circumstance  respecting  these 
organic  nerves  is  worth  noticing,  viz. 
that  in  the  very  long  courses  which 
they  run,  they  may  be  seen  to  taper, 
and  gradually  become  less  distinct, 
their  diminution  not  being  occasioned 
(or  but  slightly)  by  a  separation  of  a 
part  of  their  substance  in  giving  off 
filaments,  but  taking  place  as  it  were 
per  se.  This  remark  I  wish  to  apply 
to  the  small  branches,  and  not  to  the 
trunk.  I  have  occasionally  observed, 
that  when  two  branches  proceeding 
nearly  in  the  same  direction,  and  unit¬ 
ing  at  an  acute  angle,  proceed  onward 
in  a  common  trunk,  the  size  of  this  is 
by  no  means  proportionate  to  the  ag¬ 
gregate  of  the  two  from  which  it  is 
formed  ;  it  seems,  indeed,  as  if  some  of 
the  anastomoses  resembled  rather  the 
blending  of  vessels  than  the  juxtaposi¬ 
tion  of  nerves.  Having  mentioned  the 
above  facts,  which  have  some  bearing 
on  the  question  as  to  how  the  nerves 
terminate,  I  may  now  add,  that  after  a 
diligent  examination  of  the  portal  vein 
and  hepatic  artery,  I  am  disposed  to 
believe  that,  in  both  these  situations, 
the  nerve  filaments  frequently  form 
real  terminal  loops.  The  point,  how¬ 
ever,  is  most  difficult  of  determina¬ 
tion  ;  for  the  great  majority  of  minute 
branches  form  anastomoses  with  others, 
and  even  when  a  filament  has  been 
:raced  from  one  trunk  apparently  re¬ 
turning  into  another,  it  remains  often 
doubtful  what  is  the  real  direction 
W’hich  this  last  is  taking;  whether  in  fact 
it  may  not  be  running  in  the  same  course 
as  the  anastomosing  filament  itself. 
Admitting,  however,  that  looping  does 
occur,  either  by  the  peculiar  mode  of 
junction  before  described,  or  in  the 
ordinary  way,  I  still  think  that  it  does 
not  sufficiently  account  for  the  great 
multitude  of  nerves  which  run  upon 
the  coats  of  the  vessels  ;  and  it  seems 
on  the  whole  most  probable,  that  the 
greater  number  of  branches  have  no 
proper  termination,  but  that  as  the 
plexus  proceeds,  the  smaller  filaments 
gradually  rejoin  the  larger  branches, 
and  these  again  diminish  in  size,  taper¬ 
ing  as  it  were  of  themselves,  and  not 
merely  lessened  by  the  separation  of 
filaments.  This  is  not  so  satisfactory 


58 


DR.  C.  H.  JONES  ON  THE  NERVES  OF  THE  LIVER. 


an  account  as  I  could  wish  to  have 
given,  but  it  is  most  in  accordance  with 
repeated  observations,  and  it  is  not  con¬ 
tradicted  by  any  knowledge  we  have  of 
the  functions  of  the  nerves. 

The  coats  of  the  hepatic  veins  ex¬ 
amined  in  a  similar  manner  to  those  of 
the  portal,  exhibit  a  much  more  sparing 
supply  of  organic  nerves;  sometimes  1 
have  scarcely  been  able  to  find  any 
filaments  upon  them.  The  ducts  also 
seem  to  have  but  few  nerves  appro¬ 
priated  to  them  ;  when  a  branch  is  laid 
open  and  examined  from  the  outer  sur¬ 
face,  it  is  manifestly  by  no  means  so 
richly  supplied  as  the  bloodvessels  in 
the  same  canal,  a  circumstance  which 
was  certainly  contrary  to  what  I  had 
expected. 

How  far  the  organic  nerves  accom¬ 
pany  the  vessels  in  the  portal  canals  is 
not  easily  determined  ;  they  certainly 
do  not  enter  the  lobules,  and  probably 
cease  before  the  vessels  in  their  dimi¬ 
nishing  progress  have  laid  aside  the 
tractile  coat  of  circular  fibres;  the 
smaller  hepatic  arteries  have  not  ap¬ 
peared  to  me  to  possess  so  many  nerves, 
in  proportion,  as  the  larger. 

Respecting  the  structure  of  the 
nerves  in  the  liver,  they  consist  almost 
wholly  of  the  fibres  termed  by  Henle 
“  gelatinous,”  with  which,  however, 
are  mingled  a  few  cerebro-spinal 
tubules.  Many  of  the  branches,  in¬ 
deed  all  the  smaller  ones,  are  composed 
of  gelatinous  fibres  only,  and  it  is  by 
no  means  uncommon  to  see  only  a 
single  tubular  fibre  in  a  nerve  of  some 
magnitude.  In  this  case,  of  course, 
the  tubule  must  terminate  without 
forming  a  loop,  and  it  is  difficult  to 
make  out  exactly  what  becomes  of  it; 
but  I  think  that  it  loses  the  white  in¬ 
vestment,  and  is  then  confounded  with 
the  surrounding  substance.  I  may 
here  mention  an  observation  which  has 
some  interest,  in  respect  of  the  mode  of 
development  of  the  tubular  fibre,  and 
its  relation  to  the  gelatinous.  A  small 
nerve  running  upon  an  hepatic  artery 
presented  the  usual  elongated  nuclei 
set  in  a  finely  striated  substance ; 
some  of  these  had  a  pellucid  middle 
portion  and  dark  margins.  In  the 
situation  of  one  of  them,  on  the  edge 
of  the  nerve,  there  was  a  very  exact 
resemblance  of  a  small  tubular  fibre: 
it  was  scarcely  more  than  twice  the 
length  of  the  elongated  nuclei,  and 
appeared  very  much  as  if  it  had  re¬ 


sulted  from  the  development  of  one  of 
them :  it  lay  quite  alone,  no  other  por¬ 
tion  of  tubular  fibre  existing  in  the 
same  nerve.  I  subsequently  noticed 
similar  appearances  in  other  branches. 
This  single  observation  is  not  of  much 
weight;  but,  if  confirmed,  there  would 
be  additional  evidence  in  favour  of  the 
view  that  the  tubular  fibres  are  a 
higher  development  of  the  gelatinous. 
The  tubular  fibres  extend  a  considera¬ 
ble  way  in  the  peripheral  direction.  I 
have  seen  them  in  branches  taken 
from  a  portal  canal  shortly  before  its 
termination  at  the  free  border  of  the 
liver.  I  may  remark,  that  though  I 
have  spoken  of  the  nerves  in  the  liver 
as  mainly  consisting  of  gelatinous 
fibres,  yet  it  appears  to  me  very  doubt¬ 
ful  whether,  in  this  part  of  the  sympa¬ 
thetic  system  at  least,  there  are  really 
distinct  and  separate  fibres  which 
could  be  termed  ultimate.  I  should 
rather  describe  the  organic  nerves  (in 
the  liver)  as  bands  of  a  finely  striated 
or  granular  material,  in  which  elon¬ 
gated  nuclei  are  set  at  intervals  ;  that 
this  basis  substance  has  a  tendency  to 
divide  in  the  longitudinal  direction  is 
certain;  but  I  do  not  think  that  it 
actually  is  so  divided.  This  view  im¬ 
mediately  suggests  itself  when  one  is 
examining  a  minute  branch  contain¬ 
ing  only  a  few  nuclei,  and  is  also  con¬ 
firmed  by  the  appearance  of  the  cut 
extremity  of  a  nerve,  from  which 
nuclei  may  be  sometimes  seen  project¬ 
ing  without  being  surrounded  by  any 
of  the  substance  which  should  consti¬ 
tute  the  fibre. 

I  have  spoken  unhesitatingly  of  the 
sympathetic  plexuses  and  their  ramifi¬ 
cations  in  the  liver  as  consisting  of 
organic  nerves,  feeling  no  manner  of 
doubt  that  they  really  discharge  the 
function  of  conductors  of  the  nervous 
influence.  This  opinion,  besides  the 
satisfactory  arguments  adduced  in  its 
favour  by  the  authors  of  the  “  Physio¬ 
logical  Anatomy/’  is  supported,  I 
think,  by  these  circumstances:  —  1. 
Acetic  acid,  moderately  diluted,  pro¬ 
duces  less  effect  on  these  nerves  than 
on  white  fibrous  tissue;  though  they 
are  rendered  more  transparent  by  it, 
yet  a  kind  of  fibrous  striation,  inde¬ 
pendent  of  the  nuclei,  continues  to  be 
more  or  less  plainly  discernible,  some¬ 
times  in  a  very  marked  manner  ;  and 
when  a  piece  of  the  coats  of  the  portal 
vein  is  treated,  as  I  have  described 


59 


DR.  MAYO’S  OUTLINES 


above,  the  nerves  are  seen  by  the  I 
naked  eye  as  whitish  bands  ramifying 
and  interlacing,  completely  distinct 
from  the  surrounding  transparent  sub¬ 
stance.  2.  In  examining  small  vessels 
from  the  pia  mater  of  a  sheep’s  brain, 

I  have  found  distinct  organic  nerves 
ramifying  upon  their  coats  ;  while  in 
similar  vessels  from  the  brain  of  a  cat 
I  have  found  the  nerves  manifestly 
consisting  of  tubular  fibres ;  moreover, 
in  following  the  course  of  these  latter, 

I  think  I  have  observed  that  a  fasci¬ 
culus,  which,  in  the  commencement  of 
its  course,  consisted  mainly  of  cerebro¬ 
spinal  tubules,  after  proceeding  some 
distance,  changed  its  character,  and 
came  to  present  the  appearance  of  or¬ 
ganic  nerves  either  completely  or  in 
part,  a  single  tubule  being  still  some¬ 
times  visible  in  a  longitudinally  striated 
band  bearing  elongated  nuclei.  Now, 
if  a  nerve  consisting  of  tubular  fibres 
can  be  replaced  by  one  consisting  of 
gelatinous  fibres,  and  if  one  also  may 
be  converted  into  the  other,  as  in  fact 
we  know  to  occur  in  the  progress  of 
foetal  development,  then  is  it  highly 
probable  that  the  functions  of  either 
variety  of  fibres  are  similar,  if  not  quite 
identical.  3.  The  arrangement  of  the 
gelatinous  fibres  in  well-defined  fasci¬ 
culi  which  closely  accompany  the  course 
of  vessels,  the  regular  manner  in  which 
they  ramify  and  anastomose,  and  their 
entire  distinctness  from  the  surround¬ 
ing  areolar  tissue,  seem  to  me  to  shew 
conclusively  that  they  must  be  special 
structures  designed  for  some  more 
special  function  than  that  fulfilled  by 
the  areolar  investment  of  vessels  and 
ducts. 

In  concluding  this  brief  account  of 
the  organic  nerves  in  the  liver,  I  can¬ 
not  but  remark  on  the  very  abundant 
supply  with  which  the  hepatic  artery  is 
provided ;  I  believe  it  exceeds  in  this 
respect  the  vessels  of  most  other  parts. 
The  difference  between  the  portal  and 
hepatic  veins,  with  regard  to  their 
nervous  supply,  is  also  worthy  of  no¬ 
tice,  and  seems  to  assimilate  the  former 
still  more  to  the  arterial  character. 
Lastly,  it  may  be  presumed,  from  the 
non-penetration  of  the  nerves  into  the 
parenchyma  of  the  lobules,  that  the 
function  of  the  hepatic  cells  is  carried 
on  completely  without  the  operation  of 
nervous  influence ;  while  the  absorbing 
action  of  the  ultimate  ducts,  as  they  lie 


OF  MEDICAL  PROOF. 


in  the  fissures  and  canals,  is  to  a  cer¬ 
tain  extent  under  the  control  of  this 
power. 

54,  Sloane  Street, 

June  1848. 

OUTLINES  OF  MEDICAL  PROOF. 

By  Thomas  Mayo,  M.D.  F.R.S. 

Physician  to  the  Infirmary  of  St.  Marylebone. 

[Continued  from  last  volume.] 

The  task  of  pursuing  this  important 
subject,  which  I  wished  to  place  in  the 
hands  of  Mr.  Green,  as  his  right  by 
pre-occupation  of  the  ground,  has  been 
returned  by  him  to  me.  Having  made 
a  commencement  of  that  part  of  the 
subject,*  which  may  be  considered  a 
sequel  to  Mr.  Green’s  views  in  his 
“Mental  Dynamics,”  I  am  unwilling 
that  it  should  be  altogether  dropped. 
It  is  no  doubt  possible  that  there  may 
be  intellects  «so  highly  gifted,  as  to 
thread  the  mazes  of  medical  proof 
without  any  rules  or  assistance.  Nay, 
it  is  possible,  that  in  this,  as  in  other 
pursuits,  there  may  be  intellects  so  con¬ 
stituted,  as  to  work  by  a  principle  of 
natural  dialectics  more  effectually  than 
under  cultivation.  Such  cases  of  each 
kind  are,  I  believe,  rare.  It  may  with 
more  reason  be  expected  that  time  will 
be  lost,  abortive  discussions  engaged 
in,  results  erroneously  assumed,  ex¬ 
periments  be  confounded  with  ob¬ 
servation,  the  abuse  of  theory  mis¬ 
taken  for  its  use,  and  thus,  vast  piles 
of  thought  and  inquiry  be  raised  upon 
insecure  foundations,  if  our  attention 
should  at  no  time  be  called  to  the 
specialities  of  our  medical  reasoning. 
And  yet  few  will  venture  to  assert,  that 
this  kind  of  inquiry  had  been  carried 
out,  when  I  propounded  an  essay  on 
the  Outlines  of  Medical  Proof. 

Now  with  respect  to  the  filling  up  of 
these  Outlines,  the  task  may  be  at¬ 
tempted  by  a  methodical  expansion  of 
each  of  the  heads  of  the  subject,  or  by 
detached  essays,  in  which  medical  sub¬ 
jects  may  be  contemplated  in  relation 
to  the  rules  and  principles,  which 
1  have  there  ventured  to  lay  down. 
With  respect  to  the  first  of  these  two 
ways,  if  great  works  did  not  exist  in  our 
language  on  the  logic  of  induction  and 


*  Outlines  of  Medical  Proof,  by  Thos.  Mayo, 
M.D  F.R.S. 


60 


DR.  MAYO  S  OUTLINES  OF  MEDICAL  PROOF. 


deduction,  which  render  my  task  one 
of  detecting  specialities  in  our  manner 
of  proof,  rather  than  of  embracing  the 
whole  subject  of  proof, — If  Sir  John 
Herschel,  Mr.  Mill,  and  Dr.  Whewell, 
had  not  laid  out  this  whole  subject,  the 
more  comprehensive  and  methodical 
procedure  might  be  preferable.  It 
might  be  requisite  that  the  general  in¬ 
quiry  should  precede  the  peculiar  one. 
But  with  these  works  our  task  is  limited 
in  extent,  though  it  remains  of  undi¬ 
minished  importance.  For  I  have  a 
right  to  expect  that  the  works  alluded 
to  shall  have  been  read  in  the  course  of 
the  preliminary  mental  dynamics,  so 
ably  sketched  by  Mr.  Green.  After  all 
this  has  been  effected,  the  necessity  will 
still  remain  for  such  further  considera¬ 
tions  as  I  have  opened  in  that  small 
work,  which  I  now  propose  to  continue 
in  detached  essays,  through  the  pages 
of  the  Medical  Gazette. 

The  course  of  reasoning  pursued  by 
me  in  the  Outlines,  in  its  relation  to 
pathology  and  therapeutics,  supposes  a 
series  of  facts  used  collectively  for  the 
purpose  of  establishing,  or  giving  pro¬ 
bability,  to  certain  conclusions.  At 
least,  the  only  exception  to  this  viewT 
consists  in  my  brief  reference  to  the 
application  of  extemporaneous  hypo¬ 
thesis  to  medical  reasoning.*  For  this 
application  may  be  made,  and  often  is 
very  effectually  made,  through  the 
medium  of  even  one  well-selected  and 
well- appreciated  fact.  Indeed,  the 
consideration  of  facts  or  cases,  as  im¬ 
plying  proof,  when  used  singly,  or  with 
no  reference  to  their  aggregate  effects, 
demands  a  place  here,  inasmuch  as  it 
illustrates  one  of  the  most  distinctive 
qualities  of  the  medical  mind.  Those 
who  tread  the  safe  path  of  practical 
medicine,  however  carefully  they  may 
bear  principles  in  mind,  act  imme¬ 
diately  from  facts  remembered  or  con¬ 
jured  up  through  an  effort  of  the  ima¬ 
gination,  which  operates  upon  its  col¬ 
lected  stores  of  reading  and  experience. 
Meanwhile,  they  are  aware  that  no 
two  (clinical)  facts  are  alike;  and 
herein  they  are  distinguished  from  less 
safe  and  less  enlightened  inquirers. 
In  their  hands,  indeed,  the  deduction 
from  one  case  or  fact  to  the  other  in¬ 
volves  an  hypothesis  as  to  the  nature 
of  their  agreement  or  disagreement, 

*  Outlines  of  Medical  Proof,  page  20. 


while  the  less  cultivated  or  gifted  per¬ 
son  adopts  his  prototype  whole  and 
unbroken.*  His  practice,  accordingly, 
being  founded  on  the  common  points, 
or  the  assumed  common  points,  of 
cases,  without  reference  to  their  dis¬ 
tinctions,  can  never  reach  the  idiosyn¬ 
crasy  of  the  patient,  or,  at  all  events, 
must  reach  it  only  by  accident. 

Indeed,  it  is  not  always  understood 
what  a  volume  of  proof  may  be  con¬ 
tained  in  the  limits  of  a  single  case 
judiciously  applied.  Of  this  it  w7ould 
be  easy  to  multiply  instances.  The 
fact  of  femoral  and  crural  phlebitis 
having  been  succeeded  in  a  given  case 
by  symptoms  of  cerebral  disorder,  no 
cerebral  lesion  being  evinced  on  dis¬ 
section,  gives  ample  ground,  in  any 
fresh  case  in  which  such  venous  in¬ 
farction  may  be  detected,  for  the  hypo¬ 
thesis  of  a  functional  origin  of  any 
cerebral  disturbance  that  may  arise  in 
the  course  of  the  case.  Again,  a  single 
case  of  well-marked  cerebral  symp¬ 
toms,  which,  ending  fatally,  shall  have 
exhibited  pericarditic  inflammation 
without  any  structural  disease  of  the 
brain,  will  powerfully  assist  a  diagnosis 
referring  any  future  cerebral  disturb¬ 
ance  to  disease  of  heart,  when  the  latter 
is  manifested  during  life  by  its  appro¬ 
priate  symptoms. 

Now,  in  these  two  cases,  an  explana¬ 
tory  hypothesis  is  suggested.  We  have 
seldom  this  advantage  in  reasoning 
from  the  effect  of  remedies  ;  yet  here  a 
single  case  may  be  powerfully  sugges¬ 
tive  of  practical  measures.  A  gen¬ 
tleman,  aged  70,  of  a  powerful  frame 
and  strong  constitution,  who  had  la¬ 
boured  for  many  years  under  attacks 
of  gout  in  the  ankles  and  hands,  with 
permanent  thickening,  nodosity,  and 
imperfect  use  of  the  afflicted  articu¬ 
lations,  has  been  placed  by  me  for 
more  than  sixteen  months  on  a  plan 
of  daily  small  doses  of  the  Vinum 
Colchici,  with  very  gentle  aperients. 
During  that  time  his  general  health 
has  become  very  good,  and  he  has  re¬ 
mained  entirely  free  from  attacks  of 
gout.  I  can  offer  no  explanation  of  the 
modus  operandi  of  colchicum  in  this 
case;  and  the  accompanying  system  of 
gentle  purgation  may  have  largely  con¬ 
tributed  to  its  successful  procedure. 
Besides,  his  diet  has  been  more  regular 
than  usual  during  its  course ;  yet, 
single  as  it  is,  when  viewed  in  relation 
to  the  known  influence  of  colchicum 


DR.  MAYO  S  OUTLINES  OF  MEDICAL  PROOF. 


61 


on  gout,  it  affords  a  motive  for  similar 
treatment  in  a  similar  case.  The  pulse 
of  this  gentleman,  I  may  observe,  was 
naturally  slow  :  I  carefully  modified 
the  dose  of  colchicum,  so  as  not  to 
depress  it  below  its  normal  standard, 
to  which  depression  it  was  prone  under 
any  increase  of  the  doses. 

This  use  of  cases  is,  in  truth,  a  philo¬ 
sophical  empiricism;  and  the  instances 
which  I  have  given  strengthen  the  im¬ 
portance  which  I  have  attached  on 
other  occasions  in  this  journal  to  a 
record  of  single  cases.  Our  medical 
literature  requires,  indeed,  a  larger 
stock  of  single  cases  or  monographs, 
not  only  in  this  empirical  point  of 
view,  but  as  embodying  the  varieties 
of  nosological  generalisations,  so  as  to 
afford  the  modifying  influences  of  con¬ 
stitution,  temperament,  &c.  by  observ¬ 
ance  of  which  our  treatment  is  indivi¬ 
dualized,  and  the  idiosyncrasies  of  the  pa¬ 
tient  receive  attention.  How  unimpres¬ 
sive, and  therefore  uninstructive,  are  the 
“  varieties”  of  Sauvages,  stated,  as  they 
are,  in  the  abstract !  and  how  imme¬ 
diately  would  they  be  vitalized  if  his 
diagrams  were  changed  into  portraits  ! 
Meanwhile  we  accumulate,  in  our  re¬ 
ports  expections,  and  not  examples,  as 
if  a  perfect  acquaintance  with  the  latter 
ought  not  to  precede  an  enumeration 
of  the  former. 

It  may  be  alleged,  with  slight  show 
of  reason,  that  cases  expressing  all 
these  varieties  would  be  interminable, 
and  might  mislead  us  out  of  the  more 
philosophical  road  to  successful  prac¬ 
tice — that,  namely,  which  lies  through 
general  principles.  I  have  already 
suggested  that  facts  are,  after  all,  the 
medium  through  which  we  apply,  as 
well  as  construct,  our  general  princi¬ 
ples  ;  but  I  may  further  assert,  that 
principles  can  be  applied  through  no 
other  medium  ;  and  that  all  practice  is 
resolvable  into  the  application  of  a  fact 
conceived  or  remembered,  however 
large  or  limited  may  be  the  principle 
which  the  fact  illustrates.  Let  him 
who  doubts  this  remark  test  its  accu¬ 
racy  by  examining  the  operations  of 
his  own  mind,  as  applied  to  a  new 
case.  The  place  assigned  to  it  by  noso¬ 
logy  will  not  satisfy  him  ;  he  views  it 
by  the  light  of  his  experience — in 
other  words,  he  determines  its  patho¬ 
logy  and  treatment  either  in  direct 
reference  to  some  other  cases,  or  with 
a  tacit  recognition  of  the  kind  of  prac¬ 


tice  which  a  similar  case  has  before 
required  ;  and  thus,  while  he  is  apply¬ 
ing  the  general  principles  of  classifica¬ 
tion,  he  tacitly,  if  not  overtly,  assigns 
to  the  case  those  specific  differences 
w'hich  separate  it  from  other  cases  of 
that  class.  A  time,  no  doubt,  arrives 
with  most  men,  in  which  practical 
conclusions  are  arrived  at  with  a  ra¬ 
pidity  which  defies  such  analysis ;  but 
their  character  is  not  therefore  lost, 
because  its  manifestations  have  become 
too  rapid  for  observation.  And  it  is 
expedient  to  give  the  medical  mind 
that  pabulum  through  well-recorded 
facts,  which  may  be  digested,  as  it 
were,  into  such  conclusions.  With 
respect  to  these  empirical  stores  be¬ 
coming  oppressive,  no  apprehension 
need  be  entertained  on  that  score.  At 
present,  for  want  of  such  records,  the 
normal  is  but  partially  known  ;  and  #e 
are  constantly  finding  ourselves  in  a 
false  position,  as  apparent  discoverers 
of  new  facts,  which  are  perhaps  only 
crude  expressions  of  what  have  been 
previously  accredited  and  forgotten, 
carent  quia  rate. 

The  functions  of  single  cases,  which 
I  have  endeavoured  to  elucidate,  will 
appear  yet  more  important,  when  it  is 
recollected  that  there  are  diseases  re¬ 
cognized  in  nosology,  in  respect  to 
which  our  knowledge  is  at  present  so 
far  inchoate  as  only  to  exist  in  the 
shape  of  examples:  in  which  no  gene¬ 
ral  expression  of  their  character  can  be 
made,— no  diagram  can  be  offered; 
and  we  must  be  contented  to  recognise 
the  disease  in  its  portraits — that  is  to 
say,  its  cases.  Thus,  in  hysteria,  there 
is  no  generalization  on  the  subject  of 
it  which  advances  us  a  step;  no  de¬ 
scription  of  it,  except  such  as  is  embo¬ 
died  in  cases,  will  enable  us  to  deal 
with  it  in  practice.  And  I  believe  it 
remains  one  of  the  opprobria  medicine, 
mainly  because  we  are  not  sufficiently 
aware  of  that  fact,  and  have  not  suffi¬ 
ciently  enriched  our  records  with  mo¬ 
nographs  indicating  its  varieties.  I 
know  no  work  on  hysteria  which  is  so 
useful,  because  it  is  thus  enriched  by 
cases,  as  that  of  M.  Louvet  Villermay. 

The  fact  that  many  practitioners 
make  a  bad  use  of  cases,  and  convert 
their  experience  into  a  source  of  error, 
is  unquestionable.  A  generic,  instead 
of  a  specific  affinity,  is  often  accepted, 
as  justifying  the  use  of  the  precedent; 
nay,  there  are  practitioners  whose 


62 


Dll.  SIMPSON  ON  LOCAL  ANAESTHESIA - 


measures  can  generally  be  traced  to 
the  last  case  of  the  disease  that  they 
have  seen.  It  is  hoped  that  the  above 
remarks  may  tend  to  prevent  this  abuse 
of  observation,  by  pointing  out  the  real 
Value  of  the  ogga  ttjs  efnreipias. 

[To  be  continued.] 


LOCAL  ANAESTHESIA ; 

NOTES  ON  ITS  ARTIFICIAL  PRODUCTION  BY 
CHLOROFORM,  &C.,  IN  THE  LOWER 
ANIMALS  AND  IN  MAN. 

By  J.  Y.  Simpson,  M.D.  F.R.S.E. 

Professor  of  Midwifery  in  the  University  of 
Edinburgh. 


A  few  months  ago  I  published  some 
remarks,  with  the  object  of  proving 
that  the  artificial  production  of  a  state 
of  general  anaesthesia  before  the  perfor¬ 
mance  of  surgical  operations,  was  not 
altogether  an  idea  of  modern  times.* 
I  shewed  that  Pliny,  Apuleius,  and 
other  early  writers,  aver  that  such  a 
state  of  general  anaesthesia  can  be  pro¬ 
duced  by  using  mandragore  ;  and  that, 
in  the  13th  century,  Theodoric  had 
published  a  receipt  for  producing  it,  by 
the  inhalation  of  vapours  arising  from 
the  watery  extracts  of  various  narcotic 
herbs.  In  our  own  days,  this  receipt 
of  Theodoric’s,  or  one  apparently 
analogous  to  it,  has  been  apparently 
found  quite  sufficient  for  the  purpose, 
by  Dauriol. 

The  ancients  seem  also  to  have  en¬ 
tertained  the  idea  of  the  possibility  of 
producing  a  state  of  local  and  limited 
anaesthesia  in  any  part  to  be  operated 
upon.  Dioscorides,  who  repeatedly 
mentions  the  production  of  general 
anaesthesia  by  mandragore,  states  it,  as 
a  matter  of  report,  that  local  anaesthesia 
in  a  part  was  capable  of  being  pro¬ 
duced  by  the  application  of  the  Mem¬ 
phian  stone.  “The  Memphis  stone,1 ” 
says  he,  “is  found  in  Egypt,  near 
Memphis,  of  the  size  of  a  calculus, 
fatty,  and  of  different  colours.  They 
say  that  this,  when  bruised  and  spread 
over  parts  that  are  to  be  cut  or  caute¬ 
rized,  without  danger  so  obtunds  their 
sensibility  that  they  do  not  feel  pain.”f 
(Hoc  tradunt  trito  et  iliito  partes  quae 
urendee  vel  secandae  sunt  citra  pencu- 
lum  ita  obstupeseere,  ut  non  sentiant 
cruciatum.) 

*  Monthly  Journal  of  Medical  Science,  vol. 
1847-8,  p.  451. 

t  Dale’s  Discoridis  Opera,  lib.  y.  cap.  158. 


Whilst  we  may  entirely  doubt  that 
local  anaesthesia  was  capable  of  being 
produced  by  such  an  apocryphal  appli¬ 
cation  as  the  above,  the  passage  is 
curious,  as  evidence  that  the  idea  of 
obtunding  a  single  part  of  the  body 
against  the  pain  of  an  operation  was 
not  unknown  or  unthought  of  in  for¬ 
mer  times.  Nay,  many  old  authorities 
believed,  that  against  the  fire  ordeal 
any  part  of  the  body  could  be  so  pro¬ 
tected  and  defended,  by  previous  appli¬ 
cations,  that  the  human  hand,  for  in¬ 
stance,  should  not  feel  the  contact  of 
the  red-hot  iron.  The  writings  of 
Eusebe  Salverte  and  Beckmann  contain 
ample  notices  on  this  disputed  ques¬ 
tion.  Upwards  of  half  a  century  ago, 
Dr.  Moore  ingeniously  pvoposed  to 
effect  a  local  anaesthesia  of  any  limb 
that  was  to  be  operated  upon  by  the 
surgeon,  by  previously  compressing, 
with  tourniquets  and  pads,  the  nervous 
trunks  going  to  that  limb  ;  and  he  has 
left  us  one  interesting  account  of  a  case 
of  amputation  at  St.  George’s  Hospital, 
in  which  the  plan  was  tried,  seemingly 
with  partial  success,  by  John  Hunter. 

The  possible  production  of  local 
anaesthesia  by  this  or  other  means  is 
certainly  an  object  well  worthy  of  study 
and  attainment.  Surgeons  everywhere 
seem  to  be  more  and  more  acknowledg¬ 
ing  the  facility,  certainty,  and  safety, 
with  which  the  state  of  general  anaes¬ 
thesia  can  be  produced  at  will,  before 
operating;  as  well  as  the  moral  and 
professional  necessity  of  saving  their 
patients  from  all  unrequisite  pain.  But 
if  we  could  by  any  means  induce  a 
local  anaesthesia  without  that  tempo¬ 
rary  absence  of  consciousness  which  is 
found  in  the  state  of  general  anaesthe¬ 
sia,  many  would  regard  it  as  a  still 
greater  improvement  in  this  branch  of 
practice.  If  a  patient,  for  instance,  could 
have  his  hand  so  obtunded  that  he 
could  see,  and  yet  not  feel ,  the  perfor¬ 
mance  of  amputation  upon  his  own 
fingers,  the  practice  of  anaesthesia  in 
surgery  would  in  all  likelihood  advance, 
and  progress  still  more  rapidly  than 
ever  it  has  done. 

In  the  following  remarks  it  is  my 
object  to  state  the  results  of  a  number 
of  experiments  which  I  have  performed 
(1),  upon  the  lower  animals*  and  (2) 


*  Through  the  kindness  of  Professor  Balfour 
I  have  had  various  opportunities  of  trying  the 
effect  of  chloroform  vapour  upon  the  sensitive 
plant  ( Mimosa  Pudica).  When  the  vapour  vyas 


NOTES  ON  ITS  ARTIFICIAL  PRODUCTION  BY  CHLOROFORM. 


63 


upon  man,  with  a  view  to  the  possi¬ 
bility  of  the  production  of  such  a  state 
of  local  anaesthesia,  by  the  local  appli¬ 
cation  of  chloroform  and  other  anaes¬ 
thetic  agents  to  individual  parts  of  the 
body. 

I. — Local  Ancesthesia  in  the  lower 
animals. 

At  a  meeting  of  the  Medico-Chirur- 
gical  Society  of  Edinburgh,  held  on 
the  17th  of  March,  I  took  occasion  to 
state  that  I  had  successfully  chloro¬ 
formed  several  of  the  lower  animals — 
annelida,  Crustacea,  fishes,  &c. ;  that  in 
some,  and  more  especially  in  the  com¬ 
mon  earthworm  (Lumbricus  Terrestris), 
I  had  been  able  to  produce  local  anaes¬ 
thesia  by  applying  the  chloroform 
vapour  locally  ;  and  had  thus  at  will 
rendered  anaesthetic,  individual  parts 
and  portions  of  the  worm,  as  the  head 
merely,  or  the  tail  merely,  or  the  mid¬ 
dle  part  of  the  worm  merely,  the  head 
and  tail  remaining  unaffected.  At  the 
same  time  I  recapitulated  what  I  had 
stated  at  one  of  the  February  meetings 
of  the  Society — that,  in  the  human 
subject,  local  anaesthesia  of  a  portion 
of  the  gums  could  be  produced  by  rub¬ 
bing  the  part  with  hydrocyanic  acid. 
After  the  date  of  the  above  meeting  I 
was  led  to  make  some  additional  ex¬ 
periments  upon  the  possible  production 
of  local  anaesthesia  in  man ;  and  in 
reporting  the  proceedings  of  the  pre¬ 
ceding  sederunt  of  the  Society,  in  the 
last  number  of  the  Monthly  Journal  of 
Medical  Science,  the  editor  has  stated, 
in  a  short  foot-note,  some  of  the  results 
of  these  experiments  upon  the  human 
subject.* 

Nothing  could  be  more  curious  or 
satisfactory  than  the  experiments  al¬ 
luded  to,  on  the  production  of  local 
ansesthesia  by  the  local  application  of 
chloroform  vapour  to  different  parts  of 
the  body  of  the  earthworm.  The  re¬ 
sulting  degree  of  local  ansesthesia  in 
the  part  exposed  is  generally  in  the 


either  too  strong  or  too  long  continued,  the  plant 
was  destroyed.  When  it  was  weaker,  and  ap¬ 
plied  only  for  a  few  minutes,  the  leaflets  in  some 
plants  closed  as  when  irritated,  and  did  not  ex¬ 
pand  again  for  an  unusual  length  of  time.  In 
other  plants  under  exposure  to  the  chloroform 
vapour,  no  closure  of  the  leaflets  took  place,  and, 
in  a  few  minutes,  the  plant  became  so  ansesthe- 
tized,  that  the  mechanical  or  other  irritation  of 
the  leaflets  or  stalk  did  not  produce  any  of  the 
common  movements;  nor  did  their  irritability 
become  restored  for  a  considerable  time  after¬ 
wards. 

*  See  Monthly  Journal,  No.  xci.  p.  48. 


course  of  two  or  three  minutes  most 
complete  as  regards  both  sensation 
and  motion.  In  fact,  after  being  suffi¬ 
ciently  exposed,  the  chloroformed  por¬ 
tion  of  the  animal  is  quite  flat  and 
flaccid,  does  not  move  under  any  irrita¬ 
tion,  and  can  be  doubled  and  twisted 
up  upon  itself  like  a  piece  of  loose 
wetted  cord.  If  the  part  paralysed  by 
the  chloroform  is  small,  it  will  be 
dragged  along  by  the  movements  of 
the  other  unaffected  portions  of  the 
worm.  It  generally,  in  the  course  of  a 
few  minutes,  gradually  regains  its 
powers  of  motion,  and  its  irritability 
and  contraction,  under  stimuli. 

The  easiest  method  of  performing 
this  experiment  is  to  place  a  small 
quantity  of  chloroform  in  the  bottom 
of  a  tumbler,  paste  over  the  mouth  of 
it  a  covering  of  paper,  and  making  ail 
aperture  in  this  covering  sufficient  only 
to  admit  the  portion  of  the  animal  that 
is  to  be  chloroformed.  When  held  in 
this  position,  the  part  of  the  animal 
below  the  paper,  and  exposed  to  the 
vapour  of  chloroform,  is  generally 
thrown  into  violent  movements  for  a 
minute  or  two  before  the  state  of  anaes¬ 
thesia  supervenes.  I  have  repeated 
the  same  experiments  with  the  vapour 
of  sulphuric  ether  and  bisulphuret  of 
carbon. 

I  have  tried  the  same  experiment, 
with  the  same  result,  upon  the  medi¬ 
cinal  leech. 

The  results  wTere,  if  possible,  still 
more  marked  in  anotherof  theArticulata 
that  was  submitted  to  experiment.  A 
small  centipede  (Julus  Sabulosus?) 
was  rendered  completely  anaesthetic 
and  motionless  in  the  posterior  seg¬ 
ments  of  the  body,  by  exposing  that 
part  alone,  for  a  few  minutes,  to  the 
vapour  of  chloroform.  The  five  or  six 
last  rings  of  the  centipede,  with  the 
suspended  and  motionless  feet  attached 
to  them,  were  for  a  short  time  after¬ 
wards  dragged  about  in  a  kind  of  para¬ 
plegic  state,  and  by  the  brisk  and 
lively  movements  of  the  anterior  and 
not  anaesthetic  portion  of  the  animal. 
Betimes,  howrever,  each  segment,  with 
its  corresponding  feet,  regained  its 
power  of  motion  :  and  this  in  regular 
order,  from  before  backwards.  In  the 
same  and  in  other  centipedes  I  have 
produced  perfect  local  and  limited 
anaesthesia  of  the  head  alone,  or  of  in¬ 
dividual  segments  and  portions  of  the 
body  alone,  by  brushing  these  parts 
with  liquid  chloroform. 


64 


DR.  SIMPSON  ON  LOCAL  ANAESTHESIA - 


By  immersing  the  tail  of  the  water- 
newt  in  chloroform  vapour,  the  sensi¬ 
bility  and  motions  of  that  part  were 
rapidly  destroyed,  and  returned  a  few 
minutes  afterwards.  By  a  longer  de¬ 
gree  of  immersion  of  the  tail  alone,  the 
whole  animal  became  anaesthetic  ;  and 
in  several  experiments  it  was  found 
possible,  but  difficult,  to  give  the  ani¬ 
mal  in  this  way  a  fatal  dose  of  the 
vapour. 

The  hind-leg  of  the  frog  becomes 

o  o 

anmsthetic  when  exposed  for  four  or 
five  minutes  to  the  vapour  of  chloro¬ 
form.  Immediately  after,  it  drags  the 
limb  in  progressing  ;  and  bears,  appa¬ 
rently  without  feeling,  pricking  and 
irritation  of  it ;  but  a  galvanic  current 
passed  through  it  excites  both  sensa¬ 
tion  and  motion.  In  one  case  the 
motory  power  of  the  limb  was  not 
completely  restored  at  the  end  of  the 
third  day.  No  effect  appeared  to  re¬ 
sult  from  keeping  the  hind-leg  of  the 
frog  immersed  in  strong  tincture  of 
Indian  Hemp. 

The  hind-leg  of  a  healthy  active 
rabbit  was  confined  in  a  large  bladder 
containing  the  vapour  of  chloroform. 
At  the  end  of  an  hour,  the  common 
sensibility  of  the  limb  to  pinching  and 
squeezing  was  much  impaired ;  but 
still,  a  current  of  galvanism,  passed 
from  side  to  side  through  it,  produced 
crying  and  signs  of  pain.  The  power 
of  moving  the  limb  seemed  unimpaired. 

TJie  hind-leg  of  a  guinea-pig,  simi¬ 
larly  treated,  exhibited  the  same  phe¬ 
nomena  at  the  end  of  an  hour;  but  the 
anaesthesia  was  more  complete.  The 
skin  of  the  leg  was  red  and  congested. 

The  posterior  extremities  and  pelvis 
of  a  strong  guinea-pig  were  enclosed  in 
a  bag  containing  the  vapour  of  chloro¬ 
form.  At  the  end  of  an  hour  no  signs 
of  pain  could  be  extracted  by  pinching 
and  squeezing  either  limb ;  and  a  cur¬ 
rent  of  galvanism,  passed  through  a 
hind-leg,  evidently  caused  much  less 
pain  than  when  the  same  current  was 
passed  through  a  fore-leg.  The  whole 
hinder  parts  were  very  red  and  con¬ 
gested.  The  animal  was  also  in  some 
degree  paraplegic;  and  dragged  itself 
along,  by  strong  efforts,  with  its  ante¬ 
rior  limbs. 

In  a  late  number  of  the  Gazette, 
Mr.  Nunneley,  of  Leeds,  has  published 
some  interesting  remarks  on  the  subject 
of  the  artificial  production  of  local 
anaesthesia. 


Mr.  Nunneley  states  that  chloroform 
and  other  anaesthetic  agents  can,  he 
believes,  be  applied  locally  to  a  part  to 
producelocal  anaesthesia;  the sensorium 
being  unaffected,  consciousness  being 
retained,  and  the  limbs  and  other  parts 
not  subjected  to  the  action  of  the  anaes¬ 
thetic  agent,  retaining  their  usual 
aesthetic  condition.  His  opinions  re¬ 
garding  the  supposed  value  and  safety 
of  this  new  mode  of  administering  anaes¬ 
thetic  agents  had  been  formed  by  Mr. 
Nunneley  on  the  resutts  of  experi¬ 
ments.  By  the  local  application  of 
chloroform  to  the  limbs  of  frogs  and 
toads,  and  the  hind  legs  of  rabbits,  he 
had  rendered  these  parts  anaesthetic, 
and  he  obtained,  (he  states),  similar  re¬ 
sults  in  the  human  subject,  from  keep¬ 
ing  his  finger  immersed  in  anaesthetic 
fluids  for  half  an  hour  or  an  hour;  and 
in  one  case  where  the  operation  for 
artificial  pupil  was  to  be  undergone,  he 
had,  (he  mentions),  rendered  the  parts 
nearly  insensible,  by  applying  to  the 
eye  for  twenty  minutes  previously  a 
small  quantity  of  the  vapour  of  chloro¬ 
form.  This  naturally  leads  us  on  to 
the  consideration  of  the  second  and 
most  important  subject — viz.  the  artifi¬ 
cial  production  of — 

II. — Local  Anaesthesia  in  the  human 
subject. 

In  a  previous  paragraph,  I  have  al¬ 
ready  alluded  to  some  experiments  on 
the  production  of  local  anaesthesia  in 
the  gums,  by  rubbing  them  with  prussic 
acid.  Early  in  the  present  year  I  was 
led  to  make  a  variety  of  experiments  on 
this  subject,  in  consequence  of  being 
assured,  on  what  I  believed  to  be  satis¬ 
factory  evidence,  that  a  dentist  at 
Limoges,  in  France,  M.  Pernot,  had 
the  power  of  extracting  teeth  with  little 
or  no  pain,  in  consequence  of  pre¬ 
viously  rubbing  some  obtruding  agent 
on  the  gums.  I  tried  at  the  time  a 
great  variety  of  substances  in  order  to 
obtain  this  local  anaesthesia ;  such  as 
various  aethers,  bisulphuret  of  carbon, 
benzin,  aconite,  &c.  Among  all  the 
agents  employed,  the  effect  of  prussic 
acid  was  the  most  decided  and  complete; 
any  part  of  the  gum  strongly  rubbed  by 
it  speedily  became  benumbed  and  insen¬ 
sible,  but  the  resulting  degree  of  anaes¬ 
thesia  was  by  no  means  sufficient  for 
the  purpose  required.  The  results  of 
these  experiments  were  stated  orally 
to  the  Edinburgh  Medico-Chirurgical 


NOTES  ON  ITS  ARTIFICIAL  PRODUCTION  BY  CHLOROFORM. 


G5 


Society,  at  their  meeting  on  the  1 6th 
February. 

Before  that  date  I  had  met  with  one 
instance  in  which  local  anaesthesia  of 
the  human  hand  had  been  produced  in 
a  young  lady,  in  consequence  of  her 
accidentally  holding  in  it  for  a  con¬ 
siderable  time  a  scent-bottle  containing 
some  chloroform.  1  tried  at  various 
times  to  produce  a  similar  result  in 
myself,  and  in  others,  by  keeping  a 
hand  wrapped  in  a  napkin  soaked  in 
chloroform  and  other  anaesthetic 
agents,  but  with  little  or  indeed  no  ap¬ 
preciable  success,  till  I  used  the  vapour 
of  chloroform  raised  by  heat ;  the  hand, 
for  the  purpose,  being  immersed  in  a 
deep  jar  in  which  a  small  quantity  of 
chloroform  was  poured,  the  jar  placed 
in  a  basin  of  water,  of  the  temperature 
150°  or  upwards,  and  the  wrist  or  fore¬ 
arm  being  at  the  same  time  surrounded 
by  handkerchiefs,  so  as  to  prevent  the 
escape  of  the  vapour.  In  the  last 
number  of  the  Monthly  Journal, 
(p.  48),  these  experiments  are  noticed; 
and  it  is  correctly  stated  that  the  degree 
of  local  ansesthesia  of  the  human  hand 
which  I  have  been  thus  able  to  produce, 
is  only  “  partial,  and  perhaps  super¬ 
ficial.” 

A  number  of  circumstances  influence, 
however,  the  effect  and  the  degree  of 
it ;  and  as  I  have  made  a  considerable 
variety  of  experiments  both  upon  my¬ 
self  and  upon  others,  in  order  to  ascer¬ 
tain  these  points,  I  will  shortly  state 
the  results.  Let  me  premise,  that  in 
the  experiment  upon  which  the  follow¬ 
ing  results  are  founded,  the  hands  of 
the  same  individual  were  generally 
held  simultaneously  in  two  different 
jars,  differently  arranged  in  regard 
to  material  or  otherwise,  in  order  to 
make  two  different  and  comparative 
experiments  at  the  same  time;  and  the 
relative  degree  of  ansesthesia  in  each 
hand  was  ascertained  during  the  ex¬ 
periment  by  pricking  the  fingers  with 
the  thumb-nail,  without  removing  the 
hand  from  the  jar  ;  after  they  were  re¬ 
moved,  these  and  other  more  severe 
measures  were  used  w'ith  the  same  view, 
as- tests  of  the  degree  of  ansesthesia. 

1.  When  the  hand  is  exposed  to  an 
ansesthetic  vapour,  especially  if  it  is 
raised  by  heat,  it  betimes  presents 
the  sensations  of  a  limb  benumbed  by 
compression  of  its  larger  nervous 
trunks :  the  sensations,  in  fact,  of  par¬ 
tial  paralysis.  Usually,  after  a  short 


time,  a  glowing  or  burning  feeling  is 
perceived  in  the  parts  most  exposed, 
and  gradually  there  supervenes  a  sensa¬ 
tion  of  thrilling  and  tingling  (like  a 
limb  asleep),  which  deepens  more  and 
more.  The  skin  becomes  red,  and  the 
hand  at  last  feels  stiff  and  clumsy,  and 
as  if  enlarged  ;  and  painful  impres¬ 
sions,  as  pricking,  pinching,  &c.,  are 
felt  less  acutely.  After  the  hand  is 
removed  from  the  vapour,  it  is  gene¬ 
rally  half  an  hour  or  more  before  its 
usual  feelings  are  restored.  Tne  nerves 
of  motion  are  usually,  apparently,  as 
much  affected  as  the  nerves  of  sensa¬ 
tion. 

2.  The  vapour  of  chloroform  proved 
stronger  than  any  other  that  was  tried. 
When  one  hand,  for  instance,  was  im¬ 
mersed  in  a  jar  containing  the  vapour 
of  sulphuric  ether,  and  the  other  hand 
in  a  jar  containing  the  vapour  of  chlo¬ 
roform,  (both  jars  containing  similar 
quantities,  and  subjected  to  the  same 
degree  of  heat),  the  hand  in  the  chlo¬ 
roform  jar  was  both  more  speedily  and 
more  deeply  affected  than  the  other. 
In  addition  to  the  vapour  of  chloroform, 
and  ether,  I  tried  comparative  experi¬ 
ments  with  the  vapours  of  aldehyde, 
bisulphuret  of  carbon,  iodide  of 
methyle,  &c.  The  aldehyde  had  little 
or  no  effect  of  any  kind.  The  iodide 
of  methyle  produced  a  very  severe 
burning  sensation,  and  left  the  hand 
intensely  red  for  a  day  or  two  after¬ 
wards,  but  with  no  marked  ansesthetic 
influence.  Among  several  of  us  that 
tried  the  vapour  of  bisulphuret  of  car¬ 
bon,  only  one  bore  it  for  any  great 
length  of  time,  (about  an  hour),  and  in 
him  it  did  not  render  the  hand  anses- 
thetic  in  any  very  appreciable  degree ; 
in  myself  and  others,  the  sensation  of 
heat  and  burning  soon  became  so  utterly 
intolerable,  as  to  force  us  to  withdraw 
the  hand.  Immersion  of  the  hand  for 
half  an  hour  in  very  strong  tinctures 
of  aconite,  opium,  and  Indian  hemp, 
and  in  solution  of  belladonna,  produced 
no  very  appreciable  local  ansesthetic 
effect. 

3.  The  ansesthetic  effect  is  increased 
both  in  rapidity  and  in  degree  by  immers¬ 
ing  the  hand  with  the  cuticle  softened 
and  moist.  When  one  hand,  for  in¬ 
stance,  is  immersed  without  any  pre¬ 
paration,  and  the  other  is  prepared  by 
being  bathed  and  fomented  for  ten  or 
twenty  minutes  previously,  the  limb 
almost  immediately  begins  to  tingle 


66 


DR.  SIMPSON  ON  LOCAL  ANAESTHESIA 


under  exposure  to  the  vapour — the  dry 
hand  not  for  some  minutes.  The 
degree  of  anaesthesia  is  also  ultimately 
deeper  in  the  moistened  hand.  Im¬ 
mersion  of  the  hand  in  warm  water 
alone  for  ten  or  fifteen  minutes  pro¬ 
duces  a  very  marked  degree  of  local 
anaesthesia  in  it.  Exposure  of  it  in  the 
same  way  to  ice-cold  water  leads  to  the 
same  result,  but  is  too  painful  to  be 
long  borne. 

4.  The  hand,  when  plunged  in  liquid 
chloroform,  is  usually  somewhat  more 
deeply  apathized  than  the  other  hand 
simultaneously  held  in  the  vapour  of 
chloroform.  This  was  the  more  general 
result  with  those  who  tried  the  experi¬ 
ment;  but  in  some  the  chloroform 
vapour  was  as  anaesthetic,  or  more  so, 
than  the  liquid.  Few  persons  can  keep 
the  hand  for  any  adequate  length  of 
time  in  liquid  chloroform  ;  the  sensa¬ 
tion  of  burning  becomes  so  intense  and 
painful,  as  to  force  them  to  withdraw  it 
in  a  very  few  minutes.  On  one  occa¬ 
sion,  1  held  my  hand  for  upwards  of  an 
hour  in  liquid  chloroform,  without  the 
part  being  more  apathized  than  it  would 
have  been  by  exposure  to  the  vapour. 
One  of  my  pupils,  Mr.  Adam,  held  his 
hand  in  the  liquid  chloroform  for  up¬ 
wards  of  two  hours  :  no  great  degree 
of  local  anaesthesia  resulted.  In  those 
cases  in  which  the  hand  wTas  long 
steeped  in  liquid  chloroform,  the  sensa¬ 
tions  of  burning  returned  severely  from 
time  to  time,  as  if  in  wares,  during  the 
experiment;  and  on  removing  it  from 
the  jar,  the  feelings  of  heat  were  tempo¬ 
rarily  aggravated.  The  normal  sensi¬ 
bility  of  the  parts  speedily  returned, 
and  were  completely  restored  within 
a  few  minutes  in  all.  But  the  skin 
sometimes  remained  red  and  injected 
for  a  longer  period. 

5.  The  degree  of  delicacy  of  skin 
in  the  person  or  part  exposed  to  the 
anaesthetic  vapour  influences  the  re¬ 
sult.  In  females  I  have  seen  the  de¬ 
gree  of  local  anaesthesia  of  the  hand 
that  was  produced  much  greater  and 
deeper  than  I  could  ever  render  it  in 
the  male  subject.  In  applying  the 
chloroform  vapour  in  small  cupping 
glasses,  &c.  to  different  parts  of  the 
body,  as  the  insides  of  the  arms,  &c., 
the  resulting  degree  of  local  anaes¬ 
thesia  seemed  in  a  great  measure  re¬ 
gulated  by  the  tenuity  of  the  skin  of 
the  part  experimented  upon.  The 
skin  of  the  axilla  seems  too  tender  to 


allow  of  the  vapour  being  applied  for 
a  length  of  time  sufficient  to  produce 
anaesthesia.  One  of  my  students,  who 
kept  both  his  lower  extremities  enve¬ 
loped  in  strong  chloroform  vapour 
raised  by  heat,  for  three  continuous 
hours,  felt  no  appreciable  local  anaes¬ 
thetic  effect  from  it. 

6.  When  strong  chloroform  vapour 
is  locally  applied  to  mucous  surfaces, 
the  attendant  sensations  of  heat  and 
smarting  are  loo  severe  to  allow  of  its 
sufficient  continuance:  at  least,  this  is 
the  result  that  I  have  obtained  in 
applying  it  with  small  glasses  to  the 
insides  of  the  lips,  the  tongue,  and 
eye.  Mr.  Nunneley  states,  as  we  have 
already  mentioned,  that  before  ope¬ 
rating  on  a  difficult  case  of  artificial 
pupil,  he  had  applied  for  twenty 
minutes  a  small  quantity  of  the  vapour 
of  chloroform  to  the  eye  by  means  of 
a  small  jar  which  accurately  filled  the 
orbit,  with  the  effect  of  rendering  the 
parts  nearly  insensible.  Dr.  Duncan 
and  I  have  several  times  tried  to 
repeat  this  experiment  upon  ourselves, 
but  in  none  of  the  trials  which  we 
made  (with  the  eye  either  shut  or 
open),  could  we  endure  the  burning 
action  of  the  vapour  upon  the  part 
above  two  or  three  minutes;  and  we 
found  no  other  result  except  always 
rendering  the  eye  experimented  on 
red  and  injected,  and  suffused  with 
tears.* 

7.  The  degree  of  anaesthesia  pro¬ 
duced  in  a  limb  by  exposure  of  it  to 
the  strong  vapour  of  chloroform,  does 
not,  in  general,  perceptibly  increase 


*  I  have  tried  the  application  of  various  anaes¬ 
thetic  gases  and  vapours  to  the  vagina,  in  cases 
of  vaginal  irritation  and  neuralgia  ;  but  hitherto 
without  much  success.  The  stronger  forms 
cannot  be  borne.  I  was  induced  to  try  them  in 
consequence  of  the  following  curious  statement 
regarding  carbonic  acid,  published  by  Pereira, 
(Materia  Medica,  p.  155) : — 

“  A  lady,  who  had  suffered  for  a  considerable 
time  from  some  uterine  affection,  and  had  derived 
no  relief  from  the  treatment  adopted,  was  advised 
to  consult  a  physician  in  Italy  (Dr.  Rossi).  After 
he  had  examined  the  condition  of  the  uterus,  he 
assured  her  that  there  was  no  organic  disease,  but 
merely  a  considerable  degree  of  irritation,  for 
which  he  proposed  to  apply  carbonic  acid  as  at 
sedative.  This  was  done  by  means  of  a  pipe 
and  tube,  communicating  with  a  gasometer 
situated  in  another  room.  "The  patient  obtained 
immediate  relief,  and  although  she  was  obliged 
to  be  carried  to  the  doctor’s  house,  on  account  of 
the  pain  experienced  in  walking,  she  left  it  in 
perfect  ease.  On  her  return  to  England  she  had 
a  relapse  of  the  complaint,  and  applied  to  Dr. 
Clutterbuck  to  know  whether  she  could  have  the 
same  remedy  applied  in  London,  in  order  to  save 
her  the  necessity  of  returning  to  Italy.” 


NOTES  ON  ITS  ARTIFICIAL  PRODUCTION  BY  CHLOROFORM. 


67 


after  fifteen  or  twenty  minutes.  The 
same  sensations  continue  if  the  hand 
is  still  retained  in  the  jar ;  hut  an 
increased  length  of  exposure  does  not, 
after  a  time,  produce  a  corresponding 
degree  oflocal  insensibility. 

But  the  degree  of  local  anaesthesia 
produced  in  the  human  hand  or  skin 
by  exposing  it  to  the  local  action  of 
the  vapour  of  chloroform,  has  never,  in 
my  experiments,  been  by  any  means 
so  perfect  and  complete  as  to  annul 
the  pain  of  any  severe  operation,  such 
as  deep  incisions  or  amputation  of  a 
finger.  As  compared  with  the  other 
non-exposed  hand,  the  chloroformed 
hand  is  generally  rendered  to  a  marked 
amount  less  sensitive  ;  but  the  insensi¬ 
bility  is  never,  I  fear,  so  deep  and  per¬ 
fect  as  will  save  the  patient  from  the 
pain  of  the  surgeon’s  knife.  In  short, 
I  entirely  doubt  whether  in  the  human 
subject  we  shall  ever  be  able  to  reduce 
the  knowledge  of  the  possible  reduc¬ 
tion  of  local  anaesthesia  to  any  prac¬ 
tical  purpose.  It  is  principally  interest¬ 
ing  in  a  toxicological  and  physiological 
point  of  view,  and  in  relation  to  the 
mode  of  action  of  anaesthetic  agents.* 
Its  bearings  are  more  upon  the  theory 
than  upon  the  practice  of  anaesthesia. 

These  remarks  relate  necessarily  to 
local  anaesthesia  as  capable  of  being 
produced  by  the  anaesthetic  agents 
with  which  we  are  at  present  ac¬ 
quainted.  Others  may,  no  doubt,  yet 
be  detected  much  more  powerful  than 
any  we  at  present  know,  and  their 
local  application  may  enable  us  to 
effect  the  local  anaesthesia  desired. 
At  the  same  time,  this  consummation, 
even,  seems  doubtful;  for  perhaps  any 
agent  possessing  a  deeper  and  more 
rapid  anaesthetic  local  power,  would, 
by  absorption,  affect  the  system  gene¬ 
rally,  it  may  be  dangerously,  before 
complete  local  insensibility  of  a  part 
could  be  effected.  Some  time  ago.  in 
attempting  to  produce  local  anaesthesia 


*  Perhaps  we  will  be  less  surprised  at  the  dif¬ 
ference  in  the  degree  of  local  anaesthesia  capable 
of  being  produced  in  the  lower  animals,  as  com¬ 
pared  with  man,  when  we  recollect  the  difference 
that  exists  between  the  structure  and  functions 
of  their  skins  and  that  of  the  human  subject. 
“  In  animals  whose  skin  is  moist,  and  which 
possess  a  very  delicate  cuticle,  cutaneous  ab¬ 
sorption  is  a  constant  and  important  function. 
Such  are  frogs,  salamanders,  and  similar  ani¬ 
mals.  The  experiments  of  Edwards  have  esta¬ 
blished  the  skin  in  them  to  be  entirely  absorb¬ 
ing,  and  instrumental  in  their  support.”  (See 
Jackson  on  Absorption,  in  American  Cyclo¬ 
pedia  of  Practical  Medicine,  No.  II.  p.  115). 


in  my  hand  by  exposing  it  to  the 
vapour  of  hydrocyanic  acid,  ere  the 
hand  was  much  or  very  perceptibly 
benumbed,  I  began  to  feel  the  consti¬ 
tutional  effects  of  the  poison  :  my  re¬ 
spiration  became  irregular,  and  I  felt 
giddy  and  faint,  when  my  assistant 
removed  my  hand  from  the  jar.  All 
due  care  was  taken  to  prevent  me 
breathing  any  of  the  vapour,  and  I  sat 
during  the  experiment  in  a  current  of 
air.  I  felt  the  benumbing  influence  of 
the  acid  extending  from  the  hand 
upwards  along  the  arm  a  minute 
or  two  before  the  experiment  was 
stopped. 

I  have  tried  the  long  immersion  of 
the  hand  in  various  gases,  as  carbonic 
acid  and  common  coal  gas  (both  of  them 
powerful  general  anaesthetics  when  in¬ 
haled),  without  any  effect.  Chaptal, 
however,  alleges  that  he  had  felt  the 
limbs  plunged  in  carbonic  acid  much 
benumbed ;  and  Collard  de  Martigny 
found,  that,  when  the  general  surface 
of  his  body  was  immersed  in  carbonic 
acid  (arrangements  being  made  that 
none  of  it  was  breathed),  giddiness, 
ringing  in  the  ears,  and  the  other 
symptoms  produced  by  the  action  of 
this  gas,  supervened  in  eight  or  ten 
minutes,  proving  that  it  was  absorbed. 
Davy  felt  the  premonitory  exhilara¬ 
tion  of  nitrous  oxide  gas  by  exposing 
t,he  surface  of  his  body  to  it  in  the 
same  way. 

Chaussier  inclosed  the  leg  of  a  dog 
in  a  bag  containing  sulphuretted  hy¬ 
drogen,  and  found  that  he  could  in  this 
way  in  a  few  minutes  induce  the  poi¬ 
sonous  effects  of  the  gas ;  and  similar 
experiments  were  repeated  by  Leb- 
kuchner  and  Nysten,  and  my  friend 
Dr.  Madden,  on  the  rabbit,  &c.,  with 
similar  results.  I  have  held  my  hand 
enclosed  in  a  bag  filled  wdth  the  con¬ 
stantly  renewed  vapour  of  sulphuretted 
hydrogen  for  above  half  an  hour, 
without  feeling  any  local  effects. 

The  facts  which  I  have  stated  seem, 
in  the  present  state  of  our  knowledge, 
to  point  to  the  following 

Conclusions. 

1.  In  animals  belonging  to  the  class 
Articulata,  complete  local  and  limited 
anaesthesia  can  be  produced  by  the 
local  and  limited  application  of  the 
vapour  of  chloroform  to  individual  parts 
of  the  body  of  the  animal. 

2.  In  batrachian  reptiles,  the  tail 


68 


THE  RECENT  CASE  OF  DEATH  FROM  CHLOROFORM. 


or  an  individual  limb  can  be  affected 
in  the  same  way  with  local  anesthesia  ; 
but,  in  addition,  general  anaesthesia  of 
the  animals  usually  results  in  a  short 
time,  by  the  action  of  the  chloroform 
absorbed  through  the  exposed  part. 

3.  In  the  smaller  mammalia,  a  single 
limb,  or  even  the  lower  or  pelvic  half 
of  the  body,  can  be  rendered  anaesthe¬ 
tic  by  local  exposure  of  these  parts  to 
the  influence  of  chloroform. 

4.  In  the  human  subject,  local  anaes¬ 
thesia  of  a  part,  as  the  hand,  can  be 
produced  by  exposing  it  to  the  strong 
vapour  of  chloroform  ;  but  the  result¬ 
ing  decree  of  this  local  anaesthesia  is 
not  sufficiently  deep  to  allow  the  part  to 
be  cut  or  operated  upon  without  pain. 

5.  Any  agent  possessing  a  stronger 
local  benumbing  or  anaesthetic  in¬ 
fluence  would  probably  be  dangerous, 
by  its  acting  on  the  general  economy 
before  the  local  anaesthesia  was  esta¬ 
blished  to  a  depth  sufficient  for  ope¬ 
rating. 

6.  Artificial  local  anaesthesia  from 
any  known  anaesthetic  agents  seems 
objectionable  in  any  part  intended  to 
be  operated  upon,  in  consequence  of 
the  vascular  congestion  and  injection 
which  attend  upon  and  result  from  this 
local  anaesthesia. 

7.  There  are  few  operations  in  which 
there  is  not  previously  a  broken  sur¬ 
face,  and  the  application  of  chloroform, 
& c.,  to  such  a  surface  would  be  far  too 
severe  to  be  endured  ;  their  application 
to  the  unbroken  healthy  skin  being 
usually  attended  with  considerable 
pain. 

THE  CORNEA  NOT  CONCERNED  IN  ADAPTING 

THE  EYE  TO  VISION  AT  DIFFERENT 

DISTANCES. 

The  increased  convexity  of  the  cornea, 
which  was  said  to  be  one  of  the  important 
changes  effected  by  compression  of  the  eye, 
and  on  the  occurrence  of  which  its  power  of 
adaptation  to  the  perception  of  near  objects 
was  supposed  to  depend,  could  not  be 
detected  by  Hueck.  He  attentively  watched 
the  cornea  while  the  sight  was  changed  from 
an  object  thirty  feet  distant  from  the  eye,  to 
one  only  seven  inches  distant,  but  beyond 
the  movements  resulting  from  respiration 
and  from  the  pressure  of  the  orbicularis 
muscle,  he  could  not  perceive  any  change  in 
the  cornea  ;  no  protrusion,  and  no  sinking. 
This  agrees  with  the  observations  of  Dr. 
Young,  who  also  was  unable  to  perceive  any 
such  change  as  was  said  by  Sir  E.  Home 
and  others  to  take  place. — Baly  and  Kirkes's 
Recent  Advances  in  Physiology. 


MEDICAL  GAZETTE. 


FRIDAY,  JULY  14,  1848. 


We  elsewhere  report  two  cases  of  death 
from  the  inhalation  of  chloroform  va¬ 
pour,*  the  one  having  occurred  in  the 
United  States,  and  the  other  quite  re¬ 
cently  in  this  country.  The  unfortu¬ 
nate  case  of  Mr.  Badger  is  sufficient  to 
shew  that  even  they  who  are  most  ex¬ 
perienced  in  the  use  of  this  agent,  are 
not  always  able  to  discriminate  those 
cases  in  which  the  inhalation  of  the 
vapour  is  likely  to  be  attended  with 
fatal  effects.  The  deceased  was  a 
healthy  muscular  young  man,  who, 
according  to  the  testimony  of  his  father, 
had  suffered  from  no  difficulty  of 
breathing,  or  any  other  apparent  dis¬ 
ease.  The  inspection  of  the  body,  how¬ 
ever,  revealed  a  diseased  state  of  the 
heart  and  liver,  although  not  sufficient 
to  account  for  sudden  death.  Hence  we 
arrive  at  the  conclusion  that  a  young 
and  healthy-lookmg  person,  whose 
appearance  and  previous  habits  of  life 
would  create  no  suspicion  of  the  exist¬ 
ence  of  latent  organic  disease,  may 
still  be  in  such  a  condition  of  body 
that  the  respiration  of  the  vapour  will 
operate  upon  him  like  a  fatal  poison. 
It  is  not  here  as  with  a  liquid  or  solid, 
taken  into  the  stomach, — the  poison 
enters  at  once  into  the  circulation,  and 
penetrates  through  the  whole  of  the 
system ;  and  but  a  few  minutes  elapse 
between  apparently  perfect  health  and 
the  death  of  the  patient.  The  circum¬ 
stances  under  which  the  poison  is  ad¬ 
ministered,  do  not,  in  these  unfavour¬ 
able  cases,  admit  of  the  application  of 
any  remedy.  The  attempt  to  abstract 
blood  has  uniformly  failed. f  Art  is 
powerless  in  dealing  with  the  poison- 

*  Pages  77  and  79. 

t  See  the  cases  reported  by  Dr.  Meggison  and 
Dr.  Jameson,  in  our  last  volume,  p.  250  and  p. 
318. 


THE  RECENT  CASE  OF  DEATH  FROM  CHLOROFORM. 


69 


ous  effects  of  this  vapour.  It  may  be 
said,  and  we  doubt  not  the  truth  of 
the  statement,  that  hundreds,  nay 
thousands  of  persons,  young  and 
healthy-looking  like  the  deceased,  have 
inhaled  this  vapour  without  any  such 
disastrous  effects  following.  We  have, 
however,  heard  of  some  very  narrow 
escapes,  even  where  precaution  and 
skill  of  the  best  kind  had  been  em¬ 
ployed  in  its  administration ;  and 
doubtless  the  experience  of  many  of 
our  readers  will  furnish  them  with 
cases  corroborative  of  this  remark. 
But  the  death  of  only  one  person  in  a 
thousand,  when  the  vapour  has  been 
skilfully  administered— and  there  wTas 
nothing  in  the  patient’s  aspect  or 
account  of  himself  to  induce  the  ope¬ 
rator  to  withhold  his  consent  to  its  em¬ 
ployment — becomes  a  most  serious  mat¬ 
ter.  There  should  be  some  extraordinary 
advantage  or  benefit  to  the  individual 
to  justify  such  a  fearful  risk;  but  the 
advantage,  if  any,  in  reference  to  the 
dental  art,  is  the  alleviation  of  pain 
merely  for  a  few  minutes;  and  the 
naked  question  now  to  be  considered 
is,  will  any  operator  feel  himself  justi¬ 
fied,  after  the  case  of  Mr.  Badger,  in 
employing  this  dangerous  vapour  for 
the  annulling  of  pain  in  the  extrac¬ 
tion  of  teeth  ?  If  latent  disease  of  the 
heart  or  liver  could  always  be  clearly 
diagnosed  in  a  patient,  we  should  not 
be  called  upon  to  put  this  question  : 
but  as  Mr.  Badger’s  case  proves  that  a 
most  experienced  man  like  Mr.  Robin¬ 
son  saw  nothing  about  the  deceased 
to  justify  his  refusal  to  employ  chloro¬ 
form,  it  is  clear  that  the  most  skilful 
dentist  may  be  working  in  the  dark, 
and  thus  unconsciously  be  the  means 
of  sacrificing  life  for  the  sake  of 
humouring  a  patient  by  annulling  a 
degree  of  pain  which  every  healthy 
adult  should  be  able  to  bear.  The 
facts  of  this  case  have,  however,  a  bear¬ 
ing  far  beyond  dentistry.  We  con¬ 


sider  that  our  remarks  apply  to  all  the 
minor  operations  of  surgery  ;  and 
judging  by  an  extract  of  a  letter  else¬ 
where  inserted,*  Dr.  Meigs,  a  trans¬ 
atlantic  physician  of  some  repute,  holds 
a  similar  opinion  in  respect  to  the  use 
of  chloroform  in  obstetric  practice. 

We  have  been  arguing  the  question, 
as  if  the  deceased  had  died  from  the 
effects  of  chloroform  vapour.  We 
think,  indeed,  that  the  facts  speak  for 
themselves,  and  justify  the  verdict  of 
the  jury.  There  wfas  no  asphyxia  here ; 
it  could  not  be  supposed  that  the 
deceased  died  from  the  effects  of  treat¬ 
ment,  as  it  has  been  suggested  in  other 
cases  ;  nor  can  it  be  insinuated  that  the 
chloroform  was  administered  in  an  im¬ 
proper  dose,  or  in  an  improper  manner. 
To  attribute  unskilfulness  to  Mr. 
Robinson,  would  be  unwarrantable ;  in 
his  evidence  he  states  that  he  has  ad¬ 
ministered  the  vapour  in  at  least  three 
thousand  cases,  so  that  the  advocates, 
if  there  be  any,  of  the  perfect  harmless¬ 
ness  of  chloroform  vapour,  must  fall 
back  upon  the  hypothesis  of  death  from 
natural  causes  occurring  at  the  time 
by  a  sort  of  special  coincidence.  We 
do  not  believe,  however,  that  this  view 
will  be  seriously  adopted.  It  will  not 
benefit  the  ultra-chloroformists  ;  w7hile 
the  public  and  the  unbiassed  portion 
of  the  profession  wall  be  led  to  think, 
that  on  all  these  occasions  of  fatal 
effects  following  its  use,  there  is  a  desire 
to  conceal  or  distort  the  facts,  so  that 
alarm  may  not  be  created. 

It  appears  from  the  evidence,  that 
Mr.  Robinson  employed  on  this  occa¬ 
sion  one  drachm  and  a  half  of  chloro¬ 
form  :  this  is  about  the  usual  dose.  The 
inhaler  w’as  not  held  close  to  the  mouth 
or  face,  and  deceased  had  not  inhaled 
more  than  a  minute,  wThen  it  appeared 
to  have  produced  so  slight  an  effect, 
that  he  requested  to  have  the  vapour 


*  Page  85. 


70 


THE  RECENT  CASE  OF  DEATH  FROM  CHLOROFORM. 


made  stronger.  Before  this  could  be 
done,  however,  the  head  and  hand  of 
the  deceased  dropped  —  i.  e.  in  one 
second  after  he  had  spoken  to  the 
operator.  A  period  of  about  five,  minutes 
elapsed  from  the  time  at  which  the 
deceased  entered  the  surgery  to  his 
death.*  When  seen  by  Dr.  Waters 
immediately  afterwards,  the  face  was 
livid,  the  pupils  were  dilated,  and  the 
temperature  of  the  body  was  lower 
than  natural.  There  was  general  con¬ 
gestion  of  the  membranes  of  the  brain, 
and  of  the  surface  of  the  corpora  striata 
and  optic  thalami.  “The  lungs  pre¬ 
sented  a  little  sign  of  congestion.” 
These  are  the  chief  appearances  indi¬ 
cative  of  the  action  of  chloroform. 
The  great  difference  in  this  and  the 
two  other  cases  to  which  we  have  re¬ 
ferred,  consists  in  the  lungs  being 
much  less  congested.  The  fatal  effects 
of  the  vapour,  however,  came  on  quite 
suddenly  in  the  case  of  Mr.  Badger, 
but  more  slowly  in  the  cases  reported 
by  Dr.  Meggison  and  Dr.  Jameson. 
This  may  perhaps  account  for  the  dis¬ 
covery  of  a  smaller  amount  of  conges¬ 
tion  in  the  lungs.  On  the  other  hand, 
the  liver  was  much  enlarged,  and  the 
heart  diseased;  but  the  morbid  state  of 
these  organs  was  not  such  as  to  explain 
the  sudden  death,  under  the  circum¬ 
stances,  irrespective  of  the  action  of 
chloroform  vapour.  We  consider  it  to 
be  an  irresistible  inference  from  the 
facts  of  the  case,  that  but  for  the  use 
of  chloroform  the  deceased  might  now 
have  been  living ;  while,  on  the  other 
hand,  it  is  highly  probable  that,  but 
for  the  existence  of  disease  in  the  heart 
and  liver,  the  chloroform  vapour  would 
not  have  proved  fatal.  With  these  ad¬ 
missions  there  can,  we  apprehend,  be 
no  doubt  that  the  inhalation  of  the 
vapour  was  the  immediate  cause  of 
death. 

*  In  Greener’s  case  a  drachm  of  chloroform 
was  used,  and  the  death  of  the  patient  took  place 
in  three  minutes.  See  our  last  volume,  p.  251. 


The  most  startling  features  of  this 
case  are,  that  a  person  may  very  sud¬ 
denly  die  from  the  effects  of  the  vapour, 
without  the  occurrence  of  any  one 
warning  symptom  to  indicate  the  near 
approach  of  death;  and  that  the  va¬ 
pour  will  prove  fatal  in  cases  which 
may  appear  to  be  perfectly  favourable 
to  its  administration.*  Mr.  Wakley, 
the  coroner,  very  justly  remarked,  in 
his  summing  up  at  the  inquest,  that — 
“  The  appearance  of  perfect  health 
displayed  by  this  gentleman,  and  the 
youthful  glow  which  brightened  his 
countenance,  were  well  calculated  to 
lull  any  suspicion  that  there  existed 
the  great  amount  of  derangement  of 
structure  which  had  been  described  by 
the  medical  witnesses”  This  remark 
should  be  borne  in  mind  by  all  who 
may  hereafter  employ  chloroform  va¬ 
pour  in  minor  surgical  operations.  It  is 
obviously  not  always  in  the  power  of 
the  operator  to  judge  from  the  aspect  of 
a  patient  whether  he  may  or  may  not 
safely  use  the  vapour;  and  if  among 
a  thousand  patients  who  inhale  it  only 
one  should  die,  it  is  really  a  serious 
question  whether  the  risk  can  justify 
the  transient  benefit  derived  from  the 
state  of  anaesthesia.  Every  practi¬ 
tioner,  before  resorting  to  its  employ¬ 
ment  hereafter,  should,  we  consider, 
put  to  himself  the  question  pro¬ 
posed  by  Dr.  Meigs — “What  sufficient 
motive  have  I  to  risk  the  life  or  the 
death  of  one  in  a  thousand  in  a  ques¬ 
tionable  attempt  to  abrogate  one  of  the 
general  conditions  of  man  ?” 

Since  these  remarks  were  written, 
we  have  introduced  into  our  columns 
two  other  cases  of  the  alleged  fatal 


*  Air.  Robinson  advised  the  deceased  not  to 
take  the  vapour,  as  the  dental  operation  would 
occupy  but  a  short  time.  It  does  not  appear  that 
this  advice  was  given  from  any  doubt  in  the  ope¬ 
rator’s  mind  that  chloroform  could  not  be  safely 
administered,  or  it  is  quite  certain  that  a  man 
of  Mr.  Robinson’s  experience  and  professional 
knowledge  would  not  have  yielded  to  the  caprice 
of  a  patient. 


PROGRESS  OF  THE  ASIATIC  CHOLERA 


71 


action  of  chloroform.*  The  case  which 
occurred  in  France  strongly  confirms 
the  opinion  which  we  have  expressed, 
that  it  is  unadvisable  to  employ  this 
agent  in  minor  surgical  operations. 


We  regret  to  find,  from  the  reports  in 
the  foreign  journals,  that  the  Asiatic 
cholera  is  rapidly  extending  through 
the  southern  and  western  parts  of 
Russia.  It  is  now  prevalent  through¬ 
out  Moldavia  and  Wallachia.  At  Ga- 
latz,  the  population  of  which  is  esti¬ 
mated  at  40,000,  it  appears  that  there 
have  been  since  February  746  cases 
and  237  deaths.  In  Moscow  the  dis¬ 
ease  has  again  broken  out  with  re¬ 
doubled  virulence,  and  appears  to  set 
at  defiance  all  kinds  of  medical  treat¬ 
ment.  In  two  days  there  were  222 
cases,  and  more  than  one-half  had 
proved  fatal.  The  fact  of  most  interest 
to  us  in  reference  to  its  progress  west¬ 
ward,  is  its  appearance  at  St.  Peters- 
burgh.  This  had  been  frequently 
rumoured  during  the  early  part  of  the 
spring,  but  the  intelligence  is  now 
confirmed ;  and  it  would  appear  that 
the  fatality  of  the  disease  has  even 
been  greater  than  in  Moscow.  Up  to 
the  24th  June  there  had  occurred  in 
the  Russian  capital  no  less  than  one 
thousand  cases,  of  which  more  than 
one-half  had  proved  fatal.  As  in 
1831-2,  the  malady  may  continue  to 
extend  to  the  maritime  ports  of  the 
Baltic,  and  so  across  the  German 
ocean  to  our  own  shores. 


ROYAL  COLLEGE  OF  SURGEONS. 

Gentlemen  admitted  Members  on  the  30th 
ult.  : — B.  W.  Browne.  —  A.  Harris. — A. 
Brown. — H.  Swift. — T.  R.  Armitage. — J.  S. 
Burton. — J.  Dix.— -C.  Miles. — B.  Buck. — 
M.  P.  S.  Ward. 

Gentlemen  admitted  Members  on  the  7th 
inst.  —  Messrs.  Parfitt  —  J.  Rhodes  —  T. 
Taaffr — T.  M.  D.  Davidson — P.  Wright — 
L.  Parnell — A.  Butler — J.  Lawrence. 


I\dnefo4. 


Clinical  Observations  on  the  Pathology 
and  Treatment  of  Continued  Fever  : 
from  cases  occurring  in  the  Medical 
Practice  of  St.  Bartholomew’ s  Hos¬ 
pital.  By  Ed.  L.  Ormerod,  M.B. 
Demonstrator  of  Morbid  Anatomy  at 
St. Bartholomew’s  Hospital,  pp.  244. 
London:  Longman  and  Co.,  1848. 
Not  long  since*  we  had  the  opportu¬ 
nity  of  expressing  a  favourable  opinion 
of  a  valuable  contribution  on  the  sub¬ 
ject  of  clinical  surgery,  by  Mr.  Orme¬ 
rod  ;  and  we  have  now  to  introduce  to 
our  readers  a  work  on  clinical  medicine 
by  the  brother  of  that  gentleman.  Both 
authors  appear  to  have  manifested  an 
equally  laudable  zeal,  in  extensively 
availing  themselves  of  the  advantages 
afforded  by  a  large  metropolitan  hospi¬ 
tal,  of  studying  disease  in  its  various 
phases.  In  this  study  they  have  pro¬ 
ceeded  on  the  only  sure  plan  of  collect¬ 
ing  sound  and  available  information  in 
regard  to  the  nature  and  treatment  of 
disease  —  that,  namely,  of  steadiiy 
watching,  and  carefully  recording,  the 
progress  of  cases.  The  results  of  such 
a  method  of  observation  on  a  particular 
class  of  diseases — that  of  continued 
fever — are  furnished  by  Dr.  Ormerod 
in  the  work  now  before  us.  This  con¬ 
sists  of  a  number  of  carefully-narrated 
cases,  judiciously  arranged,  and  inter¬ 
spersed  with  remarks  on  the  more  pro¬ 
minent  features  offered  by  each.  As 
stated  by  the  author  in  his  preface, 
several  of  these  cases  have  already  ap¬ 
peared  in  a  weekly  periodical ;  6ut 
they  are  now  re-published  in  a  more 
connected  form,  and  with  additional 
observations. 

In  the  Preliminary  Remarks  we 
meet  with  the  following  points,  which 
are  worthy  of  quotation  from  the  rela¬ 
tion  they  bear  to  the  frequently-dis¬ 
puted  question  whether  more  than  one 
actually  different  disease  is  not  included 
under  the  general  term  fever:— 

“1.  The  type  of  an  epidemic,  being  of 
course  that  of  the  majority,  is  general,  not 
universal ;  and  among  the  exceptional  cases 
occurring  in  any  one  year  may  be  found 
illustrations  of  the  most  varied  types  of 
fever,  such  as  may  present  themselves  as  the 
ordinary  form  during  other  years.  2.  But 


*  See  pages  76  and  84. 


Med.  Gaz.  vol.  xxxviii.  p.  76  and  84. 


72  ON  THE  PATHOLOGY  AND  TREATMENT  OF  CONTINUED  FEVER. 


^hese  varieties  cannot  always  reproduce 
themselves ;  for  of  several  members  of  a 
family  living  under  the  same  circumstances 
and  affected  with  fever,  all  have  not  by  any 
means  invariably  the  same  form  of  the  dis¬ 
ease,  nor,  when  it  spreads  in  a  ward  from 
one  patient  to  another,  is  the  like  disease 
always  reproduced.  3.  And  the  distinctions 
between  these  forms  seem  to  rest  on  no  sure 
foundations  ;  for  even  the  important  distinc¬ 
tion,  to  limit  ourselves  to  one  instance,  as  to 
whether  Peyer’s  glands  are  affected  or  not, 
gives  no  available  grounds  during  life  for  any 
classification.  In  the  midst  of  an  epidemic 
generally  characterised  by  such  lesions,  cases 
are  met  with  where  the  intestines  are  quite 
healthy,  and  conversely;  and  the  symptoms 
which  divide  these  cases,  which  enable  us  to 
predict  the  presence  or  absence  of  such 
lesions,  are  merely  incidental.”  (p.  2.) 

The  conclusion  which  may  be  drawn 
from  these  remarks,  and  from  subse¬ 
quent  observations,  is,  that  although 
differing  in  detail,  the  several  varieties 
of  fever  have,  in  the  opinion  ot  the 
author,  a  close  identity ;  the  common 
features  of  resemblance  being  found, 
not  in  the  local  affections,  but  in  the 
peculiar  disturbance  of  the  system 
generally.  Consequently,  we  find  the 
author  discussing  his  subject  in  two 
parts  —  the  essential  fever  and  its 
secondary  local  affections.  The  first 
division  is  very  briefly  considered  :  it 
comprises  some  carefully-written  re¬ 
marks  on  the  morbid  poison  of  fever, 
with  the  particulars  of  one  or  two  in¬ 
teresting  cases  illustrative  of  the  myste¬ 
rious  rapidity  and  force  with  which 
this  subtle  agent  will  seize  upon  the 
mainsprings  of  life,  and  in  a  brief  space 
of  time  produce  complete  prostration, 
followed  either  by  speedy  death  or 
almost  equally  speedy  recovery.  In 
such  cases  the  whole  influence  of  the 
poison  seems  to  be  exerted  upon  the 
system  at  large,  and  is  not  charac¬ 
terised  by  the  implication  of  any  par¬ 
ticular  organ  or  system  of  organs,  ex¬ 
cept,  perhaps,  the  nervous  system. 

The  various  complications  by  which 
the  essential  part  of  fever  is  usually  to 
a  greater  or  less  degree  accompanied, 
are  entered  into  at  considerable  length 
by  the  author.  Of  these  complications, 
affections  of  the  Brain  are  the  most  ob¬ 
scure  and  the  least  understood,  the 
symptoms  being  indefinite  during  life, 
mixed  up  with  those  depending  upon 
the  condition  of  the  system  produced 
by  the  specific  influence  of  the  disease 
itself,  and  rarely  accompanied  by 


organic  lesions  of  the  brain  dis¬ 
coverable  by  dissection.  Affection  of 
the  brain  in  fever  seems  almost  exclu¬ 
sively  connected  with  the  essential 
nature  of  the  epidemic  ;  while  affection 
of  the  Lungs,  which  is  the  next  com¬ 
plication  considered,  appears  to  be  in 
great  measure  influenced  by  the  season 
of  the  year,  and  by  external  tempera¬ 
ture,  being  most  common  and  severe 
in  the  early  part  of  the  year,  subsiding 
during  the  summer,  and  reappearing 
with  the  colder  months.  The  pulmo¬ 
nary  affection  in  nearly  all  such  cases  is 
pneumonia,  or  rather,  as  the  author 
believes,  a  condition  of  the  tissue  of 
the  lung,  probably  intermediate  be¬ 
tween  pneumonia  and  bronchitis,  not 
exactly  referable  to  either ;  and  hence, 
in  individual  cases,  presenting  charac¬ 
ters  sometimes  more  like  one,  some¬ 
times  more  like  the  other  of  these  affec¬ 
tions.  A  still  more  common  form  of 
complication  in  fever  is  that  afforded 
by  affection  of  the  Bowels,  which  con¬ 
sists  in  the  well-known  peculiar  inflam¬ 
matory  affection  of  the  mucous  mem¬ 
brane  of  the  lower  part  of  the  small 
intestine,  accompanied  with  more  or 
less  extensive  sloughing  and  con¬ 
sequent  ulceration  of  the  patches  of 
Peyer’s  glands.  The  morbid  anatomy 
of  the  intestinal  canal  in  this  affection 
is  described  with  much  care  by 
the  author.  Following  this,  we  have 
some  account  of  the  affection  of 
the  spleen  and  liver,  and  the  changes 
of  the  blood  in  fever;  and  then 
a  general  summary  of  the  cases, 
with  a  brief  description  of  the  form  of 
fever  which  prevailed  in  1847,  and 
which  the  author  describes  as  being  “  of 
short  duration,  but  very  liable  to  re¬ 
lapse,  and  contagious  in  an  extremely 
slight  degree,  presenting,  in  the  majority 
of  cases,  an  eruption  of  miliary  vesi¬ 
cles  ;  the  mortality  was  also  very  small, 
and  the  subjects  of  the  disease  were  for 
the  most  part  Irish,  newly  arrived  in 
London.” 

We  have  given  but  few  extracts 
from  this  work ;  indeed,  its  very  nature, 
consisting  almost  entirely  of  the  de¬ 
tails  of  cases,  with  observations  sug¬ 
gested  by  them,  almost  precludes  the 
possibility  of  doing  so.  The  cases 
themselves,  with  the  accompanying  re¬ 
marks,  must  be  carefully  read,  and 
attentively  studied,  to  be  properly 
appreciated  ;  and  we  may  safely  assert, 
that  in  the  perusal  of  them,  the  student 


DR.  GREGORYS  OBSERVATIONS  ON  “  OCHLESIS.” 


73 


will  be  furnished  with  a  valuable  guide 
in  his  study  of  Continued  Fever,  while 
the  practitioner  will  probably  derive 
many  useful  practical  hints  in  the 
management  of  this  disease.  Occa¬ 
sionally  we  have  been  a  little  puzzled 
respecting  the  true  meaning  of  a  pas¬ 
sage,  by  the  studied  accuracy  and  formal 
correctness  of  the  author’sstyle  of  com¬ 
position;  but,  on  the  whole,  this  is  a 
trivial  fault,  and  it  does  not  materially 
detract  from  the  practical  utility  of  the 
work. 


iProcceDmgs  of  j&orietteg. 


ROYAL  MEDICAL  &  CHIRURGICAL 
SOCIETY. 

J.  M.  Arnott,  Esq.,  F.R.S.,  President. 

June  27,  1848. 

Observations  on  “  Ochlesis  f  or  the  Dis¬ 
order  generated  by  the  Accumulation  of 
the  Sick.  By  George  Gregory,  M.D., 
Physician  to  the  Small- pox  and  Vaccina¬ 
tion  Hospital. 

The  object  of  this  communication  is  to  give 
a  brief  sketch  of  the  evils  which  result  from 
the  accumulation  of  a  vast  number  of  sick 
persons  under  one  roof.  The  author  desig¬ 
nates  the  general  condition  of  disease  pro¬ 
duced  under  these  circumstances  by  the 
term  “  ochlesis,”  derived  from  o%Aos,  a 
crowd.  The  normal  type  of  the  disorder  is 
erysipelas  of  the  face  ;  but  there  is  a  vast 
number  of  allied  affections  which  appear  at 
different  times  with  it,  either  separately  or 
in  combination.  These  are,  erysipelas  of 
the  extremities,  especially  affecting  wounds 
or  sores ;  trails  of  erythematous  redness, 
following  the  course  of  the  chief  absorbent 
trunks,  and  terminating  in  abscesses  ;  cel¬ 
lular  inflammation  of  the  lower  limbs,  or 
phlegmasia  dolens;  cellular  inflammation  of 
the  neck,  leading  to  abscess,  cynanche, 
otitis,  glossitis;  inflammation  of  the  joints, 
terminating  in  purulent  effusion ;  sponta¬ 
neous  gangrene  of  the  genitals  and  of  the 
extremities ;  gangrene  supervening  upon 
wounds  or  sores ;  spontaneous  gangrene  of 
some  portion  of  the  trunk  of  the  body,  espe¬ 
cially  in  new-born  children ;  gangrene  of 
the  umbilicus.  Instances  of  pure  fever,  of 
a  low  type,  from  the  same  source,  are  not 
uncommon.  Diarrhoea  sometimes  is  the 
result,  from  the  mucous  membrane  of  the 
bowels  becoming  affected  ;  and  in  the  wards 
of  lying-in  hospitals,  the  “  ochletic”  miasm 
expends  all  its  virulence  on  the  peritoneum. 
The  author  has  seen  an  asthenic  form  of 


laryngitis  produced  by  the  same  cause,  and 
believes  that  the  pneumonia  which  springs 
up  in  hospitals  has  likewise  its  source  in  the 
contagious  ochletic  miasm.  This  miasm, 
too,  he  thinks,  produces  the  excessive  de¬ 
pression  which  attends  the  worst  cases  of 
sea  scurvy,  and  he  has  seen  it  occasion,  in 
the  Small-pox  Hospital,  a  state  resembling, 
in  all  respects,  scurvy  itself.  All  the  dis¬ 
orders  originating  in  the  ochletic  miasm  are 
characterised  by  a  low  condition  of  the  vis 
vitse,  and  intractability.  The  experience  of 
the  Small-pox  Hospital  during  many  epi¬ 
demic  visitations,  especially  in  the  years 
1842,  1844,  1847,  and  1848,  has  convinced 
the  author  of  the  fact  that  all  the  diseases 
which  he  has  enumerated  may  arise  from 
the  same  miasm.  Contagious  peritonitis  is 
perhaps  the  only  form  of  the  ochletic  malady 
that  he  has  not  seen  at  that  hospital  during 
the  last  twenty-five  years ;  but  he  regards 
it  as  quite  certain  that  this  is  “  part  and 
parcel”  of  the  same  disease.  The  chief 
agent  in  the  production  of  ochlesis  is,  cer¬ 
tainly,  the  crowding  together  of  the  sick  in 
one  spot ;  but  matters  are  made  much  worse 
by  unfavourable  locality,  by  dampness  of 
the  surrounding  soil,  imperfect  drainage,  or 
choked  sewers,  by  deficient  ventilation,  by 
the  character  of  the  cases  congregated,  by 
neglect  of  personal  cleanliness,  by  the  em¬ 
ployment  of  unpurified  bedding,  and  by  in¬ 
efficient  purification  of  the  wards.  Since, 
however,  the  ochletic  miasm  is  evolved  only 
at  certain  times,  a  peculiar  but  unknown 
condition  of  the  atmosphere  must  concur 
towards  the  actual  result.  The  ochletic 
miasm  appears  to  attach  itself  strongly  to 
the  walls  and  floor  of  the  apartment :  hence 
the  use  of  covering  the  floor  with  a  mixture 
of  quick-lime  and  water,  of  lime-whiting 
the  walls,  of  fumigating  with  nitric  acid  or 
chlorine,  &c.  The  great  means  of  checking 
the  development  of  ochlesis,  however,  is  to 
restrict  the  admission  of  patients,  and  to 
leave  the  infected  ward  unoccupied  for  a 
certain  time. 

On  the  Minute  Anatomy  of  the  Emphyse¬ 
matous  Lung.  ByG.  Rainey,  M.R.C.S., 
Demonstrator  of  Anatomy  at  St.  Tho¬ 
mas’s  Hospital. 

The  author  first  describes  the  minute 
anatomy  of  the  pulmonary  tissue  in  the 
healthy  state.  He  then  gives  an  account  of 
the  microscopic  examination  of  portions  of 
lung  which  were  in  the  state  of  ordinary 
vesicular  emphysema.  The  first  change 
which  attracted  his  attention  was  the  per¬ 
forated  or  cribriform  state  of  portions  of  the 
lining  membrane  of  the  air-cells.  He  next 
observed  that  the  membrane  in  the  vicinity 
of  these  perforations,  as  well  as  in  many 
parts  which  had  not  yet  become  cribriform, 
was  studded  with  minute  portions  of  oil, 


74  ON  THE  MINUTE  ANATOMY  OF  THE  EMPHYSEMATOUS  LUNG. 


the  membrane  itself  being  thinner  at  these 
points.  He  supposes,  therefore,  that  the 
conversion  of  the  nutritive  material  of  the 
pulmonary  membrane  into  oil  induces  a 
weakened  condition  of  the  membrane,  and 
renders  it  unable  to  support  the  capillary 
plexuses,  and  to  resist  the  pressure  of  the 
air  in  the  air-cells,  and  that  the  perforations 
already  mentioned  are  the  consequence. 
Other  changes  follow.  The  meshes  of  the 
capillary  network  become  wider,  and  the 
capillaries  themselves  smaller.  Several  cells 
become  broken  up  into  one  cavity.  Frag¬ 
ments  of  the  lacerated  cell-walls  are  then 
seen  containing  extremely  elongated  and 
contracted  capillaries,  with  very  large  and 
generally  very  long  areolar  spaces.  When 
the  cavity  has  become  very  large,  the  air- 
cells  which  were  broken  up  to  form  it  have 
in  a  great  measure  disappeared,  and  its  sides 
are  held  together  merely  by  fibrous  bands 
composed  of  the  remains  of  small  bronchial 
tubes  and  of  condensed  interlobular  cellular 
tissue.  When  such  a  cavity  is  situated  near 
the  surface  of  the  lung,  the  pleura  and  sub- 
serous  tissue  become  thickened.  The  dis¬ 
ease  is  regarded  by  the  author  as  an  instance 
of  “  fatty  degeneration.” 

Dr.  Copland,  who  had  entered  the  room 
after  the  reading  of  the  paper,  said  that  he 
could  gather  sufficient  from  its  conclusion  to 
know  its  purport  and  intention.  He  quite 
agreed  with  the  author  as  to  the  evils  pro¬ 
duced  by  crowded  and  ill-ventilated  rooms. 
When  he  was  attached  to  the  Lying-in  Hos¬ 
pital,  fever  of  a  most  fatal  kind  prevailed 
from  bad  air  and  the  vitiated  secretions  of 
the  patients.  So  fatal  was  this  disease,  that 
it  often  runs  its  course  in  twenty-four,  and 
sometimes  even  in  eighteen  hours.  The 
morbid  emanations  from  an  atmosphere  so 
tainted,  spread  to  the  walls,  floor,  &c.,  and 
the  evil  was  further  increased  by  washing 
the  floors.  He  had  found  the  best  antidote 
to  the  poison  was  dry-scrubbing  the  floors, 
and  sprinkling  them  freely  with  chloride  of 
lime.  Another  mode  in  which  disease  was 
propagated,  was  through  the  feather-beds 
becoming  surcharged  with  morbid  matter. 
These  beds  were  frequently  not  cleaned  lor 
twenty  or  thirty  years,  and  the  emanations 
from  them  were  the  cause  of  sporadic  cases 
of  low  and  puerperal  fevers.  Again,  the 
way  in  which  houses  were  at  present  built 
favoured  the  spread  of  disease  ;  for  the  con¬ 
tents  of  the  water-closets  were  not  carried 
off  the  premises,  but  into  a  cesspool  under 
the  kitchen-floor  ;  fever  of  a  bad  kind  was 
thus  periodically  produced.  He  should  not 
enlarge  upon  the  subject,  but  he  had  gone 
fully  into  it  in  the  article  in  his  Dictionary, 
under  the  head  of  “  Domestic  Sources  of 
Pestilence.”  In  answer  to  a  question  from 
Dr.  Gregory,  Dr.  Copland  said,  that  since 
the  hospital  he  had  alluded  to  had  been  better 


ventilated,  &c.,  disease  had  been  much  less 
prevalent,  only  an  occasional  sporadic  case 
of  peritonitis  assuming  asthethe  nic  form. 

Dr.  Chambers  agreed  with  Dr.  Copland 
in  regard  to  the  ill  effects  of  ill-ventilated  and 
crowded  wards  ;  but  this  was  not  the  sole 
cause  of  the  spread  of  disease,  for  in  many 
cases  it  was  propagated  by  contagion.  He 
instanced  cases  of  phlegmonous  erysipelas 
and  puerperal  peritonitis,  arising,  in  the  first 
instance,  from  crowded  and  ill-ventilated 
rooms,  but  propagated  afterwards  by  con¬ 
tagion. 

Dr.  Copland  was  fully  aware  of  similar 
cases  to  those  mentioned  by  the  last  speaker. 

Mr.  Arnott  mentioned  the  value  of  dry¬ 
rubbing  the  floors  in  hospitals  to  prevent 
the  spread  of  disease,  and  instanced  the  case 
of  the  Manchester  Infirmary,  in  which,  pre¬ 
vious  to  the  system  of  dry-rubbing  being  re¬ 
sorted  to,  erysipelas  of  the  operations  was  of 
very  frequent  occurrence.  Now,  under  the 
influence  of  dry-rubbing,  erysipelas  was 
nearly  extinct. 

Dr.  Copland  said  scrofula  and  swelled 
glands  was  a  very  common  disease  in  the 
wards  of  St.  Marylebone  workhouse,  until 
he  recommended  the  employment  of  dry¬ 
rubbing,  since  which  these  complaints  had 
very  much  diminished  in  frequency. 

Dr.  Webster  alluded  to  the  case  of  a 
house  in  Glasgow,  containing  350  or  400 
inhabitants.  It  was  badly  ventilated,  and 
fever  of  a  malignant  character  was  constantly 
occurring.  A  system  of  ventilation  was 
afterwards  adopted  :  a  pipe  communicating 
from  each  room,  with  a  large  common 
chimney,  was  constructed,  and  fever  did  not 
again  occur. 

Dr.  R.  Chambers  could  bear  testimony 
to  the  value  of  dry- rubbing  in  the  wards 
of  an  hospital  as  a  preventive  of  disease. 

Mr.  Partridge  said,  that  however  strik¬ 
ing  the  good  effects  of  dry-rubbing  were  in 
the  wards  of  the  Manchester  Infirmary,  they 
were  no  less  beneficial  in  the  hospital  at 
Birmingham.  In  this  hospital,  under  the 
system  of  washing  the  floors,  erysipelas  after 
operations  was  exceedingly  common.  Dry¬ 
rubbing  was  resorted  to,  and  the  erysipelas 
disappeared.  The  wards  were  again  washed, 
erysipelas  again  returned,  and  was  only 
eventually  got  rid  of  by  a  return  to  the 
wholesome  system  of  dry-rubbing. 

Mr.  San  key  did  not  ascribe  the  decrease 
of  cases  of  erysipelas  in  hospitals  entirely  to 
the  system  of  dry-rubbmg.  He  mentioned, 
that  in  the  fever  hospital  to  which  he  was 
attached,  erysipelas,  which  was  remarkably 
prevalent  at  a  given  period,  became  less  and 
less  general,  without  any  obvious  cause.  On 
referring  to  the  lists  of  the  registrar-general, 
he  found  that  the  prevalence  and  diminu¬ 
tion  alluded  to  bore  a  direct  ratio  to  the 
state  of  the  disease  throughout  the  entire  of 


CASES  ILLUSTRATIVE  OF  SOME  CONSEQUENCES  OF  LOCAL  INJURY.  75 


the  metropolis.  This  fact  shewed  that  some 
other  causes  for  the  prevalence  of  a  disease 
in  an  hospital,  besides  bad  ventilation  and 
washing  the  floors,  must  exist ;  for  in  the 
fever  hospital  these  two  causes  were  not  in 
operation ;  neither  did  he  think  that  dis¬ 
eases  like  erysipelas  and  phlebitis  were  more 
prevalent  in  hospitals  than  out  of  them,  for 
he  had  admitted  many. 

Cases  illustrative  of  some  consequences  of 
Local  Injury.  By  Thomas  Hodgkin, 
M.D. 

The  cases  detailed  are  divided  into  two 
groups :  the  one,  in  which  the  effects  had 
more  or  less  the  character  of  common  in¬ 
flammation  ;  the  other,  distinguished  by  the 
production  of  an  adventitious  structure  hav¬ 
ing  the  character  of  malignant  disease.  The 
following  is  an  outline  of  the  first  of  three 
cases  included  in  the  former  group  : — 

R.  M - ,  about  forty-five  years  of  age, 

an  active  man  of  business,  of  spare  habit, 
but  enjoying  nearly  uninterrupted  health, 
had,  rather  more  than  two  months  before  his 
death,  fallen  upon  the  edge  of  the  kerb¬ 
stone,  in  one  of  the  streets  of  London,  but 
was  not  sensible  of  having  received  much  in¬ 
jury.  About  six  or  seven  weeks  afterwards 
he  was  exposed  to  wet  and  cold,  after  being 
heated  and  fatigued.  In  the  evening  he  was 
chilly  and  distressed,  and  felt  severe  pain  in 
the  right  side.  He  went  out  the  next  day, 
and  was  again  exposed  to  wet  and  cold,  but 
after  this  was  confined  to  the  house.  A 
blister  was  applied  to  the  seat  of  pain,  and 
aperients  and  effervescing  salines  were  given. 
He  complained  no  more  of  pain  in  the  side, 
but  remained  feverish  and  weak.  Two  half¬ 
glasses  of  claret  produced  a  most  dispropor¬ 
tionate  mental  excitement,  which  returned 
in  paroxysms.  In  a  day  or  two  after  this 
he  passed  into  a  state  of  coma,  with  very 
rapid,  feeble  pulse.  Ammonia  was  given. 
He  revived,  and  complained  transiently  of  a 
little  pain  in  the  left  arm  and  leg.  A  small 
induration  was  found  near  the  calf  of  the  leg  : 
this  slowly  increased,  and  the  day  before  his 
death  caused  considerable  pain.  After  the 
mental  disturbance  had  passed  off,  his  head 
was  generally  hot,  and  his  face  for  some  time 
rather  flushed  ;  the  expression  of  his  counte¬ 
nance  generally  quite  composed  ;  the  breath¬ 
ing  quick,  but  easy,  with  a  little  stertor  dur¬ 
ing  sleep  or  somnolence;  the  tongue  was 
moist,  with  a  white  fur  on  its  surface ;  the 
pulse  generally  numbered  120 ;  vomiting 
occurred  twice  or  three  times  before  death. 
A  short  time  before  death  'small  pustules  or 
maturating  vesicles  were  noticed  on  the  body 
and  limbs. 

On  the  examination  of  the  body,  a  small 
subcutaneous  collection  of  pus  was  found 
near  the  head  of  the  right  fibula.  A  larger 
tumor  at  the  upper  part  of  the  left  calf  was 


not  opened.  Nothing  remarkable  was  found 
within  the  cranium,  except  that  in  the  corti¬ 
cal  substance  of  the  brain,  at  one  particular 
spot,  there  seemed  to  bean  evident  but  very 
partial  softening,  by  which  the  separation  of 
the  external  layer  of  the  cortical  substance 
from  the  subjacent  layer  was  favoured.  The 
right  pleura  presented  marks  of  recent  in¬ 
flammation  near  its  lower  part,  and  over  the 
fifth  or  sixth  rib,  from  its  anterior  extremity 
to  its  angle,  was  elevated  by  rounded  puru¬ 
lent  deposits  of  various  sizes.  The  corre¬ 
sponding  part  of  the  pulmonary  pleura  pre¬ 
sented  similar  purulent  deposits,  and  the  ad¬ 
joining  part  of  the  lung  was  in  a  state  of  re¬ 
cent  hepatization.  The  muscular  structures 
on  the  exterior  cf  the  same  rib  were  found 
sprinkled  with  similar,  but  smaller  purulent 
deposits.  The  left  pleura  and  lung,  and  the 
heart,  were  healthy.  In  the  abdomen,  the 
only  remarkable  appearances  were  numerous 
scattered  depressions  in  the  mucous  mem¬ 
brane  of  the  stomach,  probably  the  enlarged 
orifices  of  follicles,  marks  of  severe  inflam¬ 
mation  of  the  mucous  membrane  of  the  large 
intestine,  from  the  middle  of  the  arch  of  the 
colon  to  the  rectum,  and  the  presence  of  a 
small  quantity  of  semi-transparent  lymph 
between  the  convolutions  of  the  intestines — 
between  the  middle  and  lower  parts  of  the 
abdomen.  Of  the  second  class  of  cases  seven 
examples  are  given.  The  author,  in  his  re¬ 
marks,  first  directs  attention  to  the  pecu¬ 
liarities  of  the  former  class  of  cases ;  the 
slight  primary  effects  of  the  local  injury,  and 
the  anomalous  character  of  the  secondary 
effects  ;  the  disturbance  of  the  mental  facul¬ 
ties  in  two  of  the  cases  ;  the  constitutional 
disturbance,  exciting  the  suspicion  that  the 
brain,  heart,  or  some  important  part  of  the 
alimentary  canal,  was  in  a  state  of  acute  in¬ 
flammation  ;  and  in  two  cases,  the  severity 
and  rapidity  of  the  symptoms,  which  were 
nearly  as  great  as  in  cases  of  dissection  and 
other  poisoned  wounds.  He  expresses  the 
opinion,  that  these  symptoms  were  due  to  a 
morbid  poison  being  generated  in  the  system 
— an  opinion  favoured  by  the  occurrence  of 
vesicles,  with  puriform  contents,  on  the 
surface  of  the  body.  To  explain  the  forma¬ 
tion  of  this  morbid  poison,  he  supposes  that 
the  immediate  effect  of  the  local  injury  is  so  to 
impair  a  portion  of  the  animal  tissue,  as  to  ren¬ 
der  it  incapable  of  the  proper  maintenance 
of  those  molecular  changes  by  which  inter¬ 
stitial  absorption  and  deposition  are  carried 
on  ;  that  the  changes  which  take  place  in 
dead  animal  matter  proceed  in  the  injured 
part  very  slowly,  and  during  health  produce 
no  inconvenience  ;  but  that  if  a  febrile  state 
of  the  body  be  set  up  by  cold  or  other  cause, 
the  morbid  influence  of  the  part  in  which 
these  chemical  changes  are  going  on,  pro¬ 
duces  inflammation  or  derangement  of  a 
more  specific  kind  in  the  surrounding  tissues, 


76 


DEATH  FROM  CHLOROFORM  IN  FRANCE 


and  the  further  producton  of  a  like  cause  of 
irritation  in  the  system  generally.  In  one 
case  a  remarkable  odour  of  malt  or  saccha¬ 
rine  matter  was  observed.  This  the  author 
regards  as  an  almost  certain  omen  of  death. 
In  the  second  group  of  cases,  instead  of  the 
vitality  of  the  injured  part  being  reduced, 
the  most  striking  phenomenon  is  the  produc¬ 
tion  of  a  new  growth,  to  which  vital  organi¬ 
zation  is  essential.  All  living  parts,  whether 
old  or  new,  are  nourished  from  living  mate¬ 
rial,  and  every  living  cell  is  produced  from  a 
previous  cell.  In  these  cases  the  injury  does 
not  destroy  life,  but  only  modifies  the  nutri¬ 
tion  of  the  part,  by  exerting  an  influence  on 
small  molecules.  The  resuit  is,  that  the  new 
cells  formed  there  are  modified,  from  being, 
as  it  were,  incubated  in  a  peculiar  nidus. 
When  once  the  production  of  morbid  cor¬ 
puscles,  suited  to  the  production  of  a  morbid 
tissue,  has  taken  place,  the  growth  of  such 
structure  at  the  affected  part  may  also  be 
made  the  subject  of  ocular  demonstration  ; 
but  the  subsequent  appearance  of  a  similar 
structure  in  other  parts  of  the  body,  is  still 
nvolved  in  some  mystery.  The  author  ex¬ 
plains  his  own  views  on  this  difficult  ques¬ 
tion. 


ACADEMY  OF  MEDICINE. 

July  4. 

Death  from  Chloroform  in  France. 

At  the  Meeting  of  the  Academy  of  Medicine 
on  the  4th  of  July,  the  following  instance  of 
the  fatal  effects  of  chloroform  vapour  was 
communicated  to  the  members  by  M.  Gorre, 
Surgeon- in- Chief  to  the  Hospital  of  Bou¬ 
logne. 

The  patient  was  a  female  about  30  years 
of  age  ;  and  the  operation  which  was  per¬ 
formed  on  her  under  the  use  of  chloroform 
vapour,  was  merely  that  of  opening  an  ab¬ 
scess  caused  by  a  foreign  body  lodged  be¬ 
neath  the  skin.  Before  commencing  the 
operation,  M.  Gorre  held  under  the  nostrils 
of  the  patient  a  handkerchief  on  which  he 
had  poured  about  fifteen  or  twenty  drops  of 
chloroform.  The  patient  had  only  made  a 
few  inhalations,  when  she  cried  out,  u  I  am 
suffocating. ”  Her  face  became  pale, — the 
expression  of  her  countenance  was  changed, 
the  respiration  was  difficult,  and  there  was 
frothing  at  the  mouth.  The  handkerchief 
was  withdrawn,  and  the  operation  was  per¬ 
formed.  During  its  performance,  which 
occupied  a  very  short  time,  one  of  the 
assistant-surgeons  endeavoured  to  restore 
the  patient  from  the  state  of  inanimation  into 
which  she  had  fallen.  M.  Gorre  and  his 
assistants  persisted  for  two  hours  in  the  use 
of  every  possible  means  to  rouse  her ;  but 
their  efforts  were  vain.  They  could  hardly 
persuade  themselves  that  she  was  dead, 
although  it  is  most  probable  that  she  died 


about  the  time  at  which  the  operation  was 
commenced.  The  author  compared  the  sud¬ 
denness  of  death  to  that  state  in  which  the 
individual  dies  from  the  introduction  of  air 
into  the  veins. 

There  is  but  a  very  meagre  account  of  the 
post-mortem  examination.  A  quantity  of 
air  was  found  in  the  veins,  especially  in 
those  of  the  brain  and  at  the  base  of  the 
skull,  as  well  as  in  the  pulmonary,  hepatic, 
and  crural  veins.  The  blood  was  remark¬ 
ably  dark ,  and  very  fluid ;  in  colour,  it 
resembled  ink. 

M.  Gorre  referred  death,  first,  to  the  poi¬ 
sonous  action  of  chloroform  vapour  specially 
exerted  on  the  brain  ;  and,  secondly,  to  the 
spontaneous  evolution  of  air  in  the  circulat¬ 
ing  system,  probably  arising  from  the  peculiar 
action  of  the  narcotic  vapour  on  the  blood. 
Whatever  may  be  the  explanation,  observes 
the  author,  the  facts  clearly  prove  that 
chloroform  vapour  may,  in  certain  constitu¬ 
tions,  destroy  life  with  tremendous  rapidity  ; 
and,  even  in  the  hands  of  experienced  men, 
there  is  no  certainty  that  these  dangerous 
results  will  not  follow  in  a  very  unexpected 
manner.  The  dangers  arising  from  its  use, 
pointed  out  by  MM.  Bouisson  and  Sedillot, 
are  not  exaggerated  ;  and  it  would  be  the 
height  of  imprudence,  with  a  knowledge  of 
this  possible  risk  of  life,  to  employ  this 
agent  in  the  performance  of  minor  surgical 
operations. 

Some  discussion  followed  the  reading  of 
this  paper. 

M.  Velpeau  thought  that  the  dose  of 
fifteen  or  twenty  drops  was  too  small  to 
occasion  fatal  consequences.  He  doubted 
whether  death  could  be  fairly  ascribed  to 
the  use  of  chloroform  ;  and  considered  it 
more  probable  that  it  was  one  of  those  in¬ 
stances  of  sudden  death  which  now  and  then 
occur  during  the  performance  of  trivial 
operations,  and  for  which  no  known  cause 
can  be  assigned.  M.  Gorre  appeared  to 
think  that  the  patient  had  died  in  a  state  of 
syncope  ;  and  he  inquired  whether  the  intro¬ 
duction  of  air  into  the  veins  might  not  have 
been  the  cause  of  death.  This,  however, 
is  not  probable  ;  for  death  appears  to  have 
actually  occurred  before  the  commencement 
of  the  operation,  and,  therefore,  before  any 
wound  could  have  been  made  into  a  vein. 
Moreover,  as  the  body  was  not  inspected 
until  twenty-four  hours  after  death,  and 
while  the  temperature  was  high,  the  air 
found  in  the  blood-vessels  may  really  have 
resulted  from  putrefaction.  M.  Velpeau 
thought,  that  if  death  really  did  result  from 
chloroform,  that  the  case  was  of  too  ex¬ 
ceptional  a  kind  to  justify  the  conclusion  of 
M.  Gorre,  that  chloroform  should  be  no 
longer  employed  in  surgical  operations. 

M.  Moreau  stated,  that  M.  Robert  had 
lately  lost  a  patient  under  the  use  of  chloro- 


DEATH  FROM  THE  INHALATION  OF  THE  VAPOUR  OF  CHLOROFORM.  77 


form,  administered  during  the  performance 
of  amputation  of  the  thigh. 

M.  Roux  agreed  with  M.  Velpeau,  that  it 
was  very  doubtful  whether  death  had  been 
here  occasioned  by  chloroform.  The  mode 
of  administration  may  have  had  something 
to  do  with  the  fatal  result.  When  a  hand¬ 
kerchief  is  used,  there  is  always  a  privation 
of  air  and  an  impediment  to  respiration. 
He  thought  that  there  might  have  been  a 
rupture  of  the  lungs  in  a  strong  effort  to 
breathe,  and  that  air  might  thus  have  found 
its  way  into  the  circulation  and  have  caused 
death. 

M.  Baillarger  suggested  that  death 
might  have  been  occasioned  by  an  attack  of 
syncopal  epilepsy,  brought  on  by  the  respi¬ 
ration  of  chloroform  vapour.  It  should 
never  be  administered  to  individuals  subject 
to  convulsive  attacks. 

M.  Piorry  stated,  in  confirmation  of  this 
view,  that  nervous  females  who  respire  it 
often  suffer  from  violent  hysterical  attacks. 

M.  Gibert  and  M.  Amussat  considered 
that  the  explanation  given  by  M.  Roux  was 
probably  the  true  view  of  the  facts — i.  e. 
that  death  had  taken  place  from  the  intro¬ 
duction  of  air  into  the  veins,  occasioned  by 
a  rupture  of  the  lungs. — Gazette  Medicate, 
8  Juillet. 

***  From  this  report  it  will  be  seen,  that 
these  cases  of  alleged  death  from  chloroform 
vapour  give  rise  to  as  much  controversy  in 
Finance  as  in  England.  It  is  to  be  regretted 
that  the  post-mortem  appearances  were 
not  more  fully  given.  There  can  be  little 
doubt  from  the  details,  that  the  patient  was 
either  dying  or  dead  before  the  operation 
was  commenced,  and  it  is  somewhat  sur¬ 
prising  that  a  surgeon  should  have  operated 
under  circumstances  calculated  to  create 
alarm.  The  majority  of  the  speakers  appear 
to  have  considered  that  death  was  caused  by 
chloroform  vapour.  M.  Gorre  assigned  to 
it  a  directly  poisonous  action — a  view  strongly 
corroborated  by  the  remarkable  state  of  the 
blood.  MM.  Roux,  Gibert,  and  Amussat 
considered  that  death  was  an  indirect  result  of 
chloroform,  assuming  that  the  lung  was  rup¬ 
tured  in  the  attempts  to  respire  the  vapour, 
and  that  air  thus  found  its  way  into  the 
blood-vessels  and  destroyed  life.  If  this  be 
true,  it  is  wonderful  that,  out  of  some  thou¬ 
sands  of  cases,  it  has  not  occurred  before  : 
but  it  is  not  reconcileable  with  the  altered 
state  of  the  blood,  which  bore  the  characters 
of  poisoning  by  chloroform;  and  it  is  singular 


that  the  condition  of  the  lungs  is  not  referred 
to  in  order  that  the  correctness  of  this  opi¬ 
nion  might  be  fairly  tested.  Whether  the 
air  in  the  veins  was  the  result  of  putrefaction 
or  any  other  cause  it  is  impossible  to  say, 
but  it  is  not  a  little  singular,  that  in  the 
American  case  of  poisoning  by  chloroform, 
elsewhere  reported,*  bubbles  of  air  were  met 
with  in  the  veins  of  the  brain,  although  no 
vein  had  been  opened,  and  the  inspection 
proved  that  the  lungs  were  not  ruptured. 

We  think  that  the  short  and  simple  ex¬ 
planation  of  the  matter  is,  that  the  woman 
was  poisoned  by  the  vapour  of  chloroform. 

- — — r-.v.  . . -  .=a 

#tetucal  trials  ant)  Inquests. 


DEATH  DURING  THE  INHALATION  OF  THE 
VAPOUR  OF  CHLOROFORM. 

An  inquest  was  held  on  Saturday,  July 
1st,  before  Mr.  Wakley,  in  Francis  Street, 
Gower  Street,  on  the  body  of  Walter 
Samuel  Badger,  Esq.  solicitor,  of  Rother¬ 
ham,  Yorkshire. 

Thomas  Badger,  Esq.,  Rotherham,  on 
being  sworn,  stated  that  he  was  an  attorney, 
and  also  coroner  for  the  county  of  York, 
and  that  the  deceased  gentleman  was  his 
son,  and  was  twenty-two  years  of  age.  That 
he  (the  deceased)  left  witness  at  Rotherham 
on  the  Wednesday  previous,  between  two 
and  three  o’clock  p.m.  ;  that  he  appeared  to 
be  then  in  perfectly  good  health,  and  started 
for  London ;  that  he  had  always  been  in 
good  health.  After  running,  or  taking  any 
violent  exertion,  deceased  would,  like  other 
persons,  be  somewhat  out  of  breath,  but  he 
had  no  difficulty  of  breathing,  aud  was  not 
subject  to  fainting  fits. 

Jane  Cornwall  deposed,  that  she  is  ser¬ 
vant  to  Mr.  Robinson,  surgeon- dentist,  of 
Gower  Street,  and  that  she  was  present  at 
the  death  of  the  deceased  gentleman,  in  the 
surgery  of  Mr.  Robinson’s  house,  on  the 
previous  day  (Friday,  June  30th)  ;  stated 
that  she  always  attended  Mr.  Robinson  when 
he  administered  the  chloroform  or  ether  to 
ladies,  and  that  she  was  present  when  gen¬ 
tlemen  were  the  subjects  of  operation,  if  the 
footman  happened  not  to  be  in  the  way. 
That  the  whole  time,  from  the  period  when 
the  deceased  gentleman  entered  the  surgery 
to  that  of  his  death,  was  not  more  than'  five 
minutes.  That  the  bell  rang,  and  she  went 
in  as  usual,  and,  on  entering  the  room,  saw 
the  deceased  sitting  in  the  oparating- chair. 


*  Page  79. 


78  DEATH  FROM  THE  INHALATION  OF  CHLOROFORM  IN  ENGLAND. 


That  Mr.  Robinson  said  to  him,  “  If  you 
feel  afraid,  don’t  take  the  chloroform;” 
when  deceased  replied,  that  he  did  not  feel 
afraid,  and  he  would  take  it.  Mr.  Robin¬ 
son  observed,  “  Then  I’ll  give  it  you  ;  we’ll 
sit  down  and  take  it  very  quietly.”  Be¬ 
lieves  that  deceased  wanted  some  stumps  of 
teeth  extracted.  Before  deceased  had  takqp 
six  inhalations,  he  said  that  the  chloroform 
was  not  strong  enough.  The  apparatus  or 
inhaler  was  held  by  Mr.  Robinson,  at  a 
distance  of  an  inch  and  a  half  or  two  inches 
from  deceased’s  mouth  and  nose  :  it  was 
not  applied  close  to  his  mouth  and  face. 
When  deceased  remarked  that  the  chloro¬ 
form  was  not  strong  enough,  Mr.  Robinson 
said,  “  Let  me  take  them  out  without.”  In 
a  moment  the  gentleman’s  hand  dropped 
from  the  part  of  the  chair  whereon  it  was 
resting,  and  then  his  head,  and  witness  never 
heard  him  speak  or  saw  him  move  after. 
He  was  talking  the  instant  before  his  head 
and  hand  dropped,  and  said  to  Mr.  Robin¬ 
son,  “  It  is  very  pleasant.”  Perhaps  the 
inhaler  had  been  taken  from  before  his 
mouth  a  second  or  so  before  his  head  and 
hand  fell.  It  was  held  by  Mr.  Robinson 
himself,  and  was  not  before  deceased’s 
mouth  and  nose  a  minute  altogether.  Of 
that  she  is  certain.  Immediately  after  de¬ 
ceased’s  head  and  hand  dropped,  Mr.  Ro¬ 
binson  applied  cold  water  to  his  face.  A 
surgeon  was  sent  for  instantly,  and  Mr. 
Hardy  and  Dr.  Waters  attended,  and  tried 
to  bleed  him.  Bleeding  was  attempted  in 
less  than  two  minutes  after  deceased’s  head 
dropped.  The  doctors  laid  the  deceased  on 
the  floor.  Witness  has  lived  upwards  of 
three  years  with  Mr.  Robinson,  and  firmly 
believes  she  has  seen  him  administer  the 
chloroform  seven  or  eight  hundred  times, 
and  has  never  seen  any  ill  effects  from  it  at 
any  time  ;  has  seen  no  one  faint  from  its 
use,  and  has  not  heard  any  one  complain  of 
its  effects ;  is  positive  that  the  deceased 
himself  asked  to  have  the  chloroform  ad¬ 
ministered,  and  Mr.  Robinson  requested 
him  not,  but  to  have  the  operation  per¬ 
formed  without. 

Albert  Salton,  footman  to  Mr.  Robinson, 
deposed,  that  he  was  present  at  the  death, 
or  immediately  after  the  death,  of  the  de¬ 
ceased  gentleman.  The  bell  rang  ;  he  went 
to  the  surgery.  Mr.  Robinson  said,  “  Come 
here !”  He  went  and  held  deceased’s  hand. 
Deceased  seemed  going  off  in  a  fit,  and  in 
half  a  minute  Mr.  Robinson  sent  witness 
for  a  doctor,  and  he  returned  with  one  in 
about  a  minute.  That  an  attempt  was  made 
to  bleed  deceased,  when  only  a  few  drops  of 
dark-coloured  blood  were  obtained.  When 
witness  entered  the  room,  deceased  was  in 
the  operating- chair,  and  appeared  to  be 
leaning  backwards.  Dr.  Waters  laid  him 
on  the  floor.  Witness  had  let  the  deceased 


in  when  he  knocked  at  the  door ;  he  then 
appeared  in  good  health.  Has  seen  Mr. 
Robinson  administer  chloroform  in  hundreds 
of  cases ;  ladies  have  sometimes  fainted. 
Mr.  Robinson  has  not  administered  ether 
for  six  or  eight  months  past,  but  has  used 
chloroform  only. 

James  Robinson,  surgeon- dentist,  Gower- 
street,  deposed  that  he  had  never  seen  the 
deceased  gentleman  until  Thursday ;  that 
he  applied  to  witness  on  that  day  to  have  an 
operation  performed  on  his  teeth,  but  that 
being  engaged,  he  (Mr.  Robinson)  was 
obliged  to  make  an  appointment  for  the  fol¬ 
lowing  day  (yesterday).  Just  after  deceased 
had  entered  the  surgery,  he  said  that  his 
heart  failed  him,  and  that  he  would  not  have 
his  teeth  out  without  taking  the  chloroform. 
Told  him  that  it  would  be  over  in  a  moment, 
and  that  he  had  better  not.  He  persisted  ; 
witness  then  called  in  the  female  servant,  the 
footman  being  engaged.  Put  a  drachm  and 
a  half  of  chloroform  on  the  sponge  of  the 
inhaler  ;  that  is  the  usual  quantity ;  then 
held  the  inhaler  at  a  distance  from  his 
mouth,  and  he  had  not  inhaled  a  minute 
before  he  said,  “It  is  not  strong  enough  ; 
make  it  stronger.”  Witness  then  asked  the 
girl  for  the  bottle  containing  the  chloroform, 
but  before  he  could  take  it  from  her,  to  apply 
more  to  the  sponge,  the  head  and  hand  of  the 
deceased  gentleman  dropped.  Witness  imme¬ 
diately  applied  cold  water  to  his  face  with  a 
towel,  and  poured  cold  water  on  his  head  from 
a  pitcher.  He  also  immediately  dispatched 
his  servant  for  the  doctor,  and  slit  up  the 
sleeve  of  his  (the  deceased’s)  coat,  for  the 
purpose  of  bleeding  him.  At  that  moment 
the  doctors  arrived,  and  made  the  attempt, 
but  all  their  efforts  proved  unavailing.  Had 
only  used  a  drachm  and  a  half  of  chloroform 
altogether  ;  it  had  been  only  placed  upon 
the  sponge  once.  Believes  that  he  has  ad¬ 
ministered  ether  and  chlorolorm,  in  his  own 
practice  and  that  of  operating  surgeons, 
between  three  and  four  thousand  times.  Not 
a  second  before  deceased’s  head  and  hand 
dropped,  he  was  laughing  and  talking. 

John  Waters,  M.D.,  South-crescent,  Bed- 
ford-square,  deposed  that  he  was  called  to 
the  deceased  by  Mr.  Robinson’s  footman. 
Went  instantly  ;  found  the  deceased  seated 
in  an  operating-chair  ;  on  examination  of  his 
chest,  he  thought  he  could  detect  three  or 
four  contractions  of  the  heart.  Attempted 
venesection,  but  could  only  obtain  a  very 
small  quantity  of  dark  blood.  Found  him 
in  an  erect  position ;  laid  him  on  the  floor ; 
cold  was  applied  to  the  head,  and  warmth 
to  the  extremities.  The  face  was  livid ; 
pupils  dilated  ;  temperature  of  body  lower 
than  natural ;  chest  exposed.  Tried  artificial 
respiration,  but  all  the  efforts  that  were  used 
failed.  [Had  made  a  post-mortem  examina¬ 
tion  that  morning  (Saturday)  about  twenty 


DEATH  FROM  THE  INHALATION  OF  CHLOROFORM  IN  AMERICA.  79 


hours  after  death.  The  body  was  well 
formed  and  muscular  ;  the  neck  plethoric 
and  rather  short ;  countenance  of  a  bluish 
livid  appearance ;  eyes  [pupils  ?]  dilated, 
particularly  the  left ;  chest  well  formed,  but 
generally  dull  all  over  on  percussion,  par¬ 
ticularly  the  right  side  ;  parietes  less  reso¬ 
nant  over  the  heart’s  region  than  in  the  natu¬ 
ral  state.  Abdomen  prominent,  from  a 
deposition  of  fat;  dulness  on  percussion, 
extending  into  the  right  iliac  region  ;  lower 
extremities  not  oedematous.  On  dividing 
the  scalp  there  was  observed  some  turges- 
cence  of  the  vessels.  The  membranes  pre¬ 
sented  a  congested  appearance  all  over  the 
cerebral  mass ;  there  was  nothing  abnormal 
in  the  cerebrum,  nor  any  effusion  into  either 
ventricle  ;  the  surface  of  the  corpora  striata 
and  optic  thalami  were  slightly  congested ; 
the  cerebellum  and  pons  Varolii  offered 
nothing  remarkable.  On  raising  the  ster¬ 
num,  observation  was  made  of  the  very 
small  diameter  to  which  the  chest  was  re¬ 
duced,  for  it  was  found  that  the  lungs  and 
heart  were  pushed  upwards  to  a  line  extend¬ 
ing  between  the  third  and  fourth  ribs ;  the 
lungs  were  healthy  and  crepitant  throughout 
their  entire  extent ;  there  were  some  adhe¬ 
sions  on  the  right  side,  of  long  standing,  but 
no  marked  congestion.*  On  dividing  the 
pericardium,  no  undue  effusion  of  serous 
fluid  was  found.  The  heart  looked  of  a  paler 
colour  than  usual,  and  was  flaccid,  but  was 
not  in  a  hypertrophied  or  dilated  condition  ; 
some  spots  of  adipose  matter  were  observed 
here  and  there  on  its  surface.  On  dividing 
the  left  ventricle,  its  walls  were  found  thinner 
than  natural,  and  its  tissue  was  interspersed 
with  “  fatty”  degenerescence ;  this  morbid 
state  was  particularly  observable  at  the  apex, 
where  the  muscular  tissue  only  measured 
about  two  lines,  and  the  abnormal  deposi¬ 
tion  was  very  evident  at  this  point ;  the 
right  ventricle  and  septum  offered  nothing 
remarkable  but  the  lesion  of  secretion 
already  observed  ;  both  ventricles  contained 
clots  of  dark  grumous  blood.  The  inner 
surface  of  the  aorta  felt  rather  rough,  and 
the  mitral  valves  were  unequal  at  their 
edges,  with  some  slight  rugosity  ;  on  divid¬ 
ing  their  base,  the  tissue  was  hard,  and  made 
a  grating  noise  under  the  scalpel.  Abdo¬ 
men  :  The  omentum  was  loaded  with  fat ; 
stomach  not  distended  by  gases ;  liver  pre- 
ternaturally  enlarged,  and  extending  upwards 
in  a  line  between  the  third  and  fourth  ribs  ; 
it  was  of  a  pale  brownish  colour,  and  in 
some  parts  almost  approaching  to  a  dirty 
white  ;  this  wras  particularly  observable  in 
the  Spigelian  lobe,  where  the  fatty  degene¬ 
rescence  was  very  evident ;  there  appeared 


*  In  his  evidence  at  the  inquest,  Dr.  Waters 
stated  that  the  lungs  presented  a  little  sign  of 
congestion. 


to  be  no  other  change  of  structure.  It 
weighed  eight  pounds .*  The  other  organs  of 
the  abdomen  were  h  ealthy.jf  Witness  at¬ 
tributes  the  death  to  the  diseased  state  of 
the  heart,  and  the  obstruction  to  the  flow  of 
blood  through  it,  produced  by  the  pressure 
of  the  enlarged  liver.  On  being  asked  to 
connect  the  history  of  the  case  as  it  had 
been  proved  on  oath,  with  the  post-mortem 
appearances,  and  then  to  state  whether  he 
attributed  any  ill  effects  to  the  inhalation  of 
chloroform,  witness  said,  that  in  all  proba¬ 
bility  the  death  would  not  have  happened  if 
the  chloroform  had  not  been  administered. 
The  death,  therefore,  might  be  attributed  to 
the  action  of  the  chloroform  on  an  exten¬ 
sively  diseased  heart. 

Mr.  Erasmus  Wilson  deposed  that  he  was 
present  at  the  examination  of  the  body,  with 
Dr.  Waters,  and  agreed  with  him  as  to  the 
morbid  conditions  which  he  had  described. 
He  attributed  death  to  the  stoppage  of  the 
heart’s  action.  On  being  asked  to  what 
circumstance  or  circumstances  he  attributed 
the  cessation  of  the  heart’s  action,  witness 
said  that  it  was  probably  the  effect  of  the 
chloroform,  owung  to  the  diseased  condition 
of  the  heart  and  the  small  space  the  heart 
had  to  act  in,  occasioned  by  the  pressure  of 
the  enlarged  liver,  and  the  quantity  of  fatty 
matter  deposited  in  the  abdomen. 

After  a  summing-up  by  the  Coroner,  the 
jury  returned  the  following  verdict “  That 
Walter  Samuel  Badger  died  from  the  mortal 
effects  produced  by  the  inhalation  of  chloro¬ 
form  upon  a  heart  extensively  diseased,  and 
greatly  obstructed  in  its  action  by  a  liver 
much  enlarged  beyond  its  natural  size. — 
Lancet ,  July  8. 


DEATH  FROM  THE  INHALATION  OF  CHLORO¬ 
FORM  IN  THE  UNITED  STATES. 

Report  of  the  principal  facts  connected 
with  a  fatal  case  of  Chloroform  Inhala¬ 
tion,  which  occurred  in  Cincinnati,  on 
the  23 d  of  February ,  1848. 

General  History.— The  subject  of  the  fol¬ 
lowing  report,  Mrs.  Martha  G.  Simmons, 
was,  at  the  time  of  her  decease,  thirty-five 
years  and  ten  months  old.  Her  husband 
states  that  she  generally  enjoyed  excellent 
health;  sometimes  she  was  “nervous,”  and 
suffered  occasionally  with  neuralgic  pains 
about  the  face  and  pain  in  the  ear,  appa¬ 
rently  arising  from  decayed  teeth.  She  also 
suffered  at  times  from  “sick  headache.” 
She  was  the  mother  of  six  children,  five  of 
whom  were  still  living  ;  her  last  accouche¬ 
ment  occurred  eight  weeks  previous  to  her 
death.  Nothing  unusual  was  observed,  either 
at  the  time  of  parturition  or  subsequently  ; 

*  The  average  weight  is  from  four  to  five 
pounds. 

t  From  Dr.  Waters’s  report  of  the  post-mor¬ 
tem  examination. 


80  DEATH  FROM  THE  INHALATION  OF  CHLOROFORM  IN  AMERICA. 


her  health  remained  good,  and  the  ordinary- 
quantity  of  milk  was  secreted. . 

On  the  23d  of  February  she  dined  at  a 
quarter  past  12  o’clock,  and  after  dinner 
walked  to  a  dentist’s,  a  distance  of  about 
three-fourths  of  a  mile,  for  the  purpose  of 
having  some  roots  of  teeth  extracted.  She 
arrived  at  the  dentist’s  16  minutes  before  3 
o’clock,  appeared  slightly  flushed  from  the 
exercise  of  walking,  but  exhibited  no  alarm 
on  account  of  inhaling  the  chloroform. 

At  3  o’clock,  fifteen  minutes  after  her 
arrival,  Mrs.  S.  commenced  inhaling  chlo¬ 
roform.  Mrs.  Pearson  and  Mrs.  Cross,  two 
female  friends,  were  present,  and  report  the 
following  as  the  events  which  occurred  : — 
The  respiratory  movements  appeared  to  be 
free ;  chest  heaving.  While  inhaling,  the 
face  became  pale.  At  the  expiration  of 
about  one  minute ,  the  instruments  were  ap¬ 
plied,  and  four  roots  of  teeth  extracted. 
The  patient  groaned,  and  manifested  what 
they  regarded  as  evidences  of  pain,  while 
the  teeth  were  being  extracted,  although  she 
did  not  speak,  or  exhibit  any  other  sign  of 
consciousness.  As  the  last  root  came  out, 
which  was  about  two  minutes  from  the  begin¬ 
ning  of  the  inhalation,  patient’s  head  turned 
to  one  side,  the  arms  became  slightly  rigid, 
and  the  body  drawn  somewhat  backwards, 
with  a  tendency  to  slide  from  the  operating- 
chair.  At  this  instant,  Mrs.  Pearson  states 
that  she  placed  her  finger  upon  the  patient’s 
pulse  ;  observed  that  it  was  feeble  and  im¬ 
mediately  ceased  to  beat ;  respiration  also 
ceased  about  the  same  time.  The  face, 
which  was  previously  pale,  now  became 
livid,  as  also  did  the  finger  nails;  the  lower 
jaw  dropped,  and  the  tongue  projected  a 
little  at  one  corner  of  the  mouth,  and  the 
arms  were  perfectly  relaxed.  The  females 
regarded  her  as  being  then  quite  dead. 
Efforts  were  made  to  resuscitate  the  patient : 
ammonia  was  applied  to  the  nostrils,  cold 
water  dashed  in  the  face,  mustard,  brandy, 
&c.  applied.  The  patient  was  now  removed 
from  the  operating-chair  and  laid  on  a  sofa  ; 
but  she  did  not  breathe,  nor  exhibit  any 
sign  of  life,  after  being  placed  in  the  recum¬ 
bent  position. 

Statement  of  the  dentists.  —  Messrs. 
Meredith  and  Sexton,  the  dentists  who  ope¬ 
rated  in  the  above  case,  make  the  following 
statement: — The  patient  took  the  chloro¬ 
form  vapour  from  Morton’s  inhaler  ;  it  con¬ 
tained  a  sponge  (perhaps  one-third  filling 
the  glass  globe  of  4|  inches  diameter)  satu¬ 
rated  with  the  liquid ;  to  this,  25  drops 
more  were  added  when  the  patient  began  in¬ 
haling.  Breathing  at  first  slow ;  inhaled 
twelve  or  fifteen  times,  occupying  from  a 
minute  to  seventy-five  seconds.  One  of 
the  dentists  thinks  she  remained  about  ten 
minutes  in  the  operating-chair,  and  that  life 
was  not  extinct  until  the  end  of  that  time ; 


the  other  estimates  the  time  at  five  minutes. 
One  says  he  does  not  know  whether  she 
breathed  after  being  laid  on  the  sofa  or  not ; 
the  other  thinks  she  did  not. 

The  only  material  difference  between  the 
statements  of  the  females  and  The  dentists, 
relates  to  the  length  of  time  which  elapsed 
from  the  beginning  of  the  inhalation  to  the 
instant  of  death.  The  females  estimate  it  at 
about  tivo  minutes  ;  the  dentists  at  from  five 
to  ten  minutes.  It  is  clear,  however,  that 
the  patient  could  not  have  been  laid  on  the 
sofa  short  of.  five  or  ten  minutes  ;  for  one  of 
the  dentists  went  out  to  a  neighbouring  esta¬ 
blishment  twice  to  procure  resuscitating 
agents  before  the  patient  was  removed  from 
the  chair,  which  probably  occupied  the  time 
specified.  But  whether  the  patient  con¬ 
tinued  to  breathe  during  those  five  or  ten 
minutes,  or  whether  the  pulse  and  respira¬ 
tion  ceased  at  the  end  of  two  minutes,  when 
the  last  tooth  was  extracted,  as  supposed  by 
Mrs.  Pearson,  seems  impossible  positively 
to  decide.  The  most  that  can  be  said  is, 
that  she  died  within  a  very  short  time — not 
exceeding  ten ,  and  possibly  at  the  end  of  two 
minutes. 

Medical  aid. — After  the  patient  was  laid 
on  the  sofa,  medical  aid  was  sought,  and  Dr. 
A.  H.  Baker  was  the  first  physician  who 
arrived  :  this  was  probably  thirty  minutes 
after  respiration  had  ceased.  He  imme¬ 
diately  pronounced  her  dead,  but  proceeded 
to  employ  vigorous  measures  for  resuscita¬ 
tion.  The  principal  means  employed  con¬ 
sisted  in  artificial  respiration,  electro -mag¬ 
netism,  and  external  stimulants.  Prof. 
Locke  applied  electro-magnetism,  which 
caused  active  muscular  contraction,  but  no 
evident  effect  on  the  heart.  About  an  hour 
after  the  accident,  Professors  Mussey  and 
Lawson  arrived,  and  aided  in  the  further 
employment  of  the  means  above  specified. 
Not  the  slightest  sign  of  life  was  manifested 
after  the  arrival  of  Dr.  Baker;  the  heart  did 
not  respond  to  the  electricity,  and  the  only 
change  produced  was  some  slight  removal  of 
the  lividity  of  the  countenance  by  the  arti¬ 
ficial  respiration. 

Post-mortem  examination. —  The  post¬ 
mortem  examination  was  made  twenty-six 
hours  after  death.  Present — Drs.  Mussey, 
Lawson,  Baker,  and  Mulford. 

Examination  by  Dr.  Lawson.  Record 
by  Dr.  Mussey. 

External  appearances. — Lips  livid,  but 
face  pale  ;  bloody  froth  issuing  from  the 
mouth.  Anterior  surface  of  body  and  limbs 
free  from  discolouration,  but  posteriorly  the 
skin  presented  a  deep  livid  hue.  Cornea 
dull  and  flaccid,  and  a  dull-red  horizontal 
belt  extended  across  each  eye,  corresponding 
to  the  part  which  was  unprotected  by  the 
lids  ;  this  belt  was  one-tenth  of  an  inch  in 
diameter,  and  made  its  appearance  a  few 


6n  the  use  of  tar  in  cutaneous  diseases. 


81 


hours  after  death.  Limbs  quite  rigid.  Ab¬ 
domen  distended  with  gas.  Patient  rather 
muscular;  weight  probably  from  140  to  150 
pounds;  hair  dark  ;  eyes  dark  brown;  tem¬ 
perament  sanguineo-bilious. 

Brain. — Integuments  contained  but  little 
blood.  On  removing  the  upper  part  of  the 
skull,  a  larger  quantity  of  blood  than  usual 
flowed  from  the  vessels  of  the  dura  mater. 
Superficial  vessels  of  the  brain  moderately 
distended  ;  two  or  three  ounces  of  fluid  blood, 
intermixed  with  bubbles  of  air,  flowed  from 
the  sinuses  of  the  dura  mater.  General 
aspect,  colour,  and  consistence  of  the  brain, 
normal. 

Lungs. — Considerably  but  not  intensely 
congested  :  crepitated  freely  at  all  points  ; 
no  extravasation.  Lining  membrane  of 
bronchia  slightly  congested,  apparently  the 
result  of  recent  catarrh  ;  deeply  stained  by 
the  blood.  Pleura  at  all  points  highly  in¬ 
jected  ;  six  drachms  of  bloody  serum  in  the 
right,  and  two  ounces  in  the  left  chest. 

Heart  and  large  blood-vessels. — Pericar¬ 
dium  contained  six  drachms  of  bloody  serum. 
Heart  flaccid,  and  all  its  cavities  entirely 
empty  ;  inner  surface  of  both  ventricles  and 
auricles  deeply  stained.  Aorta  and  pulmo¬ 
nary  artery  empty;  no  blood  in  the  cava 
within  the  chest,  and  a  very  small  quantity 
in  the  part  which  lies  within  the  abdomen  : 
indeed,  so  small  was  the  amount  that  it  could 
not  be  appreciated  until  the  vessel  was 
opened.  Lining  membrane  of  all  the  blood¬ 
vessels  deeply  stained. 

Abdomen. — One  ounce  and  a  half  of 
bloody  serum  in  the  right  hypochondrium. 
Stomach  and  intestines  distended  with  gas. 
Partially  digested  aliment,  amounting  to 
about  three  gills,  was  found  in  the  stomach. 
Liver  paler  than  natural,  arising  from  the 
absence  of  blood  ;  kidneys  considerably  en¬ 
gorged.  No  marks  of  previous  disease  in 
any  of  the  abdominal  organs.  Uterus  and 
bladder  normal ;  the  former  exhibited  the 
usual  condition  of  the  organ  two  months 
after  delivery. 

Blood. — Fluid  as  water  in  every  part  of 
the  body ;  not  a  coagulum  was  seen  in  any 
vessel.  Examined  with  the  microscope,  the 
globules  appeared  altered  somewhat  in  form  ; 
some  wyere  irregular  in  shape,  and  they 
seemed  generally  distended  and  more  globu¬ 
lar  than  is  normal ;  they  were  also  somewhat 
fragmentary,  a  part  apparently  having  been 
ruptured  ;  their  number  seemed  somewhat 
diminished.  The  colour,  in  every  part  of 
the  system,  was  that  of  dark  venous  blood. 

Sympathetic  nerve. — The  sympathetic 
nerve,  together  with  its  larger  gangalia,  in¬ 
cluding  the  semilunar  ganglion,  presented  a 
natural  colour. 

The  Chloroform  used.  —  The  specific 
gravity  of  the  chloroform  employed  was 
found  to  be  1*3.  It  contained  some  alcohol, 


but  upon  the  whole  it  is  regarded  as  a  fan- 
article  ;  it  was  the  same  which  the  dentists 
had  previously  used  in  numerous  cases 
without  any  unpleasant  results. —  Western 
Lancet,  and  Phil.  Med.  Exam.  April  1848. 


dTom&ponfccnce. 


ON  THE  USE  OF  TAR  IN  CUTANEOUS 
DISEASES. 

Sir, — Will  you  allow  me  to  express  my 
obligation  to  Mr.  Wetherfield  for  his  obser¬ 
vations  on  the  use  of  tar  in  cutaneous  dis¬ 
eases,  in  the  last  number  of  the  Gazette  ? 
The  notorious  intractability  of  these  disorders 
naturally  excites  one’s  attention  to  any  re¬ 
medy  which  has  proved  successful ;  accord¬ 
ingly,  the  treatment  by  tar,  especially 
since  the  introduction  of  capsules,  has  come 
into  very  general  use ;  and  it  is  unques¬ 
tionable  that  some  obstinate  cases  have 
yielded  to  it.  I  still,  however,  must  main¬ 
tain  my  preference  for  a  previous  trial  of 
arsenic  in  decreasing  doses,  and  on  a  full 
stomach,  for  the  following  reasons  : — 

1.  As  far  as  my  experience  has  extended, 
it  has,  when  regularly  and  properly  adminis¬ 
tered,  never  yet  failed  in  any  of  the  diseases 
enumerated  by  your  correspondent,  provided 
the  patient  be  free  from  organic  disease,  and 
temperate  in  his  habits.  And  we  have  yet 
to  learn  whether,  in  any  of  the  cases  of  re¬ 
puted  failure,  the  arsenic  has  been  carefully 
administered  in  accordance  with  the  condi¬ 
tions  I  have  specified  ; — and  this  is  an  all- 
important  point ;  for  in  a  majority  of  my 
own  successful  cases  arsenic  had  failed , 
having  previously  been  tried  on  an  essen¬ 
tially  different  plan  ;  and  in  many  of  them, 
tar  had  likewise  failed. 

2.  Arsenic  not  only  cures  the  disease,  but, 
when  continued  for  a  certain  time  after  the 
final  disappearance  of  the  disease,  always  in 
a  great  degree,  and  frequently  entirely,  de¬ 
stroys  all  tendency  to  the  morbid  action. 
This  is  not  the  case  with  tar.  On  Mr. 
Wetherfield’s  own  showing,  some  of  his  pa¬ 
tients  were  only  relieved  for  the  time,  and 
“  suffered  repeatedly  from  the  disease.” 

3.  Although  Mr.  Wetherfield’s  patients 
appear  to  have  made  no  complaints — to 
their  honour  be  it  spoken — yet  the  odour  of 
tar,  to  say  nothing  of  its  trouble  and  filth, 
is  to  some  persons  intolerable  ;  and  to  none 
can  it  be  agreeable  to  reflect,  that  they  carry 
it  about  writh  them  into  every  company. 
Arsenic  is  not  open  to  this  objection. 

4.  Arsenic,  besides  being  more  certain 
and  lasting  in  its  effects,  as  well  as  less  un¬ 
pleasant,  is  as  safe  as  tar.  Of  this  I  have 
abundant  proofs  in  the  history  of  many 
thousands  of  cases.  Nor  have  1  yet  met 


82  EXTRACTION  OF  FOREIGN  SUBSTANCES  FROM  THE  CONJUNCTIVA. 


with  a  patient  who,  from  idiosyncrasy,  could 
not  bear  it.  I  have  explained  in  my  book, 
that  where  the  system  was  remarkably  sus¬ 
ceptible,  and  in  a  degree  intolerant  of  the 
remedy,  the  disease  was  so  much  the  more 
amenable  to  its  influence,  yielding  speedily 
to  such  very  minute  doses  as  the  patient 
could  bear  with  impunity. 

Nevertheless,  if  I  should  meet  with  a  case 
in  which  arsenic  cannot  be  borne  in  any 
dose,  I  will  certainly  give  a  trial  to  the  tar. 

I  may  perhaps  be  allowed  to  add,  how¬ 
ever,  that  it  is  our  duty  in  every  case,  as  it 
will  prove  our  interest,  as  well  as  that  of  the 
patient,  to  try  at  once  the  most  effective 
remedy  we  have  at  hand,  especially  if  it  be 
safe,  and  subjects  the  patient  to  no  annoy¬ 
ance. 

Again  thanking  your  correspondent  for  his 
hints,  and  anxiously  courting  the  most  rigid 
inquiry  into  my  own  method  of  administer¬ 
ing  arsenic,  I  remain,  sir, 

Your  obedient  servant, 

Thomas  Hunt. 

Herne  Bay,  July  1,  1848. 


ON  THE  EXTRACTION  OF  FOREIGN  SUB¬ 
STANCES  FROM  THE  CONJUNCTIVA. 

Sir, — Having  myself  frequently  suffered 
from  this  cause,  and  having  frequently  met 
with  instances  where  particles  of  coke  ex¬ 
pelled  from  the  engine,  so  small  as  to  be 
almost  invisible,  have  become  impacted  in 
the  conjunctivse  of  railway  travellers,  I  beg 
to  submit  to  your  notice  a  small  instrument 
which  I  have  found  of  service  in  the  extrac¬ 
tion  of  these  minute  particles,  provided  that 
any  portion  of  them  projects  above  the  sur¬ 
face  of  the  conjunctiva.  It  consists  simply 
of  a  common  sewing  needle,  of  sufficient 
length  to  be  twisted  over  the  flame  of  a  can¬ 
dle  into  a  loop  the  eighth  part  of  an  inch  in 
diameter,  and  bent  so  as  to  form  a  concavity 
equal  to  the  convexity  of  the  eyeball ;  it  is 
filed  to  form  an  edge  on  the  inner  side  of 
the  loop  ;  and  the  ends  are  inserted  into  a 
small  handle,  thus — 


Direct  view. 


e,  cutting  edge. 


Profile  view. 


I 


*  The  external  sharp  edge  is  to  be  ground 
or  filed  off. 


In  using  it,  the  concave  surface  is  applied 
to  the  eyeball  so  as  to  enclose  the  foreign 
body  ;  the  instrument  is  then  drawn  in  the 
direction  of  the  handle,  and  the  internal 


edge,  catching  against  the  projecting  portion 
of  the  body,  raises  and  withdraws  it. 

The  advantages  of  this  instrument  are, 
that  it  can  be  introduced  within  the  eyelids, 
even  when  closed,  and  be  passed  over  the 
surface  of  the  eyeball  in  any  direction, 
without  the  slightest  fear  of  injury.  Even 
when  the  particles  are  so  small  as  to  be  in¬ 
visible  to  the  naked  eye,  having  detected 
their  position  by  a  lens  they  can  thus  be 
scraped  off  with  ease.  Lastly,  the  instru¬ 
ment  can  be  constructed  in  a  few  minutes 
in  any  situation,  no  cottage  being  so  desti¬ 
tute  as  not  to  be  able  to  provide  the  mate¬ 
rials — viz.,  a  needle,  a  candle,  a  file  or  a 
whetstone,  and  a  bit  of  wood  for  a  handle. 

I  am,  sir,  your  obedient  servant, 

T.  Ogier  Ward,  M.D.  Oxon. 

Kensington, 

June  30th,  1848. 

mr.  solly’s  case  of  scirrhus  of  the 

PAROTID  GLAND. 

Sir, — In  the  36th  volume  of  the  Me¬ 
dical  Gazette  (p.  1449)  you  published  a 
clinical  lecture  of  mine  on  Scirrhus  of  the 
Parotid  Gland,  and  excision  of  the  lower 
jaw.  I  now  forward  to  you  the  ultimate 
result,  regretting  that  a  variety  of  circum¬ 
stances  have  delayed  it  so  long.  The  wound 
nearly  healed,  and  that  rapidly ;  but  a  small 
point  remained  near  the  meatus  auditorius 
externus,  from  which  the  disease  sprang  up 
again.  It  extended  very  slowly  from  this 
point  externally ,  but  it  was  evidently  ad¬ 
vancing  internally  ;  for  the  man  became 
amaurotic,  and  exhibited  general  symptoms 
of  cerebral  disease.  He  died  comatose  after 
some  days  of  insensibility. 

My  colleague,  Mr.  Dixon,  examined  the 
parts  after  death,  and  has  kindly  drawn  up 
the  following  account. — I  am,  sir, 

Your  obedient  servant, 

Samuel  Solly. 

The  following  is  a  short  account  of  the 
morbid  parts  removed  from  your  patient, 
Thomas  Partner.  I  did  not  see  the  pre¬ 
paration  until  after  it  had  been  nearly  five 
months  in  spirit  ;  so  that  the  dissection  was 
far  less  satisfactory  than  it  otherwise  would 
have  been. 

An  irregular  soft  tumor  occupies  the  inner 
half  of  the  right  middle  fossa  of  the  skull, 
spreading  over  the  petrous  portion  of  the 
temporal  bone,  and  for  some  distance  along 
the  basilar  process  of  the  occipital.  Through¬ 
out  this  extern  it  adheres  to  the  dura  mater, 
although  it  may  be  detached  from  that  mem¬ 
brane  without  tearing;  but  around  the  in¬ 
ternal  auditory  foramen,  and  thence  to  the 
apex  of  the  petrous  portion  of  the  temporal 
bone,  the  tumor  and  dura  mater  are  insepa¬ 
rably  united  to  each  other.  The  9th  and 
8th  nerves  pass  freely  out  of  the  skull,  but 


83 


ON  THE  CAUSES  OF  THE  CRACKED  METAL  SOUND. 


the  facial  and  auditory  nerves  cannot  be 
disentangled  from  a  dense  nodule  of  the 
morbid  growth,  which  envelopes  them  at 
their  entrance  into  the  foramen  auditivum. 
The  trunk  and  ganglion  of  the  5th  nerve  are 
alsocompletely  imbedded  in  the  tumor.  Of  the 
nerves  which  pass  along  the  cavernous  sinus, 
the  3d  can  alone  be  recognized,  and  that 
very  indistinctly,  as  the  tumor  has  pene¬ 
trated  the  outer  wall  of  the  sinus,  and  matted 
together  the  4th  and  6th  nerves,  and  the 
ophthalmic  branch  of  the  5th.  The  optic 
nerve  is  quite  free  from  disease. 

The  osseous  structure  of  the  skull  does  not 
appear  to  be  changed,  except  just  around  the 
foramen  ovale  in  the  sphenoid  bone,  where 
it  is  discoloured  and  rather  soft ;  and  hei'e 
the  corresponding  portion  of  dura  mater  is 
thickened. 

The  inferior  maxillary  nerve,  asit  is  passing 
through  the  foramen,  is  pulpy.  Its  inferior 
dental  branch,  at  the  foramen,  and  the  second 
division  of  the  5th  nerve,  where  it  emerges 
on  the  cheek,  appear  to  be  undiminished  in 
bulk.  The  teeth  in  the  lower  jaw  are  firmly 
set  in  the  gums,  and  it  seems  probable  that 
the  trunk  of  the  dental  nerve  was  not  divided 
in  the  operation,  as  I  remember  the  patient 
retained  feeling  in  the  chin  and  lower  lip, 
after  the  ramus  of  the  jaw  had  been  re¬ 
moved. 

Of  course  no  very  accurate  examination 
can  be  made  of  a  tumor  which  has  been  so 
long  steeped  in  spirit.  The  diseased  growth 
within  the  skull  seems  chiefly  made  up  of 
nucleated  cells  ;  and  that  in  the  parotid  re¬ 
gion  presents  the  same  structure,  but  many 
of  its  cells  are  caudate. 


ON  THE  CAUSES  OF  THE  CRACKED  METAL 
SOUND. 

Sir, — Thereviewer  of  Dr.  Blakiston’s  work 
on  Diseases  of  the  Chest,  in  the  number  of 
the  British  and  Foreign  Medico -Chirurgical 
Review  for  the  last  quarter,  commenting 
on  the  author’s  variance  in  the  cause  of  pro¬ 
duction  of  the  cracked  metal  sound  with 
Dr.  Walshe,  details  two  other  conditions 
under  which  it  may  occur,  which  in  the  re¬ 
viewer’s  opinion  corroborates  the  view  of  the 
latter  physician. 

Laennec  imagined  that  both  air  and  fluid 
in  the  pulmonary  excavation  were  necessary 
for  its  production  ;  the  bruit  de  pot  fele 
was  deemed  by  him  to  be  pathognomic  of  a 
vomica  in  the  lung. 

Dr.  Walshe  thinks  that  air  alone  is  neces¬ 
sary  for  its  production,  and  the  immediate 
physicial  cause  for  its  elicitation  to  be  a 
forcible  expulsion  of  air  from  an  anfrac¬ 
tuous  excavation  in  the  lung  into  the  air- 
tubes  entering  it. 

The  reviewer,  after  hinting  that  the  occa¬ 
sional  absence  of  the  sound  may  be  due  to 


the  blocking  up  of  some  of  the  bronchial 
tubes  leading  to  the  vomica,  by  some  of  its, 
as  well  as  of  their  own  contents,  (which 
must  under  such  circumstances  be  unusually 
viscid)  ;  or  to  the  imperfect  manner  in  which 
percussion  is  often  formed,  states  that  the 
cracked  metal  sound  can  be  elicited  under 
the  following  circumstances  : — 

1.  In  a  cavity  quite  empty  of  fluid,  freely 
communicating  with  the  surrounding  bron¬ 
chial  tubes. 

2.  In  compression  of  the  lung  from  pleu¬ 
ritic  effusion,  and  where  the  tubular, 
amphoric,  or  amphorotympanitic  sound  is 
usually  produced  on  percussion  :  here  the 
sound  on  percussion  is  often  very  analogous 
to  the  bruit  de  pot  fele. 

The  reviewer  remarks,  if  such  be  correct,  a 
jogging  and  splashing  of  air  with  fluid  in  a 
cavity  is  not  indispensable  for  its  produc¬ 
tion.  Dr.  Stokes  has  also  remarked,  that  in 
some  cases  of  bronchitis  in  young  subjects, 
the  sound  on  percussion  over  the  lower  and 
back  portions  of  the  lungs,  is  often  like  the 
cracked-jar  sound  of  cavities. 

My  object,  sir,  in  making  these  remarks, 
is  to  point  out  another  condition  under  which 
this  sound  may  be  present ;  this  may  be  de¬ 
tailed  as  follows  : — I  was  asked  about  six 
months  back  to  see  a  lad,  who  had  had  a 
pulmonary  complaint,  (imagined  to  be 
phthisis)  for  two  years  past ;  he  was  mori¬ 
bund  when  I  saw  him,  and  died  two  hours 
after. 

On  percussing  the  upper  part  of  the  left 
side  immediately  under  the  clavicle,  the 
cracked  metal  sound  was  elicited  in  the  most 
perfect  manner. 

On  post-mortem  inspection  (correspond¬ 
ing  to  the  part  where  the  sound  was  pro¬ 
duced  during  life),  two  circumscribed  por¬ 
tions  of  sub-pleural  emphysema  were  seen 
together  as  large  as  a  full  sized  hen’s  egg ; 
there  was  a  cavity  in  the  left  lung,  nor  was 
the  disease  of  a  tuberculous  character  ;  it 
was  an  example  of  chronic  pneumonia.  It 
is  unnecessary  to  particularize  the  other 
morbid  appearances  :  suffice  it  that  the  cir¬ 
cumscribed  interlobular  and  subpleural  em¬ 
physema  elicited  a  sound  indistinguishable 
from  the  bruit  de  pot  fele  of  pulmonary  ex¬ 
cavations. 

I  will  not  occupy  your  space  further  than 
to  remark,  that  the  physical  cause  of  its  pro¬ 
duction  was  the  collection  of  air  chiefly  in 
the  cellular  tissue  over  the  upper  portion  of 
the  left  lung,  which,  by  forcible  percussion, 
was  made  to  permeate  the  surrounding 
cellular  tissue,  returning  after  the  percussion 
stroke  to  the  situation  where,  before  the 
stroke,  it  was  chiefly  collected. 

The  entire  lung  was  condensed,  unfitted 
for  respiration,  and  closely  adherent  (except 
at  the  upper  part)  to  the  walls  of  the  chest ; 
the  emphysema  was  doubtless  due  to  a  rup- 


84  DEATH  FROM  CHLOROFORM  IN  INDIA.  THE  WOUNDED  IN  PARIS. 


ture  of  a  superficial  air-cell,  and  prevented 
extending  by  the  thickened  and  adherent 
state  of  the  pleura,  which  had  recently  been 
inflamed. — I  remain,  sir, 

Your  obedient  servant, 

R.  C.  Golding. 

29,  King  William  Street,  Trafalgar  Sq., 

July  7th,  1848. 

DEATH  FROM  CHLOROFORM  IN  INDIA. 

Sir, — The  following  case  of  death  from 
the  inhalation  of  chloroform  vapour  has  been 
communicated  to  me ;  and  feeling  the  im¬ 
portance  of  placing  similar  facts  fairly  before 
the  profession,  I  trust  you  will  give  it  inser¬ 
tion  in  your  journal.  It  is  extracted  from 
Allen’s  Indian  Mail,  July  4th. — I  have  the 
honour  to  be,  sir,  your  obedient  servant, 
Robert  Barnes,  M.B. 

Gloucester  Terrace,  Hycle  Park, 

July  11,  1848. 

At  Hyderabad.  From  the  pen  of  the 
operating  surgeon.  Furnished  by  Dr.  Har- 
dinge,  to  whom  it  was  addressed  for  public 
communication  : — “  A  most  distressing  case 
has  just  occurred  in  my  public  practice  here. 
Chloroform  has  proved  fatal  in  my  hands. 
A  young  woman  presented  herself  this 
morning  with  disease  of  the  distal  phalanx 
of  the  middle  finger  of  the  left  hand,  requir¬ 
ing  amputation  at  the  middle  joint.  As  she 
appeared  of  timid  disposition,  and  exhibited 
more  than  usual  reluctance  to  submit  to  the 
little  operation,  I  administered  a  drachm  of 
chloroform  in  the  usual  way,  namely,  by 
sprinkling  it  on  a  pocket-handkerchief  and 
causing  her  to  inhale  the  vapour.  She 
coughed  a  little,  and  then  gave  a  few  con¬ 
vulsive  movements.  When  these  subsided, 
I  performed  the  necessary  incisions,  which, 
of  course,  did  not  occupy  more  than  a  few 
seconds.  Scarcely  a  drop  of  blood  escaped. 
The  patient  was  then  put  into  the  recumbent 
posture  with  the  head  low.  Active  means 
were  taken  to  bring  her  out  of  the  state  of 
coma  into  which  she  had  apparently  fallen. 
But  although  these  means,  including  arti¬ 
ficial  respiration,  were  perseveringly  em¬ 
ployed  for  five  hours,  the  unfortunate 
woman  never  breathed  again.  I  am  in¬ 
clined  to  think  that  death  was  almost  in¬ 
stantaneous  ;  for  after  the  convulsive  move¬ 
ment  above  described,  she  never  moved,  or 
exhibited  the  smallest  sign  of  life.  No  op¬ 
portunity  was  afforded  me  of  making  a  post¬ 
mortem  examination  ;  so  that  it  must  for 
ever  remain  a  secret  whether  or  not  there 
were  any  special  circumstances,  such  as 
aneurism  of  one  of  the  great  vessels,  or  dis¬ 
ease  of  the  heart.” 

[The  chloroform  was  supplied  by  Messrs. 
Twemlow  and  Co.,  Bombay.  It  required  a 
drachm  and  a  half  of  the  same  chloroform 
in  another  case  to  produce  a  slight  effect.] 


jjMetucai  Intelligence* 


THE  ASIATIC  CHOLERA  IN  RUSSIA. 

The  following  is  an  extract  from  a  letter 
dated  St.  Petersburgh,  June  19  (July  1): — 
“  The  cholera  has  now  raged  here  for  more 
than  a  week,  and  about  800  cases  are  re¬ 
ported  daily.  The  great  mortality  among 
the  Moujiks  has  led  them,  in  their  ignorance, 
to  believe  that  they  are  being  poisoned  whole¬ 
sale,  and  yesterday  several  disturbances  took 
place,  in  consequence  of  some  of  the  people 
attacking  persons  whom  they  suspected  of 
strewing  poison  over  the  provisions  exposed 
for  sale  in  the  markets.  One  man  was 
beaten  to  such  a  degree  that  he  has  since  ex¬ 
pired,  and  a  respectable  English  merchant 
(resident  of  this  place)  who  attempted  to  in¬ 
terfere,  was  hardly  able  to  escape  a  similar 
fate.  Summary  punishment  has,  however, 
been  inflicted  by  the  authorities  on  the  poor 
deluded  Moujiks  who  were  the  principal 
aggressors,  for  three  of  them  were  this 
morning  publicly  flogged  in  the  market¬ 
place.  A  letter  dated  Bucharest,  June  23, 
announces  that  politics  are  completely  in 
abeyance  in  consequence  of  the  fearful 
spreading  of  the  cholera  within  the  last  few 
days.  The  number  of  cases  are  now  186  a 
day,  of '•whom  a  fifth  are  rapidly  carried  off. 
An  universal  panic  has  seized  all  the  inhabi¬ 
tants,  and  every  person  that  can  fly  from  the 
city  to  the  mountains  does  so  in  the  greatest 
haste.  Even  the  gipsies  of  Transylvania 
have  demanded  their  passports  in  order  to 
hasten  home,  and,  if  possible,  escape  the 
fearful  contagion.  All  the  public  tribunals 
are  closed. 

THE  WOUNDED  IN  PARIS. 

According  to  an  official  return,  published 
in  the  Moniteur,  1,179  wounded  still  re¬ 
mained  in  the  civil  hospitals  of  Paris  on 
Saturday. 

In  the  Military  hospital  of  the  Val- de- 
Grace  there  are  no  less  than  500  cases  of 
wounds,  many  of  them  of  a  very  severe 
description. 

According  to  a  circular  published  by  M. 
Thierry,  it  appears  that  the  late  struggle  for 
“  liberty,  equality,  and  fraternity,”  was 
attended  with  the  following  results  : — 

From  the  23d  to  the  28th  June,  there 
were  received  into  the  hospitals  1781  cases 
of  wounds ;  but  of  these,  162  w7ere  dead 
when  brought  in.  In  addition  to  these  there 
were  in  five  days  195  deaths.  On  the  29th 
June  there  remained  in  the  hospitals  1267 
wounded  ;  and  in  the  temporary  Ambulances 
364,  making  a  total  of  1631  persons  still 
under  treatment. 


M.  BOUCHUT  ON  THE  SIGNS  OF  DEATH. 


85 


OBITUARY. 

On  Saturday,  the  24th  inst.,  in  his  47th 
year,  John  M.  M.  Jameson,  M.D.,  late  of 
the  Highway,  Enfield. 

At  Southampton,  on  the  4th  inst.,  James 
Claudius  Paxton,  Esq.,  M.B.  and  Radcliffe 
Travelling  Fellow  of  the  University  of 
Oxford. 

On  the  30th  ult.,  at  Cavan,  after  a  short 
illness,  Doctor  M’Donald,  one  of  the  oldest 
practitioners  in  the  north  of  Ireland.  For 
upwards  of  30  years  he  was  physician  to  the 
county  fever  hospital  in  that  town  :  the  ordi¬ 
nary  duties  of  which  (together  with  a  most 
extensive  practice,)  he  discharged  with  that 
skill  and  untiring  energy  that  marked  his 
whole  life. 

On  the  26th  ult.,  of  fever,  at  the  residence 
of  his  brother,  Partry-house,  Mayo,  George 
Lynch,  Esq.,  M.D.,  aged  34,  late  physician 
to  the  Fever  Hospital,  Ballinrobe,  and  fifth 
son  of  the  late  Major  Lynch,  of  Partry- 
house,  Mayo. 

On  the  9th  inst.,  at  Oxford,  Charles 
Webb,  Esq.,  surgeon,  aged  53. 


Selection*  from  journals. 


FORENSIC  MEDICINE. 

ON  THE  SIGNS  OF  DEATH.  BY  M.  BOUCHUT. 

From  his  inquiry  into  the  circumstances  by 
which  apparent  death  may  be  distinguished 
from  real  death,  M.  Bouchuthas  ascertained 
that  all  forms  of  apparent  death,  especially 
those  which  are  due  to  asphyxia  and  syn¬ 
cope,  present,  whatsoever  be  the  diversity  of 
their  symptoms,  one  common  character — 
namely,  the  persistence  of  the  pulsations  of 
the  heart — which  distinguishes  them  from 
real  death.  A  commission  of  the  French 
Institute,  appointed  to  inquire  into  the 
merits  of  M.  Bouchut’s  investigations  on 
this  subject,  report,  that  having  repeated  his 
observations  and  experiments  upon  man  and 
animals,  in  which  syncope  has  been  carried 
to  its  utmost  limits,  they  can  fully  confirm 
the  fact,  that  in  all  such  cases  the  pulsations 
of  the  heart  continue,  and  may  be  detected 
by  auscultation.  According  to  M.  Bouchut, 
the  certain  signs  of  death  are  of  two  kinds — 
immediate  and  remote.  The  immediate 
signs  of  death  in  man  are — first,  prolonged 
absence  of  the  movements  of  the  heart,  as 
recognizable  by  auscultation  ;  secondly,  the 
simultaneous  relaxation  of  all  the  sphincters, 
due  to  the  paralysis  of  those  muscles  ;  and 
lastly,  the  flaccidity  of  the  globe  of  the  eye, 
and  the  loss  of  transparency  of  the  cornea. 
In  the  opinion  of  the  Commission,  these 
signs  have  not  an  equal  value,  the  first  being 
by  far  the  best  and  most  certain.  For,  if 
ever  the  movements  of  the  heart  are  unde¬ 
tectable  by  auscultation,  for  a  period  of  five 
minutes  together,  it  may  with  certainty  be 


concluded  that  death  has  ensued.  More¬ 
over,  this  cessation  of  the  movements  of  the 
heart  is  always  accompanied  by  two  striking 
phenomena — namely,  the  arrest  of  the  respi¬ 
ratory  movements,  and  loss  of  sensation 
and  of  the  power  of  motion.  The  second 
circumstance — namely,  the  simultaneous  re¬ 
laxation  of  the  sphincters — admits  of  more 
doubt  as  a  certain  sign  of  death.  The  con¬ 
dition  of  the  eye,  the  Commission  thinks, 
cannot  with  safety  be  taken  into  consideration 
as  a  sign  of  death.  So  that  cessation  of  the 
movements  of  the  heart  is  the  only  certain 
proof  of  the  complete  cessation  of  life.  The 
remote  signs  of  death  are  stated  by  M. 
Bouchut  to  be — cadaveric  rigidity,  absence 
of  muscular  contraction  on  the  stimulus  of 
galvanism,  and  the  occurrence  of  putrefac¬ 
tion.  These  points  are  admitted  by  all  medi¬ 
cal  jurists,  and  cannot  be  disputed.  Since 
general  putrefaction  of  the  body,  however, 
only  ensues  after  the  lapse  of  a  considerable 
time  subsequently  to  the  manifestation  of  the 
other  signs,  it  is  not  necessary  to  wait  for 
its  occurrence  before  pronouncing  on  the 
reality  of  death  ;  consequently,  all  houses 
established  for  the  purpose  of  keeping  bodies 
until  putrefaction  commences,  as  is  done  in 
Germany,  must  be  productive  of  no  advan¬ 
tage.  The  Commission  also  urges  the  neces¬ 
sity,  in  all  cases,  of  entrusting  to  medical 
men  the  duty  of  deciding  whether  death  be 
real  or  apparent ;  for  by  them  only  can  the 
cessation  of  the  heart's  movements,  the 
existence  of  cadaveric  rigidity,  and  the  loss 
of  muscular  contractility,  be  recognised  and 
rightly  estimated. — Gazette  Meclicale,  Mai 
31,  1848.  A 


DR.  MEIGS  ON  THE  USE  OF  CHLOROFORM 
IN  MIDWIFERY. 

( Extract  from  a  letter  addressed  to 
Dr.  Simpson.) 

I  have  been  accustomed  to  look  upon  the 
sensation  of  pain  in  labour  as  a  physiological 
relative  of  the  power  or  force ;  and  notwith¬ 
standing  I  have  seen  so  many  women  in  the 
throes  of  labour,  I  have  always  regarded 
a  labour-pain  as  a  most  desirable,  salutary, 
and  conservative  manifestation  of  life-force. 
I  have  found  that  women,  provided  they 
were  sustained  by  cheering  counsels  and 
promises,  and  carefully  freed  from  the  dis¬ 
tressing  element  of  terror,  could  in  general 
be  made  to  endure,  without  great  complaint, 
those  labour- pains  which  the  friends  of  the 
anaesthesia  desire  so  earnestly  to  abolish  and 
nullify  for  all  the  fair  danghters  of  Eve. 
Perhaps,  dear  sir,  I  am  cruel  in  taking  so 
dispassionate  a  view  of  the  case ;  and  it  is 
even  possible  that  I  may  make  one  of  the 
number  of  those  “amazed"  converts  of 
whom  you  speak  in  your  worthy  letter  to 
me.  But,  for  the  present,  regarding  the 
pain  of  a  natural  labour  as  a  state  not,  by 


8  0  DR.  MEIGS  ON  THE  USE  OF  CHLOROFORM  IN  MIDWIFERY. 


all  possible  means  and  always,  to  be  eschewed 
and  obviated,  I  cannot  bring  myself  to  the 
conviction  that  of  the  two,  whether  labour- 
pain  or  insensibility,  insensibility  is  to  be 
preferred.  If  I  could  believe  that  chloro - 
formal  insensibility  is  sleep  indeed,  the  most 
considerable  of  my  objections  would  vanish. 
Chloroform  is  not  a  soporific ;  and  I  see  in 
the  anaesthesia  it  superinduces  a  state  of  the 
nervous  system  in  no  wise  differing  from  the 
anaesthetic  results  of  alcoholic  potations,  save 
in  the  suddenness  and  transitiveness  of  its 
influence.  I  freely  admit,  for  I  know  it, 
that  many  thousands  of  persons  are  daily 
subjected  to  its  power.  Yet  I  feel  that  no 
law  of  succession  of  its  action  on  the  several 
distinct  parts  of  the  brain  has  been  or  can  be 
hereafter  ascertained,  seeing  that  the  succes¬ 
sion  is  contingent.  Many  grave  objections 
would  perhaps  vanish  could  the  law  of  the 
succession  of  influences  on  the  parts  of  the 
brain  be  clearly  made  out,  and  its  provisions 
ensured.  There  are,  indubitably,  certain 
cases  in  which  the  intellectual  hemis¬ 
pheres  are  totally  hebetized,  and  deprived  of 
power  by  it,  while  the  co-ordinating  lobes 
remain  perfectly  unaffected.  In  others  the 
motor  cords  of  the  cerebro-spinal  nerves  are 
deprived  of  power,  whilst  the  sensitive  cords 
enjoy  a  full  activity,  and  vice  versa. 

I  readily  hear,  before  your  voice  can  reach 
me  across  the  Atlantic,  the  triumphant  reply 
that  an  hundred  thousand  have  taken  it 
without  accident !  I  am  a  witness  that  it  is 
attended  with  alarming  accidents,  however 
rarely.  But  should  I  exhibit  the  remedy  for 
pain  to  a  thousand  patients  in  labour,  merely 
to  prevent  the  physiological  pain,  and  for  no 
other  motive — and  if  I  should  inconsequence 
destroy  only  one  of  them,  I  should  feel  dis¬ 
posed  to  clothe  me  in  sackcloth,  and  cast 
ashes  on  my  head  for  the  remainder  of  my 
days.  What  sufficient  motive  have  I  to  risk 
the  life  or  the  death  of  one  in  a  thousand,  in 
a  questionable  attempt  to  abrogate  one  of  the 
general  conditions  of  man  ? 

As  to  the  uses  of  chloroform  in  the 
medical  or  therapeutical  treatment  of  pain, 
the  question  changes.  There  is  no  reasonable 
therapia  of  health.  Hygienical  processes 
are  good  and  valid.  The  sick  need  a  physi¬ 
cian,  not  they  that  are  well.  To  be  in 
natural  labour  is  the  culminating  point  of 
the  female  somatic  forces.  There  is,  in 
natural  labour,  no  element  of  disease — and, 
therefore,  the  good  old  writers  have  said 
nothing  truer  nor  wiser  than  their  old  saying, 
that  “  a  meddlesome  midwifery  is  bad.'1  Is 
chloroformization  meddlesome  ? 

If  I  were  amputating  a  limb,  or  extirpat¬ 
ing  a  tumor,  I  should  see  all  the  steps  of  my 
incisions,  ligations,  &c.  But  if  I  apply  my 
forceps  in  a  right  occipito-posterior  position, 
(fourth  of  Baudeloque,)  I  know  that  I  thrust 
the  blade  of  the  male  branch  far  upwards 


l  betwixt  the  face  of  the  child  and  the  upper 
!  third  of  the  vagina,  which,  in  this  case,  is 
i  already  greatly  expanded,  and  that  the  ex¬ 
tremity  of  the  blade  is  separated  from  the 
peritoneum  only  by  the  mucous  and  con¬ 
densed  cellular  coat  of  the  tube.  Now  no 
!  man  can  absolutely  know  the  precise  degree 
;  of  inclination  his  patient  will  give  to  the 
plane  of  her  superior  strait,  while  in  pain  ; 
an  inclination  to  be  modified  by  every  move¬ 
ment  of  her  body  and  limbs.  Under  such 
]  absolute  uncertainty,  the  best  guide  of  the 
accoucheur  is  the  reply  of  the  patient  to  his 
interrogatory,  “Does  it  hurt  you?”  The 
patient’s  reply,  “  Yes  and  No,”  are  worth  a 
thousand  dogmas  and  precepts,  as  to  planes 
and  axes,  and  curves  of  Carus.  I  cannot, 
therefore,  deem  myself  justified  in  casting 
away  my  safest  and  most  trustworthy  diag¬ 
nosis,  for  the  questionable  equivalent  of  ten 
minutes  exemption  from  a  pain,  which,  even 
in  this  case,  is  a  physiological  pain. — Phil. 
Med.  Exam.,  March  1848. 


PHYSIOLOGICAL  ACTION  OF  CHLOROFORM. 

To  understand  the  physiological  action  of 
this  substance,  it  is  necessary  to  remember 
that  sensation  is  dependent,  first,  on  the 
existence  of  consciousness,  which  is  a  func¬ 
tion  of  the  brain  proper  (that  is,  all  that 
portion  of  the  encephalon  situated  above  the 
corpus  callosum) ;  secondly,  on  the  integrity 
of  the  spinal  cord  ;  and  thirdly,  on  the  in¬ 
tegrity  of  the  expanded  filaments  of  the 
nerves  which  receive  the  impression.  Loss 
of  sensation  may  be  caused  by  injuring 
either  of  these  portions  of  the  nervous 
system ;  for,  if  the  nervous  filaments  are 
diseased,  impressions  cannot  be  received; 
if  the  spinal  cord  be  injured,  impressions 
are  not  transmitted  to  the  brain  ;  and,  if 
the  brain  be  disordered,  the  consciousness  of 
the  impression  is  not  experienced.  Now 
the  object  of  giving  chloroform  ought  to  be 
to  suspend  the  brain’s  functions  without 
affecting  the  spinal  cord,  the  medulla  ob¬ 
longata,  or  the  sensibility  of  nerves,  and 
thus  produce  loss  of  sensation  by  rendering 
the  mind  unconscious  of  the  impressions 
made  upon  nerves.  It  is  questionable, 
therefore,  whether  chloroform  or  ether  should 
be  denominated  anaesthetic  agents,  because 
anaesthesia  is  generally  understood  to  mean 
loss  of  sensibility  in  a  part ;  whereas,  in 
point  of  fact,  it  is  suspension  of  the  faculties 
of  mind,  and  unconsciousness  of  external 
stimuli,  that  they  produce.  In  man  this  is 
rendered  apparent  by  the  fact  that  the  func¬ 
tions  of  circulation, respiration,  uterine  con¬ 
tractions,  &c.  &c.  proceed  during  the  coma¬ 
tose  state,  which  would  not  be  the  case  if  the 
sensibility  of  the  nerves  distributed  to  those 
organs  were  destroyed.  In  animals,  similar 
facts  may  at  once  be  demonstrated  by  the 


CASE  OF  POISONING  BY  FOWLER’S  MINERAL  SOLUTION 


87 


action  of  galvanism,  which,  when  they  are 
perfectly  comatose,  produces  convulsions, 
spasms,  and  other  reflex  movements. — Dr. 
H.  Bennett’s  Report ;  Edinburgh  Monthly 
Journal ,  Jan.  1848. 


TOXICOLOGY. 

CASE  OF  POISONING  BY  FOWLER’S  MINE¬ 
RAL  SOLUTION - DEATH  FROM  A  SMALL 

DOSE  OF  ARSENIC.  BY  DR.  H.  T. 

CASTLE,  LEEDS. 

H.  T - ,  a  widow,  being  reported  to  have 

died  suddenly  from  poison  administered  to 
her  by  a  man  with  whom  she  cohabited,  a 
legal  examination  was  deemed  requisite. 

Fifty  hours  after  death  the  body  presented 
the  following  appearances  : — Under  parts  of 
the  body  generally  discoloured,  from  cada¬ 
veric  extravasation  ;  extremities  of  the 
fingers  blue  ;  abdomen  tense.  On  opening 
the  abdomen,  the  stomach  and  intestines 
were  seen  distended  with  gas  ;  inflammation 
of  the  former  and  of  the  small  intestines 
was  at  once  detected  through  their  coats, 
and,  on  exposing  their  mucous  surface,  it 
was  found  to  be  general  and  intense.  At 
the  cardiac  extremity  of  the  stomach,  and 
towards  the  lesser  arch,  several  patches  were 
seen  of  a  deeper  tint  than  the  surrounding 
inflammation.  Passing  the  colon,  the  in¬ 
flammation  reappeared  in  the  rectum,  which 
had  apparently  suffered  in  an  equal  degree 
with  the  stomach. 

The  uterus  contained  no  foetus,  but  was 
considerably  enlarged  ;  its  internal  surface 
was  in  colour  modena-red,  and  copiously 
bedewed  with  mucus.  The  vagina  was 
healthy.  In  dividing  the  ovaries,  the  scalpel 
had,  in  one,  passed  through  the  centre  of 
(what  I  believe  to  be)  a  corpus  luteum : 
this  body  is  a  perfectly  empty  cyst,  the  walls 
consist  of  two  or  more  membranes,  and  the 
cavity  will  contain  a  good-sized  pea.  A 
slight  mark,  as  of  a  cicatrix,  is  to  be  seen  on 
the  surface  of  the  ovary,  corresponding  with 
the  position  of  the  cyst.  The  bladder  was 
not  examined.  There  was  no  appearance  of 
recent  disease  in  the  chest  or  head.  The 
heart  was  flabby,  and  contained  a  little  fluid 
blood.  The  stomach,  its  scanty  contents, 
and  part  of  the  liver,  were  sent  to  an  able 
chemist,  who  found  traces  of  arsenic  in  each. 

From  the  imperfect  evidence  adduced  at 
the  inquest,  it  appeared  that  the  deceased 
had  taken,  between  Saturday  and  the  fol¬ 
lowing  Wednesday,  half  an  ounce  of  “  Fow¬ 
ler’s  solution,”  in  unknown  doses.  On  the 
Friday  following  she  grew  worse,  complained 
of  general  illness  and  fever,  but  of  no  sick¬ 
ness,  purging,  nor  particular  pain  of  the 
stomach.  On  Saturday  she  had  frequent 
“•fainting  fits,”  but  on  Sunday  appeared  to 
be  a  little  better,  till,  after  eating  a  small 
quantity  of  pudding,  and  drinking  some 


ginger-beer,  she  had  another  fainting  fit, 
and  in  a  few  minutes  expired. 

The  chief  points  in  this  case  appear  to 
be  : — 

1.  The  small  quantity  of  the  poison  that 
sufficed  to  prove  fatal — perhaps  the  smallest 
on  record,  the  (apparent)  absence  of  vomit¬ 
ing  and  diarrhoea,  and  the  unusual  termina¬ 
tion  by  mortal  fainting. 

2.  The  relation  between  the  state  of  the 
intestinal  mucous  membrane  and  that  of  the 
uterus.  Four  months  previous  to  her  death, 
the  deceased  had  borne  a  child,  which  she 
had  not  suckled,  and  she  was  stated  not 
to  have  been  “  unwell”  since  her  delivery. 
There  was  also  some  reason  to  suspect  that 
“  herbs,”  to  procure  abortion,  had  been 
purchased  for  her  only  a  fortnight  before 
death.  Assuming  that  emmenagogues  had 
been  taken,  I  incline  to  the  opinion  that  the 
arsenic  caused  abortion. — Provincial  Jour¬ 
nal ,  June  28. 

***  This  case  is  interesting,  from  the 
fact  that,  admitting  arsenic  to  have  been  the 
sole  cause  of  death,  it  is  the  only  instance 
recorded  in  which  Fowler’s  mineral  solution 
has  destroyed  life.  The  whole  quantity  of  - 
arsenic  taken  by  the  deceased  in  a  period  of 
about  five  days  amounted  to  1*83  grains. 
This  is  the  smallest  dose  of  arsenious  acid 
which  has  yet  been  known  to  have  proved 
fatal  to  an  adult.  The  poison,  probably 
from  its  having  been  given  in  small  and 
divided  doses,  did  not  produce  the  usual 
symptoms  of  vomiting  and  purging,  al¬ 
though  its  irritant  action  on  the  alimentary 
canal  was  indicated  by  intense  inflammation. 
It  appears  in  this  instance  to  have  destroyed 
life  by  indirectly  affecting  the  heart,  and  by 
inducing  fatal  syncope.  It  may  be  a  ques¬ 
tion,  however,  whether  some  other  irritant 
substances  were  not  simultaneously  adminis¬ 
tered  for  the  purpose  of  inducing  abortion. 

A  correspondent  of  the  Provincial  Journal, 
Mr.  Hunt,  in  commenting  upon  this  case, 
has  fallen  into  a  strange  mistake  respecting 
the  fatal  dose  of  arsenic.  Quoting  Dr. 
Christison  as  to  the  smallest  fatal  dose  on 
record,  he  says  that  it  is  six  grains  for  an 
adult,  and  four  grains  and  a  half  for  a  child. 
This  may  have  been  perfectly  true  when  Dr. 
Christison  published  his  last  edition,  but  a 
use  is  here  made  of  the  observation  which 
that  author  could  never  have  intended.  Dr. 
Christison  merely  stated  a  fact  as  to  the 
smallest  dose  then  recorded  ;  but  he  nowhere 
says  that  a  smaller  quantity  than  this  will 
not  destroy  life.  If  Mr.  Hunt  will  turn  to 
the  39th  volume  of  this  journal,  at  page  116, 
he  will  find  a  case  reported  by  Dr.  Letheby, 
in  which  two  grains  and  a  half  of  arsenic 
destroyed  a  young  female.  The  objection  to 
Dr.  Castle’s  case  on  this  ground  is  therefore 
unfounded. 


88  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY,  ETC. 


REVOLUTIONARY  ATTACK  ON  A  PROFESSOR 
OF  CHEMISTRY. 

The  Parisian  insurgents,  in  carrying  out 
their  views  of  liberty,  attacked  the  house  of 
an  eminent  chemist  in  the  Faubourg  St.-Mar- 
ceau.  They  insisted  that  he  should  imme¬ 
diately  prepare  gun-cotton  for  their  use. 
For  twenty -four  hours  he  resisted  this  at¬ 
tempt  on  the  part  of  the  revolutionists,  in¬ 
forming  them  that  he  had  not  the  materials 
for  the  purpose.  These  were,  however,  im¬ 
mediately  procured.  Muskets  were  pointed 
at  the  chest  of  the  professor,  and  the  lives 
of  his  wife  and  daughter  were  equally 
threatened,  and  under  these  circumstances 
he  was  compelled  to  set  about  the  prepara¬ 
tion  of  gun-cotton.  He  had  prepared  only 
a  small  quantity  when  the  quarter  was  taken 
possession  of  by  the  Government  troops ; 
and  he  and  his  family  were  thus  rescued  from 
the  perilous  position  in  which  these  friends 
of  liberty  had  placed  them. — L’  Union  Med . 


BIRTHS  &  DEATHS  in  the  Metropolis 


During  the  week  ending  Saturday,  July  8. 


Births. 
Males ....  675 
Females..  607 


Deaths. 
Males....  492 
Females..  478 


Av.  of  5  Sum. 
Males. . . . 
Females. . 


1282 


970 


972 


Deaths  in  different  Districts. 

West — Kensington;  Chelsea;  St.  George, 

Han  over  Square;  Westminster;  St.  Martin 
in  the  Fields;  St.  James..  (Pop.  301,326)  160 
North  — St.  Marylebone  ;  St.  Pancras  ; 

Islington  ;  Hackney . (Pop.  366,303)  191 

Central— St. Giles  and  St.  George;  Strand; 
Holboi'n ;  Clerkenwell ;  St.  Luke;  East 
London  ;  West  London  ;  the  City  of 

London  . (Pop.  374,759)  161 

ast — Shoreditch ;  Bethnal  Green  ;  White¬ 
chapel  ;  St.  George  in  the  East ;  Stepney ; 

Poplar . (Pop.  393,247)  220 

South  — St.  Saviour;  St.  Olave ;  Ber¬ 
mondsey  ;  St.  George,  Southwark ; 
Newington;  Lambeth;  Wandsworth  and 
Clapham  ;  Camberwell ;  Rotherliithe  ; 
Greenwich . (Pop.  479,469)  238 

Total .  970 


Causes  of  Death. 

All  Causes . 

Specified  Causes . 

1.  Zymotic(orEyidemic, Endemic, 

Contagious)  Diseases .. 
Sporadic  Diseases,  viz. — 

2.  Dropsy,  Cancer,  &c.  of  uncer¬ 

tain  seat  . 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  . 

4.  Lungs  and  other  Organs  of 

Respiration . 

5.  Heart  and  Bloodvessels . 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion  . 

7.  Diseases  of  the  Kidneys,  &c.. . 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c . 

9.  Rhematism,  Diseases  of  the 
Bones,  Joints,  &c . 

10.  Skin,  Cellular  Tissue,  &c . 

11.  Old  Age . 

12.  Violence,  Privation,  Cold,  and 

Intemperance . 


Av.  of 
5  Sum. 

970 

972 

969 

968 

338 

257 

45 

45 

94 

120 

76 

80 

28 

28 

70 

79 

11 

8 

5 

10 

3 

7 

2 

1 

25 

50 

13 

S 

The  following  is  a  selection  of  the  numbers  of 
Deaths  from  the  most  important  special  causes: 


Small-pox  .  35 

Measles  .  15 

Scarlatina  . 100 

Hooping-cough..  25 

Diarrhoea  .  57 

Cholera  .  7 

Typhus  .  65 

Dropsy .  10 

Sudden  deaths  ..  1 

Hydrocephalus . .  35 
Apoplexy .  15 


Paralysis .  16 

Convulsion .  40 

Bronchitis .  35 

Pneumonia .  27 

Phthisis . 152 

Dis.  of  Lungs,  &c.  7 

Teething .  10 

Dis.  Stomach,  &c.  3 
Dis.  of  Liver,  & c.  13 

Childbirth .  3 


Dis .  of  U  terus,  &c.  1 


Remarks. — The  total  number  of  deaths  was 
about  equal  to  the  summer  average.  The  most 
remarkable  feature  in  this  week’s  mortality  is 
the  extraordinary  increase  of  deaths  from  scarlet 
fever. 

We  have  to  call  the  attention  of  the  Registrar- 
General  to  an  error  in  his  table.  The  average 
mortality  of  5  Springs  (943)  is  retained  under 
the  head  of  5  Summers,  whereas  the  summer 
mortality  is  higher— 972. 


METEOROLOGICAL  SUMMARY. 

Mean  Height  of  Barometer .  29-84 

“  “  Thermometer1  .  63* 

Self-registering  do.b - max.100’9  min.  33* 

“  in  the  Thames  water  —  67'  —  61*5 

a  From  12  observations  daily.  b  Sun. 

Rain,  in  inches,  0T6 :  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological.—' The  mean  temperature  of  the 
week  was  2°  above  the  mean  of  the  month. 


BOOKS  RECEIVED  DURING  THE  WEEK. 

Dr.  Asliwell’s  Practical  Treatise  on  Diseases 
peculiar  to  Women.  3d  edition. 

The  Baths  and  Watering  Places  of  England.  By 
Edwin  Lee. 

On  the  true  Pathological  Nature  of  Cholera,  and 
the  mode  of  treating  it.  By  G.  S.  Hawthorne, 
M.D. 

Practical  Observations  on  the  Effects  of  Chloro¬ 
form  in  Cases  of  Natural  Labour.  By  J.  H. 
Stallard,  M.R.C.S.  &c. 

Comptes  Rendus,  No.  25,  19  Juin  1848. 

The  Dublin  Medical  Press,  July  12. 

General  Index  to  the  British  and  Foreign  Medi¬ 
cal  Review.  Edited  by  John  Forbes,  M.D. 
Vol.  25. 

A  Plain  Statement  with  reference  to  Medical 
Reform.  By  Edwin  Lee. 

***  This  and  two  other  pamphlets  on  Medi¬ 
cal  Reform  by  the  same  author  are,  we  under¬ 
stand,  gratuitously  distributed  to  the  profession 

on  application  to  the  publisher,  Mr.  Churchill. 


NOTICES  to  CORRESPONDENTS. 

If  a  Third  Year’s  man  will  address  a  letter  to 
the  author  of  the  work  privately,  it  will,  we 
are  sure,  procure  him  the  information  which 
he  desires. 

The  communication  which  we  have  received 
from  (Jpton-on-Severn,  did  not  reach  us  until 
our  pages  were  quite  full. 

Dr.  Letheby’s  communication  next  week. 


89 


& oitfcoit  rS teal  ®afftte. 


Scrturcs. 


COURSE  OF  SURGERY, 
Delivered  in  the  years  1846  and  1847, 

By  Bransby  B.  Cooper,  F.R.S. 

Surgeon,  and  Lecturer  on  Surgery  at  Guy’s 
Hospital. 


Lecture  XXXI I. 

SURGERY  OF  REGIONS. 

CONTINUATION  OF  THE  LARYNGO-PH A YN- 
GEAL  REGION. 

Wounds  in  this  region.  Extraction  of 
foreign  bodies  lodged  in  the  rima  glot- 
tidis.  Symptoms  of  the  intrusion  of  a 
foreign  substance — case.  Fixed  bodies  in 
the  air -tube  — treatment — cases.  Foreign 
substances  impacted  in  the  bronchi  — 
mode  of  removal  by  forceps.  Mr.  Lis¬ 
ton  s  case — intrusion  of  coins — case  — 
necessity  for  an  artificial  opening,  before 
attempts  be  made  to  extract  the  substances 
through  the  glottis.  Suffocation  from 
the  presence  of  extraneous  substance 
not  common  asphyxia.  Opening  in  the 
trachea  for  oedema ,  or  ulceration  of  the 
arytenoid  cartilages.  Opening  the  oeso¬ 
phagus. 

Tying  the  carotid  artery  above  the  omo- 
hyoideus — mode  of  proceeding.  Tying 
the  artery  below  the  omo-hyoideus.  Me¬ 
thod  of  operating  —general  precautions . 
Diagnosis  in  abscess  of  the  region — case. 
SUPRA-CLAVICULAR  REGION — its  limits. 
Tying  subclavian  artery — mode  of  ope¬ 
rating — precautions.  Laceration  from 
wounds  —  case.  Tumors — difficulty  in 
their  diagnosis — removal.  Wry  neck — 

cause — treatment. 

Posterior  region  of  the  neck.  Unim¬ 
portance  of  the  surgery  of  this  region. 
Carbuncle.  Danger  of  wounds  in  this 
region. 

Continuation  of  the  Laryngo -pharyngeal 
Region. — Incisions  between  the  cricoid  car¬ 
tilage  and  trachea  immediately  destroy  the 
voice,  as  the  expired  air  rushing  through 
the  wound  prevents  the  vibration  of  the 
vocal  chords.  Wounds  in  this  situation  are 
extremely  dangerous,  as  the  parts  offer  very 
little  resistance  to  the  cutting  instrument, 
which,  therefore,  frequently  penetrates  to  a 
sufficient  depth  to  divide  the  carotid  artery 
and  jugular  vein,  which  would  necessarily 
prove  immediately  fatal;  but  should  these 
vessels  escape,  the  division  of  the  inferior 
laryngeal  nerve  might  lead  to  suffocation, 
from  the  inability  to  cough  up  the  blood 
through  the  paralysed  trachea. 

xlii.—  1077.  July  21,  1848. 


It  is  in  this  situation  that  the  operation  of 
opening  the  windpipe  is  performed,  when  a 
foreign  body  has  passed  into  the  glottis, 
and  is  lodged  in  the  rima  glottidis.  This 
part  is  selected,  as  it  affords  an  immediate 
opening  for  the  passage  of  the  air,  and  is  at 
the  same  time  conveniently  situated  for  the 
dislodgement  of  the  extraneous  matter. 
When,  however,  oedema  of  the  glottis  occurs 
from  swallowing  acids  or  hot  water,  the 
opening  should  be  made  in  the  trachea,  as 
the  part  just  mentioned  may  participate  in 
the  swelling. 

If  any  portion  of  the  space  between  the 
cricoid  cartilage  and  sternum  be  wounded, 
the  trachea  can  scarcely  escape  ;  the  oesopha¬ 
gus  is  also  likely  to  suffer,  and,  from  the  com¬ 
paratively  superficial  situation  of  the  carotid 
arteries,  they  are  very  liable  to  be  divided. 
It  is  also  in  this  space  that  the  windpipe 
is  opened  for  the  extraction  of  foreign  bodies 
which  have  accidentally  passed  through  the 
glottis.  The  symptoms  which  accrue  from, 
such  an  accident  are  frequently  very  insidi¬ 
ous  ;  but  as  the  removal  of  the  substance,  if 
any  should  have  entered  the  glottis,  is  abso¬ 
lutely  imperative  to  save  the  life  of  the 
patient,  the  surgeon  should  make  every 
exertion  to  ascertain  with  certainty  whether 
any  extraneous  body  has  really  intruded 
itself.  The  symptoms  are  usually  as  follows  : 
— A  child  at  play,  having  perhaps  put  beads 
or  pebbles  into  its  mouth,  is  suddenly  seized 
with  a  violent  fit  of  coughing  of  a  most  re¬ 
markable  character  :  the  eyes  are  staring  ;  the 
vessels  being  turgescent,  and  the  lips  blue  ; 
and  sometimes  the  child  falls  after  a  few 
moments  from  complete  exhaustion.  A 
surgeon  is  probably  sent  for ;  but  when  he 
arrives  he  often  finds  that  the  cough  has 
ceased,  and  the  other  symptoms  subsided, 
and,  indeed,  the  patient  appears  to  have  re¬ 
covered  from  the  attack.  This  is,  however, 
merely  a  deceptive  calm,  and  the  course  of 
the  trachea  and  bronchi  should  be  examined 
with  the  stethoscope  ;  and  if  the  patient  be 
old  enough,  he  should  be  questioned  as  to 
whether  he  is  conscious  of  any  substance 
moving  up  and  down  the  windpipe.  Gene¬ 
rally  in  such  a  case  a  flapping  noise  can  be 
heard  upon  placing  the  ear  over  the  cricoid 
cartilage  :  this  is  produced  by  the  foreign 
body  striking  against  the  rima  glottidis,  and 
is  generally  followed  by  a  recurrence  of  the 
fit  of  coughing.  A  repetition  of  these 
physical  signs  is  quite  sufficient  to  deter¬ 
mine  the  diagnosis,  and  no  time  should  be 
lost  before  means  be  adopted  for  the  re¬ 
moval  of  the  extraneous  body.  Some  sur¬ 
geons  have  recommended  that  the  patient 
should  be  placed  in  the  prone  position,  on 
an  incline  of  50°  or  60°,  with  his  head  down¬ 
wards  ;  and  while  in  this  position,  bis 
shoulders  should  be  struck  for  the  pur¬ 
pose  of  dislodging  the  foreign  body,  if  it 


LARYNGOPHARYNGEAL  REGION 


90 


should  have  become  impacted  in  one  of 
the  bronchial  tubes.  It  appears  to  me, 
however,  that  this  mode  of  proceeding  is 
extremely  dangerous,  unless  an  opening  be 
first  made  in  the  trachea  ;  for  should  the 
substance  be  driven  by  a  violent  effort  to 
the  rima  glottidis,  and  become  fixed  there, 
there  is  not  only  imminent  danger  of  the  pa¬ 
tient  being  suddenly  choked,  but  also  of  some 
vessel  in  the  head  or  lungs  giving  way  under 
his  efforts,  particularly  from  the  position  in 
which  he  is  placed. 

In  the  well-known  case  of  the  emi¬ 
nent  engineer  who  was  under  the  care 
of  Sir  Benjamin  Brodie  and  Mr.  Key, 
all  attempts  to  relieve  the  patient  from 
the  urgent  symptoms  failed,  until  an  open¬ 
ing  was  made  into  the  trachea.  The 
reason  for  this  seems  obvious  ;  for  if,  before 
an  opening  be  made,  the  foreign  substance 
be  forced  up  to  the  rima  glottidis,  the  air- 
tube  is  closed,  and  unless  a  powerful  inspi¬ 
ration  drives  the  substance  back  again, 
suffocation  must  immediately  result:  and 
even  if  the  substance  be  dislodged,  no  per¬ 
manent  benefit  can  be  derived ;  while, 
on  the  other  hand,  if  after  an  opening 
be  made  the  foreign  body  reaches  the 
glottis,  breathing  is  still  carried  on,  and 
the  rima  glottidis  remains  quiescent,  until, 
in  the  act  of  coughing,  the  arytenoid 
muscles  perform  the  natural  effect  in  en¬ 
larging  the  rima  glottidis,  and  permitting 
the  expulsion  of  the  intruded  body.  A 
few  months  after  the  occurrence  of  the 
case  above  alluded  to,  a  boy  about  four¬ 
teen  years  of  age  was  sent  up  to  me  from 
Foots  Cray,  who  said  that  he  had  got  a 
pebble  in  his  windpipe.  He  suffered,  how¬ 
ever,  so  little,  and  the  stethoscopic  signs 
were  so  equivocal,  that  I  thought  it  possible 
he  might  have  ejected  the  stone  in  a  fit  of 
coughing,  and  that  the  irregular  sounds  that 
did  present  themselves  might  depend  upon 
the  injury  the  foreign  body  might  have  in¬ 
flicted  upon  the  mucous  membrane  of  the 
windpipe  ;  although  it  must  be  observed 
that  the  patient  himself  felt  convinced  that 
the  stone  was  still  there.  The  next  day  Dr. 
Addison  examined  the  boy  with  me,  and  as 
he  distinctly  heard  the  flapping  noise  I  have 
spoken  of,  I  determined  immediately  upon 
the  removal  of  the  stone.  With  this  view  I 
first  made  a  longitudinal  incision  of  about  an 
inch  and  a  half  in  length  midway  between 
the  sternum  and  cricoid  cartilage,  and  ex¬ 
posing  the  trachea,  fixed  it  by  means  of  a 
hook,  while  I  divided  with  a  sharp-pointed 
bistoury  three  of  the  rings.  There  was  no 
bleeding  to  interrupt  the  course  of  the  opera¬ 
tion.  The  patient  was  then  placed  head  down¬ 
wards  on  an  inclined  plane,  as  already  de¬ 
scribed,  and  in  about  three  or  four  minutes 
the  stone  fell  in  the  hand  of  Mr.  Hilton,  who 
was  kindly  assisting  me.  The  boy  expe¬ 


rienced  immediate  relief,  and  recovered  with¬ 
out  the  occurrence  of  one  bad  symptom. 
A  piece  of  muslin  was  placed  over  the  wound 
in  the  trachea,  to  prevent  the  intrusion  of 
dust  or  any  foreign  matter,  and  the  tempera¬ 
ture  of  the  ward  was  such  as  not  to  require  to 
be  raised  artificially,  to  prevent  the  injurious 
effects  which  result  from  admission  of  cold 
air  into  the  lungs ;  for  it  is  to  be  re¬ 
membered,  that  naturally  the  air  becomes 
warm  in  its  passage  through  the  mouth, 
nose,  and  that  portion  of  the  air-tube  above 
the  opening  which  had  been  artificially 
made. 

It  sometimes  happens  that  the  bodies 
which  intrude  themselves  into  the  trachea 
are  of  such  shape  and  character,  that  they 
become  at  once  fixed  in  the  tube,  instead  of 
moving  under  the  influence  of  respiration. 
Such  bodies  generally  produce  less  immediate 
urgent  symptoms  than  those  that  move  in 
the  air-tube,  as  they  are  not  liable  to  adjust 
themselves  to  the  rima  glottidis,  and  the 
periodical  spasms  are  consequently  absent. 

The  mode  of  their  removal,  therefore, 
differs  from  that  which  has  already  been 
described  ;  for  it  becomes  necessary  to  ex¬ 
tract  them  by  means  of  forceps  of  various 
shapes,  introduced  into  a  factitious  open¬ 
ing  in  the  trachea.  Mr.  Liston  has  success¬ 
fully  removed  a  large  piece  of  bone  from  the 
right  bronchus  of  a  female ;  and  this  is,  I 
believe,  the  only  instance  in  which  the 
operation  has  ever  been  successfully  per¬ 
formed.  In  the  above-mentioned  case,  the 
extraneous  substance  had  remained  in  the 
bronchus  for  six  months,  rendering  the  pa¬ 
tient  subject  to  frequent  attacks  of  bronchitis, 
which  were  indeed  threatening  phthisis — a 
condition  which  induced  Mr.  Liston  to  re¬ 
commend  the  operation  as  the  only  means 
of  preserving  life.  In  describing  the  opera¬ 
tion,  Mr.  Liston  states  that  the  introduc¬ 
tion  of  the  forceps  was  productive  of  the 
most  violent  effects,  but  after  the  patient 
had  recovered  from  the  spasm  which  was  at 
first  excited,  he  ultimately  succeeded  in  re¬ 
moving  the  substance,  and  the  patient  per¬ 
manently  recovered. 

Small  coins  or  similarly  shaped  substances 
may  also  require  to  be  removed  by  the  for¬ 
ceps  ;  for  if  they  become  fixed  edgewise  in 
the  tube,  they  do  not  move  under  the  in¬ 
fluence  of  respiration,  and  therefore  can 
only  be  dislodged  by  mechanical  means. 

Mr.  Key  performed  this  operation  on  a 
man  who  had  a  sixpence  in  the  right  bron¬ 
chus  ;  but  the  patient  died  suddenly  while 
under  the  operation.  It  appears  to  me  that 
some  very  important  pathological  deductions 
may  be  made  from  these  two  last  cases  :  in 
the  first,  the  foreign  substance  had  been  suf¬ 
ficiently  long  in  its  situation  to  enable  the 
mucous  membrane  to  become  in  some  degree 
adapted  to  its  presence  ;  while  in  the  second, 


OPERATION  FOR  OPENING  THE  TRACHEA. 


91 


the  parts  remained  in  their  normal  highly 
sensitive  condition,  and  unfitted  to  sustain  the 
violence  inseparable  from  the  introduction  of 
the  forceps.  This  instrument  should,  there¬ 
fore,  in  my  opinion,  never  be  employed,  if 
the  extraneous  body  moves  within  the  trachea; 
for-even  if  it  be  impacted  in  the  rima  glottidis, 
an  opening  in  the  trachea  below  it  at  once 
saves  the  patient  from  suffocation,  and  gives 
time  for  the  change  of  position  of  the  sub¬ 
stance  to  be  effected ;  while  the  introduction 
of  forceps  alone,  produces  such  violent 
symptoms,  as  are  of  themselves  sufficient  to 
cause  sudden  death.  This  appears  to  result 
(as  we  frequently  see  in  the  fatal  termination 
of  tetanus),  from  violent  Spasmodic  contrac¬ 
tion  of  the  glottis — an  effect  which  cannot 
be  referred  to  simple  asphyxia  ;  for  in  ordi¬ 
nary  suffocation,  some  minutes  will  elapse 
before  dissolution  ensues  ;  while  in  the  above 
case,  death  is  produced  instantaneously.  The 
immediate  cause  of  death  under  these  cir¬ 
cumstances  is  yet  quite  inexplicable. 

The  operation  of  opening  the  trachea  for 
diseases  of  the  larynx  is  sometimes  had  re¬ 
course  to,  when,  either  from  oedema  about 
the  glottis,  or  from  ulceration  of  the  aryte¬ 
noid  cartilages,  difficulty  of  breathi  ig  be¬ 
comes  urgent ;  but  most  of  these  cases,  parti¬ 
cularly  of  the  latter  description,  terminate 
fatally:  I  believe,  however,  generally  because 
the  operation  is  not  had  recourse  to  until  the 
disease  of  the  arytenoid  cartilage  has  pro¬ 
ceeded  beyond  the  possibility  of  reparation  : 
and  I  am  inclined  strongly  to  recommend 
the  opening  of  the  trachea  at  an  earlier 
period,  as  it  affords  the  only  means  of  keep¬ 
ing  the  arytenoid  cartilages  in  a  state  of  rest 
— a  condition  essentially  necessary  to  the  re¬ 
covery  of  every  inflamed  joint ;  and  in  this 
case  such  an  operation  affords  the  only  means 
of  obtaining  the  desired  object.  I  have  once 
succeeded  in  curing  ulceration  of  the  aryte¬ 
noid  cartilages  by  the  above  plan,  with  a 
rapidity  that  I  have  never  known  to  result 
in  any  other  mode  of  practice.  I  was  con¬ 
sulted  by  an  officer  in  the  Indian  service, 
who  was  sent  home  on  sick  leave,  from 
protracted  secondary  symptoms  ;  he  had 
ulceration  of  the  throat,  attended  by  loss 
of  voice,  great  pain  of  the  larynx  in  speak¬ 
ing,  and  even  in  forced  respiration  ;  and 
Upon  grasping  the  larynx  the  pain  was 
greatly  increased.  I  prescribed  iodine, 
iodide  of  potassium  with  opium,  and  the 
remedies  usually  employed  in  such  cases ; 
the  ulcers  in  the  throat  healed  under  this 
treatment,  but  the  laryngeal  symptoms  in¬ 
creased  in  urgency.  I  proposed  to  make  an 
opening  in  the  trachea,  and  when  I  explained 
the  object  of  this  operation,  my  patient 
readily  consented,  and  in  the  course  of  three 
months  he  had  completely  recovered,  with 
the  exception  of  a  slight  alteration  in  his 
voice,  which  proceeded  probably  from  anchy¬ 


losis  of  the  left  arytenoid  with  the  cricoid 
cartilage.  My  colleague,  Mr.  Cock,  has 
within  the  last  two  years  saved  the  lives  of 
several  children  by  opening  the  trachea  to 
relieve  the  violent  dyspnoea  arising  from  the 
oedema  caused  by  swallowing  hot  water  :  in 
this  case  the  relief  is  not  merely  that  derived 
from  the  admission  of  air  into  the  lungs,  but 
also  from  the  quiescent  state  in  which  the 
parts  are  allowed  to  remain. 

Foreign  bodies  sometimes  lodge  in  the 
oesophagus  in  this  region  of  the  neck,  and 
from  being  tightly  impacted  they  resist  the 
application  of  the  probang:  under  these  cir¬ 
cumstances,  their  removal  is  effected  by 
cutting  down  to  the  oesophagus  at  the  point 
where  the  body  is  felt,  making  the  incision, 
however,  at  the  left  side  of  the  trachea  :  the 
substance  must  be  removed  by  forceps.  Con¬ 
siderable  precaution  is  requisite  in  exposing 
the  oesophagus,  not  only  from  its  natural 
proximity  to  the  carotid  sheath,  but  because 
in  its  dilated  state  it  encroaches  still  more  on 
that  artery. 

The  supra-sternal  fossa,  which  I  have 
already  spoken  of  as  being  placed  at  the  in¬ 
ferior  extremity  of  the  triangular  space  com¬ 
prising  the  anterior  region  of  the  neck,  is 
sometimes  the  seat  of  abscess;  and  wrhen 
the  matter  escapes  externally  from  this  point 
(which  often  happens  from  ulceration  of  the 
fascia),  there  is  some  difficulty  in  healing  the 
wound,  owing  to  the  mobility  of  the  part. 
Great  inconvenience  also  arises  from  the 
difficulty  of  breathing  and  alteration  in  the 
voice  :  from  the  trachea  having  lost  its  sup¬ 
port  from  the  fascia,  the  pressure  of  the 
atmosphere  interferes  with  the  natural 
functions  of  the  canal :  such  abscesses  are 
frequently  connected  with  the  absorbent 
glands  and  loose  cellular  membrane  of  the 
anterior  mediastinum. 

In  stating  the  limits  of  the  anterior  cervi¬ 
cal  region,  I  mentioned  that  it  was  bounded 
on  either  side  by  a  deep  sulcus,  in  which  the 
carotid  arteries  may  be  seen  pulsating  as  they 
take  their  course  from  the  chest  to  the  thy¬ 
roid  cartilage,  wdiere  the  common  carotids 
terminate  by  dividing  into  the  external  and 
internal  carotid  branches.  It  is  in  this  course 
that  ligatures  are  applied  to  the  common 
carotid  in  cases  of  wxmnds,  aneurism,  and 
in  some  cases  where  the  supply  of  blood  to 
a  diseased  structure  appears  to  maintain  the 
abnormal  condition. 

The  carotid  artery  may  be  tied  in  any 
part  of  its  passage  through  the  sulcus,  but  as 
the  omo-hyoideus  muscle,  in  its  course  from 
the  os  hyoides  to  the  shoulder,  crosses  the 
carotid  sheath,  the  application  of  a  ligature 
on  the  artery  above  that  muscle  is  termed 
the  high,  while  that  below  is  contradis¬ 
tinguished  as  the  inferior  operation. 

The  carotid  artery  in  these  two  situations 
is  very  differently  placed  with  respect  to  th^ 


92 


OPERATION  OF  TYING  THE  CAROTID  ARTERY. 


structures  that  cover  it :  above  the  omo- 
hyoideus  and  the  cricoid  cartilage,  it  is  only 
covered  by  the  skin,  platysma  myoides,  and 
fascia  of  the  neck  ;  but  still  it  is  not  so 
superficially  placed  as  in  the  dead  subject 
it  would  appear,  for  by  the  contractions  of 
the  sterno-cleido-raastoideus  muscle,  and 
the  motions  of  the  larynx  during  life,  the 
relative  depth  of  the  vessel  is  continually 
changing. 

Below  the  omo-hyoideus  muscle,  between 
that  and  the  sternum,  the  carotid  is  much 
more  deeply  seated,  and  is  covered  by  the 
sterno-cleido-mastoideus,  sterno-hyoideus, 
and  sterno-thyroideus  muscles,  as  well  as  by 
the  skin,  platysma  myoideus,  and  cervical 
fascia. 

Within  the  carotid  sheath  (a  covering  pro¬ 
duced  by  the  deep  fascia  of  the  neck)  is 
placed  not  only  the  artery,  but  also  the 
internal  jugular  vein  and  pneumo-gastric 
nerve  :  the  former  lying  on  the  tracheal  or 
inner  side,  the  vein  on  the  outer,  and  the 
nerve  between  the  two. 

Operation  of  tying  the  carotid  artery 
above  the  omo-hyoideus.  —  The  patient 
should  be  placed  in  the  recumbent  position, 
with  the  neck  extended  and  the  head  turned 
towards  the  opposite  shoulder  ;  an  incision 
is  then  to  be  made,  about  two  inches  and  a 
half  long,  commencing  a  little  below  the 
angle  of  the  lower  jaw,  and  continuing  as 
low  as  the  inferior  edge  of  the  cricoid  carti¬ 
lage — occupying  the  mid  space  between  the 
anterior  edge  of  the  sterno-mastoideus 
muscle  on  the  outer  side,  and  the  os  hyoides 
and  larynx  on  the  inner  :  this  first  incision 
is  to  cut  through  the  skin  and  platysma 
myoides,  and  expose  the  deep  fascia  of  the 
neck,  which  is  also  to  be  divided  to  the  same 
extent,  and  in  the  same  direction,  taking 
care  to  avoid  as  much  as  possible  the  venous 
trunks  that  may  cross  in  the  direction  of  the 
incision.  The  edges  of  the  wound  should 
now  be  drawn  asunder  by  broad  retrac¬ 
tors,  when  the  carotid  sheath  is  exposed ; 
and  usually  the  descending  branch  of  the 
lingual  nerve  will  be  seen  crossing  the  sheath 
from  without  to  within,  in  the  upper  part  of 
the  exposed  space.  The  sheath  is  now  to  be 
opened  very  cautiously,  by  raising  a  portion 
of  it  on  the  laryngeal  side  with  a  pair  of 
forceps,  and  a  small  opening  being  made, 
a  silver  director  is  to  be  introduced,  by 
cutting  down  upon  which,  the  opening  may 
"be  enlarged  for  the  purpose  of  laying 
bare  the  artery :  this  being  effected,  an 
aneurismal  needle  is  then  to  be  passed 
beneath  the  vessel,  being  directed  from 
without  to  within  ;  the  point  of  the 
needle  is  kept  close  to  the  artery,  so  as  to 
preclude  the  liability  of  including  the 
pneumo-gastric  nerve.  The  needle  is  usually 
armed  with  the  ligature  before  it  is  passed 


under  the  artery,  but  I  am  in  the  habit  of 
first  passing  the  needle,  as  its  passage  is 
much  easier  without  the  silk,  which  I  in¬ 
troduce  when  the  instrument  is  beneath  the 
vessel.  After  this,  nothing  remains  but  the 
tightening  and  tying  the  ligature,  having 
first  carefully  ascertained  that  the  artery 
alone  is  included.  The  edges  of  the  wound 
are  now  to  be  brought  together,  and  main¬ 
tained  by  one  suture  in  the  centre,  and  by 
strips  of  adhesive  plaster.  When  the  pa¬ 
tient  is  placed  in  bed  his  head  should  be 
well  supported,  and  maintained  in  such  a 
position  as  to  relax  all  the  muscles  of  the  neck. 
Much  is  said  by  surgeons  of  a  difficulty  aris¬ 
ing  in  this  operation  from  the  distension  of 
the  jugular  vein,  but  1  have  three  times  tied 
the  carotid  artery  without  having  in  either 
instance  even  seen  the  vein  ;  indeed,  I  believe 
this  may  generally  be  prevented  by  making 
the  opening  into  the  sheath  on  its  laryngeal 
side.  Directions  are  also  given  to  avoid 
the  sympathetic  nerve  in  passing  the  needle 
under  the  vessel,  but  as  this  nerve  is  not 
within  the  carotid  sheath,  but  lies  com¬ 
pletely  behind  it,  such  precautions  seem  to 
me  unnecessary. 

Tying  the  carotid  artery  in  the  inferior 
region  of  the  neck. — In  this,  as  in  the  ope¬ 
ration  just  described,  the  patient  should  be 
placed  in  the  recumbent  position — a  position 
which  I  prefer,  indeed,  in  all  operations, 
when  admissible,  as  in  the  sitting  posture  a 
fixed  point  is  obtained  for  the  full  force  of 
voluntary  muscular  action,  while,  when  lying, 
the  patient  is  deprived  of  such/?omtf  d'appuiy 
and  is  therefore  rendered  comparatively 
helpless.  The  head  and  neck  must  be  placed 
in  much  the  same  position  as  before  de¬ 
scribed,  but  hardly  so  extended  an  incision 
is  required  ;  it  should  commence  opposite 
the  cricoid  cartilage,  and  be  continued  down¬ 
wards  to  within  somewhat  less  than  an  inch 
of  the sterno-clavicular  articulation, taking  the 
course  of  the  inner  edge  of  the  sterno- mas¬ 
toid  muscle.  The  skin,  platysma  myoides, 
and  superficial  fascia,  are  divided  by  the 
incision,  and  the  edge  of  the  sterno-cleido-mas¬ 
toideus  exposed,  along  which  a  vein  of  con¬ 
siderable  size  is  generally  seen  :  this  must 
be  avoided  :  the  muscle  and  the  vein  are  to 
be  drawn  outwards,  and  the  sterno-hyoideus 
and  the  sterno-thyroideus  inwards,  by  means 
of  retractors.  At  the  upper  extremity  of 
the  wound  the  omo-hyoideus  muscle  is  seen 
crossing  the  vessels,  and  is  connected  by  the 
deep  cervical  faseia  to  the  sheath  of  the  ves¬ 
sels  ;  this  fascia  being  divided  below  the 
muscle,  the  carotid  sheath,  with  the  lingual 
nerve  lying  on  its  inner  side,  is  exposed  ;  the 
sheath  is  next  to  be  opened,  and  the  ligature 
passed  around  the  artery  in  the  manner 
before  described.  When  this  operation  is 
performed  upon  the  left  side  of  the  neck, 


ULCERATION  OF  THE  CAROTID  ARTERY.  SUPRA-CLAVICULAR  REGION.  03 


there  is  certainly  some  difficulty,  from  the 
comparatively  superficial  situation  of  the 
jugular  vein,  which  partially  covers  the 
artery,  and  therefore  extreme  caution  is  re¬ 
quired  to  avoid  injuring  it. 

The  internal  jugular  vein  is  sometimes 
subject  to  dilatation,  so  that  the  swelling 
presents  itself  in  the  carotid  sulcus,  and, 
indeed,  may  offer  considerable  difficulty  to 
the  surgeon  to  distinguish  it  from  disease  of 
the  carotid  artery  itself,  as,  from  the  vicinity 
of  the  swelling  to  that  vessel,  it  more  or 
less  partakes  of  its  pulsating  nature.  A 
patient  was  admitted  into  the  London  Hos¬ 
pital,  with  a  swelling  about  the  size  of  an 
egg  on  the  right  side  of  the  neck,  which  was 
at  first  suspected  to  be  cai’otid  aneurism  : 
upon  further  examination,  however,  it  was 
believed,  from  the  softness  of  the  tumor,  the 
facility  with  which  it  was  emptied,  and  the 
slight  pulsation  which  it  afforded,  and  that, 
not  being  quite  synchronous  with  the  action 
of  the  heart,  that  it  was  disease  of  the  vein, 
and  not  of  the  artery ;  the  absence  of  the 
bruit  de  sovfflet  also  tended  to  confirm  this 
view.  The  patient  died  a  short  time  after, 
of  disease  of  the  lungs,  and  the  diagnosis 
was  found  to  be  correct. 

Burns,  in  his  work  on  the  Head  and  Neck, 
mentions  instances  of  dilatation  of  the  inter¬ 
nal  jugular  vein  forming  a  pouch  of  con¬ 
siderable  size  behind  the  angle  of  the  lower 
jaw,  but  he  does  not  mention  that  the  tumor 
partook  of  the  pulsation  of  the  carotid  ar¬ 
tery ;  and,  therefore,  the  diagnosis  would  be 
more  easy  here  than  if  it  occurred  lower 
down  in  the  neck,  where  the  proximity  of 
the  two  vessels  is  so  much  greater. 

Strumous  abscesses  of  the  neck  may 
sometimes  lead  to  ulceration  of  the  carotid 
artery,  producing  spurious  aneurism.  The 
well-known  case  of  Mr.  Liston  is  worthy  of 
attention.  An  attempt  to  attach  blame 
to  him  was  made  on  that  occasion,  but  a 
short  history  of  the  case  will,  I  think,  prove 
that  this  was  great  injustice.  A  child  of 
highly  strumous  habit,  with  several  cicatrices 
on  the  neck,  indicating  that  the  strumous 
tendency  had  been  of  long  duration,  was  ad¬ 
mitted  into  the  North  London  Hospital.  The 
patient  had  a  fluctuating  tumor  on  the  neck, 
in  which  the  house-surgeon  had  discovered  a 
pulsatory  motion  ;  and  on  Mr.  Liston’s  visit 
he  mentioned  the  circumstance  to  him.  Mr. 
Liston,  however,  considering  the  youth  of 
the  patient,  the  proof  of  the  existence  of 
former  abscesses,  and  the  unheard-of  exis¬ 
tence  of  aneurism  at  so  early  an  age,  and 
believing  that  the  pulsation  was  merely 
communicated  to  the  mass,  and  did  notarise 
from  the  opening  of  any  vessel  into  it,  eva¬ 
cuated  the  contents  of  the  swelling  ;  arterial 
blood  rushed  from  the  wound,  which  was 
directly  closed,  so  as  to  stop  the  haemorrhage; 
and  the  next  day  the  carotid  artery  was  tied. 


It  may  be  said,  truly,  that  Mr.  Liston’s 
great  scientific  knowledge  brought  him  into 
this  dilemma  :  the  rare  occurrence  at  any 
time  of  life  of  the  ulceration  of  an  artery 
from  abscess,  the  peculiar  diathesis  and 
temperament  of  the  patient,  the  frequency 
of  a  pulsating  motion  being  communicated 
from  an  artery  to  a  tumor  in  its  neighbour¬ 
hood,  and  a  knowledge  that  nothing  else 
could  be  done  than  tie  the  artery  (if  it  should 
prove  to  be  aneurism),  led  him  into  the  error. 
The  exploration  does  not,  therefore,  deserve 
the  condemnation  that  has  in  some  instances 
been  attached  to  it.  The  case  will,  however, 
afford  ample  instruction  to  you,  gentlemen  ; 
pointing  out  the  paramount  necessity  for  the 
closest  investigation  before  you  attempt  to 
open  an  abscess  in  the  vicinity  of  a  great 
artery. 

Supra-clavicular  region. — This  is  a  small 
triangular  space  above  the  clavicle,  bounded 
on  the  inner  side  by  the  sterno-cleido- 
mastoideus,  on  the  outer  by  the  trapezius 
muscles,  and  is  terminated  above  by  the 
approximation  of  the  two.  The  passage  of 
a  portion  of  the  subclavian  artery  through 
this  space  renders  it  especially  important  to 
the  surgeon.  At  this  point  of  its  course  the 
subclavian  artery  can  be  pressed  against  the 
first  rib,  so  as  to  command  it,  during  opera¬ 
tions  in  which  it  is  requisite  that  the  flow  of 
blood  through  this  vessel  should  be  checked. 
It  is  here  also  that  a  ligature  is  applied  to 
the  subclavian  in  cases  of  wounds  or  disease 
of  the  axillary  artery.  The  application  of  the 
ligature  is  performed  as  follows  : — The  pa¬ 
tient  is  to  be  placed  upon  a  table  in  the  re¬ 
cumbent  posture,  and  the  shoulder  on  the 
diseased  side  must  be  forcibly  pressed 
backwards,  the  arm  being  drawn  down¬ 
wards  and  held  close  to  the  side,  for  the 
purpose  of  depressing  the  clavicle.  The 
skin  is  then  to  be  drawn  downwards  tightly 
over  the  clavicle,  and  when  thus  stretched, 
an  incision  is  to  be  made,  commencing  at 
the  external  edge  of  the  mastoid  muscle,  and 
extending  to  the  anterior  margin  of  the 
trapezius  ;  or,  if  the  latter  should  encroach 
so  much  upon  the  sterno-cleido  as  to 
leave  but  a  small  space  between  them,  some 
of  the  fibres  of  the  trapezius  must  be  cut 
through  so  as  to  give  sufficient  room  :  by  this 
incision  both  the  skin  and  platysma  myoides 
must  be  divided.  As  the  skin  is  tightly 
stretched  when  the  incision  is  made,  the 
moment  it  is  divided,  the  upper  segment  re¬ 
tracts,  owing  to  its  elasticity,  and  a  wide 
opening  is  formed,  exposing  the  loose  cellu¬ 
lar  tissue  beneath,  as  well  as  the  external 
jugular  vein,  which  will  be  seen  lying  close 
to  the  mastoid  muscle.  The  next  object  in 
the  operation  is  to  expose  the  external  edge  of 
the  scalenus  anticus  muscle,  which  is  easily  re¬ 
cognised  from  its  glistening  tendinous  struc- 


94 


WOUNDS  IN  THE  SUPRA-CLAVICULAR  REGION. 


ture  ;  to  reach  this  muscle,  the  cellular  tissue 
must  be  cleared  away  with  the  handle  of  the 
knife,  deepening  the  wound  in  a  direction 
parallel  with  the  outer  edge  of  the  sterno- 
cleido-mastoideus,  in  the  course  of  which 
muscle  the  skin  may  be  further  divided  up¬ 
wards  if  more  room  be  required,  and  thus 
the  object  of  search,  the  scalenus  anticus 
muscle,  may  be  brought  into  view.  A  deep 
triangular  space  is  now  exposed,  of  which 
the  scalenus  anticus  forms  the  inner,  the 
omo-hyoideus  the  outer,  and  the  first  rib  the 
lower  boundary,  and  it  is  in  this  triangle 
that  the  portion  of  the  subclavian  artery  to 
be  secured  is  situated.  The  artery  may  be 
here  immediately  detected  by  pressing  the 
finger  upon  the  first  rib,  when  the  pul¬ 
sations  will  be  readily  felt.  With  the  finger¬ 
nail  or  a  director  the  cellular  tissue,  which 
ties  the  artery  down  to  the  rib,  is  now  to 
be  detached,  and  an  aneurismal  needle 
passed  under  the  vessel,  the  point  being 
directed  from  before  backwards,  and  from 
below  upwards,  so  as  to  preclude  the  liability 
of  including  the  vein. 

The  operation  has  thus  been  divided 
into  three  steps,  in  each  of  which  spe¬ 
cific  dangers  may  arise.  In  the  first 
incision,  the  external  jugular  vein  may  be 
divided.  To  avoid  this,  the  course  of  the 
vein  should  be  accurately  ascertained  pre¬ 
viously,  that  you  may  modify  your  incision 
accordingly.  This  accident  did  occur  to  a 
surgeon  in  St.  Petersburg!),  the  result  of 
which  was  instantaneously  fatal,  from  air 
rushing  into  the  vein  ancl  filling  the  right 
auricle  of  the  heart.  In  the  second  step, 
the  first  object  is  to  expose  the  scalenus 
anticus,  which  affords  an  infallible  guide  to 
the  precise  situation  of  the  subclavian  artery. 
In  seeking  the  scalenus,  which  is  indeed 
“  the  landmark”  in  the  operation,  care  must 
be  taken  that  its  tendinous  outer  edge  only 
is  exposed  ;  for  if  you  work  too  much  in¬ 
wards — that  is  to  say,  under  the  mastoid 
muscle — you  are  likely  to  expose  and  injure 
the  phrenic  nerve  which  lies  on  the  central 
part  of  the  scalenus.  Some  years  ago  I 
performed  this  operation  on  a  clergyman, 
in  the  presence  of  the  late  Dr.  Babington 
and  Mr.  Travers :  no  difficulty  whatever 
occurred  ;  but  immediately  after  its  comple¬ 
tion,  the  patient  was  seized  with  a  constant 
hacking  cough,  as  if  resulting  from  convul¬ 
sive  motion  of  the  diaphragm.  This  scarcely 
ceased  night  or  day  until  the  sixth  day  after 
the  operation,  when  he  died.  No  post¬ 
mortem  examination  was  permitted;  but 
there  can  be  no  doubt  in  my  mind  but  that 
the  phrenic  nerve  had  been  injured,  although 
it  could  not  possibly  be  included  in  the 
ligature. 

In  the  third  step — viz.  that  of  applying 
the  ligature  to  the  artery — the  principal 
danger  is  the  liability  of  including  the  first 


dorsal  nerve  with  the  artery,  or  taking  it  up 
instead  of  that  vessel,  for  it  is  placed  in  close 
contiguity  above  and  to  its  outer  side.  I 
have  seen  this  nerve  taken  up  instead  of  the 
artery,  by  a  most  excellent  surgeon,  but  the 
ligature  was  cut  off  again,  and,  the  artery 
being  secured,  the  patient  recovered.  A. 
case  is  recorded  where  this  accident  hap¬ 
pened,  and  in  which  the  ligature  was  left 
upon  the  nerve,  when  abscess  on  the  brain 
followed,  and  the  patient  died.  The  sub¬ 
clavian  vein  can  hardly  be  endangered  during 
the  application  of  the  ligature,  as  it  is  much 
anterior  to  the  artery,  being  separated  from 
it  by  the  scalenus  anticus  muscle.  The  pre¬ 
caution  of  passing  the  needle  from  before  to 
behind  is  alone  sufficient  to  protect  this 
vessel  from  inclusion. 

The  operation  in  thin  persons,  and  wrhen 
the  clavicle  is  not  much  raised  by  the 
aneurismal  tumor,  is  not  to  be  con¬ 
sidered  difficult ;  but  in  stout  people, 
and  where  the  clavicle  is  much  elevated, 
it  is  perhaps  the  most  difficult  of  surgical 
operations  ;  and  in  some  cases,  indeed,  the 
difficulties  have  proved  insuperable.  Various 
ingenious  mechanical  contrivances  have  been 
invented  for  the  purpose  of  seizing  the  liga¬ 
ture  after  the  aneurismal  needle  has  been 
passed  under  the  artery,  and  this  is  often  by  far 
the  most  difficult  part  of  the  whole  operation. 
Sometimes  the  superior  dorsal  artery  of  the 
scapula  is  so  much  enlarged,  from  the  ob¬ 
struction  to  the  flow  of  the  blood  through 
its  natural  channel,  that  it  may  be  mistaken 
for  the  subclavian  ;  but  its  comparatively 
superficial  position  would  to  an  anatomist 
preclude  the  possibility  of  such  a  mistake. 
Care  should  be  taken  not  to  injure  this 
vessel  in  the  operation,  as  it  constitutes  one 
of  the  great  sources  of  blood  to  the  upper 
extremity  after  the  subclavian  has  been 
tied. 

Wounds  in  the  supra- clavicular  region 
may  lead  to  the  laceration  of  the  subclavian 
artery  or  axillary  nerves;  but  still  they 
are  so  defended  by  the  clavicle,  that  their 
laceration  can  scarcely  occur  immediately 
from  an  external  force,  but  is  most  fre¬ 
quently  produced  from  the  bone  itself  being 
broken,  the  sharp  fractured  extremities 
lacerating  them.  The  following  case  of 
this  kind  was  admitted  under  my  care  at 
Guy’s  Hospital : — William  Morgan,  a  sailor, 
18  years  of  age,  had  fallen  from  the  mast-head 
of  a  vessel  upon  a  “belaying  pin,”  which 
entered  his  chest  just  above  the  clavicle,  and, 
penetrating  about  seven  inches,  broke  off, 
and  the  boy  was  precipitated  into  the 
Thames.  He  was  immediately  picked  up 
and  conveyed  to  the  house  of  Mr.  Ran¬ 
dall,  a  surgeon  at  Rotherhithe,  who  ex¬ 
tracted  the  fragment  of  the  pin  by  employing 
considerable  force,  which  was  followed  by 
profuse  haemorrhage.  Upon  his  admission 


WRY-NECK - DIVISION  OF  THE  STERNO-CLEIDO  MASTOIDEUS.  95 


into  the  hospital,  he  complained  of  great 
pain  in  the  shoulder,  and  an  uneasy  sensa¬ 
tion  in  the  abdomen  ;  there  was  also  con¬ 
siderable  contusion  about  the  head.  A 
large  lacerated  opening  presented  itself 
above  the  clavicle,  of  the  breadth  of  three 
fingers.  Through  this  the  clavicle  might  be 
felt  broken  into  two  or  three  portions,  and 
the  subclavian  artery  was  perfectly  laid  bare, 
as  it  passed  over  the  first  rib.  There  was 
emphysema  extending  from  the  neck  down 
the  side  and  back.  The  surface  of  the  body 
was  cold,  and  the  abdomen  tympanitic,  with 
partial  priapism.  The  edges  of  the  wound 
in  the  supra-clavicular  region  were  partly 
brought  together  by  strips  of  adhesive 
plaster,  an  opening  being  left  to  permit  of 
the  exudation  of  blood.  Julep.  Ammon, 
was  given,  in  the  hope  of  producing  reaction, 
and  fomentations  were  applied  to  the  abdo¬ 
men.  He  sunk,  however,  the  day  after  the 
accident.  On  examination  of  the  body,  it 
was  found  that  the  wound  extended  from 
the  left  clavicle  into  the  axilla,  and  the  sub¬ 
clavian  artery  was  lacerated.  On  further 
dissection,  it  was  proved  that  the  wound 
extended  from  the  axilla  into  the  chest  be¬ 
tween  the  third  and  fourth  ribs,  penetrating 
the  lung ;  and  a  piece  of  cloth  torn  from  his 
jacket  by  the  pin  was  firmly  fixed  in  the 
wound,  forming  a  plug,  which  probably  pre¬ 
vented  immediate  death  from  haemorrhage. 
On  opening  the  abdomen,  the  spleen  was 
found  lacerated  on  its  inner  and  posterior 
surface.  In  this  case,  had  there  been  no 
laceration  of  lung  or  spleen,  and  had  hae¬ 
morrhage  occurred  on  reaction,  a  ligature 
upon  the  subclavian  artery  might  have  saved 
the  life  of  the  patient. 

Tumors  sometimes  form  in  the  super- 
clavicular  region,  and,  as  they  may  possibly 
gain  a  pulsatory  motion  from  the  subclavian 
artery,  they  may  perhaps  be  mistaken  for 
aneurism  of  that  vessel  ;  and  in  this  situa¬ 
tion  I  have  known  abscesses,  glandular  en¬ 
largements,  and  exostoses,  lead  to  great 
diagnostic  difficulties. 

High  up  in  the  lateral  region  of  the  neck, 
between  the  trapezius  and  sterno-cleido 
mastoidei  muscles,  tumors  are  frequently 
seated.  These  are  generally  glandular  en¬ 
largements,  but  are  sometimes  of  a  fluctuat¬ 
ing  character,  when  it  becomes  difficult  to 
decide  whether  the  swelling  is  chronic  ab¬ 
scess  or  an  adventitious  serous  cyst.  The 
latter  I  have  termed  hydrocele  of  the  neck. 
Two  of  these  cases  have  occurred  in  the 
course  of  my  practice,  both  of  which  were 
cured  by  the  application  of  setons,  and  are 
related  in  Guy’s  Hospital  Reports,  vol.  i. 
p.  105.  In  the  dissection  of  tumors  from 
this  region,  or  indeed  from  any  part  of  the 
body  in  which  large  vessels  or  nerves  are 
situated,  the  surgeon  should  always  be  pre¬ 
pared  with  strong  hooked  forceps  to  draw 


the  tumor  from  its  bed  as  soon  as  it  has 
been  exposed;  and  in  the  dissection  the 
edge  of  the  knife  should  always  be  directed 
to  the  tumor,  as  if  the  surgeon  were  dissect¬ 
ing  the  neighbouring  parts  from  the  tumor, 
rather  than  the  tumor  from  the  parts.  The 
most  common  operation  in  this  region  is, 
however,  phlebotomy  of  the  external  jugular 
vein.  The  vessel  is  here  placed  beneath 
the  platysma  myoides  muscle,  and  both 
decision  and  precision  are  required  to  enable 
the  surgeon  to  lay  open  the  vein. 

In  cases  of  wry-neck,  division  of  the 
sterno-cleido  mastoideus  is  sometimes  re¬ 
commended  ;  but  if  the  distortion  has  re¬ 
sulted  without  any  external  injury,  as  from 
burns  or  cicatrices  from  other  causes,  the 
operation  is  useless,  as  the  deformity  most 
likely  depends  upon  disease  of  the  cervical 
vertebrae  or  the  spinal  nerves.  The  diag¬ 
nosis  may  be  very  difficult  to  ascertain  whe¬ 
ther  the  distortion  results  from  paralysis  of 
the  opponent  muscle,  or  spasm  of  that 
affected ;  and,  if  the  latter,  whether  the 
affection  be  idiopathic  or  sympathetic.  If 
paralysis  be  suspected,  electricity,  strych¬ 
nia,  blisters,  and  the  internal  administra¬ 
tion  of  mercury,  are  indicated  ;  but  if  the 
contraction  results  from  the  muscle  itself, 
its  division,  and,  at  the  same  time,  that  of 
the  accessory  nerve  which  passes  through 
it,  may  be  had  recourse  to. 

Contractions  after  burns  may  also  lead  to 
operations  in  any  region  of  the  neck,  as  the 
resulting  deformities  may  affect  most  im¬ 
portant  vital  functions  ;  for  when  the  chin 
is  drawn  downwards  towards  the  sternum 
by  the  violent  contraction  of  the  cicatrices, 
deglutition  and  respirationareinterfered  with, 
and  the  voice  becomes  altered.  From  the  ten¬ 
dency  to  eversion  of  the  lower  lip,  the  saliva 
is  constantly  flowing  from  the  mouth,  and 
the  deformity  renders  the  unfortunate  object 
unfitted  for  social  life.  Division  of  the 
cicatrix  is  not  sufficient  permanently  to  re¬ 
move  these  distortions,  as  the  muscles  have 
usually  become  permanently  shortened,  so 
as  to  have  adapted  themselves  to  the  ab¬ 
normal  condition  of  the  parts.  Portions  of 
them,  therefore,  or  indeed  the  entire  muscle, 
where  it  is  not  of  any  great  dimensions, 
should  be  divided  by  transverse  incisions,  as 
the  tissue  which  re-unites  them,  being 
always  incapable  of  contraction,  may  check 
the  liability  to  the  recurrence  of  the  de¬ 
formity  ;  and  if  the  healthy  part  of  the 
muscle  still  has  a  tendency  to  contract,  the 
elasticity  of  the  re-uniting  medium  will 
offer  but  little  resistance  to  the  subsequent 
means  employed  for  the  purpose  of  prevent¬ 
ing  the  drawing  down  of  the  head.  In  the 
neck  I  believe  it  is  the  platysma  myoides 
muscle,  and  not  the  contraction  of  the 
granulations,  which  produces  the  deformity  ; 
for  extension  alone  during  the  granulating 


96 


RARITY  OF  PERITONITIS  IN  CHILDHOOD 


process  after  burns  will  scarcely  ever  prevent 
the  occurrence  of  these  contractions. 

Before  dismissing  the  region  of  the  neck, 
gentlemen,  I  will  for  a  moment  recal  your 
attention  to  the  circumstance  of  its  being 
frequently  the  seat  of  the  attempts  both  of 
the  assassin  and  the  suicide :  it  may  also 
frequently  be  the  object  of  the  former  to  en¬ 
deavour  to  impress  the  belief  that  death  had 
been  produced  by  the  hand  of  the  individual 
himself ;  and  it  is  therefore  highly  important 
that  you  should  make  yourselves  thoroughly 
acquainted  with  the  signs  that  will  enable 
you  to  judge  of  the  nature  of  the  case,  as 
to  whether  the  violence  was  inflicted  before 
or  after  death.  I  can  do  no  better  than 
to  refer  you  to  the  excellent  work  on  medical 
jurisprudence  by  my  colleague,  Mr.  Alfred 
Taylor,  which  is  as  frequently  found  in  the 
library  of  the  barrister  as  in  that  of  the 
surgeon.  This  fact  will  convince  you  of  the 
necessity  of  rendering  yourselves  fully  con¬ 
versant  with  the  subject,  or  you  may  find, 
in  a  court  of  justice,  that  the  lawyers  are 
better  acquainted  with  it  than  yourselves. 

THE  POSTERIOR  REGION  OF  THE  NECK. 

This  region  offers  but  little  opportunity 
for  surgical  remark,  the  blood-vessels  being 
comparatively  unimportant  in  this  aspect, 
so  that  wounds  offer  no  difficulties  with  re¬ 
ference  to  haemorrhage ;  but  it  may  be 
noticed  that  the  strong  fascia  of  this  region 
may  somewhat  interfere  with  the  re- union 
of  wounds  of  the  parts.  Particular  notice 
is,  however,  required  in  reference  to  this  re¬ 
gion,  as  it  is  the  frequent  seat  of  carbuncle, 
and  probably  the  severer  symptoms  attend¬ 
ing  the  disease  in  this  part  of  the  body  are 
also  attributable  to  the  low  degree  of  vital 
power  possessed  by  the  fascia  so  abundantly 
developed  in  this  region.  The  treatment 
of  the  disease  I  have  already  described  in 
Lecture  XIII.  Deep  sinuous  ulcerations 
also  frequently  occur  in  this  region,  depend¬ 
ing  either  upon  sloughing  of  the  ligamentum 
nuchae,  or,  not  unfrequently,  upon  disease 
of  the  vertebrae.  The  disease  is  extremely 
difficult  to  cure,  requiring  free  incisions  for 
the  ready  removal  either  of  the  sloughing 
tendon  or  bone,  whichever  may  be  the  cause 
of  the  malady.  The  part  of  this  region  most 
assailable,  and  where  wounds  are  most 
dangerous,  is  its  upper  extremity,  between 
the  atlas  and  vertebra  dentata.  In  this  space 
the  spinal  marrow  is  only  protected  from 
external  injury  by  soft  parts,  so  that  a 
deeply  penetrating  wTound  might  at  once 
divide  the  spinal  marrow,  and  produce  im¬ 
mediate  death. 


LECTURES 

ON  THE 

DISEASES  OF  INFANCY  AND 
CHILDHOOD, 

Delivered  at  the  Middlesex  Hospital. 

By  Charles  West,  M.D. 

Physician-Accoucheur  to,  and  Lecturer  on  Mid¬ 
wifery  at,  the  Middlesex  Hospital,  and  Senior 
Physician  to  the  Royal  Infirmary  for  Children. 


Lecture  XXXIV. 

Peritonitis — rare  in  childhood ,  hut  some¬ 
times  occurs  during  foetal  existence,  or  in 
very  early  infancy — is  then  possibly  de¬ 
pendent  on  syphilitic  taint — when  epi¬ 
demic  in  large  institutions,  is  often  con¬ 
nected  with  infantile  erysipelas. 
Peritonitis  in  after  childhood — generally 
secondary  to  some  febrile  attack — case 
illustrative  of  its  symptoms,  which  are 
much  the  same  as  in  the  adult— occa¬ 
sional  escape  of  the  fluids  effused  through 
the  abdominal  walls,  and  recovery  of  the 
patient.  Inflammation  sometimes  cir¬ 
cumscribed,  especially  in  connection  with 
disease  about  the  appendix  coeci — illus¬ 
trative  case — treatment. 

Chronic  peritonitis — almost  always  a  tuber¬ 
cular  disease.  Morbid  appearances — 
symptoms — their  vagueness — pauses  in 
the  advance  of  the  disease — close  analogy 
between  its  symptoms  and  those  referred 
to  tabes  mesenterica — considerable  tuber¬ 
cular  disease  of  those  glands  rare — slight¬ 
ness  of  its  symptoms  when  uncomplicated. 
Treatment  of  both  affections. 

From  the  study  of  the  affections  of  the  mu¬ 
cous  lining  of  the  intestinal  canal,  we  pass 
by  a  natural  transition  to  that  of  the  diseases 
of  its  serous  investment.  Peritonitis,  how¬ 
ever,  which  is  not  very  common  as  an  idio¬ 
pathic  affection  at  any  period  of  life,  is  still 
more  rare  during  the  greater  number  of  the 
years  of  childhood  ;  while  its  symptoms  do 
not  deviate  in  any  important  respect  from 
those  which  characterize  it  in  the  adult.  It 
would  be  idle  to  spend  our  time  in  speculat¬ 
ing  on  the  reasons  for  the  rarity  of  inflam¬ 
mation  of  the  peritoneum  in  early  life.  The 
tendency  of  inflammatory  disease  in  child¬ 
hood  appears,  indeed,  to  be  to  attack  the  mu¬ 
cous  rather  than  the  serous  membranes  ;  a 
faci  of  which  we  have  another  illustration  in. 
the  comparative  rarity  of  acute  pleurisy  in 
the  child.  Some  connection  may  perhaps 
be  thought  to  subsist  between  the  great  irri¬ 
tability  of  the  intestinal  mucous  membrane, 
and  its  proneness  to  disease  during  the 
greater  part  of  childhood,  and  the  immunity 
from  it  which  the  peritoneum  exhibits  dur- 


NFLAMMATION  OF  THE  PERITONEUM  DURING  INTRA-UTERINE  LIFE.  97 


ing  the  same  period.  At  any  rate,  it  is  cer¬ 
tain  that  in  the  new-born  infant,  in  whom  the 
former  peculiarity  has  not  yet  become  de¬ 
veloped,  inflammation  of  the  peritoneum  is 
of  more  common  occurrence  than  in  subse¬ 
quent  childhood. 

Inflammation  of  the  peritoneum ,  giving 
rise  to  adhesions  between  the  intestines,  and 
to  the  effusion  of  lymph  and  serum  into  the 
cavity  of  the  abdomen,  occurs  sometimes 
even  during  intra-uterine  life ,  and  occasions 
the  death  of  the  foetus.  It  is  not  possible  to 
say  with  certainty  to  what  cause  the  disease 
should  be  attributed,  at  a  time  when  the 
being  is  sheltered  from  all  those  influences 
from  without  which  may  excite  inflammation 
after  birth ;  but  it  is  worthy  of  notice  that 
in  many  instances  of  peritonitis  in  the  foetus, 
traces  of  syphilitic  disease  are  observed  upon 
it ;  or  there  is  clear  evidence  of  the  exist¬ 
ence  of  venereal  taint  in  the  mother.  In  such 
cases,  the  inflammation  of  the  serous  lining 
of  the  abdomen  is  probably  due  to  the  altered 
state  of  the  circulating  fluid — a  cause  to 
which,  in  after-life,  inflammation  of  the 
serous  membranes  is  frequently  owing.  In 
the  only  instance  of  non-congenital  perito¬ 
neal  inflammation  that  has  come  under  my 
notice  in  early  infancy,  there  was  no  other 
cause  than  this  to  which  it  could  be  attri¬ 
buted. 

In  this  case,  a  little  boy,  five  weeks  old 
(whose  mother  had  twice  before  been  con¬ 
fined  prematurely  with  still-born  children), 
began  to  have  snuffles  at  the  age  of  three 
weeks.  In  the  course  of  the  next  week  a 
few  copper-coloured  spots  appeared  about 
his  face ;  his  scrotum  next  grew  sore,  then 
his  voice  became  hoarse  and  his  lips  cracked; 
and  at  the  end  of  the  fourth  week  he  grew 
sick,  and  his  abdomen  enlarged  and  became 
tender.  When  brought  to  me  the  child  was 
extremely  small ;  he  was  greatly  emaciated  ; 
the  skin  of  his  face  wrinkled  ;  his  appearance 
distressed ;  his  chin  covered  with  copper- 
coloured  blotches ;  the  angles  of  his  mouth 
ulcerated  ;  his  lips  cracked  ;  and  small  sores 
beset  his  scrotum.  His  abdomen  likewise 
was  very  large  :  it  was  remarkably  promi¬ 
nent  about  the  umbilicus,  and  its  superficial 
veins  were  much  enlarged.  It  was  ex¬ 
tremely  tense,  somewhat  tympanitic ;  and 
though  dull  in  places,  it  yet  did  not  yield 
the  impression  of  distinct  fluctuation  any¬ 
where.  The  abdomen  was  exceedingly 
tender  to  the  touch,  but  the  child  seemed  in 
pain  also  at  other  times ;  he  had  been  very 
sick  for  nearly  a  week,  vomiting  almost  im¬ 
mediately  after  sucking,  and  likewise  throw¬ 
ing  up  a  yellow  fluid  at  other  times.  The 
bowels  were  purged  several  times  a  day.  The 
mother,  who  did  not  suffer  at  that  time  from 
any  syphilitic  symptom,  was  put  upon  a 
mild  mercurial  course,  with  iodide  of  potas¬ 
sium  and  sarsaparilla ;  and  the  mercury 


with  chalk  was  likewise  administered  to  the 
child.  By  degrees,  as  the  syphilitic  spots 
faded,  the  abdomen  grew  less  tender  and 
less  swollen,  it  became  soft ;  and  in  the 
course  of  time  the  infant  regained  perfect 
health. 

The  symptoms  in  this  case  ran  a  chronic 
course  ;  but  peritonitis  of  an  acute  character, 
and  tending  to  a  rapidly  fatal  termination, 
is  sometimes  observed  to  occur  among  very 
young  infants  when  collected  together  in 
large  numbers,  and  under  conditions  un¬ 
favourable  to  health.  A  French  physician, 
M.  Thore,*  during  a  year’s  observation  at 
the  Hospice  des  Enfans  Trouves  at  Paris, 
found  that  acute  peritonitis  existed  in  about 
six  per  cent,  of  the  infants  who  died  at  that 
institution.  The  disease,  such  as  he  observed 
it,  seems  to  be  exclusively  an  affection  of 
early  infancy,  since,  though  the  hospice  con¬ 
tains  children  of  all  ages,  yet  no  child  above 
the  age  of  ten  weeks  was  attacked  by  it, 
while  thirty-five  out  of  fifty-nine  were  less 
than  a  fortnight  old.  The  previous  health 
of  the  children  had  in  some  instances  been 
good,  but  in  many  cases  the  peritonitis 
appeared  as  a  consequence  or  complication 
of  some  other  affection.  A  sudden  tympa¬ 
nitic  swelling  of  the  abdomen  was  often  thq 
first  symptom  of  the  disease,  and  was  soon 
associated  with  vomiting  of  a  greenish  mat¬ 
ter ;  which  phenomenon,  however,  was  sel¬ 
dom  of  long  continuance.  The  bowels  were 
generally  constipated  throughout,  the  respi¬ 
ration  and  pulse  soon  became  accelerated, 
and  the  heat  of  skin  increased,  while  the 
child  evidently  suffered  pain  in  the  abdomen. 

With  the  advance  of  the  disease  the  counte- 

♦ 

nance  altered,  the  skin  grew  cold,  and  the 
pulse  feeble ;  and  in  the  majority  of  cases 
the  child  died  within  twenty-four  hours, 
while  life  was  not  in  any  instance  prolonged 
beyond  the  third  day. 

The  appearances  found  after  death  were 
much  the  same  as  those  which  characterize 
peritonitis  in  the  foetus.  In  none  of  the 
sixty-three  cases  which  were  examined  was 
there  any  puriform  matter  in  the  abdominal 
cavity,  but  only  a  dirty  serous  fluid,  in  which 
flocculi  of  lymph  were  often  floating  ;  while 
the  intestines  were  more  or  less  coated  with 
false  membrane,  which  was  especially  abunT 
dant  about  the  spleen  and  liver.  Pleurisy 
was  found  associated  with  the  peritonitis  in 
a  third  of  the  cases,  and  the  frequency  of  this 
complication  is  another  point  of  resemblance 
between  the  disease  as  it  occurs  during  foetal 
life  and  in  early  infancy.  Its  causes,  too., 
appear  to  be  such  as  act  through  the  medium 
of  the  circulating  fluid  ;  for  in  seventeen  out 
of  sixty-three  cases  the  peritonitis  followed 
on  erysipelas,  and  in  lour  on  phlebitis  of  the 


*  Dela  Peritonite  chez  les  Nouveau-nds,  in  the 
Archives  Gen.  de  Med.  for  Aug.  and  Sept.  1846. 


98  ACUTE  IDIOPATHIC  PERITONITIS  A  RARE  DISEASE  IN  CHILDHOOD. 


umbilical  vein — affections  which,  it  is  known, 
are  immediately  dependent  on  epidemic 
causes,  and  are  excited  by  the  same  atmos¬ 
pheric  conditions  as  induce  puerperal  fever 
in  lying-in  women.  The  influence  of  such 
agencies  is  still  farther  shewn  by  the  fact 
that  forty-two  per  cent,  of  the  cases  of  peri¬ 
tonitis  recorded  by  M.  Thore  occurred  during 
the  months  of  April  and  May,  while  the 
Others  were  somewhat  unequally  distributed 
over  the  remainder  of  the  year. 

When  the  child  grows  older  it  is  no  longer 
so  susceptible  of  noxious  influences  as  be¬ 
fore  ;  and  when  they  come  into  play,  the 
mucous  membrane  of  the  bowels  suffers 
rather  than  their  serous  investment.  Hence 
acute  idiopathic  peritonitis  becomes  a  very 
rare  disease  in  childhood;  and  peritoneal 
inflammation  usually  occurs  as  a  sequela  of 
some  affection  which  has  been  attended  with 
considerable  alteration  in  the  circulating 
fluid.  It  sometimes  succeeds  to  an  attack 
of  scarlatina  ;  and  the  possibility  of  its  oc¬ 
currence  should  lead  us  to  look  with  great 
suspicion  upon  any  complaint  of  pain  in  the 
abdomen  made  by  children  during  their 
convalescence  from  that  disease ;  while, 
though  the  danger  of  its  supervention  after 
other  febrile  affections  is  less  considerable, 
the  risk  is  by  no  means  to  be  forgotten. 

The  symptoms  and  course  of  the  disease 
appear  to  be  much  the  same  whether  it 
occurs  as  a  primary  or  as  a  secondary  affec¬ 
tion  ;  but  there  is  a  great  difference  between 
the  severity  of  the  symptoms  and  the  amount 
of  danger  to  which  the  patient  is  exposed,  in 
different  cases. 

I  do  not  recollect  ever  to  have  witnessed 
more  intense  suffering  than  was  endured  by 
a  little  boy,  nine  years  old,  who,  after  re¬ 
covering  from  fever,  yet  seemed  to  regain 
his  health  by  but  slow  degrees,  and  had 
almost  habitual  constipation.  He  came 
under  my  notice  on  May  25,  and  was  much 
benefited  by  alterative  and  slightly  aperient 
medicines ;  when  he  was  suddenly,  and 
without  any  known  cause,  seized  on  the  3d 
of  June  with  profuse  diarrhoea,  and  severe 
pain  in  the  abdomen.  On  the  following 
day,  when  1  saw  him,  his  face  was  haggard 
and  anxious,  and  his  abdomen  excessively 
tender ;  while  the  diarrhoea  continued  even 
more  profusely  than  before.  Some  leeches 
were  applied  to  the  abdomen,  and  calomel 
and  Dover’s  powder  were  given  every  four 
hours  ;  but  the  leeches  drew  but  little  blood, 
and  though  the  purging  ceased,  the  pain  in 
the  abdomen  increased  in  severity.  On  the 
tjth  of  June  I  found  the  boy  lying  on  his 
back,  with  his  legs  stretched  straight  out; 
while  the  slightest  movement,  or  any  attempt 
to  sit  up,  produced  excruciating  pain.  The 
abdomen  was  tympanitic,  very  tender  to  the 
touch,  and  especially  so  just  below  the  um¬ 
bilicus.  The  pulse  was  frequent  and  sharp  ; 


the  tongue  moist,  and  uniformly  coated  with 
yellow  fur.  Leeches  were  again  applied,  in 
greater  numbers  than  before ;  and  the  mer¬ 
curial  was  given  every  three  instead  of  every 
four  hours.  Towards  evening  he  was  rather 
better,  but  the  pain  came  on  severely  in  the 
night,  and  was  aggravated  in  paroxysms, — 
being  referred  especially  to  the  neighbour¬ 
hood  of  the  umbilicus.  He  had  passed  no 
urine  for  many  hours,  but  only  half  a  pint 
was  drawn  off  bv  the  catheter,  and  this  was 
dark  coloured,  and  had  a  very  strong  smell. 
The  bowels  had  acted  only  once,  and  then 
scantily.  The  same  remedies  were  continued, 
but  the  child’s  conditiou  continued  to  grow 
worse  ;  and  during  the  night  he  was  in 
such  pain  that  he  frequently  shrieked  aloud 
so  as  to  alarm  the  neighbours.  On  the 
morning  of  the  7th  he  had  turned  round 
upon  his  right  side,  and  lay  with  his  knees 
drawn  up  towards  his  abdomen,  his  head 
supported  in  his  mother’s  lap, — his  face  ex¬ 
pressive  of  the  most  intense  suffering ;  and 
he  was  shrieking  frequently  with  pain.  The 
abdomen  was  much  distended,  and  so  tender 
that  it  could  not  endure  the  slightest  touch. 
The  pulse  had  become  frequent  and  thready. 
He  had  made  water  twice  of  his  own  accord. 
The  abdomen  was  now  covered  with  a  large 
blister ;  beef-tea  and  brandy  were  given  to 
support  the  vital  powers ;  and  while  the 
mercurial  was  continued,  an  endeavour  was 
made,  by  a  full  dose  of  opium,  to  procure  a 
temporary  abatement  of  the  child’s  sufferings. 
When  seen  at  6  p.m.  he  had  vomited  fre¬ 
quently  a  dark-green  fluid,  and  had  passed 
three  natural  liquid  evacuations.  He  was 
lying  in  the  same  attitude  as  before,  dozing 
with  half-closed  eyes,  his  forehead  wrinkled, 
the  corners  of  his  mouth  drawn  down,  terror 
and  pain  stamped  on  his  countenance, — 
seeming  as  if  dying,  till  roused  by  a  return 
of  pain,  when  he  called  with  loud  and  piteous 
cries  on  his  mother  for  help.  His  pulse 
was  now  smaller,  and  more  thready.  Dur¬ 
ing  the  night  his  sufferings  were  unceasing  ; 
towards  morning  he  became  quieter,  and  died 
quietly  at  9  a.m.,  on  June  the  8th. 

On  opening  the  abdomen,  thin  pus,  un¬ 
mixed  with  lymph,  poured  forth  in  great 
abundance.  It  quite  concealed  the  intestines 
from  view,  and  must  have  amounted  to  at 
least  a  quart.  The  peritoneum  lining  the 
abdominal  walls  was  highly  vascular,  espe¬ 
cially  in  the  hypogastric  region  ;  that  cover¬ 
ing  the  intestines  had  lost  its  natural  trans¬ 
parency,  was  softer,  and  seemed  thicker,  but 
not  much  injected.  There  was  no  lymph 
effused  on  any  part  of  the  parietal  perito¬ 
neum,  nor  were  there  any  adhesions  between 
the  intestines  ;  but  the  spleen  and  liver,  the 
latter,  especially  on  its  convex  surface,  were 
coated  with  lymph.  The  whole  tract  of  the 
intestines  was  examined  with  great  care,  and 
was  found  to  be  quite  healthy ;  the  mucous 


GENERAL  PERITONITIS  VERY  RARE  IN  CHILDHOOD. 


99 


membrane  being  rather  pale.  There  was 
some  crude  tuberculous  matter  in  the  mesen¬ 
teric  glands.  The  right  side  of  the  chest 
contained  a  pint  of  pus,  similar  to  that  in 
the  abdomen  ;  the  pleura  presented  a  general 
intense  vascularity,  especially  remarkable  in 
that  lining  the  diaphragm  ;  and  there  was  a 
patch  of  lymph,  of  small  extent,  forming  a 
connection  between  the  two  surfaces  of  the 
lung ;  while  the  right  lung  generally  had  a 
rather  thick  coating  of  false  membrane. 
Some  tubercles  in  the  bronchial  glands,  and 
a  compressed  state  of  the  substance  of  the 
right  lung,  formed  the  rest  of  the  morbid 
appearances. 

There  can  be  no  doubt  but  that  in  the 
early  stages  of  this  case  a  more  active  plan 
of  treatment  ought  to  have  been  adopted. 
It  is  related,  however,  not  as  an  illustration 
of  the  therapeutical  principles  by  which  you 
should  be  guided,  but  as  affording  a  remark¬ 
ably  good  specimen  of  the  symptoms  of  acute 
peritonitis.  The  inflammation  of  the  pleura 
was  doubtless  secondary  to  that  of  the  peri¬ 
toneum,  and  the  effusion  into  the  cavity  of 
the  chest  probably  coincided  with  the  time 
when  the  child  assumed  the  position  on  his 
right  side.  We  learn  from  this  case,  that 
pain,  coming  on  suddenly,  referred  particu¬ 
larly  to  one  part  of  the  abdomen,  but  ex¬ 
tending  over  the  whole,  greatly  aggravated 
on  pressure,  or  on  the  slightest  movement, 
so  as  to  compel  the  patient  to  remain  in  the 
recumbent  posture,  with  the  legs  extended 
and  motionless,  characterize  the  disease. 
The  abdomen  before  long  becomes  tympani¬ 
tic,  and  this  tympanites,  if  considerable, 
greatly  aggravates  the  patient’s  sufferings. 
The  state  of  the  bowels  varies  :  frequently 
they  are  relaxed  at  the  outset  of  the  illness, 
sometimes  they  continue  so  throughout, 
while  they  are  but  rarely  constipated. 
Vomiting  is  not  a  constant  symptom,  and 
when  it  does  occur,  the  irritability  of  the 
stomach  varies,  both  in  its  degree  as  well  as 
in  the  time  at  which  it  appears.  The  symp¬ 
toms  sometimes  continue  to  increase  in  seve¬ 
rity  until  death  takes  place ;  at  other  times 
they  undergo  a  sudden  diminution,  or  even 
cease  altogether,  though  this  seeming 
amendment  is  attended  or  rapidly  followed 
by  sinking  of  the  vital  powers,  and  soon 
afterwards  by  the  patient’s  death. 

Fortunately  cases  of  general  peritonitis 
are  very  rare  in  childhood,  and  still  rarer  is 
their  termination  by  the  effusion  of  pus  into 
the  cavity  of  the  abdomen.  Even  under 
these  apparently  hopeless  circumstances, 
however,  nature  does  sometimes  make  an 
effort  at  cure.  The  active  symptoms  dimi¬ 
nish  in  intensity  ;  the  abdominal  parietes 
grow  thin  at  some  spot,  at  wh  ch  a  passage 
at  length  is  formed  through  which  the  pus 
is  discharged,  and  recovery  sometimes  slowly 
follows  ;  the  result  of  a  process  precisely 


analogous  to  that  which  nature  has  recourse 
to  in  pleurisy,  when  she  brings  about  the 
evacuation  of  the  fluid  through  an  opening 
spontaneously  formed  in  the  parietes  of  the 
thorax.  An  instance  of  the  cure  of  a  case 
of  peritonitis,  in  a  child  seven  years  old,  was 
related  by  Dr.  Aldis,  at  a  meeting  of  the 
Medico- Chirurgical  Society,  in  Nov.  1846  ;* 
a  few  similar  cases  may  be  found  in  medical 
journals  and  one  has  come  under  my 
own  observation,  in  the  person  of  a  little 
girl,  whose  history  I  related  in  the  seventh 
lecture,  as  affording  an  illustration  of  that 
rare  affection,  inflammation  of  the  sinuses  of 
the  dura  mater. 

The  peritoneal  inflammation  which  comes 
on  during  scarlatinal  dropsy  is  not  in  gene¬ 
ral  of  a  very  active  character,  and  seldom 
produces  any  morbid  appearance  of  greater 
gravity  than  numerous  slight  adhesions  be¬ 
tween  the  intestines.  It  generally  succeeds 
to  ascites,  and  the  abdominal  affection 
seldom  exists  alone,  but  is  usually  associated 
with  pleurisy,  and  abundant  serous  effusion 
into  the  chest,  and  the  symptoms  of  disease 
of  the  respiratory  organs  very  often  mask 
those  of  the  abdominal  inflammation,  which 
latter,  indeed,  seems  in  many  instances  to 
have  but  a  very  subsidiary  share  in  bringing 
about  the  patient’s  death. 

Besides  those  cases  in  which  the  peritoni¬ 
tis,  whatever  be  its  intensity,  is  general,  there 
are  others  in  which  the  inflammation  is  cir¬ 
cumscribed  to  a  part,  and  sometimes  but  a 
small  part  of  the  peritoneum.  Now  and 
then  peritonitis  affecting  only  a  very  small 
extent  of  surface  proves  rapidly  fatal, 
(though  no  such  instance  has  come  under 
my  own  notice)  ;  but  usually  there  is  a  cor¬ 
respondence  between  the  severity  of  the 
symptoms  and  the  extent  of  the  disease.  I 
imagine  the  inflammation  to  have  been  cir¬ 
cumscribed  in  some  cases,  in  which  the 
principal  pain  was  referred  to  one  part  of 
the  abdomen,  while  the  tenderness  was 
almost  limited  to  that  situation,  in  which, 
moreover,  the  abdomen  did  not  become 
generally  tense  or  tympanitic,  and  all  the 
symptoms  yielded  with  tolerable  readiness 
to  the  employment  of  remedies,  though  the 
disposition  to  pain  and  tenderness  in  one 
spot  was  some  time  before  it  wholly  disap¬ 
peared. 

Lastly,  some  notice  must  be  taken  of  a 
highly  dangerous  form  of  peritonitis,  circum¬ 
scribed  in  some  cases,  but  general  in  others, 
which  succeeds  to  inflammation  of  the 

*  Reported  in  Medical  Gazette,  Nov.  1846. 

t  For  instance,  Bernhardi,  in  Preuss.  Med. 
Zeitung,  1842,  No.  10;  and  Beyer,  Casper’s 
Wochenschr.  1842,  No.  5.  This  termination  is 
probably  less  rare  in  the  peritonitis  of  puerperal 
women,  than  under  any  other  circumstances.  See 
a  paper  by  Dr.  Sampson  v.  Himmelstiern,  in  the 
Nene  Zeitschr.  f.  Geburtskunde,  vol.  xiv.  p. 
446. 


100 


treatment  of  acute  peritonitis. 


ccacum ,  or  of  its  vermiform  appendix. 
This  affection,  however,  is  not  so  common 
in  early  life  as  in  adult  age,  and  the  same 
symptoms  characterize  it  in  either  ca«e,  so 
that  no  lengthened  description  of  it  will  be 
necessary.  It  has  only  once  come  under 
my  observation,  and,  in  that  instance, 
although  the  inflammation  had  produced 
gangrene  of  the  mucous  membrane  of  the 
appendix,  and  a  sloughing  opening  of  com¬ 
munication  between  it  and  an  abscess  in  the 
cellular  tissue  behind  the  caecum,  yet  no 
intestinal  concretion  or  other  foreign  body 
was  discovered,  to  the  lodgment  of  which, 
in  the  appendix,  the  disease  could  be  attri¬ 
buted.  All  the  viscera  in  the  right  half  of 
the  abdomen  were  thickly  coated  with 
lymph,  but  the  inflammation  had  not  at  all 
involved  the  parietal  peritoneum,  nor  ex¬ 
tended  to  the  intestines  on  the  left  of  the 
mesial  line.  Acute  pleurisy,  however,  ex¬ 
isted  on  the  right  side,  which  had  given 
rise  to  the  effusion  of  nearly  three  pints 
of  milky  serum.  The  patient  was  a  little 
boy,  only  seven  years  old,  whose  health  had 
been  habitually  good,  when  he  began  to 
complain,  on  the  5th  of  July,  of  pain  in  the 
abdomen,  and  was  attacked  at  the  same  time 
with  violent  purging  and  vomiting.  The 
purging  ceased  in  the  course  of  a  few  hours, 
but  the  vomiting  continued  at  the  time  of 
my  seeing  him  on  July  8,  when  he  likewise 
complained  of  great  pain,  and  of  exquisite 
tenderness  in  the  right  hypochondriac  re¬ 
gion.  Leeches  were  twice  applied  in  that 
situation,  and  with  manifest  relief,  and 
calomel  and  opium  were  given  every  three 
hours.  In  the  night  of  the  10th  an  aggra¬ 
vation  of  the  symptoms  took  place,  and 
auscultation  detected  a  friction  sound  in  the 
right  side  of  the  chest.  Cupping  beneath 
the  right  scapula  was  followed  by  very 
marked  improvement:  he  rested  well  on 
the  night  of  the  11th;  and  on  the  12th,  he 
not  only  breathed  without  difficulty,  but 
was  free  from  pain  in  the  hypoohondrium, 
except  on  pressure,  and  the  sickness  had 
completely  ceased.  An  aggravation  of  his 
symptoms,  however,  occurred  during  the 
night ;  on  the  13th,  he  had  changed  his  at¬ 
titude,  and  was  now  lying  on  his  right  side, 
instead  of  on  his  back — a  posture  which  he 
retained  till  his  death.  A  marked  fulness 
was  now  apparent  on  the  right  side,  extend¬ 
ing  from  the  crest  of  the  ilium  to  the  ribs. 
On  the  ensuing  day  this  part  was  not  merely 
full  and  tender,  but  exceedingly  firm  to  the 
touch  ;  a  condition  which  existed  throughout 
the  whole  lumbar  region,  and  extended  for¬ 
ward  to  about  two  inches  to  the  right  of  the 
linea  alba.  The  bowels  were  at  no  time 
much  constipated,  and  after  the  administra¬ 
tion  of  an  aperient  on  the  12th,  they  acted 
several  times  each  day,  the  motions  being 
relaxed,  but  otherwise  natural.  Sickness 


returned  on  the  13th,  and  during  the  last 
two  days  of  the  child’s  life  was  almost  con¬ 
stant — a  symptom  which  the  great  thirst 
that  existed  during  the  whole  course  of  the 
illness  rendered  ihe  more  distressing.  On 
the  12th,  there  were  physical  signs  of  some 
effusion  into  the  chest,  which  had  increased 
so  much  before  death  that  the  right  half  of 
the  chest  was  manifestly  enlarged,  and  the 
intercostal  spaces  on  that  side  were  very 
prominent.  Auscultation,  however,  of  the 
back  of  the  chest  was  impossible  for  some 
days,  owing  to  the  acute  pain  produced  by 
any  movement.  The  breath  grew  very 
short ;  the  flesh  wasted  rapidly ;  the  face 
was  habitually  expressive  of  distress,  and  at 
night  delirium  came  on.  On  the  16th,  after 
a  most  wretched  night,  his  pulse  became 
very  feeble,  and  his  extremities  cold,  while 
the  vomiting  was  incessant.  Convulsions 
came  on,  and  lasted  for  six  hours,  when 
they  ceased,  and  two  hours  afterwards  the 
child  died  tranquilly,  on  the  eleventh  day 
from  the  first  sign  of  indisposition.  The  mer¬ 
curial  treatment  had  been  continued  all 
along,  the  opium  being  increased  as  the  in¬ 
tensity  of  the  child’s  sufferings  seemed  to 
require,  and  four  days  before  death  the  in¬ 
unction  of  a  drachm  of  strong  mercurial  oint¬ 
ment  every  four  hours  was  begun  ;  but  no 
effect  seemed  to  be  produced  by  the  reme¬ 
dies. 

The  indication  for  treatment  in  cases  of 
acute  peritonitis,  are  so  clear,  that  it  would 
be  superfluous  to  occupy  much  time  in  lay¬ 
ing  down  rules  for  your  guidance.  You 
have  to  deal  with  the  active  inflammation  of 
parts  in  which  acute  disease  cannot  go  on. 
long  without  destroying  life.  Depletion, 
both  general  and  local,  and  the  employment 
of  mercury,  combined  with  opium  or  Dover’s 
powder,  in  order  to  mitigate  the  suffering 
which  attends  on  the  disease,  are  the  reme¬ 
dies  to  which  you  must  have  recourse,  and 
which  you  must  employ  with  an  unsparing 
hand.  When  the  abdominal  tenderness  has 
been  mitigated  by  bleeding,  a  warm  poultice 
frequently  renewed  will  often  afford  con¬ 
siderable  comfort ;  and  in  some  cases  of 
local  peritonitis  I  have  seen  the  warm  hip¬ 
bath  give  much  relief.  The  error  into  which 
you  are  likely  to  fall  in  the  management  of 
these  cases  is  not  that  of  pursuing  a  wrong 
course,  but  of  following  the  right  one  with 
too  little  vigour. 

In  the  peritonitis  that  follows  scarlatina, 
the  symptoms  are  often  less  urgent  than 
under  other  circumstances  ;  but  you  will 
bear  in  mind,  that  when  the  function  of  the 
kidneys  is  disturbed,  and  urea  is  circulating 
in  the  blood,  the  serous  membranes  are  very 
apt  to  become  inflamed,  and  you  will,  there¬ 
fore,  keep  on  the  look  out  for  any  indication 
of  their  suffering.  I  shall  hereafter  have  to 
point  out  to  you,  that  in  this,  as  well  as  in 


CHRONIC  PERITONITIS  ALMOST  ALWAYS  A  TUBERCULAR  DISEASE.  101 


so  many  other  cases,  prevention  is  not  only 
better  but  easier  than  cure ;  and  that  if  on 
the  first  appearance  of  the  dropsy  consecu¬ 
tive  on  scarlet  fever,  you  have  recourse  to 
active  antiphlogistic  measures,  you  will  in 
the  large  majority  of  cases  escape  the  risk 
of  these  secondary  inflammations. 

Acute  peritonitis,  like  the  acute  inflam¬ 
mation  of  any  other  tissue,  may  subside,  but 
not  altogether  cease ;  it  may  pass  into  a 
chronic  state,  and  the  patient  may  suffer 
from  the  consequences  of  the  disease  long 
after  the  disease  in  its  original  form  has  dis¬ 
appeared.  But  it  is  not  to  an  affection  of 
this  kind  that  I  wish  to  call  your  attention  in 
speaking  of  chronic  peritonitis ;  but  to  a 
disease,  the  progress  of  which  from  its  com¬ 
mencement  has  been  slow,  which  is  weeks  or 
months  in  running  its  course,  but  which 
yet  demands  our  closest  attention,  since  in  a 
very  large  number  of  cases  that  course  is  to 
a  fatal  issue. 

It  is  not,  however,  its  tardy  progress 
which  alone  distinguishes  the  chronic  from 
the  acute  inflammation  of  the  peritoneum, 
but  the  former  is  almost  invariably  associated 
with  the  tuberculous  cachexia,  and,  indeed, 
generally  succeeds  to  the  deposit  of  tubercle 
upon  the  serous  memhrane  of  the  abdomen. 
The  occasional  recovery  of  a  child  in  whom 
the  symptoms  of  chronic  peritonitis  have  ex¬ 
isted,  by  no  means  disproves  that  connection 
between  it  and  phthisical  disease  of  which 
an  examination  of  the  body  after  death  in 
fatal  cases  affords  such  convincing  proof. 

The  bodies  of  children  who  have  died  of 
this  affection  are  usually  found  to  be  ex¬ 
ceedingly  emaciated,  and  their  face  retains 
after  death  the  suffering  expression  which 
it  has  w'orn  during  their  protracted  illness. 
The  lungs  and  bronchial  glands  contain 
tubercle  in  greater  or  less  abundance,  and 
the  pulmonary  disease  is  sometimes  so  far 
advanced  as  to  have  obviously  had  no  small 
share  in  bringing  about  the  fatal  event.  On 
dividing  the  abdominal  parietes,  long  slen¬ 
der  cellular  adhesions  are  often  found  con¬ 
necting  the  peritoneum  to  the  subjacent 
viscera.  The  intestines,  too,  ax-e  found  con¬ 
nected  by  adhesions,  some  of  which  are  very 
easily  broken  down,  while  others  are  so  firm 
that  the  coats  of  the  bowels  give  way  in  the 
attempt  to  separate  them.  This  difference 
does  not  depend  on  the  age  of  the  adhesions, 
(although  in  this  respect  they  vary  greatly, 
some  being  apparently  of  very  recent  date, 
Others  of  long  standing),  so  much  as  on  their 
nature.  Those  connections  which  are  formed 
by  the  mereeffusionof  lymph,  even  when  from 
age  they  have  acquired  considerable  firmness, 
can  generally  be  broken  down  without  much 
difficulty;  and  at  any  rate  the  attempt  will 
not  produce  any  rupture  of  the  intestines. 
When,  however,  different  portions  of  the 
bowels  are  matted  together  so  inseparably 


that  it  is  easier  to  lacerate  than  to  detach  them 
from  each  other,  it  will  be  found  that  some¬ 
thing  more  than  the  mere  effusion  of  lymph 
has  produced  this  union.  It  will  be  seen  to 
have  been  effected  by  means  of  a  yellow 
granular  matter,  like  that  which  connects 
the  opposite  surfaces  of  the  arachnoid  in  a 
case  of  tubercular  hydrocephalus,  and  made 
up  like  it  in  part  of  lymph,  in  part  of  tuber¬ 
cular  deposits.  Adhesions  are  thus  formed 
between  the  opposite  surfaces  of  peritoneum, 
at  first  of  small  extent,  but  fresh  deposits  of 
tubercle  soon  take  place  in  the  vicinity,  and 
the  attendant  inflammatory  process  unites 
together  a  still  greater  extent  of  intestine. 
Nor  is  this  all ;  but  in  time  the  tubei-cle  thus 
deposited  undergoes  a  process  of  softening, 
in  the  course  of  which  the  muscular  tissue 
of  the  intestines  becomes  destroyed,  and 
their  mucous  membrane  may  thus  eventually 
be  perforated,  so  that  distant  parts  of  the 
intestinal  canal,  which  at  first  were  merely 
adherent  together,  are  sometimes  brought  by 
this  means  into  direct  communication  wiih 
each  other.  The  abdomen  generally  con¬ 
tains  a  small  quantity  of  ti’ansparent  serum, 
but  if,  as  sometimes  happens,  life  should 
have  been  cut  short  by  the  supervention  of 
acute  peritonitis  upon  the  old  disease,  the 
effusion  may  be  of  a  puriform  or  sero- 
purulent  character. 

In  addition  to  the  evidences  of  inflamma¬ 
tory  action  presented  by  the  peritoneum, 
that  membrane  and  the  various  abdominal 
viscera  are  the  seat  of  a  more  or  less  gene¬ 
rally  diffused  tubercular  deposit.  The  sur¬ 
face  of  the  peritoneum  lining  the  abdominal 
walls  is  sometimes  abundantly  beset  with 
small,  grey,  semi-transparent  granulations  ; 
but  in  the  majority  of  cases  the  tuberculiza¬ 
tion  is  less  general,  and  the  parietal  perito¬ 
neum  is  less  affected  than  other  parts  of  the 
membrane.  That  part  of  the  peritoneum 
which  lines  the  diaphragm,  or  the  abdo¬ 
minal  w’alls  in  the  immediate  vicinity  of 
the  spleen,  is  one  of  the  favourite  seats  of 
tubercular  deposit,  which  in  these  situa¬ 
tions  generally  assumes  the  form  of  small 
yellow  miliary  tu  ercles,  not  that  of  grey 
granulations.  In  some  instances  the  omen¬ 
tum  is  the  seat  of  the  chief  tubercular  de¬ 
posit ;  and  though  it  usually  assumes  the 
miliary  form,  yet  now  and  then  masses  of 
crude  tubercle  of  considerable  size  are  met 
with  in  this  situation.  The  peritoneum 
covering  the  liver  and  spleen  seldom  fails  to 
shew  an  abundant  deposit  of  tubercle ;  and 
tubercles  usually  abound  in  the  substance  of 
the  latter  organ.  The  mesenteric  glands 
likewise  are  tuberculous,  though  the  degree 
of  their  degeneration,  and  the  size  which 
they  have  in  consequence  attained,  vary 
much  in  different  cases.  The  same  remark 
holds  good  with  reference  to  the  amount  of 
tubercular  disease  in  the  interior  of  the 


102 


SYMPTOMS  OF  CHRONIC  PERITONITIS 


intestines,  which,  though  in  many  cases 
very  considerable,  yet  bears  no  invariable 
relation  either  to  the  degree  of  the  affection 
of  the  peritoneum,  or  to  that  of  the  mesen¬ 
teric  glands. 

In  cases  of  this  affection,  those  vague  in¬ 
dications  of  decaying  health  which  charac¬ 
terise  the  early  stages  of  the  tuberculous 
cachexia  often  precede  any  symptom  of 
special  disorder  of  the  abdominal  viscera. 
But  this  is  not  always  the  case  ;  for  in  some 
instances  the  child  begins,  without  any  pre¬ 
vious  indisposition,  to  complain  of  occasional 
pains  in  the  abdomen,  which  last  but  for  a 
moment,  and  which  cause  the  less  anxiety, 
from  the  appetite  being  good,  the  bowels 
regular,  and  the  general  cheerfulness  undis¬ 
turbed.  In  the  course  of  a  short  time, 
however,  the  appetite  fails,  or  becomes 
capricious ;  the  bowels  begin  to  act  irregu¬ 
larly,  being  alternately  constipated  and 
relaxed,  while  the  motions  are  usually  un¬ 
natural  in  character — dark,  loose,  and  slimy. 
The  child  now  grows  restless  and  feverish  at 
night,  its  thirst  is  considerable,  and  the  ab¬ 
dominal  pain  becomes  both  more  severe  and 
more  frequent  in  its  recurrence.  Sometimes 
the  stomach  grows  very  irritable,  and  food 
taken  is  then  occasionally  vomited ;  but 
this  symptom  is  often  absent;  while  the 
tongue,  throughout  the  early  stages  of  the 
affection,  continues  for  the  most  part  clean 
and  moist,  and  deviates  but  little  from  its 
appearance  in  health.  The  symptoms  just 
enumerated  seldom  continue  long  without 
being  accompanied  with  a  marked  change  in 
the  size  of  the  abdomen,  and  sometimes  the 
alteration  in  the  abdomen  takes  place  rather 
suddenly,  and  is  one  of  the  earliest  signs  of 
the  affection  from  which  the  child  is  suffer¬ 
ing.  The  abdomen  becomes  large,  tense, 
and  tympanitic,  while  its  parietes  often  seem 
glued  to  the  subjacent  viscera,  and  that 
manipulation  which  causes  no  discomfort, 
even  when  practised  somewhat  roughly  cn 
the  big  abdomen  of  a  rickety  child,  is  sure 
to  occasion  uneasiness,  often  even  considera¬ 
ble  pain,  when  tried  with  ever  so  much 
gentleness  in  the  child  suffering  from  chronic 
peritonitis. 

In  this  as  in  other  forms  of  tubercular 
disease,  the  progress  from  bad  to  worse 
seldom  goes  on  uninterruptedly.  Pauses 
take  place  in  its  course,  though  each  time 
they  become  shorter,  and  signs  of  amend¬ 
ment  now  and  then  appear,  but  they,  too, 
promise  less  and  less  with  each  return. 
The  child  loses  flesh  ;  the  face  grows  pale 
and  sallow,  and  anxious  ;  the  skin  becomes 
habitually  dry,  and  hotter  than  natural,  and 
the  pulse  is  permanently  accelerated.  The 
abdomen  does  not  grow  progressively  larger, 
but  it  becomes  more  and  more  tense,  al¬ 
though  its  tension  varies  without  any  evi¬ 
dent  cause,  and  sometimes  disappears  for  a 


day  or  two,  to  return  again  as  causelessly  as 
it  disappeared.  When  the  tension  is  dimi¬ 
nished,  the  abdomen  yields  a  solid  and 
doughy  sensation,  and  the  union  between 
the  contents  of  the  abdomen  and  the  abdo¬ 
minal  walls  becomes  very  perceptible.  The 
superficial  abdominal  veins  now  become 
enlarged  in  many  instances,  and  the  skin 
grows  rough,  and  looks  as  if  it  were  dirty. 
The  pain  in  the  bowrels  retains  the  same 
colicky  character  as  before,  but  it  returns 
very  frequently,  and  is  sometimes  exceed¬ 
ingly  severe,  wrhile  the  child  is  never  free 
from  a  sense  of  uneasiness.  The  tenderness 
of  the  abdomen,  however,  but  seldom  in¬ 
creases  in  proportion  to  the  increase  of  pain. 
The  bowels  are  in  general  habitually  re¬ 
laxed,  though  the  degree  of  the  diarrhoea, 
as  well  as  the  severity  of  the  abdominal  pain, 
vary  much  in  different  cases.  As  the  dis¬ 
ease  advances,  the  child  becomes  confined  to 
bed,  and  is  at  length  reduced  to  a  state  of 
extreme  weakness  and  emaciation.  Death 
is  often  hastened  by  the  concomitant  affec¬ 
tion  of  the  lungs ;  but,  should  this  not  be 
the  case,  the  patient  may  continue  for  many 
weeks  in  the  same  condition,  till  life  is  de¬ 
stroyed,  after  a  day  or  two  of  increased 
suffering,  by  some  renewed  attack  of  peri¬ 
toneal  inflammation. 

Some  of  you  have  probably  been  struck 
by  the  many  points  of  resemblance  between 
the  symptoms  that  have  just  been  described 
and  those  which  are  often  enumerated  as 
characteristic  of  mesenteric  disease.  Nor  is 
it  at  all  surprising  that  a  very  close  analogy 
should  subsist  between  chronic  peritonitis 
and  tabes  mesenterica,  since  not  only  are 
both  affections  the  results  of  the  tubercular 
cachexia,  but  in  both  the  abdominal  viscera 
are  chiefly  involved  in  the  disease,  and  both 
are  in  consequence  characterised  by  a  re¬ 
markable  impairment  of  the  functions  of 
nutrition.  It  was  natural,  too,  that  in 
former  times,  when  morbid  anatomy  was 
less  carefully  cultivated  than  at  present,  the 
attention  of  the  observer  should  have  been 
chiefly  drawn  to  the  increased  size  and 
altered  structure  of  the  mesenteric  glands — 
appearances  which  must  have  been  often 
discovered  on  an  examination  of  the  bodies 
of  children  who  had  died  after  a  slow  wast¬ 
ing  of  their  flesh,  attended  with  more  or  less 
enlargement  of  the  abdomen  and  disturbance 
of  the  bowels.  The  physiology  of  those 
days,  too,  knew  of  no  means  whereby  the 
absorption  of  the  chyle  could  be  effected 
except  through  the  medium  of  the  mesen¬ 
teric  glands  ;  and  the  coarse  appliances 
which  then  subserved  the  purposes  of  ana¬ 
tomical  investigation  did  not  suffice  to  shew 
that,  even  when  these  glands  outwardly 
present  a  considerable  degree  of  tuberculiza¬ 
tion,  their  lymphatics  in  many  instances  are 
still  pervious. 


TREATMENT  OF  CHRONIC  PERITONITIS  AND  TABES  MESENTERICA.  103 


We  know  that  the  nutrition  of  children 
is  often  much  impaired  from  other  causes 
besides  tubercular  di  ease ;  and  that,  when 
the  digestive  organs  perform  their  functions 
ill,  nothing  is  more  common  than  for  the 
abdomen  greatly  to  exceed  its  natural  size. 
Our  predecessors  had  observed  similar  facts  ; 
but,  from  the  imperfection  of  their  physio¬ 
logical  knowledge,  they  drew  from  them 
erroneous  conclusions.  Disease  of  the  me¬ 
senteric  glands  was  in  their  eyes  the  almost 
exclusive  cause  of  the  atrophy  of  children, 
and  a  preternatural  enlargement  of  the.  belly 
was  looked  upon  by  them  as  an  almost  in¬ 
fallible  sign  that  such  disease  had  already 
begun.  Tabes  mesenterica  was  consequently 
regarded  as  a  very  common  affection  ;  and 
though  its  frequency  is  now  well  known  to 
have  been  much  overrated,  yet  the  appear¬ 
ance  of  those  symptoms  that  were  once 
supposed  to  be  characteristic  of  it,  still 
excites  much  needless  alarm  among  non¬ 
professional  persons. 

The  mere  presence  of  tubercle  in  the 
mesentery  is,  it  must  be  owned,  of  very 
common  occurrence,  since  MM.  Rilliet  and 
Barthez  met  with  it  in  nearly  half  of  all 
children  in  whom  that  morbid  deposit  existed 
in  some  or  other  of  their  viscera.  But 
though  the  existence  of  tubercle  in  the 
glands  be  thus  frequent,  its  presence  in  any 
considerable  quantity  is  extremely  rare, 
since,  according  to  the  same  authorities,  it 
was  found  in  abundance  only  in  1  out  of 
every  16  children,  some  of  whose  organs 
contained  tubercle. 

The  general  character  of  tuberculous  me¬ 
senteric  glands  is  much  the  same  with  that 
of  tuberculous  bronchial  glands,  but  the 
former  are  usually  surrounded  by  a  more 
delicate  cyst;  and  although  their  size  seldom 
exceeds  that  of  a  chesnut,  yet  they  occa¬ 
sionally  undergo  a  degree  of  development 
which  far  exceeds  that  of  tuberculous  bron¬ 
chial  glands,  and  three  or  four  of  them 
coalescing  together,  sometimes  form  a  mass 
as  big  as  the  fist,  or  even  bigger. 

The  effects  produced  even  by  an  advanced 
degree  of  tuberculization  of  the  mesenteric 
glands  are  smaller  than  might  be  anticipated, 
and  much  smaller  than  those  which  result 
from  a  considerably  less  amount  of  disease 
of  the  bronchial  glands.  Nor  will  this  at  all 
surprise  us,  if  we  bear  in  mind  the  difference 
between  their  anatomical  relations.  The 
bronchial  glands  are  not  merely  situated  in  a 
cavity  which  is  bounded  by  comparatively 
unyielding  parietes,  but  the  viscera  with 
which  they  are  in  contact  are  solid  and  re¬ 
sisting,  and  they  are,  moreover,  adherent  to 
the  trachea  and  the  larger  air-tubes,  so  that 
any  increase  of  their  size  is  sure  to  produce 
compression  of  parts  whose  functions  are  of 
vital  importance.  The  mesenteric  glands, 
on  the  contrary,  are  contained  in  a  cavity 


whose  yielding  walls  allow  them  to  increase 
readily  in  size,  while  the  loose  attachments 
of  the  mesentery  still  further  permit  them  to 
attain  even  to  considerable  dimensions,  with¬ 
out  their  pressing  upon  any  viscus,  so  that 
it  is  an  exceedingly  unusual  occurrence  for 
them  to  cause  the  perforation  of  any  part  of 
the  intestines,  or  even  for  them  to  contract 
adhesions  to  their  exterior. 

To  these  causes  it  must  he  attributed  that 
there  is  no  symptom  pathognomonic  of 
tubercle  of  the  mesenteric  glands,  except 
their  being  perceptible  through  the  abdo¬ 
minal  parietes.  This,  however,  they  never 
are  during  the  early  stage  of  the  affection ; 
and  though  on  one  or  two  occasions  I  have 
felt  a  tumor  in  the  abdomen,  which,  from 
its  being  associated  with  the  evidences  of 
tuberculous  disease  in  other  organs,  I  have 
been  led  to  attribute  to  the  enlarged  mesen¬ 
teric  glands,  yet  in  these  cases  I  have  not 
had  the  opportunity  of  confirming  the  diag¬ 
nosis  by  an  examination  after  death.  There 
can,  however,  be  no  doubt  but  that  they  do 
become  perceptible  through  the  abdominal 
walls,  though  at  a  season  when,  their  cure 
being  hopeless,  little  practical  use  can  be 
made  of  the  certainty  of  our  diagnosis.  In 
its  earlier  stages,  no  symptoms  at  all  are 
present,  or  only  the  indications  of  that  ge¬ 
neral  tuberculous  disease  of  which  the  affec¬ 
tion  of  the  mesentery  is  usually  but  a  subor¬ 
dinate  part.  At  a  later  period,  when  the 
disorder  of  the  digestive  organs  attracts 
attention,  the  symptoms  are  generally  much 
the  same  with  those  of  chronic  peritonitis, 
save  that,  if  the  peritoneum  be  free  from 
disease,  the  abdomen  is  in  most  cases  both 
less  tense  and  less  tender. 

I  the  less  regret  that  so  little  time  remains 
for  the  consideration  of  the  treatment  of 
chronic  peritonitis  and  of  tabes  mesenterica , 
since  the  subject  may  be  dismissed  in  a  few 
words.  In  each  of  these  affections  two 
periods  may  be  distinguished.  During  the 
first,  while  our  diagnosis  is  still  uncertain, 
general  principles  guide  our  conduct,  and 
lead  us  to  subject  the  child  to  the  same 
dietetic  and  hygienic  management  as  we 
should  adopt  if  we  feared  the  approach  of 
any  other  form  of  phthisis.  In  the  second 
period,  the  advancing  mischief  has  removed 
all  doubt  from  our  minds,  but  at  the  same 
time  has  chased  all  hope  from  our  spirits ; 
and  we  now  minister  to  symptoms  as  they 
arise,  and  try  to  mitigate  sufferings  which 
we  cannot  cure. 

The  dyspeptic  symptoms,  the  unhealthy 
appearance  of  the  evacuations,  and  the  fre¬ 
quency  with  which  diarrhoea  occurs,  enforce 
the  necessity  for  the  diet  being  as  mild  and 
unstimulating  as  possible.  The  abdominal 
pain  which  is  experienced  in  tubercular 
peritonitis  is  almost  always  relieved  by  the 
application  of  a  few  leeches  ;  but  even  local 


104  MR.  SIBSON  ON  GASTRO-INTESTINAL  DISTENSION  OF  THE  LIVER. 


depletion  must  not  be  practised  without  | 
absolute  necessity  ;  and  in  many  instances  a 
large  poultice  to  the  abdomen,  frequently 
renewed,  will  remove  pain,  the  severity  of 
which  had  seemed  at  first  to  call  for  the 
abstraction  of  blood.  The  logwood  and 
catechu  mixture  mentioned  in  the  last  lec¬ 
ture  is  one  of  the  best  astringents  that  can 
be  employed  to  check  the  over- action  of  the 
bowels.  Sulphate  of  iron  and  opium,  in 
the  form  either  of  pills  or  mixture,  may  be 
used  if  the  diarrhoea  be  very  obstinate, 
though  we  may  be  compelled  to  abandon 
their  use,  from  finding  that  they  aggravate 
the  patient’s  symptoms ;  but  I  have  not  ob¬ 
served  the  mere  suppression  of  the  diarrhoea 
by  astringents  to  be  followed  by  any  exacer¬ 
bation  of  the  other  abdominal  symptoms. 
Astringents,  however,  are  far  from  being  the 
only  remedies  to  be  employed ;  but  mer¬ 
curials  in  a  mild  form,  and  continued  for  a 
long  period,  have  often  seemed  to  be  of 
much  service.  When  the  tenderness  of  the 
abdomen  has  been  sufficiently  relieved  to 
admit  of  it,  I  generally  direct  the  use  of  a 
liniment  twice  a  day,  consisting  of  the  Lini- 
mentum  Hydrargyri,  soap  liniment,  and 
olive  oil,  in  equal  parts,  which  has  seemed 
useful  as  a  counter-irritant  even  independent 
of  the  mercury,  which  enters  into  its  com¬ 
position  ;  besides  which  I  give  equal  parts 
of  the  Hydr.  c.  Creta  and  Dover’s  powder 
once  or  twice  a  day.  The  Dover’s  powder 
prevents  the  mercurial  from  irritating  the 
bowels,  and  also  allays  the  restlessness  and 
feverishness  at  night — an  end  to  which  the 
use  of  the  tepid  bath  every  evening  likewise 
conduces,  often  in  an  eminent  degree.  The 
comfort  of  the  child  is  often  much  pro¬ 
moted  by  wearing  a  well-adapted  flannel 
bandage  over  the  abdomen  both  by  night  as 
well  as  by  day,  and  the  support  it  affords 
may  be  increased  with  advantage  by  a  piece 
of  thin  whalebone  at  either  side. 

If  diarrhoea  be  absent,  or  if,  though  it 
be  present  in  a  slight  degree,  the  skin  be 
very  hot  and  dry,  and  the  child  very  thirsty 
and  feverish,  the  tepid  bath,  the  mercurial 
with  Dover’s  powder,  and  small  doses  of 
liquor  potassae  and  ipecacuanha,  are  the 
remedies  on  which  I  chiefly  rely,  and  to  this 
the  extract  of  dandelion  may  often  be  added 
with  advantage.  If  it  seem  likely  that  a 
mild  tonic  will  be  borne,  a  mixture  contain¬ 
ing  the  extract  of  dandelion,  extract  of  sar¬ 
saparilla,  and  sesquicarbonate  of  soda,  may 
be  given ;  or  the  Liquor  Cinchonse  or  the 
infusion  of  calumba  may  be  employed  for 
the  same  purpose.  It  is  only  with  much 
caution  that  we  can  administer  chalybeates 
in  these  cases,  and  after  having  found  that 
the  milder  vegetable  tonics  are  well  borne. 
The  ferro- citrate  of  quinine,  or  the  citrate  of 
iron,  are  the  preparations  which  it  will  gene¬ 
rally  be  desirable  to  employ  in  the  first 


instance,  and  even  their  effect  should  be 
watched  attentively.  In  conclusion,  I  need 
hardiy  mention  the  importance  of  change  of 
air,  and  the  benefits  likely  to  result  from  a 
sojourn  on  the  sea  coast ;  for  you  know  how 
much  more  powerful  nature’s  remedies  are 
in  diseases  of  this  kind  than  the  remedies  of 
man’s  devising. 


0rigtnal  (Communications. 


ON 

GASTRO-INTESTINAL  DISTENSION, 
AND  ENLARGEMENT  OF  THE  . 

-  LIVER. 

By  Francis  Sibson,  Esq,. 

General  Hospital,  near  Nottingham. 

1.  In  g astro -intestinal  distension ,  the  dia¬ 
phragm  is  raised ,  the  lungs  and  heart 
are  compressed  ;  respiration  and  circula¬ 
tion  being  impeded.  2.  Intestinal  dis¬ 
tension  is  frequent  in  the  dying  ;  3.  and 
invariable  in  peritonitis.  4.  Use  of 
O’Beirne’s  tube  if  the  colon  be  distended. 
5.  Use  of  the  oesophageal  tube  if  the 
stomach  be  excessively  distended.  6.  Dis¬ 
crimination  between  gastric  and  intes¬ 
tinal  distension.  7.  Palpitation  and 
dyspnoea  are  often  caused  by  gastric  dis¬ 
tension. 

8.  The  liver,  when  enlarged,  by  interstitial 
abscesses ,  compresses  the  right  lung  and 
the  heart,  and  pushes  the  heart  unusually 
to  the  left.  9.  The  liver,  when  simply 
enlarged,  displaces  the  other  abdominal 
viscera  downwards,  but  does  not  encroach 
on  the  lungs  and  heart,  or  interfere  with 
their  descent.  10.  Discrimination  be¬ 
tween  pneumonia  of  the  right  lower  lobe 
and  enlargement  of  the  liver  tvith  adven¬ 
titious  deposits. 

1.  The  effects  of  excessive  flatulent 
distension  of  the  stomach,  colon,  and 
small  intestines,  are  well  shown  in  the 
engraving  from  Clarke,  a  boy  who  had 
long  suffered  from  diabetes,  no  doubt 
brought  on  and  kept  up  by  masturba¬ 
tion.  In  Clarke  the  abdominal  disten¬ 
sion  was  great  for  months  before  his 
death.  Tn  him  the  abdomen  is  enor¬ 
mously  distended ;  the  diaphragm  is 
pushed  upwards,  so  that  the  upper 
convex  boundary  of  it  is  behind  the 
third  intercostal  space  on  the  right 
side,  and  the  fourth  intercostal  space 
on  the  left  side ;  and  at  the  centre  it 
is  an  inch  higher  than  the  lower  end 


MR.  SIBSON  ON  GASTRO-INTESTIN AL  DISTENSION  OF  THE  LIVER.  105 


of  the  sternum.  The  thoracic  cavity  is 
materially  lessened,  and  the  heart  and 
lungs  are  necessarily  compressed  up¬ 
wards,  being  packed  into  an  unusually 
small  space.  The  lower  ribs,  the  dia¬ 
phragmatic  and  intermediate  sets,  are 
pushed  outwards  by  the  distended  sto¬ 
mach  and  displaced  liver.  Owing  to 
the  great  distension  of  the  stomach, 
the  left  diaphragmatic  ribs  are  pushed 
outwards  more  than  the  right.  This  is 
very  apparent  to  the  eye, the  left  seventh 
cartilage,  just  below  the  sternum,  being 
more  raised  than  the  right. 

Owing  to  the  compression  and 
diminution  in  size  of  the  lungs  and 
heart,  respiration  and  circulation  are 
both  impeded  by  intestinal  distension. 

2.  Intestinal  distension  is  very  fre¬ 
quent  in  the  dying.  From  the  exami¬ 
nation  of  122  diagrams  of  the  position 
of  the  viscera,  taken  indiscriminately, 

I  find  that 

Both  the  stomach  and  intestines 
wer£  very  much  distended  in  . .  28 
They  were  considerably  distended 

in  .  13 

The  stomach  was  much  distended 
(the  intestines  not  being  so)  in  11 
The  intestines  were  much  distend¬ 
ed  (the  stomach  not  being  so)  in  11 
The  liver  was  very  much  enlarged 

in  . 7 

The  distension  was  moderate  in . .  20 
And  absent  in . 33 

Tn  these  cases  the  abdomen  was  dis¬ 
tended,  the  lower  ribs  pushed  outwards, 
the  diaphragm  raised,  and  the  heart 
and  lungs  pressed  upwards,  in  propor¬ 
tion  to  the  gastro-intestinal  distension. 
In  the  first  class  of  cases,  in  which  the 
distension  was  very  great,  the  upper 
convex  boundary  of  the  diaphragm  was 
on  the  right  side,  usually  behind  the 
third  intercostal  space  (as  in  Clarke), 
or  the  fourth  rib  ;  and  in  the  cases  in 
the  last  class,  free  from  distension,  it 
was  usually  behind  the  fourth  inter¬ 
costal  space,  or  fifth  rib. 

3.  Intestinal  distension  is  invariable 
in  peritonitis,  and  is  then  probably  due 
to  the  relaxation  or  paralysis  in  the 
muscular  coat  of  the  intestines  induced 
by  inflammation.  It  is  remarked  by 
Dr.  Stokes,  that  all  muscles  are  para¬ 
lysed  or  rendered  inactive  bv  inflam¬ 
mation.  The  removal  of  the  customary 
pressure,  caused  by  the  peristaltic 
action  of  the  intestines,  tends  no  doubt 
to  the  increase  of  their  gaseous  con¬ 


tents.  Distension  is  also  frequent  in 
affections  of  the  mucous  membrane  of 
the  stomach  and  intestines,  in  dyspep¬ 
sia,  and  in  diseases  attended  by  debility 
and  relaxation  of  the  muscular  fibre. 

4.  Intestinal  distension,  when  exces¬ 
sive,  is  in  itself  a  serious  malady  ;  and 
when  it  accompanies  acute  diseases, 
such  as  peritonitis,  it  is  a  very  formi¬ 
dable  symptom,  and  is  often,  I  believe, 
the  immediate  cause  of  death.  The 
most  successful  plan  of  treatment  usu¬ 
ally  pursued  is  to  stimulate  the  mu¬ 
cous  membrane,  and  the  muscular  coat 
of  the  stomach  and  intestines ;  but 
before  this  can  be  done  to  any  good 
purpose,  the  great  accumulation  that, 
from  its  own  distension,  paralyses  the 
muscular  coat,  must  be  removed. 

If  the  distension  be  in  the  colon,  the 
use  of  O’Beirne’s  tube  will  usually 
succeed.  In  inserting  the  tube  it  is 
important  to  remember,  that  the  peri¬ 
staltic  action  of  the  lower  portion  of 
the  gut  will  often  impede  its  introduc¬ 
tion.  This  impediment  may  be  always 
and  easily  overcome,  by  keeping  up  a 
continuous  pressure,  with  gentle  firm¬ 
ness,  upon  the  seat  of  the  contraction  j 
this  at  length  yields  of  itself,  and  the 
tube  glides  on  with  ease,  usually  at 
once  liberating  some  of  the  gaseous 
contents.  In  some  cases  the  obstacle 
may  be  overcome  by  throwing  up  a 
few  ounces  of  warm  water;  for  this 
purpose  it  is  well  to  have  an  enema 
syringe  at  hand,  adapted  to  the  tube. 
When  the  gas  is  escaping,  it  is  often  of 
service  to  press  on  the  abdomen  over 
the  colon. 

5.  If  the  stomach  be  enormously  dis¬ 
tended,  the  distension  may  be  imme¬ 
diately  relieved  by  the  introduction  of 
the  oesophageal  tube.  The  fibrous 
coat  of  the  stomach  is  paralysed  by 
long-continued  over-distension,  in  the 
same  way  that  that  of  the  bladder  is. 
As  the  distended  bladder,  when  there 
is  retention  of  urine,  must  be  emptied 
by  the  catheter  before  the  muscular 
coat  can  recover  its  tone,  so  the  dis¬ 
tended  stomach  must  be  emptied  by 
the  oesophageal  tube.  In  introducing 
the  tube  it  is  well  pot  to  do  so  rapidly, 
but  to  bear  in  mind,  and  as  it  were 
follow,  the  peristaltic  action  of  the 
oesophagus. 

6.  As  the  evacuation  of  the  gaseous 
contents  of  the  stomach  and  colon  is 
required  when  they  are  over-distended, 
it  is  of  practical  importance  to  be  able 


106 


MR.  SIBSON  ON  ENLARGEMENT  OF  THE  LIVER. 


to  distinguish  whether  the  stomach 
alone  be  distended,  or  the  colon.  If 
the  former,  the  left  lower  ribs,  the  in¬ 
termediate  and  diaphragmatic  sets, 
protrude  more  than  the  right;  the 
gastric  bulge,  as  in  the  case  of  Clarke, 
and  contrary  to  custom,  being  greater 
than  the  hepatic  bulge.  The  left  tho¬ 
racic  ribs  —  the  second,  third,  and 
fourth — are  often  flatter  than  the  right. 
The  rounded  abdominal  prominence  of 
the  stomach  can  be  seen  below  the 
xyphoid  cartilage,  and  between  the 
opposite  costal  cartilages.  By  percus¬ 
sion  the  distinctive  boundary  between 
the  stomach  and  colon  can  be  readily 
recognised,  and  a  groove  along  the 
boundary  can  be  often  seen.  If  -the 
colon  be  distended,  the  expansion  of 
the  abdomen  is  diffused,  the  liver  is 
pushed  freely  upwards,  and  the  hepatic 
and  gastric  bulges  are  both  increased, 
bearing  their  usual  relative  proportion. 
The  diffused  inequalities  of  the  colon 
may  often  be  felt  through  the  abdomen. 
If  both  stomach  and  colon  be  distended, 
as  in  Clarke,  the  combined  effects  may 
usually  be  readily  traced;  if,  after  the 
use  of  O’Beirne’s  tube,  the  gastric  dis¬ 
tension  be  great,  then  the  oesophageal 
tube  may  be  used  with  advantage. 

7.  In  many  persons  suffering  from 
dyspepsia,  a  hearty  meal  is  followed  by 
gastric  distension;  and  this  is  fre¬ 
quently  accompanied  by,  and  the  im¬ 
mediate  cause  of,  dyspnoea  and  palpi¬ 
tation.  This  was  painfully  illustrated 
in  the  case  of  a  poor  girl  who  had, 
when  in  extreme  poverty,  lived  for  ten 
months  on  boiled  potatoes  mixed  with 
barley.  Her  diet  improved  with  her 
circumstances,  but  to  this  day  the 
stomach  has  not  recovered  its  tone. 
The  action  of  the  distended  stomach 
on  the  heart  and  lungs  is  very  apparent. 
The  diaphragm  is  pushed  directly  up¬ 
wards;  the  heart,  and  to  a  less  extent 
the  lungs,  are  pressed  upon,  and  their 
size  diminished.  At  the  same  time  the 
liver  is  pressed  upwards,  and  com¬ 
pressed  between  the  stomach  and  the 
diaphragm  ;  and  an  additional  amount 
of  blood  from  the  hepatic  cava  is 
directly  thrown  into  the  right  cavities 
of  the  heart,  at  the  very  time  that  the 
heart’s  action  is  embarrassed  by  the 
upward  pressure  of  the  stomach.  The 
majority  of  the  patients  of  this  hospital 
who  complain  of  palpitation,  suffer 
from  it  most,  shortly  after  their  dinner. 
In  them  the  heart  is  usually  sound, 


and  the  cause  of  the  palpitation  di¬ 
rectly  traceable  to  gastric  distension. 

Enlargement  of  the  Liver. 

In  James  Glann,  affected  with  jaun¬ 
dice,  the  subject  of  the  accompanying 
engraving,  there  were  several  large 
abscesses  in  the  liver;  he  had  perito¬ 
nitis  and  excessive  intestinal  distension. 
The  stomach  was  of  normal  size. 

In  Glann  the  abdomen  is  much  dis¬ 
tended;  the  diaphragm  is  thrust  up¬ 
wards,  in  a  manner  very  different  from 
that  in  Clarke.  The  right  convexity 
of  the  diaphragm  is  pushed  upwards  by 
the  liver,  greatly  enlarged  from  ab¬ 
scesses,  so  that  the  upper  boundary  of 
its  convexity  is  behind  the  lower  edge 
of  the  second  rib.  The  whole  right 
lung  is  necessarily  remarkably  less¬ 
ened.  But  while  the  right  side  of  the 
chest  is  so  much  encroached  on,  the 
left  does  not  escape.  The  convexity  of 
the  liver  is  so  great,  that  it  partly  oc¬ 
cupies  the  left  side  of  the  chest,  and 
carries  the  heart,  resting  upon  it,  com¬ 
pletely  over  to  the  left  side  of  the  chest, 
so  that  no  part  of  the  heart  is  to  the 
right  of  the  sternum.  The  ventricles 
of  the  heart,  and  of  course  the  apex, 
encroach  unusually  on  the  left  lung; 
and  as  the  left  side  of  the  diaphragm 
rises  as  high  as  the  fourth  rib,  the 
whole  left  lung,  as  well  as  the  right, 
is  compressed  upwards  and  backwards, 
and  much  diminished  in  size.  Al¬ 
though  the  liver,  enlarged  from  ab¬ 
scesses,  extends  over  to  the  left  side, 
yet  by  far  the  greater  proportion  of  its 
increased  bulk  bears  upon  the  right 
side;  and  in  this  respect,  Glann,  with 
irregularly  enlarged  liver,  offers  a  well- 
marked  contrast  to  Clarke,  with  great 
gastric  distension.  In  Glann  the  right 
lower  ribs,  from  the  fifth  downwards, 
are  pushed  outwards  much  more  than 
the  left,  the  hepatic  bulge  being  much 
greater  and  more  extensive  than  the 
gastric;  while  in  Clarke  it  is  just  the 
reverse,  the  gastric  bulge  being  much 
greater  than  the  hepatic.  In  both 
cases  we  find  the  abdomen  distended, 
the  lower  ribs  prominent,  the  dia¬ 
phragm  pushed  upwards,  and  the 
heart  and  lungs  pressed  upwards,  and 
diminished  in  size,  being  encroached 
upon  by  the  abdominal  organs. 

In  a  patient  that  I  saw  some  time 
since,  the  liver  was  manifestly,  as  in 
this  case,  much  and  irregularly  en¬ 
larged;  it  encroached  upwards  on  the 


MR.  SIBSON  ON  ENLARGEMENT  OF  THE  LIVER  107 


Fig.  1.  Thos.  Clarke,  set.  15  Gastro-intestinal  distension. 
Fig.’  2.  James  Glann,  eet.  24  Extensive  abscesses  in  the  liver. 


right,  and  partially  on  the  left  side, 
carrying  the  heart  over  unusually  to 
the  left,  so  that  the  impulse  was  felt 
considerably  to  the  left  of  the  nipple. 
In  this  case  the  hepatic  bulge  was  very 
large  indeed,  and  the  liver  and  the 
cysts  connected  with  it  (probably  con¬ 
taining  hydatids)  encroached  consi¬ 
derably  on  the  abdominal  viscera. 

It  is  in  such  cases  as  Glann’s,  where 
the  enlargement  of  the  liver  is  caused 
by  .interstitial  deposits,  such  as  collec¬ 
tions  of  pus,  malignant  tumors,  or 
hydatid  cysts,  that  the  liver  encroaches 
so  much  on  the  lungs  and  heart.  In 
such  cases  the  liver  is  irregularly  en¬ 
larged,  its  circumference  and  diameter 


being  greatly  increased,  according  to 
the  size  and  position  of  the  deposits. 

9.  When  the  liver  is  simply  enlarged, 
without  adventitious  deposits,  the  liver 
scarcely  rises  higher  than  usual  into 
the  chest ;  it  encroaches  almost  wholly 
downwards,  and  to  the  left,  displacing 
the  stomach,  intestines,  pancreas,  and 
right  kidney,  and  it  interferes  but 
little  with  the  inspiratory  descent  of 
the  diaphragm.  If  the  liver  be  adhe¬ 
rent,  the  encroachment  on  the  right 
lung  is  considerable. 

10.  There  is  no  danger  of  mistaking 
enlargement  of  the  liver,  when  free  from 
adventitious  deposits  and  without  ad¬ 
hesions,  for  pneumonia  or  consolidation 


108 


MR.  SIBSON  ON  DEATH  FROM  CHLOROFORM. 


of  the  lower  lobe  of  the  right  lung.  It 
is,  however,  sometimes  difficult  to  dis¬ 
criminate  between  those  affections  of 
the  lung  and  enlargement  of  the  liver 
with  extensive  adventitious  deposits, 
or  with  adhesions.  Among  the  best 
criterions,  in  addition  to  the  other  dis¬ 
tinctive  signs,  are  the  great  increase  of 
the  hepatic  bulge,  the  unusual  en¬ 
croachment  of  the  liver  and  its  deposits 
on  the  abdomen,  and  the  complete 
absence  of  vocal  fremitus  over  the  re¬ 
gion  devoid  of  sonoriety,  if  the  disease 
he  hepatic;  and  the  non-existence  of 
such  signs  if  it  be  pulmonic. 


ON  DEATH  FROM  CHLOROFORM. 

The  death  from  chloroform  of  Mr. 
Badger,  related  in  the  Lancet  of  July 
8th,  is  an  interesting  illustration  of  the 
effect  of  enlarged  liver  on  the  space  for 
the  lungs  and  heart,  and  on  respiration 
and  circulation.  The  liver  in  Mr. 
Badger  weighed  eight  pounds,  and  the 
summit  of  it  was  behind  the  third  in¬ 
tercostal  space.  The  liver  evidently 
pressed  upon  the  heart  and  the  lungs, 
interfering  with  their  function.  In 
this  case  the  heart  was  flaccid  and 
somewhat  fat.  The  flaccid  state  of  the 
heart  shewed  that  the  death  was  im¬ 
mediately  caused  by  paralysis  of  the 
heart’s  action  :  there  were  clots  of  daik 
grumous  blood  in  both  cavities.  The 
lungs  were  not  materially  congested. 

Since  the  death  from  chloroform  of 
Greener,  near  Newcastle,  three  addi¬ 
tional  fatal  cases  have  unfortunately 
occurred.  They  are  all  well  recorded, 
especially  in  the  post-mortem  appear¬ 
ances,  and  we  are  consequently  better 
able  to  say  from  experience  what  is  the 
immeoiate  cause  of  death  from  chloro¬ 
form,  what  treatment  ought  to  be  pur¬ 
sued  when  death  is  imminent,  what 
precautions  ought  to  be  adopted  in  the 
administration,  what  class  of  persons 
ought  not  to  be  submitted  to  its  action, 
and  in  what  cases  its  employment  can¬ 
not  be  sanctioned. 

In  the  lower  animals,  from  the  ex¬ 
periments  of  Dr.  Percy,  Dr.  Glover, 
and  Mr.  Wakley,  the  first  fatal  effects 
of  chloroform,  ether,  and  alcohol,  are 
usually  the  cessation  of  respiration,  the 
heart’s  action  continuing  for  some  mi¬ 
nutes.  I  say  usually,  for  Dr.  Percy 
and  Dr.  Glover  both  noticed  that,  in 
some  dogs,  the  respiration  and  the 
heart’s  action  ceased  simultaneously. 


One  continental  experimenter  found 
that,  by  artificial  respiration,  he  could 
always  restore  the  lower  animals  when 
animation  was  suspended  by  the  action 
of  chloroform. 

If  anything  can  restore  the  human 
subject  when  animation  is  suspended 
by  excessive  chloroformization,  it  is 
artificial  respiration.  The  experiments 
on  the  lower  animals  hold  out  much 
hope  of  success  by.  this  means;  but, 
unfortunately,  from  the  four  recorded 
cases,  I  fear  that,  in  man,  even  artifi¬ 
cial  respiration  will  seldom  succeed. 

In  the  case  of  Greener  the  lips  be¬ 
came  suddenly  blanched  ;  blood  would 
not  flow  freely  from  the  arm ;  the 
lungs  were  excessively  congested ;  the 
heart  quite  healthy,  containing  in  both 
cavities  dark  fluid  blood.  It.  is  not 
stated  whether  the  heart  was  flaccid. 

In  Maria  S.,  the  fatal  case  at  Bou¬ 
logne  (Lancet,  June  6th),  the  last 
appearances  of  life  were  two  deep  and 
laborious  inspirations.  The  lungs  were 
healthy,  not  congested,  except  at  the 
depending  part.  Heart  flaccid,  like  an 
empty  bag  ;  fat  ;  cavities  quite  empty. 
Fluid  blood  black  as  ink  in  the  large 
veins.  Large  bubbles  of  air  were  found 
every  where  in  the  veins;  one  or  two 
ounces  of  bloody  serum  in  the  peri¬ 
cardium.  Artificial  respiration  was 
adopted. 

In  Mrs.  Simmonds,  the  American 
case  (who  enjoyed  excellent  health), 
whilst  inhaling  in  a  chair,  the  face  be¬ 
came  pale;  respiration  and  pulsation 
ceased  about  the  same  time.  About 
half  an  hour  later  electro-magnetism 
caused  muscular  contractions  but  no 
effect  on  the  heart’s  action.  Artificial 
respiration  and  other  means  were  used. 
Limbs  rigid;  lungs  not  intensely  con¬ 
gested,  bronchi  being  stained  with 
blood.  Pleura  highly  injected.  Heart 
flaccid ;  all  its  cavities  and  the  great 
vessels  entirely  empty;  their  inner  sur¬ 
face  deeply  stained.  Only  a  little 
blood  in  the  abdominal  cava.  Six 
drachms  of  bloody  serum  in  the  peri¬ 
cardium.  Some  bloody  serum  in  both 
pleural  cavities  and  in  the  right  hypo- 
chondrium. 

In  the  case  of  Mr.  Badger  the  heart 
was  flaccid,  and  contained  coagulated 
blood. 

A  man  died  at  Auxerre  last  August 
under  the  influence  of  ether  (Gazette, 
March  10th,  1848).  In  him  the  pulse 
and  the  respiration  ceased  about  the 


MK.  SIBSON  ON  DEATH  FROM  CHLOROFORM. 


109 


same  time.  The  countenance  just  be¬ 
fore  death  was  deeply  livid.  The 
lungs  posteriorly,  and  the  bronchial 
lining  throughout,  were  high’y  con¬ 
gested  ;  blood  fluid;  state  of  heart  not 
specified. 

In  the  three  later  fatal  chloroform 
cases  the  heart  was  quite  flaccid.  In 
the  case  of  Greener  the  state  of  the 
heart  is  not  specified,  but  the  counte¬ 
nance  became  suddenly  blanched.  In 
all  the  four  cases  it  is  manifest  the  im¬ 
mediate  cause  of  the  instantaneous 
death  lay  in  the  heart.  The  heart,  in¬ 
fluenced  by  the  poison,  ceased  to  con¬ 
tract,  not  from  the  cessation  of  respi¬ 
ration,  for  the  heart  in  asphyxia  will 
beat  from  one  to  three  minutes  after 
respiration  has  ceased,  but  from  imme¬ 
diate  death  of  the  heart. 

There  is  no  doubt  a  combination  of 
causes  operating  to  destroy  the  heart’s 
contractile  power :  the  mental  in¬ 
fluence,  the  congestion  in  the  systemic, 
and  that  in  the  pulmonic  capillaries, 
will  all  have  a  material  influence.  In 
poisoning  by  prussic  acid  in  a  dog, Dr. 
Lonsdale  found  the  heart’s  action  ceased 
with  respiration  ;  the  heart  was  dis¬ 
tended  ;  on  puncturing  the  cava  the 
heart  renewed  its  action.  In  poisoning 
by  tobacco  a  similar  state  occurred  to 
Sir  Benjamin  Brodie.  By  artificial  re¬ 
spiration  he  kept  up  the  action  of  the 
heart,  which  had  been  renewed  by 
local  stimulus  after  its  complete  cessa¬ 
tion. 

But,  besides  these  three  causes,  all 
co-operating  to  arrest  the  heart’s  action, 
there  is  indisputably  the  direct  action 
of  the  poison  on  the  muscular  tissue 
of  the  heart.  The  poison  penetrates  to 
the  heart  from  the  lungs  in  a  single 
pulsation  ;  and  at  the  beginning  of 
the  next  systole,  the  blood  is  sent 
through  the  coronary  artery  to  the 
whole  muscular  tissue  of  the  heart, 
The  blood  passing  into  the  coronary 
artery  is  less  diluted, — is  more  strongly 
impregnated  with  chloroform, — than 
is  the  blood  in  any  other  part  of  the 
system,  except  the  lungs.  The  expe¬ 
riments  of  Dr.  Simpson,  Mr.  Nunneley, 
and  others,  have  shown  the  action  of 
chloroform  to  be  local.  Those  of 
Allston,  Fontana,  Whytt,  and  Monro, 
in  the  last  century,  completely  demon¬ 
strated  the  local  action  of  opium.  Dr. 
Whytt  destroyed  the  contractility  of 
the  frog’s  heart  by  steeping  it  in  a 
watery  solution  of  opium. 


I  fear,  from  the  experience  of  these 
fatal  cases,  that  we  must  regard  chloro¬ 
form  as  one  of  the  most  uncontrolable 
narcotic  poisons  when  its  action  is 
pushed  so  far  as  to  suspend  circulation 
and  respiration.  It  is  very  manifest, 
that  in  the  American  and  Boulogne 
cases  the  heart’s  action  was  not  arrested 
from  its  over  distension,  as  it  was  in 
the  cases  of  poisoning  by  prussic  acid 
and  tobacco  previously  cited.  In  both 
those  cases,  the  heart  was  absolutely 
empty  of  blood.  A  question  arises 
here,  was  the  heart  arrested  from  want 
of  blood  ?  The  experiments  of  Dr. 
Kay  and  others  have  proved,  that  any 
limb  or  muscle  will  be  paralysed  if  it 
be  deprived  of  blood.  Indeed,  the 
action  of  the  right  side  of  the  heart, 
which  usually  continues  long  after  that 
of  the  left  has  ceased,  will  be  the  first 
to  cease  if  the  left  side  be  supplied  with 
blood  while  the  right  is  deprived  of  it. 

It  is  very  possible,  that  in  these 
cases  the  want  of  blood  for  the  heart 
to  act  upon  had  to  do  with  its  ceasing 
to  act :  this  would  he  due  to  the  ar¬ 
rest  of  the  blood  in  the  lungs  and  in 
the  system  generally,  and  the  supply 
of  blood  to  both  sides  of  the  heart. 

It  is,  however,  to  be  remarked,  that 
in  both  of  these  cases  the  blood  was 
quite  fluid  ;  that  in  both  of  them  there 
was  bloody  serum  (about  an  ounce)  in 
the  pericardium;  that  in  the  American 
case,  there  was  a  deep  red  stain  on  the 
interior  of  the  empty  heart  and  great 
vessels.  In  these  cases,  1  do  not  doubt 
that  some  blood  was  in  the  heart  at  the 
time  of  death,  but  made  its  way  out  by 
imbibition  and  otherwise,  owing  to  its 
fluidity,  during  the  twenty-four  or 
thirty  hours  that  intervened  between 
death  and  the  examination. 

In  ordinary  death,  the  right  ventricle, 
which  contains  blood,  is  flaccid,  while 
the  left,  which  is  quite  empty,  is  rigid. 
This  proves,  that  the  flaccidity  of  the 
walls  of  the  heart  in  the  cases  under 
review  was  not  due  to  the  empty  state 
of  the  ventricles. 

We  are  obliged,  then,  from  the  ex¬ 
perience  of  these  cases,  to  conclude, 
that  in  man  the  death  is  usually  instan¬ 
taneous,  and  due,  as  every  instantaneous 
death  is,  to  paralysis  of  the  heart.  In 
animals,  the  death  is  usually  due  to 
paralysis  of  the  muscles  of  respiration. 

It  is  chiefly  owing  to  the  superior 
control  of  the  mind  over  the  body  in 
man,  that  in  him  the  poison  acts  on  the 


110 


MR.  SIBSON  ON  DEATH  FROM  CHLOROFORM. 


heart  more  than  in  dogs.  It  is  from 
the  same  cause  that  opium,  which  so 
usually  produces  convulsions  in  the 
lower  animals,  so  seldom  produces  them 
in  man  ;  and  it  is  from  the  same  reason 
that  opium  produces  convulsions  so 
much  more  frequently  in  children  than 
in  adults. 

These  cases  suggest  some  important 
considerations  on  the  mode  of  chloro- 
formization .  In  three  out  of  the  four 
fatal  cases  the  chloroform  was  given  in 
the  sitting  posture.  This  posture  re¬ 
quires  much  greater  power  in  the  heart 
to  carry  on  the  circulation  than  the 
recumbent.  Chloroform  should  not,  if 
possible,  be  administered  in  the  sitting 
posture. 

In  three  out  of  the  four  fatal  cases, 
the  chloroform  was  administered  by 
the  operator :  this  should  never  be. 
Chloroformization  is  the  exhibition  of 
a  subtle  poison, and  ought  to  be  watched 
by  its  administrator  with  undivided 
attention  during  the  whole  of  its  ope¬ 
ration. 

During  chloroformization,  the  state 
of  the  eyes,  the  lips,  the  pulse,  and 
respiration,  should  be  continually 
watched.  Since  my  paper  on  the  ac¬ 
tion  of  chloroform,  in  a  former  number, 
I  have  never  in  any  case,  however 
prolonged  the  operation,  allowed  the 
action  to  proceed  so  far  as  to  cause 
dilatation  of  the  pupil. 

As  soon  as  the  eyes  turn  up,  and  the 
eyelids  cease  to  quiver  and  resist,  draw 
up  one  eyelid,  and  keep  the  eye  con¬ 
stantly  open;  watch  the  pupil  closely 
— it  is  usually  contracted,  and  ought 
never  to  proceed  to  dilatation,  except¬ 
ing,  perhaps,  in  the  reduction  of  dislo¬ 
cation  and  in  the  reduction  of  hernia. 
If  the  eyeball  begin  to  move,  and  the 
eyelids  to  quiver,  apply  the  inhaling 
mask  again  for  a  few  seconds  until  they 
again  become  fixed:  thus,  with  the 
inhalation  of  very  little  chloroform,  a 
person  may,  at  will,  be  kept  long  under 
its  influence,  and  yet  not  a  minute 
longer  than  is  needful, as  you  have  the 
patient  just  on  the  margin  of  un¬ 
consciousness. 

The  inhaler  should  be  so  constructed 
that  every  inspiration  be  made  pal¬ 
pable  by  it.  The  tell-tale  valve  of  my 
inhaler  does  this  perfectly,  and  may 
be,  and  indeed  has  been,  adapted  to 
other  inhalers.  Without  some  such 
precaution,  the  patient  might  cease  to 
breathe  unnoticed. 


The  chloroform  should  be  adminis¬ 
tered  gradually,  much  diluted  with  air 
at  first,  and  less  so  afterwards.  The 
effect  should  neither  be  produced  too 
quickly  nor  too  slowly  :  in  either  case, 
the  accumulative  effect  pointed  out  by 
Dr.  Snow  may  endanger  the  patient 
after  the  chloroform  has  been  with¬ 
drawn. 

If  the  respiration  ceases  before  the 
pulse,  artificial  respiration  must  be 
immediately  resorted  to:  it  may  be 
performed  instantly,  by  breathing  into 
the  lungs  through  the  inhaling  mask, 
described  in  a  previous  paper. 

If  the  heart  has  ceased  to  beat,  the 
case  is  almost  hopeless.  If  the  veins 
of  the  neck  be  swollen,  the  right  cavi¬ 
ties  of  the  heart  are  distended,  and  an 
ounce  of  blood  taken  from  the  jugular 
may  relieve  the  distension  of  the  heart, 
and  lead  to  the  renewal  of  its  action. 
Under  any  circumstances,  artificial 
respiration  should  be  resorted  to  as  the 
last  resource. 

In  each  of  the  four  cases,*  the  ope¬ 
ration,  though  painful,  w7as  not  serious. 
In  such  cases,  the  mind  usually  fears 
the  chloroform  more  almost  than  the 
operation.  It  is  otherwise  when  the 
operation  is  serious. 

In  dental  surgery  (except  in  extreme 
cases)  and  in  trivial  operations,  the 
use  of  chloroform  is  not  justifiable. 

As  the  heart  is  subject  to  paralysis 
from  the  action  of  chloroform,  its  use 
should  not  be  lightly  resorted  to  when 
there  is  affection  of  the  heart.  I 
do  not  speak  so  much  of  organic  dis¬ 
ease  of  the  heart  as  of  those  cases 
where  palpitation  and  dyspnoea  are 
easily  excited,  either  from  abdominal 
distension  or  from  mental  emotion. 
To  such  persons  chloroform  is,  1  con¬ 
ceive,  more  likely  to  prove  destructive 
than  to  those  with  organic  disease  of 
the  heart,  when  they  do  not  suffer  from 
palpitation.  Mr.  Walshe,  of  Worcester, 


*  Since  this  was  written,  a  fifth  case  of  death 
from  chloroform  (in  India)  has  been  reported  in 
the  Gazette.  Like  the  four  other  cases,  the 
operation  was  trivial ;  like  three  of  them,  chloro¬ 
form  was  administered  by  the  operator  himself, 
and  in  the  sitting  posture.  During  the  opera¬ 
tion  scarcely  a  drop  of  blood  escaped.  The 
patient  was  probably  already  dead !  There  was 
no  post-mortem.  I  observe  that  the  Boulogne 
case  is  reported  anonymously.  One  cannot, 
therefore,  confide  in  the  post-mortem  report  of 
that  case ;  but  if  it  be  shut  out  altogether  from 
this  paper,  it  will  not  affect  the  remarks  con¬ 
tained  in  it.  The  authentic  account  of  that  case 
in  the  Gazette  fully  justifies  the  editorial  re¬ 
marks  on  it. 


ON  RHEUMATIC  ARTHRITIS  OF  THE 


has  shown,  that  the  dread  of  a  serious 
operation  often  does  more  harm  than 
the  operation  itself ;  and  hence  the 
real  value  of  anaesthesia  is  often  not  so 
much  to  save  the  immediate  pain,  as 
the  bad  effects  of  the  dread  of  the  pain. 
This,  which  applies  to  persons  en¬ 
feebled  by  disease,  applies  with  equal 
force  to  persons  the  subject  of  heart 
disease,  and  they,  when  the  dread  of  a 
severe  operation  is  great,  may  some¬ 
times  be  peculiarly  benefited  by  the 
careful  and  short  production  of  anaes¬ 
thesia  during  the  cutting  part  of  an 
operation. 

It  is  to  be  hoped  that  Mr.  Robinson, 
to  whom  the  profession  owes  so  much 
for  his  communications  on  ether  and 
chloroform,  will  favour  us  with  an 
account  of  Mr.  Badger’s  case.  It 
would  appear,  from  the  evidence  of 
the  servant,  that  the  mask  was  never 
brought  in  contact  with  the  face: 
this  may  be  a  mistake  from  imper¬ 
fect  observation.  It  would  be  inte¬ 
resting  to  know  from  Mr.  Robinson 
whether  this  was  so;  and  whether  he 
finds  that  the  effects  of  chloroform  can 
be  usually  thus  induced.  One  dis¬ 
advantage  in  Mr.  Robinson’s  mask 
is  the  inability  to  admit  pure  at¬ 
mospheric  air  through  the  mask  :  for 
this  he  appears  to  make  up  by  not 
bringing  the  inhaler  in  contact  with 
the  face.  Another  disadvantage  is  the 
want  of  a  tell-tale  valve. 

These  fatal  cases,  unfortunate  in 
themselves,  will  be  of  service  in  check¬ 
ing  the  employment  of  chloroform  in 
trivial  cases,  and  in  persons  well  able 
to  bear  an  operation,  and  in  drawing 
attention  to  the  proper  mode  of  its 
administration;  but  they  ought  not  to 
interfere  with  its  judicious  use  in  severe 
operations,  when  the  patient,  from 
long-continued  disease  or  the  shock  of 
an  accident,  is  unable  to  bear  the  pain 
and  shock  of  an  operation.  The  em¬ 
ployment  or  non-employ nfent  of  chlo¬ 
roform  is  a  balance  between  two  evils. 

These  cases  ought  not  to  interfere 
with  the  judicious  medicinal  use  of 
chloroform.  In  neuralgia  and  chorea 
it  is  not  necessary  to  push  the  chloro- 
formization  to  the  extent  of  uncon¬ 
sciousness.  As  in  such  cases  the  full 
effect  ought  not  to  be  induced,  it  is 
perfectly  safe  to  administer  the  chloro¬ 
form  in  the  sitting  posture,  the  head 
being  supported. 


SHOULDER  AND  OTHER  JOINTS.  Ill 


ADDITIONAL  NOTES  ON  THE 

MORBID  ANATOMY,  &c.  of  CHRONIC 
RHEUMATIC  ARTHRITIS 

OF  THE 

SHOULDER  AND  OTHER  JOINTS. 

By  Edwin  Canton,  F.R.C.S. 

Demonstrator  of  Anatomy  at  the  Charing  Cross 
Hospital  School  of  Medicine. 


In  a  paper  published  in  the  Medical 
Gazette  for  March  of  the  present  year, 
I  described  the  morbid  appearances  to 
be  met  with  in  cases  of  the  above  dis¬ 
ease,  when  affecting  the  shoulder  joint. 
Since  that  time  I  have  had  additional 
opportunities  of  noticing  the  complaint 
in  this  and  other  articulations,  and 
finding  that  the  particular  features  it 
presents  after  death  have  been  mis¬ 
taken  occasionally  for  the  effects  of 
accident,  or  regarded  simply  as  changes 
natural  to  old  age,  I  am  induced  to 
communicate  further  observations,  with 
a  view  to  the  prevention  of  further  error, 
and  of  calling  attention  to  an  affection 
which  is  not  so  universally  recognised 
as,  from  the  frequency  of  its  occurrence, 
and  the  peculiarcharacter  of  its  ravages, 
I  believe  it  might  be. 

Morbid  appearances  mistaken  for  the 
effects  of  accident. — With  regard  to  the 
shoulder,  Mr.  Adams,  of  Dublin,  in 
writing  to  me  on  this  point,  remarks, 
“  there  is  no  joint  has  been  the  subject 
of  more  mistakes  relative  to  this  dis¬ 
ease  than  the  shoulder.  Almost  all  the 
cases  published  have  been  supposed  to 
be  those  of  partial  dislocation  ;  the 
history  of  the  case  being  in  ninety-nine 
out  of  a  hundred  unknown.” 

In  the  Medical  Gazette,  Yol.  xiv, 
a  paper  has  been  inserted,  entitled 
“Pathological  appearances  in  seven 
cases  of  injury  of  the  Shoulder-joint,” 
by  Mr.  G.  Smith.  The  specimens 
were  met  with  in  the  dissecting-room, 
and  their  history  could  not  be  ascer¬ 
tained. 

Capsular  tendons. — In  the  first  pre¬ 
paration,  the  tendons  of  the  spinati, 
subscapularis,  and  lesser  teres  muscles, 
are  described  as  having  been  com¬ 
pletely  detached  or  torn  away  from 
i heir  connection  to  the  tubercles.  In 
the  second  case,  the  tendon  of  the  sub¬ 
scapularis  was  partially  torn  from  the 
lesser  tubercle,  but  the  insertion  of  the 


112 


MR.  CANTON  ON  THE  MORBID  ANATOMY  OF  CHRONIC 


spinati  and  teres  minor  muscles  re¬ 
mained  perfect.  The  third  example 
was  similar  to  the  first ;  and  the  fourth 
displayed  two  of  these  muscles  torn 
from  the  tubercle  ;  the  inner  surface  of 
the  capsule  presented  a  very  rough 
fibrous  appearance,  occasioned  by  the 
portions  of  the  lacerated  tendons. 
Cases  six  and  seven  are,  in  respect  to 
these  tendons,  analogous  to  the  preced¬ 
ing  ones. 

The  appearances  described  I  have 
not  unfrequently  met  with  more  or  less 
strongly  marked  in  cases  of  chronic 
rheumatic  arthritis,  and  they  are  to  be 
seen  in  connection  with  others  in  the 
articular  surface  of  the  humerus  and 
scapula;  the  tendon  of  the  biceps;  sur¬ 
rounding  bony  growths  ;  ivory-like  de¬ 
posit,  which  characterise  this  affection, 
and  all  of  which  are  carefully  described 
by  Mr,  Smith,  as  having  been  found  in 
his  specimens.  In  tracing  the  course 
of  this  disease,  and  noticing  the  various 
morbid  changes  it  establishes  in  its  pro¬ 
gress,  it  is  easy  to  comprehend  how  from 
an  early  division  (by  absorption)  of 
the  articular  portion  of  the  bicipital 
tendon,  and  consequent  displacement 
of  the  head  of  the  humerus,  with  the 
establishment  of  new  surfaces  for  the 
accommodation  of  the  latter,  the 
tendons  of  the  capsular  muscles  at  their 
insertions  should  suffer  atrophy  from 
pressure,  and  present  irregular,  fringed, 
and  apparently  lacerated  ends  attached 
to  and  intermingling  with  those  nodu¬ 
lated  osseous  growths,  which  spring 
from  the  tubercles  of  the  humerus,  and 
elseudiere,  in  the  vicinity  of  the  joint 
in  this  affection. 

Tendon  of  the  biceps.  —  In  five  cases 
this  tendon  is  described  as  being  torn 
through.  The  lower  part  attached  to 
the  margin  of  the  bicipital  groove, 
whilst  the  superior  portion  had  either 
disappeared,  or  was  affixed  to  the  upper 
part  of  the  glenoid  surface.  In  Cases 
VI.  and  VII.  the  tendon  was  not 
separated  from  its  origin,  but  displaced 
from  the  groove,  and  lay  loose  in  the 
inner  part  of  the  cavity  of  the  joint  ;  it 
is  expanded,  and  bears  evidence  of  hav¬ 
ing  been  subjected  to  pressure  and 
friction.  The  bicipital  groove  is  nearly 
obliterated,  and  portions  of  ossific 
matter  have  been  deposited. 

The  conditions  of  the  tendon  of  the 
biceps  here  mentioned  are  those  most 
commonly  to  be  observed  in  chronic 
rheumatic  arthritis;  but  there  are  seve¬ 


ral  others  which  would  seem  to  be 
states  of  the  part  in  an  earlier  stage  of 
the  disease.  These  latter  are,  so  to 
speak,  in  keeping  also  w'ith  the  lesser 
extent  to  which  morbid  action  has  im¬ 
plicated  the  encrusting  cartilages  and 
surrounding  tissues.  Displacement  I 
have  less  frequently  seen  than  the  above 
noticed  peculiarities.  The  author  of 
the  paper  ascribes  the  appearances  to 
the  effectsof  dislocation  of  the  humerus, 
either  into  the  axilla,  or  the  dorsum 
scapula,  or  under  the  pectoral  muscle. 

Being  desirous  of  ascertaining  from 
Mr.  Smith  whether  from  subsequent 
experience  he  had  found  reason  to  alter 
his  opinion  regarding  the  origin  of 
these  morbid  phenomena,  I  wrote  to 
that  gentleman  on  the  subject,  and 
have  to  acknowledge  his  prompt  atten¬ 
tion  to  my  letter,  and  the  frankness  of 
his  reply.  He  writes,  “  I  was  in  the 
first  instance  disposed  to  view'  the  ap¬ 
pearances  as  purely  the  result  of  injury, 
but  from  the  frequency  of  their  occur¬ 
rence,  and  the  similarity  to  a  greater  or 
less  extent  of  the  apparent  mischief, 
induced  me  afterwards  to  come  to  a 
different  conclusion,  and  to  view  them 
rather  as  the  destructive  results  of  long- 
continued  chronic  inflammation  of 
fibrous  tissues.  I  am  speaking  entirely 
from  recollection ;  but,  as  far  as  I  can 
recal  to  memory,  we  became  so  familiar 
with  the  appearances,  that  we  could 
often  detect  the  morbid  condition  of  the 
joint  before  a  close  examination,  by  the 
alteration  in  the  general  form  of  the 
biceps  muscle,  the  outer  head  being 
very  much  smaller  and  shorter  than 
usual.  The  subdeltoid  bursa  generally 
communicated  with  the  shoulder-joint, 
&c.  In  tw'o  of  the  examples  there  was 
fracture  of  the  acromion  process,  about 
half  an  inch  from  the  articulation, 
which  had  formed  the  usual  appear¬ 
ances  of  an  artificial  joint.  In  these  in¬ 
stances  all  the  structures  appeared  under 
the  deltoid  muscle  to  participate  in  the 
boundaries  of  the  joint.  It  appeared 
to  me  as  if  some  strong  force  had  been 
acting  to  pull  the  humerus  upwards,  as 
by  strong  contraction  of  the  deltoid 
muscle  continued  for  a  length  of  time.” 

Mr.  Soden,  in  making  the  following 
remark,*  has  adduced  the  cases  of  Mr. 
Smith  m  support  of  his  view7, — “that 
rupture  of  the  tendon  of  the  biceps 
w’ould  appear  to  be  no  uncommon  acei- 


*  Medico-Chirurgical  Transactions,  1841. 


RHEUMATIC  ARTHRITIS  OF  THE  SHOULDER  AND  OTHER  JOINTS  113 


dent ;  for  its  occurrence,  both  separately 
and  in  combination  with  dislocation  of 
the  bone,  has  been  several  times 
noticed.” 

Dr.  Knox*  has  published  an  account 
of  the  altered  condition  of  that  portion 
of  the  tendon  of  the  biceps  flexor  cubiti, 
which  passes  through  the  shoulder- 
joint.”  The  specimens  were  obtained 
from  the  dissecting-room,  and  no 
history  of  the  cases  could  be  procured. 
The  description  given  of  these  pre¬ 
parations  shows  distinctly  that  the  ap 
pearances  presented  were  the  effects  of 
the  disease  under  consideration,  whilst 
the  concluding  observation  points  to 
violence  as  their  origin: — “So  far  as 
my  information  extends,  injuries  done 
to  tnis  tendon  in  the  part  to  which 
these  remarks  allude,  are  exceedingly 
rare,  or,  perhaps  I  should  say,  rarely 
recorded.  Systematic  writers  do  not 
even  allude  to  any  pathological  condi¬ 
tion  of  this  tendon  ;  and  this  is  a  princi¬ 
pal  reason  why  I  now  bring  this  subject 


I  have  already  given  the  history  of 
two  case*  of  chronic  rheumatic  arthritis 
of  the  shoulder-joint,  and  believe  that 
before  quitting  this  department  of  the 
subject,  the  relation  of  a  third  may  not 
be  found  out  of  place,  or  devoid  of  in¬ 
terest. 

Case. — James  Harrison,  set.  78,  re¬ 
siding  in  the  neighbourhood  of  St. 
Martin’-*  Lane.  The  patient,  a  tall, 
emaciated,  and  feeble  man,  who  for 
many  years  has  been  labouring  under 
a  large  scrotal  hernia,  combined  with 

*  Medical  Gazette,  vol.  i. 


before  the  profession,  and  solicit  to  it 
the  attention  of  practical  surgeons  and 
pathologists.” 

Bones  of  the  shoulder  in  old  age. — In. 
my  last  communication,  I  mentioned 
that  analogy  would  lead  us  to  expect 
certain  chemical  changes  to  have  taken 
place  in  the  bones  of  the  shoulder-joint 
in  advanced  life,  similar  to  those  which 
have  been  noticed  by  Mr.  Bransby 
Cooper  in  the  head  and  neck  of  the 
thigh-bone  after  the  age  of  fifty.*  And 
to  my  friend  Mr.  Harper  I  am  indebted 
for  the  subjoined  accurate  analyses, 
which,  when  formerly  alluded  to,  were 
in  progress  only.  As  a  matter  more 
immediately  connected  with,  and  pos¬ 
sessed  of  much  interest  in  the  present 
inquiry,  the  results  of  an  examination, 
of  the  shoulder-bones  already  described 
has  been  added  ;  likewise  of  the  bones 
of  the  hip  from  the  same  subject,  and 
which,  like  the  former,  are  extensively 
affected  by  chronic  rheumatic  arthritis. 


hydrocele  on  one  side,  and  an  equally 
large  femoral  rupture  on  the  other- 
states  that  in  the  year  1805,  he  “got 
thoroughly  w'et  through,”  and  the  next 
morning  suffered  from  rheumatism  of 
the  right  shoulder,  but  in  no  other  part. 
This  was  the  first  attack  of  the  com¬ 
plaint  he  had  experienced,  and  for  it  wras 
attended  by  Dr.  Hope,  in  Edinburgh. 
The  treatment  adopted  relieved  him  of 
the  affection  in  a  short  space  of  time. 
From  this  period  to  the  winter  of  1847 
the  joint  had  been  free  from  any  un- 


Amount  of  earthly 

Amount  of 

animal 

matter 

matter. 

Vh  _  • 

o  « 

m 
©  p 

• 

C3t4-.es 

<4-1  to 

©  P 

p  p 
o  «  o. 
■f  5  g 

T3  CD 

a  c 

CO  S 

Shaft. 

p  °  p 
a  C, 

"3  J5  5 

"P  CD 

g  s 

Shaft. 

Male,  set.  25,  (died  of  phthisis)  .  .  . 

45-26 

36-86 

59-83 

54-74 

63-14 

4017 

Female,  set.  82 . 

32-47 

24-70 

36-42 

67-53 

75-30 

63-58 

Male,  set.  61,  (died  of  fever)  .... 

32-88 

23  19 

54-70 

6712 

76-81 

45-30 

Female,  set.  80 . 

40-50 

2719 

44  59 

59-50 

72-81 

55-41 

Female,  set.  78,  (died  of  scirrhus  uteri) 

30-40 

23-53  48-64 

69  60 

76  47 

51-36 

Male,  set.  78 . 

32-30 

26-29 

4959 

67-70 

73-7T 

50-41 

Female,  set.  70 . 

36-32 

26-13 

46-54 

63*68 

73-87 

53-46 

Female,  set.  89 . 

40  00 

23-40 

47-22 

60  00 

76"60 

52-7 

Male,  set.  75,  (a  fine  muscular  subject)  . 

41-50 

39  70 

59-35 

58-50 

60-30 

40-65 

Female,  set.  80,  (chronic  rheumatic  arthritis 

23-13 

29  49 

61-76 

76-87 

70-51 

38-24 

Do.  Do.  (acetabulum) 

23-46 

• 

• 

76-54 

Do.  Do.  (femur)  .  . 

• 

22-43 

43-00 

• 

77-57 

57-00 

*  Guy’s  Hospital  Reports,  1847. 


114  0NT  RHEUMATIC  ARTHRITIS  OF  THE  SHOULDER  AND  OTHER  JOINTS. 


easiness,  except  in  damp  or  frosty 
weather,  when  a  “  sensation  of  gnaw¬ 
ing”  was  complained  of  in  the  part, 
and  continued  to  trouble  him  whilst 
the  inclement  weather  lasted.  This 
inconvenience,  however,  has  not  been 
of  a  nature  to  prevent  him  following 
his  usual  work,  that  of  a  gentleman’s 
servant.  In  unfavourable  weather,  the 
pain  was  always  aggravated  at  night, 
or,  as  he  says,  “when  warm  in  bed.” 
In  the  winter  of  1826,  whilst  employed 
in  dislodging  snow  from  a  house-top, 
he  caught  a  violent  cold,  through  get¬ 
ting  his  feet  wet,  and  from  that  time 
the  left  hip  has  been  affected  with 
rheumatic  pains,  which,  like  those  of 
the  shoulder,  were  found  to  be  invaria¬ 
bly  increased  in  frosty  or  damp  wea¬ 
ther,  and  when  in  bed.  The  pain  was 
always  especially  felt  “  the  first  thing 
in  the  morning,”  whilst  a  sensation  of 
cracking  and  grating  in  the  joint  was 
frequently  complained  of;  at  the  same 
time,  the  sound  emitted,  particularly 
when  rising  from  a  sitting  posture,  has 
been  audible  to,  and  remarked  upon 
by,  the  by-standers.  Nine  or  ten  years 
ago  he  became,  for  this  complaint,  a 
patient  in  the  Middlesex  Hospital, 
under  the  care  of  Mr.  Arnott.  Various 
applications  were  employed  without 
relief;  and  at  the  expiration  of  a 
month,  the  nature  of  the  disease  and 
its  intractable  character  having  been 
explained  to  him,  he  quitted  the  hos¬ 
pital.  At  this  time  he  walked  lame, 
and  was  informed,  after  admeasure¬ 
ment  of  the  limbs  had  been  made,  that 
the  left  leg  was  shorter  than  the  right 
one.  At  present  no  great  difference  is 
to  be  noticed,  inasmuch  as  the  opposite 
hip  has  become  affected. 

To  return  to  the  shoulder.  No  dis¬ 
tinct  attack  of  rheumatism  occurred  to 
it  since  the  one  above  mentioned;  but 
it  has  continued  the  seat  of  the  same 
symptoms  as  those  previously  described 
during  the  last  twelve  months.  On 
applying  a  hand  over  the  joint,  then 
rotating  and  circumducting  the  hu¬ 
merus,  a  very  well-marked  “  articular 
crepitus”  is  heard,  and  the  peculiar 
sensation  characteristic  of  it  also  is 
communicated  to  the  touch.  The  cre¬ 
pitus  is  most  readily  felt  when,  in  cir¬ 
cumduction,  the  arm  passes  forwards 
from  the  side  of  the  chest,  the  move¬ 
ment  producing  at  the  same  time  an 
indescribable  uneasiness  in  the  articu¬ 
lation.  Pressure  on  the  deltoid  muscle, 


so  as  closely  to  approximate  the  joint 
surfaces  of  the  humerus  and  scapula, 
gives  no  pain,  nor  is  any  inconvenience 
experienced  when  the  head  of  the  hu¬ 
merus  is  directed  against  the  under 
part  of  the  acromion  process.  The 
arm  can  with  difficulty  be  elevated, 
directed  forwards  or  backwards.  The 
deltoid  of  either  side,  in  common  with 
the  muscles  generally,  is  much  wasted ; 
little,  if  any,  difference  is  to  be  noticed, 
however,  between  the  two  sides.  Mea¬ 
surement  does  not  shew  the  right  hu¬ 
merus  to  be  nearer  the  acromion  pro¬ 
cess  than  it  is  on  the  left  side. 

An  incessant  dull  pain,  aggravated 
by  motion,  is  complained  of  in  the 
joint,  and  extending  thence  down  the 
front  of  and  along  the  inner  side  of 
the  arm  to  the  elbow. 

The  acromio-clavicular  articulation 
presents  a  partial  dislocation  of  the 
clavicle,  which  is  elevated,  and  appears 
to  be  fixed  near  to  the  upper  edge  of 
the  articular  surface  of  the  acromion 
process.  This  joint  on  the  opposite 
side  is  in  all  respects  normal. 

Acromio-clavicular  joint. — This  part 
is  not  always  affected  when  the  shoulder 
is  attacked,  but  I  find  it  is  not  unfre- 
quently  so.  It  soon  becomes  the  seat 
of  a  partial  dislocation  of  the  clavicle 
upwards,  and  an  unnatural  degree  of 
mobility  is  present,  or  the  bone  may 
become  fixed  in  its  new  situation  by 
soft  anchylosis,  as  in  the  instance  re¬ 
ferred  to.  I  have  lately  had  the  oppor¬ 
tunity  of  dissecting  a  joint  which  was 
in  the  first-mentioned  condition,  and 
found  the  ligaments  to  be  highly  deve¬ 
loped  ;  the  synovia  thick  and  abundant, 
the  bones  large  and  strong,  the  articular 
surfaces  expanded,  partly  diverted  of 
cartilage,  and  marked  with  other  cha¬ 
racteristics  of  the  disease.  An  inter- 
articular  body  was  seen  occupying,  as 
it  usually  does  when  present,  the  supe¬ 
rior  half  only  of  the  articulation.  It 
was  wTedge-shaped,  and  firmly  attached 
by  the  broad  end  to  the  thickened  liga¬ 
ment  above  ;  the  lower  having  been,  as 
it  were,  worn  down,  and  become  fringed 
and  free.  The  shoulder-joint  was 
healthy. 

The  disease  has  been  noticed  in  this 
situation  by  Mr.  Labatt  in  a  case  where 
the  shoulder  was  similarly  affected. 
“The  acromio-clavicular  articulation,” 
he  observes,  “  was  remarkably  relaxed, 
admitting  of  extensive  rotatory  motion. 
The  superior  ligaments  were  much 


SUDDEN  DEATH - ABNORMAL  POSITION  OF  THE  ABDOMINAL  VISCERA.  115 


thickened  and  hypertrophied,  and  en¬ 
closed  three  or  four  minute  cartilagi¬ 
nous  nuclei,  one  of  which  pressed  in 
on  the  joint.  Synovial  membrane 
nearly  absorbed ;  investing  cartilage 
thin  and  softened.” 

[To  be  continued.] 


CONTRIBUTIONS  to  PATHOLOGY. 

CASE  OF  SUDDEN  DEATH  -  ABNORMAL 

POSITION  OF  THE  ABDOMINAL  VISCERA. 

By  William  Robbs,  Surgeon, 
Grantham. 


A  case  possessing  considerable  interest 
occurred  a  few  days  back  in  the 
Grantham  Union  Workhouse.  It  was 
brought  under  the  author’s  notice  from 
the  circumstance  of  the  sudden  death 
of  a  poor  man,  which  caused  a  judicial 
inquiry  as  to  its  nature,  and,  conse¬ 
quently,  afforded  an  opportunity  for  a 
post-mortem  examination.  The  cir¬ 
cumstances  of  the  case  preceding  the 
death  of  the  subject  of  the  inquiry 
were  as  follow: — About  three  weeks 
back  he  complained  of  being  ill,  la¬ 
bouring  under  fulness  and  tenderness 
of  the  abdomen,  and  unable  to  perform 
his  duties  as  a  servant.  For  this  he 
sought  the  assistance  of  Mr.  Colling- 
wood,  a  surgeon  of  Corby,  who  con¬ 
sidered  him  labouring  under  inflam¬ 
mation  of  the  liver.  He  was  bled, 
blistered,  and  had  the  usual  remedies 
prescribed.*  As  his  recovery  was 
slow,  it  was  thought  advisable  by  his 
master  to  remove  him  into  the  Gran¬ 
tham  Workhouse.  On  Monday,  the 
‘26th  of  June,  1848,  Miles  Durkin,  aged 
26  years,  the  man  in  question,  was  ad¬ 
mitted  into  the  sick  ward  of  the  above 
institution.  On  the  following  day  he 
was  seen  by  the  author,  who  found 
him  complaining  of  pain  and  swelling 
of  his  ankles  and  feet;  fulness  of  the 
abdomen  ;  pain  in  his  left  side,  in  the 
region  of  his  heart ;  loss  of  appetite, 
and  thirst.  His  countenance  was  pale; 
tongue  red;  pulse  100,  small,  irregular, 
and  compressible.  He  stated  himself 
to  have  suffered  from  rheumatic  pains 
of  his  joints.  Small  doses  of  calomel 
and  Dover’s  powder  were  prescribed, 
to  be  given  at  intervals,  followed  by 
saline  diuretic  draughts.  On  Wednes¬ 
day,  the  28th,  he  appeared  very  much 


relieved ;  the  swelling  of  the  ankle- 
joints  was  reduced ;  he  had  taken  his 
food,  and  retained  it  on  the  stomach. 
He  was  recommended  to  persevere 
with  the  remedies.  On  Thursday  he 
was  not  visited ;  and  early  the  follow¬ 
ing  morning  he  requested  the  nurse  to 
let  him  have  his  clothes,  as  it  was  his 
intention  to  return  on  foot  to  Osgodby, 
a  distance  of  about  ten  miles.  On 
Saturday  he  was  brought  back  to 
Grantham,  and  in  the  evening  pre¬ 
sented  himself  at  the  workhouse  with 
a  vagrant  ticket  for  a  night’s  lodg¬ 
ing.  The  porter  of  the  establish¬ 
ment  aroused  the  vagrants  about  half¬ 
past  six  o’clock  on  the  following 
morning  :  the  deceased  got  out  of  bed, 
and  commenced  dressing  himself ;  and 
while  in  the  act  of  stooping  to  put  on 
his  shoes,  stretched  himself  backwards 
and  expiied.  An  examination  of  the 
body  was  made,  under  the  direction  of 
the  Coroner,  nine  hours  after  death,  in 
the  presence  of  Mr.  Priest  and  Mr.  W.E. 
Robbs.  Externally  it  presented  slight 
swelling,  and  oedema  of  the  ankle- 
joints,  feet,  and  hands;  a  frothy  mu¬ 
cous  fluid  was  issuing  from  the  nostrils 
and  mouth,  which  the  slightest  pressure 
over  the  sternum  increased.  On  divid¬ 
ing  the  integument,  the  cellular  and 
muscular  substances  presented  a  firm 
and  healthy  appearance.  The  chest 
being  opened,  both  cavities  were  re¬ 
plete  with  effusion  of  serum;  the  lungs 
were  enormously  distended;  the  bron¬ 
chial  tubes,  trachea,  and  larynx,  were 
likewise  filled,  presenting  the  appear¬ 
ance  of  suffocation  from  drowning.  The 
pericardium  contained  about  half  a 
pint  of  the  same  fluid;  the  heart  itself 
presented  a  healthy  appearance,  and 
was  not  enlarged;  the  auricles  con¬ 
tained  dark  coagulated  blood;  both 
ventricles  were  distended  with  firm 
pieces  of  fibrin,  and  the  valves  of  the 
left  were  obstructed  by  small  fleshy 
excrescences.  The  abdomen  was  next 
examined,  when  it  presented  a  very 
unusual  appearance.  The  liver  occu¬ 
pied  the  whole  of  the  left  hypochon¬ 
driac,  epigastric,  and  part  of  the  right 
hypogastric  regions  ;  the  organ  itself 
was  nearly  double  its  natural  size ;  the 
large  lobe  and  its  greatest  bulk  occu¬ 
pied  the  left  side.  The  stomach,  with 
the  spleen,  was  placed  in  the  right 
hypochondriac  region  ;  the  cardiac  end 
of  the  former  was  on  the  right,  while 
the  pyloric  extremity  presented  itself 


*  Evidence  at  the  inquest. 


116  CASE  OF  POISONING  BY  THE  SEEDS  OF  JATROPHA  CURCAS. 


on  the  left  side.  The  spleen  was 
partly  disorganised  by  inflammation 
and  suppuration.  The  caecum,  with 
its  appendix  vermiformis,  was  placed 
in  the  left  iliac  region.  The  peritoneum 
forming  the  omentum  major,  and  por¬ 
tions  covering  different  parts  of  the 
intestines,  were  of  a  scarlet  colour.  The 
arch  of  the  colon  and  rectum  were 
very  contracted  ;  the  kidneys  and 
bladder  were  healthy.  The  head  was 
not  examined.  What  renders  this  case 
of  interest  is  the  circumstance  of  the 
organs  of  the  abdomen  all  being  placed 
in  an  abnormal  position:  and  although 
the  author  has  himself  performed, 
assisted,  and  witnessed  several  hundred 
post  mortem  examinations,  he  never 
met  with  the  same  phenomenon. 


REPORT  OF  A  CASE  OF 

POISONING  BY  THE  SEEDS  OF 
JATROPHA  CURCAS, 

(the  physic-nut  of  the  west  indies). 

By  H.  Letheby,  M.B. 

Lecturer  on  Chemistry  at  the  London  Hospital. 


On  the  afternoon  of  Wednesday,  June 
28th,  James  Cole,  aged  36  years,  pre¬ 
sented  himself  for  medical  relief  at  the 
London  Hospital.  He  stated  that  his 
occupation  was  that  of  a  labourer  in 
the  London  Docks;  that  in  the  morning, 
while  at  work  there,  he  met  with  a 
broken  bag  containing  some  seeds,  of 
which  he  produced  a  sample — (they 
were  the  seeds  of  jatropha  curcas )  : 
that  in  consequence  of  being  told  by 
two  sailors  who  were  passing  at  the 
time,  that  the  seeds  were  wholesome, 
be  removed  the  husks  from  five  of  them, 
and  ate  the  kernels  ;  but  that  he  had 
no  sooner  done  so  than  another  sailor, 
whom  he  met,  assured  him  that  he  was 
eating  a  rank  poison  ;  this  he  soon 
found  to  be  the  case,  for,  after  the  lapse 
of  from  ten  minutes  to  a  quarter  of  an 
hour,  he  began,  he  said,  to  experience 
a  burning  sensation  in  his  mouth  and 
throat ;  and  the  abdomen  felt  sore  and 
distended.  In  the  course  of  a  few 
minutes  after  this  he  was  seized  with 
violent  sickness;  and  during  the  sub¬ 
sequent  hour  he  vomited  five  times,  and 
was  very  actively  purged.  The  burning 
sensation  in  the  fauces,  and  the  pain 
in  the  abdomen,  still  continued;  he 
also  felt  hot  and  feverish.  Towards 


the  termination  of  the  first  hour  and  a 
half,  a  profuse  perspiration  broke  out 
upon  the  whole  surface  of  his  body  ; 
and  then  he  became  so  exceedingly 
weak  as  hardly  to  be  able  to  walk 
about.  During  the  next  half  hour  this 
debility  had  greatly  increased  ;  he  felt 
extremely  giddy,  became  delirious,  and 
was  ultimately  quite  insensible.  He 
remained  in  this  state  nearly  twenty 
minutes  ;  but  in  another  half  hour  he 
had  so  far  recovered  as  to  be  able  to 
walk  to  the  London  Hospital,  where  he 
presented  himself  after  an  interval  of 
about  four  hours  from  the  time  at  which 
he  partook  of  the  poison.  At  this 
period  he  was  very  weak,  and  com¬ 
plained  of  a  sensation  of  heat  and  dry¬ 
ness  of  the  mouth  and  throat,  of  numb¬ 
ness  in  the  tongue,  and  of  pain  in  the 
abdominal  region.  His  countenance 
was  pale,  and  somewhat  anxious ;  the 
pupils  were  natural ;  the  hands  rather 
cold ;  the  pulse  140,  and  weak.  By 
means  of  an  opiate  and  a  mild  cordial, 
he  was  soon  relieved  and  enabled  to 
return  to  his  home. 

I  am  not  aware  of  any  recorded  in¬ 
stance  of  accidental  poisoning  from  the 
seeds  of  jatropha  curcas  ;  and  this  is 
somewhat  remarkable,  considering  that 
the  physic-nut  is  so  frequently  im¬ 
ported  into  this  country.  I  have  been 
informed  that  the  kernels  of  them  are 
used  as  a  purgative  for  cattle ;  and  I 
believe  that  they  are  also  used  for  the 
manufacture  of  what  is  now  and  then 
met  with  at  our  drug  sales  under  the 
name  of  English  croton  oil. 

This  case  indicates  that  the  primary 
action  of  jatropha  seeds  is  that  of  an 
irritant  affecting  the  mouth,  throat, 
stomach,  and  bowels,  producing  heat, 
pain,  vomiting,  and  purging.  Their 
secondary  action  is  upon  the  nervous 
and  vascularsystems, occasioning  giddi¬ 
ness,  delirium,  and  a  great  depression 
of  the  vital  powers :  the  latter  being 
characterized  by  weakness,  syncope, 
and  a  feeble  pulse.  In  these  respects, 
their  action  is  very  similar  to  that  which 
arises  from  the  seeds  of  Croton  tiglium 
and  Ricinus  communis ,  plants  which 
belong  to  the  same  family  as  the  jatro¬ 
pha.  In  illustration  of  the  effects  pro¬ 
duced  by  the  former  poison,  I  may  men¬ 
tion  the  following  case,  which  has  been 
recorded  by  Dr.  Pereira  : — A  labourer, 
aged  31,  had  been  exposed  during  eight 
hours  to  the  dust  of  croton  seeds ;  he  ex- 
periencedaburningsensation  inhisnose 


THE  UPTON  BOARD  OF  GUARDIANS  AND  THEIR  MEDICAL  OFFICERS.  117 


and  mouth ;  tightness  at  his  chest ;  epi¬ 
gastric  pain,  giddiness  and  insensibility. 
On  his  admission  into  the  London 
Hospital,  he  appeared  in  a  state  of 
collapse ;  his  countenance  was  dis¬ 
tressed  ;  his  pulse  85,  and  the  surface 
of  the  body  cold.  He  stated  that  his 
tongue  felt  too  large  for  his  mouth, 
and  appeared  to  be  without  feeling. 
Hot  brandy  and  water  were  given  to 
him,  and  he  was  put  to  bed  with  evident 
relief. 

As  an  instance  of  poisoning  by  the 
latter,  I  may  .refer  to  the  cases  which  are 
mentioned  by  Mr.  Alfred  Taylor.  Three 
sisters  made  use  of  the  seeds  of  the  cas¬ 
tor  oil  plant ;  one  ate  twenty  of  them  ; 
another  ate  four  or  five  ;  and  the  third 
only  two.  They  were  all  taken  ill.  but 
deceased,  who  partook  of  the  largest 
number,  became  faint  and  sick ;  her 
skin  was  cold,  and  dark  coloured;  her 
features  pinched  ;  the  pulse  was  small 
and  wiry ;  there  was  restlessness, 
thirst ;  pain  in  the  abdomen  ;  and  she 
lay  in  a  sort  of  drowsy,  half  conscious 
state,  like  one  suffering  from  malignant 
cholera. 

Mr.  Bennet  says  that  four  of  the 
jatropha  seeds  will  act  on  a  man  as  a 
powerful  cathartic  ;  but  it  is  evident 
from  the  case  here  mentioned,  that 
danger  might  be  incurred  by  the  ad¬ 
ministration  of  such  a  dose  ;  in  fact, 
Dr.  Christison  states  that  he  has 
known  violent  vomiting  and  purging 
occasioned  by  a  few  grains  of  the  cake 
left  after  the  expression  of  the  fixed 
oil  from  the  bruised  seeds.  It  appears 
from  this,  that  the  poisonous  principle 
of  the  jatropha,  like  that  of  the  croton 
and  ricinus,  exists  in  the  solid  and  non- 
oleaginous  parts  of  the  seed.  This 
view  is  confirmed  by  another  statement 
made  by  Dr.  Christison,  that  from 
twelve  to  fifteen  drops  of  the  oil  ex¬ 
pressed  from  the  physic-nut,  produced 
exactly  the  same  effects  as  an  ounce  of 
castor  oil.  Now  I  have  found  that 
three  kernels  will  only  yield  one  drop 
of  oil ;  it  would,  therefore,  take  from 
36  to  45  seeds  to  produce  the  dose 
mentioned  by  Dr.  Christison;  and  it 
is  scarcely  necessary  to  say  that  even 
36  of  the  seeds  would  be  quite  sufficient 
to  occasion  the  death  of  an  individual. 


MEDICAL  GAZETTE. 


FRIDAY,  JULY  21,  1848. 

We  have  great  pleasure  in  giving  in¬ 
sertion  this  week  to  a  letter  addressed 
to  the  medical  profession  generally,  by 
the  Poor-law  Medical  officers  of  the 
Upton-on-Severn  Union.*  These  gen¬ 
tlemen  have  brought  their  case  in  fair 
and  temperate  language  before  the 
Board  of  Guardians,  and  have  proved 
that  the  salaries  which  they  have  re¬ 
ceived  for  medical  attendance  on  the 
poor  are  quite  inadequate  to  cover  the 
expenses  incurred.  The  amount  of 
remuneration  varies,  it  appears,  in 
different  districts, — the  minimum  being 
one  shilling  and  sevenpence,  and  the 
maximum  four  shillings,  per  case.  The 
great  difference  thus  brought  to  light  is 
sufficient  to  shew  that  there  is  some¬ 
thing  radically  wrong  in  the  system  of 
payment  adopted.  The  maximum 
payment,  it  is  obvious,  falls  far  short 
of  what  in  reason  and  justice  it  ought 
to  be,  either  to  secure  efficient  medical 
attendance  on  the  destitute,  or,  when 
the  duty  is  conscientiously  discharged, 
to  recompense  the  hard- worked  country 
practitioner  for  the  time,  labour,  skill, 
and  responsibility,  which  must  be  in¬ 
curred  by  Union  practice.  The  whole 
system  is  marked  with  injustice  as  well 
as  inconsistency,  and  the  sooner  the 
Chief  Commissioner,  aided  by  a  com¬ 
mittee  of  respectable  medical  practi¬ 
tioners  who  have  a  practical  knowledge 
of  the  duties  to  be  performed,  can  give 
his  attention  to  the  subject,  the  more 
satisfactory  will  it  be  to  the  profession 
as  well  as  the  poor;  and  the  more 
creditable  to  himself,  as  the  occupant 
of  a  highly  responsible  office.  At  a 
meeting  which  a  deputation  of  Poor- 
law  medical  officers  had  with  Sir  George 


*  See  Page  127. 


118  THE  UPTON  BOARD  OF  GUARDIANS  AND  THEIR  MEDICAL  OFFICERS 


Grey  on  the  30th  May,*  some  facts 
were  stated  which  made  out  a  case  not 
only  for  immediate  supervision,  but  for 
the  issuing  of  a  stringent  order  for  the 
increase  of  medical  salaries  in  those 
Unions  in  which  Boards  of  Guardians 
had  not  of  their  own  accord  already 
adopted  a  more  liberal  system.  Dr. 
Burton  pointed  out  a  disgraceful  ano¬ 
maly  in  the  mode  of  payment.  In 
some  districts  the  remuneration 
amounted  to  sixteen  shillings,  while 
in  others  it  was  actually  below'  sixpence 
per  case  !  Here  we  have  even  a  greater 
difference  than  that  complained  of  in 
the  letter  of  the  Union  officers  of  Upton- 
on-Severn.  But  another  strange  feature 
in  the  system  is,  that  prison  practice  is 
far  more  lucrative  than  Union  practice. 
At  the  meeting  above  referred  to,  it 
was  stated  on  good  authority  that  the 
average  payment  for  attendance  on 
prison  patients  was  no  less  than  thirteen 
shillings  and  sixpence  per  case;  so 
that  a  destitute  person  who  commits  a 
breach  of  the  law  becomes  a  more 
profitable  patient  than  one  who,  by 
honesty  and  well-directed  industry, 
contrives  to  keep  outside  of  the  walls 
of  a  prison  !  We  can  only  explain  the 
difference  by  the  fact,  that  medical 
officers  of  prisons  cannot  be  so  readily 
found  as  medical  officers  to  Unions; 
and  the  offices  are  not  filled  by  a  sys¬ 
tem  of  low  competition,  at  the  dictation 
of  a  Board  whose  object  is  to  cut  down 
the  salaries  to  the  lowest  possible  scale, 
regardless  of  the  consequences  to  the 
medical  officer  and  the  pauper.  When 
a  pauper  dies  in  a  prison,  an  inquest  is 
commonly  held  on  the  body,  and  a 
close  inquiry  is  made  into  the  mode  of 
treatment,  general  and  medical.  Any 
thing  wrong  is  immediately  brought  to 
the  notice  of  the  public,  and  the  un¬ 
fortunate  practitioner,  as  well  as  the 
Government  which  employs  him,  comes 


in  for  a  tolerable  share  of  abuse  from 
some  busy  Parliamentary  reformer 
desirous  of  adding  a  little  to  his  popu¬ 
larity.  Inquests,  it  is  true,  occasion¬ 
ally  take  place  on  the  bodies  of  paupers 
who  die  out  of  the  precincts  of  a  prison  ; 
and  there  is  then  often  revealed  a  sys¬ 
tem  of  neglect  and  mismanagement 
which  is  disgraceful  to  the  institutions 
of  a  civilised  country.  A  medical 
officer  represents  the  urgency  of  a  case 
to  one  of  these  economical  Boards,  and 
applies  for  an  order.  This  is  refused, 
and  the  pauper  falls  a  victim  to  sheer 
neglect.  The  medical  officeris  then  held 
up  as  guilty  of  inhumanity,  because  he 
did  not  neglect  his  other  duties  to  attend 
a  patient  whose  claim  to  parochial 
medical  relief  the  board  had  peremp¬ 
torily  refused  to  recognize.  On  the 
other  hand,  if  he  had  attended,  and  the 
patient  had  recovered  under  his  care, 
the  Board  w'ould  have  declined  award¬ 
ing  any  payment  for  such  attendance, 
and  wrould  have  justified  themselves  by 
the  refusal  of  an  order,  although  the 
refusal  virtually  consigned  the  pauper 
to  a  grave.  Without  having  the 
smallest  desire  to  add  to  the  pecuniary 
profits  of  coroners,  rendered  already 
sufficiently  large  by  reason  of  un¬ 
necessary  or  ill-conducted  inquests,  we 
think  that  if  for  one  year  an  inquest 
were  held  upon  each  pauper  who  died 
in  a  Union  as  upon  each  inmate  of  a 
prison,  such  an  amount  of  neglect  and 
cruelty  would  be  brought  to  light,  that 
the  present  system  would  of  necessity 
be  immediately  abolished.  By  this  re¬ 
mark  we  by  no  means  intend  to  impute 
blame  to  the  medical  officers  of  Unions 
generally  :  on  the  contrary,  taking  them 
as  a  body,  we  believe  them  to  be  not 
only  highly  humane  and  charitable,  but 
wdlling,  as  far  as  their  means  will  allow 
them,  to  benefit  the  poor  by  their  skill, 
wTith  the  certainty  that  they  will  re¬ 
ceive  no  compensation  for  their  ser¬ 
vices.  But  the  tender-system,  and  the 


*  See  our  last  volume,  p.  1048. 


THE  UPTON  BOARD  OF  GUARDIANS  AND  THEIR  MEDICAL  OFFICERS.  119 


plan  now  about  to  be  adopted  by  the 
Upton  Board,  of  seeking  to  obtain  pro¬ 
fessional  services  at  a  salary  which  it 
is  clearly  proved  is  wholly  inadequate 
to  cover  the  expenses,  must  tend  to  en¬ 
courage  a  bad  class  of  practitioners — 
men  on  the  verge  of  starvation,  who 
will  accept  office  with  a  resolution 
to  do  as  little  as  possible,  and  who  are 
as  regardless  of  their  own  professional 
conduct  and  character,  as  they  are  of 
the  interests  of  the  sick  poor.  The  re¬ 
sult  of  a  coroner’s  inquest  or  a  trial  at 
the  assizes,  may  be  the  means  of  their 
dismissal  from  office;  but  unfortunately, 
from  the  over- stocked  state  of  the  pro¬ 
fession,  there  are  others  who  are  too 
often  ready  and  willing  to  take  their 
place. 

The  course  taken  by  the  Upton 
Union  officers,  although  likely  to 
damage  their  interests  for  a  time,  by 
leading  to  the  importation  into  the  dis¬ 
trict  of  an  unscrupulous  set  of  rival 
practitioners,  is  that  which  we  think 
conscientious  medical  men  so  situated 
should  invariably  adopt.  It  is  clearly 
proved  that  the  salaries  are  inadequate 
to  the  duties  ;  —  that  they  are  not  only 
unreasonably  low’,  but  much  lower 
than  in  many  surrounding  districts  ; — 
that  population,  and  consequently  pro¬ 
portionate  sickness, have  increased  since 
the  scale  of  salaries  wjas  first  framed  ;* 

• —  that  the  maximum  amount  per  case 
is  one  third  less  than  that  recommended 
by  the  Poor  Law  Commissioners,  and 
that  a  progressive  increase  to  this 
amount  would  meet  the  wishes  of  the 
applicants.  Their  fair  and  just  pro¬ 
positions  have,  however,  been  rejected 
by  the  Board,  and  the  medical  officers 
have  consequently  resigned.  We  do 

*  That  there  is  something-  specially  oppressive 
to  the  members  of  the  medical  profession  in  the 
conduct  of  certain  Boards  of  Guardians,  is  proved 
by  the  fact  that  owing  to  the  increase  of  duty, 
the  salaries  of  the  clerk  and  relieving  officers  of 
the  Upton  Union  have  been  recently  augmented. 
Now,  we  think  it  clear  that  this  augmentation 
has  been  either  made  most  unnecessarily,  or 
there  is  good  reason  for  extending  it  to  the  sala¬ 
ries  of  the  medical  officers. 


not  know  a  stronger  case  than  this  for 
proving  that  Local  Boards  should  not 
be  entrusted  with  an  arbitrary  power 
of  dealingout  injustice  in  this  wholesale 
fashion.  The  conduct  of  the  Upton 
Board  proves  that  it  is  composed  of 
men  who,  either  without  the  capacity 
to  understand  the  nature  of  their 
duties,  or  wilfully  perverse  in  refusing 
to  adopt  an  equitable  arrangement, 
sanctioned  and  recommended  by  the 
Poor  Law  Commissioners.  In  either 
case,  their  utter  incompetency  to  exer¬ 
cise  an  irresponsible  control  over  mem¬ 
bers  of  the  medical  profession, is  clearly 
established.  If  they  seriously  carry 
out  their  plan  of  advertising  for  other 
medical  officers,  the  advertisement 
might  fairly  run  in  the  following 
terms : — 

“  Wanted,  for  a  Union,  twenty  miles 
in  length,  and  containing  a  population 
of  16,724  persons,  some  regularly  quali¬ 
fied  gentlemen,  who  will  undertake  the 
medical  attendance  of  the  poor  at  the 
average  rate  of  two  shillings  per  case 
per  annum.  They  wall  be  required  to 
provide  drugs,  horses,  &c.” 

The  amount  will  clearly  not  pay  for 
the  medicines  likely  to  be  required  in 
any  one  case,  and  the  attendance  must 
of  course  be  given  gratuitously  !  If 
medical  practitioners  only  act  fairly 
by  each  other,  these  guardians  wdll 
search  in  vain  for  officers  to  supply 
the  place  of  those  wffiose  resignations 
they  have  most  injudiciously  accepted  j 
and  it  would  not  be  long  before  the 
evil  system  upon  which  we  have  com¬ 
mented,  was  entirely  abolished.  The 
naval  Assistant-surgeons  have  recently 
set  a  good  example :  let  candidates 
for  Union  medical  practice  act  in  like 
manner,  and  we  shall  no  longer  be 
called  upon  to  insert  appeals  to  pro¬ 
fessional  feeling  and  fair  dealing  like 
that  made  by  the  Upton  medical  offi¬ 
cers.* 

*  Since  the  above  w  as  written,  we  have  received 
from  the  Poor-Law  Medical  Convention  Office 

I 


120  INDEX  TO  THE  BRITISH  AND  FOREIGN  MEDICAL  REVIEW. 


IftcbtcfoS. 

General  Index  to  the  British  and 
Foreign  Medical  Reviexo  or  Quarter!}/ 
Journal  of  Practical  Medicine  and 
S  nr  gem.  Edited  bv  John  Forbes, 
M.D.  F.R.S.  &c.  Yol.  XXV.  8vo. 
pp.  303.  London  :  Chnrchill.  1848. 

We  take  the  earliest  opportunity  of 
announcing  the  publication  of  this 
useful  companion  to  the  possessors  of 
the  British  and  Foreign  Medical  Re¬ 
view.  A  work  consisting  of  twenty- 
four  closely  printed  volumes,  and  con¬ 
taining  in  a  condensed  form  a  com¬ 
plete  analysis  of  British  and  foreign 
medical  literature,  extending  over  a 
period  of  twelve  years,  was  obviously 
in  need  of  a  general  index ;  for  it 
could  not  be  expected  that  any  reader 
would  afford  time  or  patience  to  wade 
through  the  indices  of  twenty-four 
volumes  for  the  sake  of  a  single  refe¬ 
rence.  Happily  for  those  who,  like 
ourselves,  place  great  value  upon  the 
contents  of  this  excellent  periodical, 
such  a  trial  of  patience  is  no  longer 
necessary.  The  volume  before  us 
supplies  the  deficiency,  and  enables  a 
reader  to  trace  out  an  article  or  an 
author  with  the  greatest  facility. 
Short  as  the  period  is  which  has 
elapsed  since  we  have  received  a  copy 
of  this  index,  we  have  had  frequent 
occasion  to  refer  to  it,  and  have 
hitherto  invariably  found  it  correct. 
The  preparation  of  the  index  must 
have  been  a  work  of  enormous  labour; 
for  a  mere  transcript  of  the  indices  of 
the  volumes,  without  further  refer¬ 
ences,  corrections,  and  additions,  would 
have  entirely  failed  of  its  object. 
Every  author  knows  that  there  is  no 
part  of  his  labour  so  tedious  or  so 
wearisome  as  that  which  is  directed  to 
the  tabulating  of  the  contents  of  his 
volume  in  alphabetical  order;  and 
there  is  at  the  same  time  no  part  of  the 
work  in  which,  to  the  unreflecting, 
care  and  labour  are  so  little  apparent. 
Yet  what  is  the  best  work  of  its  class 
without  a  good  and  copious  index  ? 

It  is  like  an  extensive  library  rich  in 
valuable  works  without  a  catalogue. 
Then,  again,  index-making  is  not,  as 
some  are  apt  to  imagine,  a  mere  me¬ 
chanical  art.  The  compiler  must  enter 

an  address  to  the  profession,  taking  the  same 
view  of  this  question  as  that  which  we  have  ad¬ 
vocated.— (See  page  129.) 


into  the  thoughts  of  a  large  number  of 
readers,  and  consider  under  what  head¬ 
ing  each  is  likely  to  seek  for  a  case, 
paragraph,  or  report,  bearing  upon 
some  particular  doctrine  or  point  of 
practice.  Fie  must  divest  himself  of 
his  own  peculiar  views  in  his  own 
favourite  branch  of  the  profession,  in 
order  to  place  his  matter  in  a  form 
readily  accessible  to  all.  If  this  re- 
markmpplies  to  the  index-maker  of  a 
treatise  on  medical  science,  it  applies 
with  tenfold  force  to  him  who  would 
compile  a  serviceable  index  for  a 
periodical  of  many  years’  standing. 

The  following  extract  from  the  pre¬ 
face  will  give  some  idea  of  the,mental 
labour  which  this  index  has  cost ;  and 
it  is  highly  creditable  to  the  compiler, 
Dr.  Robert  Bower,  that,  for  the  pur¬ 
pose  of  facilitating  references,  he  has 
actually  devoted  more  than  the  usual 
amount  of  labour  to  his  task. 

“  The  alphabetical  arrangement  is  carried 
out  to  an  unusual  extent ;  all  the  subordi¬ 
nate  references  under  each  separate  heading 
being  placed  in  strict  alphabetical  order 
also.  All  the  authors’  names,  except 
when  occurring  in  the  subordinate  refer¬ 
ences,  are  printed  in  capitals  :  by  this 
arrangement  the  necessity  of  having  a  sepa¬ 
rate  list  of  authors  is  avoided,  as  the 
difference  of  type  will  attract  the  immediate 
notice  of  readers.” 

Tn  turning  over  the  pages,  we  find 
copious  references  given  to  every  sub¬ 
ject  of  interest  in  every  branch  of  the 
profession.  It  is  hardly  requisite  to 
say  that  this  Index  is  indispensable  to 
those  who  have  the  Review  ;  and  an 
examination  of  its  contents  will  doubt¬ 
less  induce  many  at  the  eleventh  hour 
to  become  purchasers  of  the  remaining 
copies. 


Memoranda  for  Young  Practitioners 
in  Midwiferu.  By  Edward  Rigby, 
M.D.  2d  edition,  considerably  en¬ 
larged.  Small  32mo.  pp.  64.  Lon¬ 
don  :  Renshaw.  1848. 

Many  of  our  student-readers  are  doubt- 
ess  familiar  with  this  little  companion, 
which  may  be  easily  carried  in  the 
waistcoat  pocket.  The  preface  informs 
us  that  the  first  edition  of  2000  copies 
has  been  for  some  time  exhausted — a 
proof  that  the  Memoranda  have  al¬ 
ready  met  with  a  very  favourable  re¬ 
ception  from  the  profession. 

To  those  who  are  unacquainted  with 
this  little  book,  we  may  remark  that  it 


ON  THE  UTILITY  OF  TRTSNITRATE  OF  BISMUTH  IN  DIARRHOEA.  121 


is  a  concentrated  essence  of  useful 
practical  information  on  pregnancy 
and  the  treatment  of  labour,  and  its 
sequelae.  The  subjects  of  which  it 
treats  are  arranged  in  twenty  five 
sections,  and  to  it  is  appended  a  series 
of  useful  formulae. 

Dr.  Rigby’s  experience,  as  an  ob¬ 
stetric  practitioner,  is  sufficient  to 
guarantee  the  accuracy  of  the  informa¬ 
tion  conveyed  in  this  aphoristical 
form  ;  and  we  do  not  hesitate  to  re¬ 
commend  his  “  Memoranda”  to  all 
students  and  junior  members  of  the 
profession  who  are  engaged  in  the 
study  and  practice  of  midwifery. 
There  are  other  medical  sciences  upon 
which  compendiums  on  this  scale  would 
be  highly  serviceable.  In  the  mean¬ 
time,  as  a  large  amount  of  knowledge 
may  be  thus  circulated  in  a  micro¬ 
scopical  form,  it  behoves  examiners 
who  forbid  references  to  books,  to  de¬ 
termine  whether  the  pockets  of  can¬ 
didates  should  not  henceforth  undergo 
a  strict  search  before  they  are  admitted 
to  the  ordeal  of  an  examination. 


Portraits  of  Diseases  of  the  Shin.  By 
Erasmus  Wilson,  F.R.S.  Fasc.  III. 

London:  Churchill,  1848. 

The  third  part  of  this  excellent  work, 
which  we  have  now  before  us,  contains 
illustrations  of  Acne  Vulgaris ,  Erythe 
mu  Palmare,  Urticaria  Persians,  and 
Melunopathia  Syphilitica.  We  shall 
only  remark  of  these  illustrations,  that 
they  are  just  as  admirably  executed  as 
those  which  have  already  appeared  in 
the  two  foregoing  fasciculi.  Great 
credit  is  due  both  to  artist  and  printer. 
The  lightness  of  the  lithographic  print¬ 
ing  is  such  that  the  coloured  shades  of 
the  skin  have  their  proper  natural  ap¬ 
pearance  unmarred  by  the  blackness 
of  the  lithographic  ink.  The  colouring 
in  the  illustration  of  Acne  Vulgaris  is 
especially  worthy  of  praise.  Acne  is 
here  seen  in  all  its  stages,  and  the 
artist  has  contrived  to  give  to  the  dis¬ 
ease  the  perfect  characters  of  inflam¬ 
mation  and  suppuration.  A  report  of 
each  case  which  has  served  as  an  illus¬ 
tration  is  attached,  giving  a  short  but 
complete  history  of  the  disease  and  the 
influence  of  treatment.  We  can  con¬ 
fidently  recommend  this  in  the  terms 
in  which  we  have  already  recommended 
the  preceding  parts,  to  the  notice  of 
the  profession. 


3Ptoc*edtng$  of  ^octettes. 


ROYAL  MEDICAL  &  CHIRURGICAL 
SOCIETY. 

June  27,  1848. 

J.  M.  Arnott,  Esq.  F.R.S. ,  President. 


On  the  Utility  of  Trisnitrate  of  Bismuth 
in  the  Diarrhoea  accompanying  Phthisis. 
By  Theophilus  Thompson,  M.D  F.R.S. 
Physician  to  the  Hospital  for  Consumption 
and  Diseases  of  the  Chest. 

The  author  considers  the  trisnitrate  of  bis¬ 
muth  to  surpass  in  efficacy  and  safety  our 
most  approved  remedies  for  this  complaint. 
He  has  taken  every  opportunity,  during  the 
last  twelve  months,  of  testing  its  powers,  and 
has  preserved  notes  of  twenty- one  of  the 
cases  in  which  it  was  administered.  Of 
these,  eighteen  were  phthisis  in  various 
stages  of  progress,  and  three,  bronchitis. 
In  fifteen  of  the  patients  the  diarrhoea  was 
entirely  removed  ;  in  four,  transient  benefit 
was  experienced  ;  and  the  remedy  proved 
useless  only  in  two  instance.  The  dose  ad¬ 
ministered  was  about  five  grains  three  or 
four  times  daily,  usually  combined  with  a 
little  magnesia  and  gum  arabic.  Dr.  Thomp¬ 
son  has  referred  to  various  authors  who  have 
written  respecting  the  properties  of  bismuth, 
but  has  not  been  able  to  collect  from  them 
any  evidence  of  its  powers  in  the  phthisical 
variety  of  diarrhoea,  but  he  entertains  a  strong 
conviction  of  its  peculiar  appropriateness  to 
this  affection,  and  has  obtained  importantcon- 
firmation  of  his  experience  in  a  recent  com¬ 
munication  from  Dr.  Lombard,  of  Geneva. 

A  Plan  of  Treating  Ovarian  Dropsy  by  the 
Ulcerative  Opening  of  the  Cyst  after  its 
Permanent  Adhesion  to  the  Walls  of  the 
Abdomen.  By  Edward  John  Tilt, M.D. 

The  author  was  led  to  attempt  this  mode 
of  cure  by  observing  the  process  of  Nature 
in  some  spontaneous  and  radical  cures  of 
ovarian  dropsy.  His  first  object  is,  to  es¬ 
tablish  solid  adhesion  between  the  peritonaeal 
covering  of  the  cyst  and  the  peritonseal  lining 
of  the  abdominal  parietes.  His  second  ob¬ 
ject  is,  to  make  the  smallest  possible  opening 
into  the  cyst,  so  that  it  may  not  be  suddenly 
emptied,  but  remain  always  full,  and  be  only 
relieved  per  stilicidium  of  the  overplus  of 
liquid  distending  its  cavity,  while  it  gradually 
contracts.  To  attain  both  these  objects  he 
adopts  the  plan  whi  h  has  ojfen  been  suc¬ 
cessful  in  effecting  the  adhesion  of  hydatid 
cysts  of  the  liver  to  the  abdominal  walls, 
it  consists  in  the  application  of  Vienna  paste 
to  the  appropriate  part  of  the  abdomen.  He 


122  ON  THE  INTERNAL  USE  OF  TURPENTINE  OIL  IN  HAEMORRHAGE. 


relates  one  case  in  which  a  radical  cure  of  an 
ovarian  cyst  was  effected  by  this  means. 

A  lady,  who  had  always  enjoyed  good 
health,  ceased  menstruating  at  forty  years 
of  age.  Soon  afterwards,  having  been  ex¬ 
posed  to  cold,  she  was  seized  with  violent  pain 
in  the  left  iliac  fossa,  followed  by  shivering 
and  high  fever.  When  these  symptoms  were 
relieved,  a  tumor  of  the  size  of  an  orange 
was  felt  in  the  situation  of  the  left  ovary. 
This  tumor  gradually  increased,  and  in  a  short 
space  of  time  the  patient  had  the  appearance 
of  being  nine  months  gone  with  child.  Vienna 
paste  was  applied  to  the  pit  of  the  stomach  ; 
an  eschar  was  produced,  and  fell  off,  and 
afterwards  a  small  opening  was  formed  by 
ulceration,  through  which  an  albuminous 
ropy  fluid  escaped.  The  abdomen  was  sup¬ 
ported  by  moderate  pressure.  In  a  few 
weeks  the  discharge  became  purulent  and 
offensive.  Tepid  water  was  then  injected 
into  the  cyst  daily  for  some  months  ;  the 
cyst  gradually  contacting,  so  that  at  length 
it  would  receive  only  an  ounce  of  water.  In 
about  a  year  the  patient  was  in  effect  well, 
although  for  several  years  a  fistulous  opening 
remained  at  the  pit  of  the  stomach.  In  the 
course  of  the  case  the  cyst  formed  a  com¬ 
munication  with  one  of  the  intestines,  and 
for  several  days  the  patient  passed  purulent 
stools,  while,  during  that  time,  no  pus 
escaped  from  the  external  wound. 

Case  of  Hydatid  Disease  of  the  Liver  cured 
by  Operation.  By  George  Owen  Rees, 
M.D.  F.R.S.  Assistant  Physician  to  Guy’s 
Hospital,  and  Principal  Medical  Officer  to 
the  Pentonville  Prison. 

The  case  is  detailed  at  some  length.  The 
patient  was  a  man  aged  thirty- one  years ; 
admitted  into  Guy’s  Hospital  on  the  13th  of 
October,  1847.  Examination  of  his  abdo¬ 
men  detected  a  distinct  tumor  occupying  the 
right  hypochondriac  and  epigastric  regions. 
Fluctuation  could  be  felt  in  it.  On  the 
4th  of  December  the  tumor  was  tapped  by 
Mr.  Hilton,  with  a  trocar  and  canula  not 
larger  than  an  ordinary  exploring  needle, 
straps  of  plaster  having  previously  been 
passed  round  the  body,  so  as  to  fix  the 
tumor  in  position,  and  to  exert  pressure 
upwards.  Thirty-eight  ounces  of  clear  fluid 
were  removed.  The  wound  quickly  closed. 
On  the  7th  of  January,  the  tapping  was 
repeated,  with  the  same  instrument,  and  with 
the  same  precautions,  as  before.  On  this  oc¬ 
casion  pus  of  a  very  offensive  odour  escaped, 
and  only  ten  ounces  were  obtained,  owing  to 
the  canula  becoming  obstructed.  On  the 
9th  of  Januai^  the  tumor  was  tapped  a  third 
time  with  a  full-sized  trocar  and  canula,  an 
elastic  gum-tube  being  passed  through  the 
canula.  Twenty-four  ounces  of  foetid  pus 
escaped,  with  membranous  flakes,  and  par¬ 
tially-destroyed  hydatids.  The  opening  was 


maintained,  and  foetid  pus,  with,  occasionally, 
hydatids,  continued  to  be  discharged  (the 
capacity  of  the  sac  at  the  same  time  dimi¬ 
nishing)  till  the  commencement  of  April. 
On  the  11th  of  April  the  discharging  orifice 
had  closed,  and  no  remains  of  the  tumor 
could  be  found  unless  it  were  a  body  about 
the  size  of  a  walnut,  below  the  right  lobe  of 
the  liver.  The  author  comments  upon  the 
diagnosis  of  the  disease,  the  propriety  of  the 
operation,  the  degree  of  danger  attending  it, 
and  the  precautions  adopted  to  avert  evil  re¬ 
sults,  and  concludes  with  some  remarks  on 
the  nature  of  the  fluid  discharged  from  the 
sac. 

On  the  Internal  Use  of  Turpentine  OH  in 

cases  of  Haemorrhage.  By  L.  Percy, 

M.D.  Lausanne,  Switzerland. 

The  author,  after  noticing  the  fact  that 
several  writers  —  Adair,  Nichol,  Johnson, 
Warneck,  Copland,  Ashwell,  and  Tereira — 
have  spoken  of  the  efficacy  of  the  essential 
oil  of  turpentine  in  haemorrhagic  diseases, 
observes  that  this  remedy  seems  nevertheless 
to  be  little  used  by  practitioners.  In  the 
cases  in  which  he  first  made  trial  of  it, 
haematuria  of  two  years’  standing,  in  an 
old  man  of  eighty,  was  stopped  in  twenty- 
four  hours  by  eight  drops  of  oil  of  turpentine, 
and  did  not  return.  He  has  since  used  it  in 
different  cases  of  haemorrhage,  and  always 
with  a  favourable  result.  The  cases  in  which 
its  use  is  indicated  are  those  of  passive  hae¬ 
morrhage.  It  must  not  be  employed  in  cases 
where  there  is  an  active  determination  of 
blood,  and  where  the  pulse  is  full.  When 
the  discharge  of  blood  is  the  consequence  of 
organic  disease,  as  of  disease  of  the  uterus, 
or  of  tubercular  disease  of  the  lungs,  the 
action  of  the  remedy  is  not  so  efficacious ; 
but  the  author  has  seen  a  case  of  scirrhus 
of  the  womb,  in  which  the  haemorrhage  was 
for  some  time  stopped  by  this  remedy.  The 
author  has  found  the  action  of  turpentine  oil 
very  rapid,  an  effect  being  manifest  in  a  few 
hours,  often  after  one  small  dose.  In  order 
better  to  ascertain  its  power,  he  used  it  alone, 
without  having  recourse  to  local  astringents 
or  cold  applications,  where  he  could  do  so 
without  fear  of  endangering  the  life  of  the 
patient.  He  has  used  it  most  frequently  in 
cases  of  menorrhagia  and  epistaxis ;  but  he 
mentions,  that  it  appears  to  him  to  be  par¬ 
ticularly  applicable  in  the  cases  of  haemor¬ 
rhage  attending  typhus.  He  noticed  the  fact 
that  turpentine  exerts  different  actions  on 
the  body  according  as  it  is  taken  in  large  or 
small  doses,  being  more  readily  absorbed  in 
the  latter  case  ;  and  he  remarks,  that  as  its 
beneficial  action  in  cases  of  haemorrhage 
must  depend  on  its  being  absorbed,  the 
inference  would  be  drawn,  that  the  doses  in 
which  it  is  given  in  such  cases  ought  to  be 
small.  His  experience  confirms  this  con- 


HYDATIDS  WITHIN  THE  CRANIUM.  OBTURATOR  HERNTA.  123 


elusion.  He  has  always  found  a  dose  of 
from  eight  to  thirty  drops  sufficient.  The 
best  vehicle  for  it  is  almond  emulsion,  with 
a  little  gum  arabic.  When  there  is  pain  in 
the  abdomen,  a  few  drops  of  laudanum  may 
be  added. 

Case  of  Hydatids  within  the  Cranium ,  giving 
rise  to  some  singular  Phenomena.  By 
James  Stewart,  M.D.  Surgeon,  Royal 
Artillery,  Woolwich.  [Communicated, 
with  some  prefatory  observations  on  Intra¬ 
cranial  Hydatids,  by  George  Gregory, 
M.D.  Physician  to  the  Small-Pox  Hos¬ 
pital.] 

In  the  first  portion  of  this  paper,  Dr. 
Gregory  remarks  on  the  greater  rarity  of 
acepbalocysts,  or  hydatids,  in  the  intra¬ 
cranial  structures  than  in  the  thoracic  or 
abdominal  tissues,  and  refers  to  Dr.  Craigie’s 
observation  that  in  the  greater  number  of 
recorded  cases  only  solitary  serous  cysts 
existed,  not  clustered  hydatids.  After 
noticing  briefly  three  cases,  one  described 
by  Rendtorff,  a  second  related  by  Mr. 
Mowatt,  of  Worthing,  in  the  second  volume 
of  the  Medico  -  Chirurgical  Transactions , 
and  the  third  communicated  by  Mr.  Burnell 
to  the  late  Dr.  Bailiie,  who  remarked  that 
none  such  had  ever  fallen  under  his  own  ob¬ 
servation,  Dr.  Gregory  states,  as  the  result 
of  his  reading,  that  the  normal  series  of 
symptoms  flowing  from  the  development 
of  intra- cranial  hydatids  seem  to  be  the 
following  : — Pain  in  the  head,  succeeded, 
after  a  considerable  time,  by  epileptic  fits, 
and  terminating  in  apoplexy.  The  Patho¬ 
logical  Museum  of  the  Army  Medical 
Department  at  Fort  Pitt,  Chatham,  con¬ 
tains  two  specimens  of  hydatids  of  the 
brain.  An  account  of  all  that  is  known 
relative  to  these  cases  has  been  furnished  to 
Dr.  Gregory  by  Dr.  French.  In  the  first 
case  no  cerebral  symptoms  were  noticed 
during  life.  After  death,  cysts,  described 
as  hydatids,  were  found  beneath  the  pia 
mater,  covering  the  hemispheres,  in  the 
right  corpus  striatum,  and  in  the  substance 
of  the  cerebrum  in  its  immediate  vicinity. 
In  the  second  case,  epileptic  fits  were  pre¬ 
sent  for  three  years  and  five  months  before 
death.  Here  there  were  small  round  bodies, 
like  hydatids,  some  hard  and  almost  carti¬ 
laginous,  not  only  beneath  the  pia  mater, 
but  also  generally  throughout  the  substance 
of  both  cerebrum  and  cerebellum.  They 
were  collected  to  the  amount  of  an  ounce  Or 
more.  Each  consisted  of  a  distinct  mem¬ 
branous  sac,  which  sometimes  appeared 
double,  and  in  layers  like  an  onion.  All 
the  cysts  contained  a  clear  fluid,  with  more 
or  less  cheesy-looking  matter.  Dr.  Gregory 
then  communicates  the  following  case,  which, 
at  his  request,  had  been  transmitted  to  him 
by  Dr.  Stewart : — The  patient,  a  gunner  of 


s 

the  Royal  Artillery,  aged  twenty-four  year 
and  nine  months,  was  admitted  into  the 
Artillery  Hospital,  Woolwich,  on  the  29th 
of  April,  1848,  immediately  on  his  arrival 
from  Malta,  with  the  following  history : — 
He  had  arrived  in  Malta  with  his  company 
in  February,  1847,  and  from  that  time  suf¬ 
fered  from  constant  headache.  In  Novem¬ 
ber,  1847,  he  had  a  severe  epileptic  fit, 
followed  by  coma.  Subsequently  imbecility 
showed  itself,  and  his  vision  became  im¬ 
paired,  the  pupils  being  sluggish,  and  the 
left  eyelid  affected  with  slight  ptosis.  His 
memory  became  defective,  and  he  became 
subject  to  immoderate  and  uncontrollable  fits 
of  laughter  when  spoken  to.  When  he  ar¬ 
rived  at  Woolwich,  he  still  presented  the  last- 
mentioned  most  remarkable  symptom.  His 
hearing  was  a  little  affected,  but  both  eyes 
were  amaurotic  ;  he  staggered  in  his  gait  like 
a  drunken  man,  and  the  expression  of  his 
countenance  was  idiotic.  On  the  22nd  of 
May,  a  large  piece  of  meat  which  he  had 
attempted  to  swallow  stuck  fast  in  the 
oesophagus,  and  he  was  only  saved  from 
suffocation  by  tracheotomy.  A  few  hours 
afterwards,  epileptic  fits  ensued,  and  were 
followed  by  coma,  in  which  he  died  on  the 
following  morning.  On  examining  the  body, 
there  was  found  in  the  middle  fossa  of  the 
base  of  the  cranium,  between  the  cranial 
bones  and  the  dura  mater,  a  mass,  the  size 
of  a  closed  fist,  which  proved  to  be  a  nest  of 
hydatids.  The  hydatids  were  very  numerous, 
and  varied  in  size  from  that  of  a  large  pea  to 
the  dimensions  of  a  small  orange.  The  con¬ 
tiguous  bones  were  roughened.  The  sub¬ 
stance  of  the  brain,  which,  together  with  the 
dura  mater,  was  pressed  towards  the  right 
side,  presented  no  abnominal  appearances. 
The  lateral  ventricles  were  filled  with  a  clear 
fluid. 

Case  of  Obturator  Hernia ,  with  Symptoms 
of  Intestinal  Obstruction  within  the 
Abdomen ,  to  relieve  which  the  Abdomen 
was  opened .  By  John  Hilton,  F.R.S. 

Assistant-Surgeon  to  Guy's  Hospital. 

Miss  — — ,  aged  36,  in  September,  1847, 
had  some  severe  pain  and  local  tenderness 
on  pressure  on  the  right  side  of  the  abdomen, 
above  Poupart’s  ligament,  with  continued 
constipation  and  some  vomiting.  During 
several  days  these  symptoms  were  relieved 
by  the  local  application  of  leeches  and 
fomentations,  and  the  use  of  aperients  and 
purgative  injections.  From  that  time  she  con¬ 
tinued  in  her  usual  health  until  Jan.  20th, 
1848,  when  she  was  suddenly  seized  with 
symptoms  of  strangulated  hernia;  but  no 
hernia  could  be  detected,  although  she  was 
repeatedly  examined  in  reference  to  that 
point.  Various  means  were  employed, 
without  any  permanent  relief  to  the  symp¬ 
toms  of  strangulated  intestine.  These  means 


124  CASE  OF  DISLOCATION  OF  THE  HEAD  OF  THE  FEMUR  BACKWARDS. 


were  continued  during  eleven  days,  when,  in 
in  consultation  with  Dr.  Fox  and  Mr.  Black- 
more,  of  Old  Street  Road,  in  whose  practice 
this  case  occurred,  it  was  resolved  to  recom¬ 
mend  the  patient  to  submit  to  an  operation, 
the  whole  importance  of  which  was  fully  ex¬ 
plained  to  her.  On  the  twelfth  day  from 
the  first  symptoms  of  strangulated  intestine, 
Mr.  Hilton  opened  the  abdomen  by  cutting 
in  the  median  line  below  the  umbilicus,  and 
ascertained  the  existence  of  an  obturator 
hernia,  which  had  not  been  at  all  suspected 
to  exist.  The  intestine  was  withdrawn  from 
the  obturator  opening  by  laying  hold  of  it 
within  the  abdomen :  no  external  tumor 
could  be  at  that  time  detected  in  the  upper 
part  of  the  thigh.  The  operation  was  per¬ 
formed  (with  the  patient  under  the  influence 
of  chloroform)  in  the  morning,  and  the 
patient  died  in  the  evening  of  the  same  day. 
The  post-mortem  examination  gave  evidence 
of  extensive  recent  peritonitis.  The  portion 
of  intestine  which  had  been  in  the  hernial 
sac  was  distinctly  seen,  and  on  examination 
was  found  to  have  been  in  a  condition 
favourable  to  recovery.  The  hernial  sac 
remained  fixed  in  the  thigh  ;  the  parts  sur¬ 
rounding  it  were  dissected  ;  and  a  drawing 
is  annexed  to  the  record  of  the  case,  showing 
the  position  of  the  hernia. 

Congenital  Malformation  and  Structural 

Disease  of  the  Heart  in  a  Child.  By 

Frederic  Robinson,  M.D.  Assistant- 

Surgeon  74th  Highlanders. 

G.  J - ,  a  male  child,  aged  one  year  and 

a  half,  had  suffered  from  his  birth  from 
violent  palpitation  of  the  heart,  and  dys¬ 
pnoea,  which  had  latterly  increased  in  seve¬ 
rity  :  the  child  had  otherwise  thriven.  The 
veins  at  parts  were  prominent,  but  the 
general  hue  of  the  skin  was  scarcely  abnor¬ 
mal.  The  heart’s  action  was  quick  and 
violent,  and  heard  over  a  great  space,  the 
sound  being  accompanied  by  a  loud  sawing 
noise.  The  child  died  with  these  symptoms. 

Autopsy. — The  left  lung  was  reduced  to 
nearly  one-third  of  its  normal  size  by  the 
encroachment  of  the  heart,  and  studded  with 
tubercles.  The  distended  pericardium  con¬ 
tained  about  four  ounces  of  serum.  The 
right  ventricle  was  large  enough  to  contain 
a  hen’s  egg,  and  was  filled  with  a  firm 
coagulum.  The  free  border  of  the  tricuspid 
valve  was  thickened  to  such  an  extent  as  to 
prevent  its  perfect  closure  i  the  pulmonary 
artery  and  valves  were  healthy.  The  left 
auricle  presented  no  musculi  pectinati,  ex¬ 
cept  in  its  appendix,  its  walls  being  as  thin 
as  a  portion  of  intestine.  A  circular  orifice, 
almost  as  large  as  the  little  finger,  existed 
in  the  septum  in  the  ventricles,  opening 
beneath  a  muscular  fold  in  the  right  cavity, 
and,  in  the  left,  immediately  below  the 
aortic  semilunar  valves.  The  foramen  ovale 


was  closed,  and  no  remains  of  the  ductus 
arteriosus  existed. 

History  of  a  Case  of  Dislocation  of  the 
Head  of  the  Femur  backwards ;  with 
some  Observations  on  that  Form  of  Dis - 
location.  By  Richard  Quain. 

An  opportunity  having  occurred  to  the 
author  of  making  a  dissection  of  the  parts 
concerned  in  a  recent  case  of  dislocation  of 
the  femur,  he  availed  himself  of  it,  and  has 
embodied  his  observations  in  this  communi¬ 
cation  to  the  Society.  The  subject  of  the  in¬ 
jury,  a  man  aged  60,  was  killed  by  a  fall  from 
a  ladder,  the  cause  of  death  being  extensive 
fracture  through  the  base  of  the  skull.  Con¬ 
siderable  deformity  being  observed  in  the 
right  lower  limb,  the  author  was  induced  to 
make  a  careful  examination  of  the  extremity, 
with  a  view  to  detect  the  nature  of  the  in¬ 
jury  it  had  sustained.  It  was  apparently, 
but  not  really,  much  shortened ;  it  was  also 
inverted,  and  separated  from  the  sound  limb. 
The  trochanter  major  was  altered  in  its  rela¬ 
tion  to  the  iliac  spine,  and  the  depression 
behind  it  was  wanting :  the  head  of  the 
femur  could  be  felt  towards  the  back  of  the 
pelvis.  The  limb  could  be  flexed,  but  not 
rotated  outwards.  On  removing  the  glutseus 
maximus,  the  head  of  the  dislocated  bone 
was  exposed  below  the  pyriform  muscle, 
and  immediately  behind  the  acetabulum. 
The  pelvis  had  sustained  a  fracture,  but  the 
fragments  were  not  altered  in  their  relation 
to  each  other.  The  obturator  externus, 
quadratus  femoris,  and  some  deep  fibres  of 
the  glutaeus  medius,  were  torn  through. 
The  inner  and  lower  part  of  the  capsular 
ligament  was  separated  from  the  neck  of 
femur,  and  the  round  ligament  was  torn  from 
the  depression  on  its  head.  The  great 
sciatic  nerve  was  stretched  but  not  injured, 
as  were  also  the  obturator  internus  and 
gemelli  muscles.  The  brim  of  the  aceta¬ 
bulum  was  slightly  fractured.  After  giving 
the  above  details,  the  author  remarked  that 
there  are  points  of  contrast  between  the 
present  and  other  cases  which  have  been 
recorded  of  a  similar  accident;  and  pro¬ 
ceeded  to  quote  the  history  of  the  dissection 
in  a  few  instances  of  the  form  of  dislocation 
in  question.  The  first  was  a  case  from 
Sir  A.  Cooper’s  “Treatise  on  Dislocations;’7 
the  second,  one  reported  by  Dr.  Scott  in 
the  third  volume  of  the  “  Dublin  Hospital 
Reports  ;”  and  a  third,  described  by  M. 
Billard,  in  the  third  volume  of  the  “  Archives 
Generates  de  Medecine.”  He  then  pro¬ 
ceeded  to  comment  on  these  cases,  direct¬ 
ing  attention  particularly  to  the  following 
points  : — 1st,  the  condition  of  the  structures 
immediately  interested  in  the  dislocation, 
and  especially  the  exact  position  of  the 
femur;  2dly,  the  characteristic  signs  of  the 
displacement ;  and  3dly,  the  restoration  of 


TUBERCULAR  deposit  in  the  peritoneum,  typhoid  fever.  12  5 


the  bone  to  its  natural  position.  The  prac¬ 
tical  inferences  drawn  by  the  author  from 
the  foregoing  observations  may  be  summed 
up  as  follows  : — 1st.  In  the  ordinary  form 
of  dislocation  backwards,  the  femur  does 
not  reach  the  sciatic  notch.  2d.  The  head 
of  the  bone  is  lodged  immediately  behind 
the  acetabulum,  over  the  base  of  the  ischiatic 
spine,  and  opposite  to  a  small  part  of  the 
sciatic  foramina.  3d.  The  injury  would  be 
correctly  named  the  dislocation  of  the  head 
of  the  femur  backwards.  4th.  During  the 
extension  made  to  reduce  this  dislocation, 
the  thigh  is  most  advantageously  directed 
across  the  pelvis,  so  that  it  shall  form  a 
right  angle,  or  nearly  a  right  angle,  with  the 
abdomen.  At  the  same  time  the  limb  is  to 
be  in  a  state  of  abduction  ;  the  femur  will 
thus  be  drawn  away  from  the  pelvis,  for¬ 
wards  and  outwards.  The  knee  is  to  be 
bent,  the  extending  force  being  fixed  above 
the  joint. 


LIVERPOOL  PATHOLOGICAL 
SOCIETY. 

The  following  morbid  specimens  were  exhi¬ 
bited  by  Mr.  Steele  : — 

Tubercular  Deposit  in  the  Peritoneum. 

This  was  taken  from  the  body  of  a  female, 
aged  28,  who  died  of  phthisis.  The  omen¬ 
tum  was  the  principal  seat  of  the  disease, 
and,  as  seen  in  the  preparation  shown,  was 
converted  into  a  thickened  mass,  presenting 
throughout  its  structure  innumerable  thickly 
studded  deposits  of  tubercular  matter,  vary¬ 
ing  in  size  from  a  pin’s  head  to  a  horse- 
bean.  The  four  layers  were  amalgamated. 
The  deposit  appeared  to  be  chiefly  in  the 
subperitoneal  cellular  tissue.  The  case 
somewhat  resembled  those  described  by  Dr. 
Baron,  but  was  not  identical  with  them,  for 
the  latter  were  cases  of  chronic  scrofulous 
inflammation  of  the  peritoneum,  whereas 
this  appeared  to  be  a  pure  case  of  tubercu¬ 
lous  diathesis,  and  might  have  been  unac¬ 
companied  by  inflammation  in  its  progress. 
The  mesentery  contained  similar  deposits, 
but  to  a  far  less  extent.  The  peritoneum 
covering  the  liver,  kidneys,  uterus,  and  ova¬ 
ries,  was  in  a  condition  similar  to  that  of 
the  mesentery. 

The  intestines  were  free,  except  towards 
the  lower  part  of  the  abdomen,  where  they 
were  agglutinated  by  a  gelatinous  fluid. 

The  iiver,  on  section,  presented  a  mottled 
appearance.  There  was  a  cavity  in  the  apex 
of  each  lung. 

Pericarditis ,  Bronchitis,  and  Pleuritis,  oc¬ 
curring  as  complications  of  Typhoid 

Fever. 

The  subject  of  this  specimen  was  a  man 
aged  22,  admitted  into  the  Fever  Hospital 


on  the  eighth  day  of  the  attack,  which  com¬ 
menced  with  chills,  pain  in  the  limbs,  cough, 
and  shortness  of  breath.  On  admission  he 
presented  the  usual  symptoms  of  typhoid 
fever.  The  conjunctivae  were  deeply  tinged 
yellow;  the  pulse  140,  incompressible;  re¬ 
spiration  laboured,  and  accompanied  with 
an  audible  rhonchus.  He  had  cough,  with 
mucous  sputa.  There  were  indistinct  dull 
red  petechise  on  the  trunk  and  extremities. 
The  physical  signs  were  dulness  on  percus¬ 
sion  on  the  left  side  of  the  chest ;  clear  on 
the  right.  The  only  sounds  elicited  by  the 
stethoscope  were  loud  mucous  rales  all  over 
the  chest. 

The  treatment  consisted  in  purgatives,  fol¬ 
lowed  by  a  pill  containing  calomel,  gr.  ij.  ; 
ipecacuan,  gr.  j.  ;  extract  of  conium,  gr.  ij., 
and  a  saline  draught,  with  half  a  grain  of 
tartar  emetic ;  each  to  be  taken  every  two 
hours.  A  blister  was  applied  to  the  chest. 
This  treatment  was  pursued  until  the  four¬ 
teenth  day,  and  afforded  marked  relief.  The 
pulse  fell  to  120,  and  was  compressible. 
The  tongue  became  cleaner;  the  pain  and 
cough  were  greatly  relieved ;  the  mucous 
rales  much  diminished ;  the  gums  slightly 
affected  by  the  mercury.  The  remedies  first 
prescribed  were  discontinued  gradually,  and 
he  was  ordered  saline  mixture,  with  nitric 
ether  and  ipecacuan  wine.  He  continued  to 
improve  until  the  eighteenth  day,  when  he 
became  much  worse.  The  pulse  was  feeble ; 
respiration  much  laboured ;  mucous  rhon¬ 
chus  loud  enough  to  be  heard  at  some  dis¬ 
tance.  He  complained  of  burning  heat  all 
over.  He  died  on  the  twenty-first  day  of 
the  attack,  and  the  thirteenth  day  after  ad¬ 
mission. 

The  body  examined  twenty-eight  hours 
after  death. — On  removing  the  anterior  pa- 
rietes  of  the  chest,  several  small  collections 
of  pus  were  observed  in  the  cellular  tissue  in 
the  anterior  mediastinum.  There  were  very 
extensive  adhesions  of  both  lungs ;  the  sur¬ 
faces  of  the  pleurae  covered  with  effusion  of 
recent  lymph.  There  was  also  effusion  of  a 
very  large  quantity  of  yellowish  serum, 
mixed  with  flakes  of  lymph,  in  both  pleural 
cavities.  The  lungs  were  both  much  con¬ 
gested.  The  mucous  membrane  of  the  tra¬ 
chea  and  bronchi  highly  injected,  and  the 
bronchial  tubes  filled  with  frothy  mucus. 
On  opening  the  pericardium  a  considerable 
quantity  of  serous  fluid  escaped.  It  was  not 
adherent,  and  its  inner  surface  was  com¬ 
pletely  covered  with  a  deposit  of  lymph, 
presenting  a  network  appearance,  which  co¬ 
vered  also  the  surface  of  the  heart.  The 
valves  and  endocardium  were  not  diseased, 
with  the  exception  of  a  very  slight  vegeta¬ 
tion  on  the  mitral  valve.  The  omentum  was 
much  congested,  and  of  a  dark  reddish  co¬ 
lour.  The  small  intestines  were  also  much 
congested,  and  presented  patches  of  ecchy- 


126  TYPHOID  FEVER.  ACCIDENT  FROM  THE  BURSTING  OF  A  GUN. 


mosis.  All  the  remaining  abdominal  organs 
were  much  congested,  and  more  friable  than 
usual.  The  head  was  not  examined. 

Pneumonia,  Pleuritis,  and  Bronchitis  oc¬ 
curring  as  complications  of  Typhoid 

Fever. 

The  inferior  lobe  of  the  left  lung  was 
shown.  It  presented  a  well-marked  speci¬ 
men  of  grey  hepatization.  The  subject  from 
whom  it  was  taken  was  admitted  into  the 
Fever  Hospital  on  the  fourteenth  day  of  the 
attack,  which  commenced  with  pyrexia  and 
slight  cough.  On  admission  he  had  cough, 
with  but  scanty  mucous  sputa.  The  pulse 
was  100.  There  were  dull  red  patechiae 
on  the  trunk  and  extremities.  The  only 
physical  signs  detected  were  loud  mucous 
rales  all  over  the  chest.  He  was  ordered 
calomel,  ipecacuan,  conium,  and  tartar 
emetic,  with  vesications  and  turpentine  fo¬ 
mentations  to  the  chest.  The  symptoms 
were  much  relieved  until  the  eighteenth  day, 
the  fourth  after  admission,  when  he  became 
delirious  ;  had  hiccough  ;  a  profuse  expecto¬ 
ration  of  very  tenacious  yellow  sputa  ;  and 
he  complained  of  burning  heat  all  over. 
On  the  twenty-first  day  a  remission  occurred, 
and  he  was  much  better  ;  but  on  the  twenty- 
fifth  he  again  became  worse,  complained  of 
urgent  dyspnoea,  and  pain  in  the  left 
mammary  region,  which  was  partially  re¬ 
lieved  by  turpentine  fomentation.  He  died 
on  the  thirtieth  day  of  the  attack,  the  six¬ 
teenth  after  admission. 

On  examination  after  death,  the  left  side 
of  the  thorax  was  found  to  contain  about 
three  pints  of  yellowish  serum  ;  there  were 
several  old  adhesions ;  the  lung  was  greatly 
compressed,  the  lower  lobe  being,  as  seen 
in  the  specimen,  solidified,  of  greater  spe¬ 
cific  gravity  than  water,  and  presenting,  on 
section,  a  greyish  granulated  appearance. 
The  right  lung  was  much  congested  through¬ 
out.  The  lining  membrane  of  the  trachea 
and  bronchi  was  of  a  bright  red  colour. 
The  air-cells  were  filled  with  a  frothy  mucus. 

In  exhibiting  the  specimens,  Mr.  Steele 
thought  he  might  be  excused  occupying  the 
time  of  the  Society  with  a  brief  sketch  of  the 
history  and  treatment  of  the  cases,  as  he 
deemed  them  of  much  practical  interest  in 
connection  with  the  epidemic  fever  now 
prevailing  (March).  In  the  cases  lately 
admitted  into  the  Fever  Hospital,  the  most 
frequent  complication  was  bronchial  :  they 
presented  the  usual  symptoms  of  typhoid 
fever,  accompanied  with  more  or  less  cough 
and  pain  in  the  chest.  The  only  physical 
signs  he  had  been  able  to  detect  in  any  of  the 
cases — with  one  exception,  in  which  pneu¬ 
monia  occurred  early,  was  well  marked,  and 
yielded  to  active  depletion — were  loud  mu¬ 
cous  rales  all  over  the  chest,  which  appeared 


to  obscure  the  signs  of  further  disease. 
Several  cases  of  this  kind  had  been  under 
his  notice,  some  of  which  recovered,  others 
had  died.  He  had  looked  upon  them  as 
cases  of  typhoid  fever,  with  universal  bron¬ 
chitis  of  a  congestive  rather  than  an  in¬ 
flammatory  character.  The  above  were  the 
only  instances  in  which  he  had  had  the  oppor¬ 
tunity  of  confirming  or  refuting  his  diagnosis 
by  a  post-mortem  examination.  It  ap¬ 
peared  to  him  difficult,  if  not  impossible,  to 
detect  the  existence  of  acute  inflammatory 
action,  obscured  as  it  was  by  the  characte¬ 
ristic  symptoms  of  typhoid  fever  of  an 
asthenic  character,  where  the  physical  signs 
were  so  much  modified,  and  indeed  oblite¬ 
rated,  by  the  more  predominant  rales  ac¬ 
companying  the  congestive  form  of  bron¬ 
chitis.  In  the  cases  described,  more  active 
treatment  than  that  adopted  was  not,  he 
thought,  indicated  by  the  symptoms  during 
life.  He  did  not  expect  to  have  found  in 
either  case  such  evident  signs  of  acute 
inflammatory  action.  The  general  character 
of  the  cases  which  have  occurred  during  the 
present  epidemic  has  been  of  an  asthenic 
character,  and  the  results  of  his  experience 
in  the  treatment  of  the  prevailing  fever  of 
this  locality  induced  him  to  believe  that 
active  depletion  was  not  justified  unless 
unequivocal  signs  of  acute  inflammation  were 
present  in  the  early  stage  of  the  disease. 


i&ogpttal  anti  Infkmarg  imports. 


LONDON  HOSPITAL. 
Accident  from  the  bursting  of  a  gun. 
Reported  by  A.  W.  Moore,  Dresser. 


John  Clayton,  aged  67,  was  brought  into 
the  accident  room  of  the  London  Hospital, 
on  the  20th  of  April,  with  an  injury  to  his 
hand,  which  he  received  from  the  bursting 
of  a  gun  :  upon  examination,  the  hand  was 
found  to  be  much  swollen  and  lacerated ; 
the  second  phalanx  of  the  thumb  was 
entirely  gone,  and  the  first  phalanx  was 
almost  entirely  denuded  of  its  integuments. 
It  was  found  necessary  to  amputate  the 
thumb  at  its  metacarpo-phalangeal  articula¬ 
tion  ;  the  arteries  bled  freely,  and  conside¬ 
rable  difficulty  was  experienced  in  securing 
them. 

After  the  operation,  the  patient  went  on 
very  well  up  to  the  28th  of  April,  when 
secondary  haemorrhage  suddenly  took  place, 
and  resisted  every  attempt  to  arrest  it,  until 
the  radial  artery  was  tied  :  this  stopped  the 
haemorrhage  for  the  time,  but  proved  to  be 
only  of  temporary  relief,  for  the  haemor- 


THE  UPTON  BOARD  OF  GUARDIANS  AND  THEIR  MEDICAL  OFFICERS.  J27 


rhage  again  broke  out  in  twelve  hours  after 
the  last  operation.  Mr.  Critchett  was  im¬ 
mediately  sent  for,  and  he  determined  to  tie 
the  brachial  artery  itself  without  delay : 
both  because  the  .fore-arm  was  much 
swollen,  rendering  the  operation  of  securing 
the  ulnar  difficult ;  and  even  if  it  could  be 
done,  the  result  would  be  very  doubtful : 
the  brachial  artery  was  accordingly  tied  at 
about  the  middle  of  the  arm.  From  this 
time  no  more  haemorrhage  took  place,  and 
the  patient  continued  very  weak  and  low  for 
two  or  three  weeks,  consequent  on  the  re¬ 
peated  haemorrhages  which  had  taken  place, 
but  under  a  generous  diet  he  gradually 
gained  strength,  and  the  wounds  healed 
kindly.  He  is  now  quite  convalescent. 

Remarks. — Although  in  this  case  the  in¬ 
juries  were  not  of  a  very  alarming  nature, 
nor  were  the  operations  novel,  yet  the  case 
will  serve  as  a  practical  illustration  of  one  or 
two  important  points  of  treatment  in  surgery. 


4T.om0ponDence, 


RESIGNATION  OF  THE  UNION  MEDICAL 

OFFICERS  OF  UPTON-ON-SEVERN.  —  RE¬ 
FUSAL  OF  THE  BOARD  OF  GUARDIANS 

TO  INCREASE  THE  SALARIES. 

To  the  Medical  Profession. 

Gentlemen, — It  is  with  feelings  of  no 
common  character,  but  which  will  be  readily 
understood  by  those  of  you  who  hold,  or 
have  held  Union  appointments,  that  we 
beg  your  attention  to  the  following  state¬ 
ment  of  some  recent  proceedings  in  this 
Union.  Though  possibly  not  unique,  yet 
we  believe  our  case  to  be  peculiar,  inas¬ 
much  as  that  it  is  not  merely  one,  two,  or 
three  of  us,  but  the  whole  Poor-law  me¬ 
dical  staff  in  this  Union,  which  is  at  the 
present  moment  engaged  in  a  struggle  with 
the  Board  of  Guardians — a  struggle  for  our 
rights  as  members  of  society,  for  every  la¬ 
bourer  is  worthy  of  his  hire — a  struggle  for 
our  independence  as  gentlemen — a  struggle 
for  the  character  of  the  whole  proiession  ; 
for  we  hold,  that  accordingly  as  you,  gen¬ 
tlemen,  act  in  this  contest,  will  our  profes¬ 
sion  appear  to  the  world,  either  as  consist¬ 
ing  of  a  number  of  noble,  high-minded,  and 
liberal  men,  determined  to  uphold  the  dig¬ 
nity,  standing,  and  reputation  of  the  class 
to  which  they  belong,  or  as  a  body  of  indi¬ 
viduals  so  utterly  void  of  esprit  du  corps , 
so  low  in  principle,  so  contemptible  in  feel¬ 
ing,  so  degraded  in  conduct,  that  there  may 
be  found  amongst  us  those  who  are  ready  to 
sacrifice  every  principle  of  honour  and  high¬ 
mindedness,  and  to  sell  their  brethren  for  a 
few  pieces  of  silver. 


We  throw  ourselves  upon  you,  gentle¬ 
men,  with  the  utmost  confidence  that  the 
noble  and  disinterested  profession  of  Medi¬ 
cine  contains  no  such  individuals  ;  with  a 
firm  reliance  on  the  truth  and  justice  of  our 
cause  ;  with  a  sure  hope  that  your  utmost 
sympathy  and  support  will  be  accorded  to 
us ;  with  the  abiding  conviction  that  the 
efforts  we  are  now  making,  humble  as  they 
may  be,  isolated  as  they  are,  will  still  be 
approved  and  followed  throughout  the  length 
and  breadth  of  this  land,  with  a  prayer  of 
faith  that  not  one  Judas  may  be  found 
amongst  us  ;  and  with  an  unflinching  deter¬ 
mination  never  to  relax  our  exertions,  and 
coute  qui  coute  to  fight  the  good  fight  of 
honour,  justice,  and  independence,  in  which 
we  are  now  engaged. 

We  remain,  gentlemen, 

Your  faithful  servants, 

Charles  Braddon, 
W.  T.  White. 

Upton-on-Severn, 

July  6th,  1848. 

A  meeting  of  the  medical  officers  of  the 
Upton-on-Severn  Union  was  held  at  Mr. 
Braddon’s  house,  June  19th,  1848:  present 
— Messrs.  Trash,  White,  Prior,  and  Brad¬ 
don,  when  the  following  resolutions  were 
passed  unanimously  : — 

1st.  That  in  the  opinion  of  this  meeting, 
the  present  salaries  paid  by  the  Board  of 
Guardians  to  their  medical  officers  are  quite 
inadequate  to  the  duties  performed. 

2d.  That  the  present  system  of  giving  a 
fixed  salary  for  each  district,  without  respect 
to  area,  population,  or  amount  of  sickness, 
is  unfair  in  principle  and  unjust  in  practice. 
Unfair  in  principle,  since  the  remuneration 
is  definite,  whilst  the  services  rendered  are 
indefinite.  Unjust  in  practice,  as,  under 
this  system,  many  orders  for  medical  relief 
are  given  to  parties  not  fairly  entitled  to 
them ;  and  many  orders  are  also  given  for 
attendance  on  cases  of  a  most  frivolous 
nature. 

3d.  That  an  application  be  made  to  the 
Board  of  Guardians  at  their  next  meeting, 
to  abolish  the  present  system  of  payment  by- 
fixed  salaries,  and  to  substitute,  in  lieu 
thereof,  payment  by  the  case,  according  to 
the  following  rates,  such  change  in  the  mode 
of  remuneration  to  come  into  effect  on  the 
24th  June  inst.  : — For  every  case  of  sick¬ 
ness  occurring  within  a  mile  of  the  medical 
officer’s  residence,  5s.  for  every  case  ;  at  a 
greater  distance  than  one  mile,  7s.  6d., 
with  the  usual  extras,  as  allowed  by  the 
late  general  order  of  the  Poor-Law  Com¬ 
missioners. 

4th.  That  this  amount  of  remuneration  is 
extremely  moderate,  appears  from  the  ascer¬ 
tained  fact  that  the  bare  cost  of  drugs, 
leeches,  instruments,  &c.  &c.  in  hospital 
and  dispensary  practice  throughout  this 


128  THE  UPTON  BOARD  OF  GUARDIANS  AND  THEIR  MEDICAL  OFFICERS. 


country,  averages  4s.  S^d.  per  case  of 
sickness. 

5th.  That  the  attention  of  the  Board  be 
directed  to  the  circumstance  that  the  Poor- 
Law  Commissioners  have  already  recom¬ 
mended  an  average  sum  of  6s.  6d.  per  case 
to  be  paid  to  the  medical  officers  in  Unions, 
and  that  this  system  has  already  been 
adopted  in  numerous  Unions,  and  found 
most  satisfactory. 

6th.  That  the  medical  officers  of  this 
Union  have  felt  so  seriously  the  incon¬ 
venience  and  injustice  of  the  present  sys¬ 
tem,  that,  unless  the  foregoing  plan  be 
adopted,  or  their  salaries  be  increased  in  a 
proportionate  ratio,  they  will  be  reluctantly 
compelled  to  discontinue  their  services. 

7th.  That  Mr.  White,  of  Kempsey,  and 
Mr.  Braddon,  of  Upton-on-Severn,  be  ap¬ 
pointed  a  deputation  to  submit  these  resolu¬ 
tions  to  the  Board  on  Thursday  next. 

H.  S.  Trash.— W.  T.  White.— C.  E. 

Prior.  —  Charles  Braddon.  —  Joseph 

Meears. 

On  Thursday,  June  22d,  we  attended  at 
the  Board- room,  and  submitted  the  fore¬ 
going  resolutions.  After  some  discussion 
it  was  determined  that  a  committee,  con¬ 
sisting  of  the  Chairman,  Vice-Chairman, 
and  five  elected  Guardians,  should  meet  at 
the  Board-room  on  Friday,  June  30th,  to 
hear  our  case  and  report  to  the  Board  on 
the  following  Thursday.  At  the  meeting  of 
the  committee  we  argued  the  case  on  the 
statements  contained  in  the  resolutions. 
We  showed  that  the  present  salaries  were 
utterly  inadequate  to  cover  the  cost  of 
house-keep  and  drugs,  in  some  districts  not 
even  of  drugs  ;  that  the  amount  of  remune¬ 
ration  varied  in  the  different  districts  from 
4s.  to  Is.  7id.  per  case  of  sickness;  that  in 
these  latter  the  medical  officers  not  only 
received  no  recompense  for  their  time,  labour, 
skill,  and  responsibility,  but  were  positive 
losers  of  money  by  tbeir  appointments. 
We  impressed  on  the  attention  of  the  Com¬ 
mittee,  that  in  very  many  of  the  Unions 
large  increases  of  salary  had  recently  been 
made.  We  instanced  the  Droitwich  Union 
in  this  county,  in  which  the  salary  of  one 
district  had  been  increased  from  £’32  to 
£40,  of  a  second  from  £35  to  ,£50,  and 
then  a  general  increase  of  25  per  cent,  had 
been  made  on  the  whole  Union.  The  clerk 
of  the  Union  also  read  to  the  Committee  a 
letter  received  from  the  clerk  of  the  Brom¬ 
yard  Union,  in  which  it  was  stated  that  the 
medical  officers  in  that  Union  are  now  paid 
8s.  per  case  of  sickness,  each  order  being 
renewable  at  the  expiration  of  every  three 
months,  so  that  it  is  possible,  and  frequently 
occurs,  that  the  medical  officers  receive  32s. 
in  one  year  for  their  attendance  on  the  same 
patient.  The  same  correspondent  stated 


that  this  system  worked  well,  and  was 
found  to  be  satisfactory  to  the  Guardians, 
the  medical  officers,  and  the  poor.  We 
referred  to  the  fact  that  whilst  population 
and  sickness  had  greatly  increased  since  the 
formation  of  the  Union,  no  increase  had 
been  made  in  the  salaries  of  the  medical 
officers,  and  yet  the  salaries  of  the  clerk  and 
the  relieving  officers  had  been  recently  aug¬ 
mented.  We  further  stated  that  if  the 
Board  would  not  entertain  the  question  of 
a  change  in  the  present  system  of  payment, 
the  medical  officers  would  waive  that  point, 
and  be  content  to  continue  their  services  if 
the  Board  would  follow  the  example  of  the 
Droitwich  Union,  by  first  increasing  the 
salaries  of  the  officers  of  the  Upton  and 
Kempsey  districts — the  two  worst  paid — 
and  then  making  an  increase  of  33^  per 
cent,  throughout  the  Union.  The  Com¬ 
mittee  received  us  courteously,  and  promised 
to  report  to  the  Board  on  Thursday  (this 
day).  Accordingly  we  attended  this  morn¬ 
ing  to  hear  the  decision  of  the  Board,  which 
was,  that  the  Kempsey  district  be  increased 
six  pounds  per  annum,  and  that  all  the 
other  salaries  remain  as  heretofore.  Under 
these  circumstances  we  had  no  other  alter¬ 
native  than  to  tender  the  resignations  of  all 
the  medical  offices  of  the  Union  with 
which  we  had  been  previously  entrusted. 
Hitherto  we  have  discharged  the  duties  of 
our  several  offices  with  zeal  and  conscien¬ 
tiousness,  and  we  defy  any  impeachment  of 
the  statement.  In  times  of  epidemics  or 
general  sickness,  we  have  never  hesitated  to 
strain  our  personal  exertions  to  the  utmost, 
though  met  by  no  return  of  private  grati¬ 
tude  or  pecuniary  compensation.  Length 
of  servitude  gives  us  no  standing  nor  title  to 
increased  recompense,  and  the  profession 
has  had  sufficient  experience  that,  in  this 
country,  Union  labour  leads  not  to  private 
practice.  That  the  profession  may  be 
fully  aware  of  the  extent  of  our  duties, 
we  beg  to  state  that  the  Union  contains  a 
population  of  16,724,  and  an  area  of  about 
53,500  acres;  it  is  twenty  miles  in  length, 
and  the  rate  of  remuneration  per  case  is 
about  two  shillings.  We  apprehend  that 
the  Board  will  immediately  advertise  for 
fresh  medical  officers,  as  there  appears  no 
disposition  amongst  the  elected  Guardians 
in  any  way  to  do  us  justice.  It  now  re¬ 
mains  with  medical  men  to  show  that  they 
are  prepared  to  accord  to  the  profession,  of 
which  they  are  members,  that  countenance 
and  support  which  it  has  a  right  to  claim  at 
their  hands. 

Chas.  Braddon. 

W.  T.  White. 

Upton-on-Severn, 

Thursday,  July  6th,  1848. 


THE  ASIATIC  CHOLERA  IN  RUSSIA.  QUARANTINE  AND  CHOLERA.  129 


ijfteDical  SntelUgenre* 


THE  PROGRESS  OF  THE  ASIATIC  CHOLERA 
IN  RUSSIA. 

By  the  last  accounts  received  of  the  progress 
of  the  cholera  in  Moldavia,  the  visitation  was 
excessively  severe.  At  Jassy,  from  the  17th 
to  the  28th,  1,799  persons  had  been  attacked, 
of  whom  810  had  died,  and  655  remained  in 
the  hospital,  and  334  only  had  been  cured. 
The  attacks  were  steadily  increasing  in  se¬ 
verity.  At  St.  Petersburgh,  from  June  24 
to  July  3,  there  had  been  5,063  cases,  of 
which  2,596  had  proved  fatal,  198  had  been 
cured,  and  2,269  remained  under  treatment. 

From  an  official  bulletin  on  the  progress 
of  the  cholera,  dated  July  1st,  it  appears 
that  on  the  morning  of  the  29th  June,  there 
were 

Persons  labouring  under  cholera  1029 
New  cases  on  that  day  ...  719 

Recoveries .  41 

Deaths . 356 

Cases  remaining  on  the  30th  .  1451 

M.  De  Chambaud  was  one  of  the  first 
victims.  Some  of  the  cases  were  so  rapidly 
fatal,  that  the  patients  died  within  four,  and 
even  two  hours  of  the  attack.  On  one  day 
there  were  595  fresh  cases,  and  356  deaths. 

In  one  week  at  Moscow  (from  the  12th  to 
the  19th  June),  there  were  1724  new  cases, 
and  728  deaths.  On  the  19th  of  June  there 
were  327  new  cases,  and  153  deaths.  The 
cholera  is  now  ravaging  with  increased  se¬ 
verity  Kasan,  Nijni-Novgorod,  Kostoma, 
Jaroslav,  Wologda,  Smolensko,  Toula,  and 
Kalma.  It  has  also  just  broken  out  at 
Pensa,  Twer,  Turhow,  Olonetz,  Watka,  and 
Orfa. 

Six  large  hospitals,  exclusively  intended 
for  cholera  patients,  have  been  opened  at  St. 
Petersburgh. 

The  French  journals  report  that  a  death 
from  Asiatic  cholera  has  recently  taken 
place  in  the  department  of  Aube.  The  pa¬ 
tient  died  in  twenty-four  hours,  and,  on  in¬ 
spection,  all  the  appearances  indicative  of  an 
attack  of  Asiatic  cholera  were  met  with. 

Letters  dated  St.  Petersburgh  of  the  7th 
inst.,  state  that  the  cholera  still  continued  to 
make  alarming  progress  in  that  city.  On 
the  4th  inst.  there  were  1064  new  cases  de¬ 
clared,  553  deaths,  and  131  recoveries.  On 
the  following  day  there  were  2983  cases  in 
the  hospitals.  The  number  of  persons  la¬ 
bouring  under  the  disease  at  Moscow  on  the 
30th  of  June  was  1974. 

QUARANTINE  AND  CHOLERA. 

The  following  quarantine  regulations  with 
reference  to  the  Russian  Baltic  ports  have 
been  adopted  at  Lubeck : — 


A  decree  issued  by  the  Senate  of  Lubeck 
imposes  a  quarantine  of  five  days  (the  days 
occupied  by  the  voyage  included)  upon  all 
vessels  coming  from  ports  in  which  the 
cholera  has  broken  out,  or  from  those  which 
are  suspected.  It  appears  that  these  regu¬ 
lations  have  been  principally  formed  with 
reference  to  the  extensive  trade  and  naviga¬ 
tion  between  this  port  and  Sweden,  where 
extraordinarily  prohibitory  regulations  exist. 
By  limiting  the  quarantine  to  five  days,  the 
continuance  of  the  communication  by  steam 
with  St.  Petersburgh  will  be  allowed,  and  it 
is  to  be  supposed  that  the  necessary  regula¬ 
tions  have  been  adopted  for  the  purpose  of 
placing  no  obstacle  in  the  way  of  transmission 
of  letters  and  despatches.  The  above  order 
decrees,  as  before  mentioned,  a  “  a  quaran¬ 
tine  of  observation”  of  five  days  (the  days 
occupied  by  the  voyage  included)  for  all 
vessels  coming  from  those  ports  infected  by 
the  cholera,  or  those  suspected  of  infection. 
The  order  contains  the  following  regula¬ 
tion  : — 

“  Should  a  vessel  have  any  one  affected 
with  cholera  on  board  during  her  voyage, 
and  should  such  person  be  cured  or  already 
dead,  it  will  be  subjected  to  a  quarantine  of 
ten  days,  reckoned  from  the  day  of  her  arrival 
in  Travemunde  roads,  and  during  this  period 
the  clothes  and  bedding  of  the  crew  must  be 
thoroughly  purified.  Vessels  which  during 
their  voyage  have  had  communication  with 
others  having  persons  affected  with  cholera 
on  board,  or  coming  from  ports  which  at  the 
time  of  their  departure  were  either  in.ected 
with  cholera  or  suspected,  are  subjected  to  a 
quarantine  of  five  days,  reckoned  from  the 
period  of  the  last  communication.  In  re¬ 
ference  to  vessels  having  persons  affected 
with  cholera  on  board  at  the  time  of  their 
arrival,  or  on  board  which  cholera  should 
break  out  during  their  quarantine,  the  ne¬ 
cessary  precautions  for  security  will  be 
adopted  by  special  measures.  All  vessels 
lying  in  quarantine  are  ordered  to  obey  un¬ 
conditionally  the  quarantine  authorities,  and 
to  abstain  from  any  communication  with  the 
land.  For  the  present,  since  the  cholera 
has  already  broken  out  in  St.  Petersburgh, 
all  vessels  coming  from  the  Russian  Baltic 
ports  and  the  other  ports  on  the  Gulf  of 
Finland,  as  well  as  from  the  ports  on  the 
south  coast  of  Finland,  as  far  as  Hangoudd 
inclusive,  are  to  be  treated  according  to  this 
order.” 

ON  POOR  LAW  MEDICAL  RELIEF.  COMMU¬ 
NICATED  BY  THE  ASSISTANT  SECRETARY 

OF  THE  CONVENTION  OF  POOR  LAW 

MEDICAL  OFFICERS. 

There  is  no  part  of  the  administration  of 
the  Poor  Law  in  which  the  public  are  more 
interested  than  in  the  medical  attendance  on 
the  sick.  The  larger  part  of  the  expenditure 


130 


ON  POOR-LAW  MEDICAL  RELIEF 


of  the  rates  is  inearred  in  the  maintenance  of 
the  sick  and  their  families  ;  and  it  is  obvious 
that  not  only  humanity  but  economy  requires 
that  the  sick  poor  man  should  have  good  and 
speedy  medical  aid,  to  enable  him  to  return 
to  work,  and  thus  remove  himself  as  quickly 
as  possible  from  dependence  on  the  general 
fund.  There  is  no  doubt  that  the  majority 
of  guardians  and  rate-payers  think  they  have, 
by  the  appointment  of  their  medical  officers, 
secured  good  and  speedy  medical  aid  to  the 
sick  poor  ;  and  it  is  hoped  and  believed  that 
in  the  majority  of  the  unions  and  districts 
throughout  the  kingdom  this  is  the  case  : 
but  this  result  arises  much  more  from  the 
conscientious  and  humane  feeling  of  the 
parish  doctor  than  from  the  excellence  of 
the  arrangements  made  by  the  boards  of 
guardians.  Such  is  the  nature  of  medical 
practice,  and  there  never  is,  and  never  can 
be,  any  regular  market  price  for  medical 
services  :  the  peer  and  the  cottager,  if  they 
have  a  broken  leg,  or  an  inflammation  of  the 
lungs,  require  the  same  attendance,  the  same 
medicines  for  their  cure  ;  yet  they  cannot  by 
any  possibility  pay  the  same  amount  of  re¬ 
muneration.  Thence  it  follows  that  different 
classes  of  society  pay  very  different  sums  for 
the  same  services.  Advantage  has  been  taken 
of  this  want  of  a  fixed  scale,  to  arrange  the 
salaries  of  parish  doctors  in  an  arbitrary  way, 
without  the  slightest  reference  to  the  actual 
amount  of  labour,  or  to  the  expenses  in¬ 
curred  :  thus  in  the  very  sickly  winter  of 
1847-8,  there  have  been  unions  in  which 
the  whole  payment  to  the  doctor  has  not 
amounted  to  threepence  per  case  :  and  in 
others  permanently,  the  amount  does  not 
exceed  sixpence  per  case,  the  medical  officer 
having  to  provide  at  his  own  expense  the 
necessary  drugs  and  applications.  The 
general  average  of  payment  in  country 
districts  in  the  south  of  England  is  about 
two  shillings  and  sixpence  per  case.  In  this 
state  one  of  two  things  must  occur — either 
the  poor  are  neglected,  they  are  supplied 
with  bad  medicines,  and  the  general  amount 
of  sickness  and  mortality  is  increased — or, 
what,  it  is  hoped,  is  far  more  common,  the 
doctor  does  justice  to  his  pauper  patient, 
and  uses  his  best  endeavours  to  get  him  well, 
but  receives  no  remuneration  for  his  exer¬ 
tions  ;  and  even  in  seasons  of  extraordinary 
sickness,  which  various  circumstances  have 
rendered  more  common  than  formerly,  he 
must  suffer  a  pecuniary  loss  :  hence  a  great 
and  natural  dissatisfaction.  Surely  it  cannot 
be  right  that  either  of  these  alternatives 
should  be  inevitable :  it  cannot  be  right 
that  a  great  and  rich  country  like  England 
should  consent  to  receive  the  gratuitous 
labours  of  a  class  of  men,  far  from  rich, 
in  an  unremitting  and  highly  responsible 
employment :  it  cannot  be  right  that  three 
millions  of  our  fellow  subjects,  and  those  the 


most  helpless,  should  be  entrusted  to  the 
unpaid  labours  of  any  class  of  men,  before 
whom  so  great  a  temptation  is  set  to  render 
imperfect  and  inefficient  assistance.  In  every 
other  transaction  of  life  it  is  considered  ne¬ 
cessary  to  pay  well  in  order  to  be  well  served ; 
and  the  medical  profession  may  indeed  be 
proud  of  the  confidence  that  is  reposed  in  its 
members,  when  they  are  expected  to  perform 
a  harassing  duty  with  the  slightest  expecta¬ 
tion  of  pecuniary  reward.  It  would  however 
be  well  for  the  public  to  consider  whether 
the  general  rule  would  uot  here  also  be  ap¬ 
plicable  ;  and  whether  a  more  liberal  pay¬ 
ment  would  not  insure,  in  the  long  run,  a 
more  efficient  and  complete  attendance  on 
the  sick,  and  thereby  a  diminution  of  charges 
for  sick  maintenance. 

At  present  the  real  amount  of  responsi¬ 
bility  of  the  medical  officer  is  by  no  means 
great.  It  is  true  he  may  often  incur  great 
blame  from  a  very  trifling  cause,  or  perhaps 
from  no  just  cause  ;  but  he  may  be  guilty 
of  great  neglect  without  its  being  known  to 
his  employers.  This  arises  from  the  circum¬ 
stance  that  boards  of  guardians,  however 
much  they  may  desire  to  insure  good  medi¬ 
cal  attendance  to  their  poor,  being  unac¬ 
quainted  with  medical  science,  and  therefore 
being  I’eally  unable  to  judge  whether  the 
amount  and  quality  of  the  attendance  ren¬ 
dered  by  their  medical  officer  is  at  all  equal 
to  the  occasion.  In  all  other  public  depart¬ 
ments  in  which  medical  services  are  required, 
there  is  a  system  of  inspection  by  competent 
medical  authorities,  which  is  absolutely 
necessary  to  a  proper  supervision,  and  which 
would  introduce  a  real  responsibility  if  it 
were  applied  to  the  Poor  Law  Medical  Sys¬ 
tem.  This  is  so  generally  acknowledged, 
that  the  only  objection  that  has  been  offered 
to  it,  is  the  expense.  Undoubtedly  if  a  sys¬ 
tem  of  inspection  were  to  be  properly  carried 
out,  it  must  be  properly  paid  for ;  but  this 
expense  would  speedily  prove  a  saving,  if, 
with  other  improvements,  it  insured  to  the 
labourer  good  and  speedy  attendance.  Such 
a  system  of  professional  inspection  is  not 
only  necessary  to  do  justice  to  the  poor,  it 
is  also  necessary  to  insure  justice  to  the 
medical  officer  ;  for  the  extent  of  his  services, 
and  the  exactness  with  which  he  performs 
his  duties,  can  only  be  appreciated  by  persons 
who  are  thoroughly  acquainted  with  medical 
science  and  practice. 

It  has  been  objected  that  the  medical  pro¬ 
fession  have  the  remedy  in  their  own  hands  ; 
that  they  need  not  continue  to  hold  their 
appointments  for  which  they  are  so  badly 
paid,  but  may  give  them  up  to  others  wha 
will  be  ready  to  take  them.  It  is  true  that 
in  many  cages,  however  low  the  so-called 
remuneration  may  be  fixed,  there  will  fre¬ 
quently  be  found  men  with  the  necessary 
testimonials,  prepared  to  take  the  appoint- 


ON  THE  AUSCULTATORY  SIGNS  OF  ANEURISM. 


ments;  but  these  men  will,  in  their  turn, 
reiterate  the  same  complaints,  and  with  the 
same  reason,  for  the  grievance  will  still  re¬ 
main — an  undue  amount  of  labour,  attended 
with  much  anxiety  and  personal  risk,  will 
be  demanded  for  an  insufficient  recompense : 
the  natural  result  follows — unless  an  abiding 
sense  of  duty  and  self-respect  animates  the 
medical  officer,  harshness  and  neglect  take 
the  place  of  kindness  and  zeal.  Is  not  this 
a  natural,  nay,  a  necessary  result  ?  And 
ought  not  the  public  to  consider  well  whether 
they  are  blameless  in  allowing  a  system  to 
go  on,  which  occasionally  deprives  the  poor 
helpless  man  of  health,  or  wounds  him  in  his 
tenderest  feelings  by  the  neglect  of  those 
who  are  dear  to  him — which  occasionally  in¬ 
creases  the  expense  of  maintenance  of  the 
poor,  by  allowing  disease  to  go  on  unchecked 
for  want  of  remedies — and  which  always  pro¬ 
duces  deep  and  heartfelt  dissatisfaction  to 
the  medical  man,  who  feels  that  of  all  public 
servants  he  is  the  hardest  worked  and  the 
least  remunerated.  These  evils  are  great 
and  real :  they  are  felt  only  by  the  doctor 
and  the  pauper ;  but  their  consequences 
affect  society  generally.  The  remedy  is 

simple  and  practicable.  Let  the  parish 

doctor  be  really  paid,  let  him,  after  a  proper 
calculation  of  his  expenses,  have  a  modest 
overplus  to  compensate  him  for  his  skill,  his 
time,  his  mental  anxiety — but  let  him  also 
be  really  responsible  to  persons  competent 
to  understand  his  functions ;  let  a  strict 
supervision  insure  a  punctual  performance 
of  his  duty  :  in  short,  act  as  in  any  other 
business  and  relation  of  life — let  a  liberal 
course  of  action  be  encouraged  on  both  sides 
— from  the  Poor  Law  authorities,  a  rate  cf 
payment  which  shall  be  no  longer  penurious 
and  illusory — from  the  medical  officer,  a 
prompt  and  earnest  attention  to  the  com¬ 
bined  interests  of  the  pauper  and  rate-payer. 

Committee  Room  of  Poor-Law  Medical 
Convention,  4,  Royal  Exchange. 

king’s  COLLEGE,  LONDON. 

APPOINTMENT  OF  MR.  BOWMAN  AS  PRO¬ 
FESSOR  OF  PHYSIOLOGY. 

We  are  informed  that,  on  the  proposition  of 
Dr.  Todd,  the  medical  profe.-sors  of  this 
College  have  recommended  to  the  council, 
that  Mr.  Bowman  should  be  appointed  Pro¬ 
fessor  of  Physiology  conjointly  with  Dr. 
Todd  ;  and  this  appointment  has  been  ac¬ 
cordingly  made,  and  Mr.  Bowman  will,  in 
future,  deliver  half  of  the  course  of  lectures 
on  Physiology. 

ELECTION  OF  PRESIDENT  AND  VICE-PRESI¬ 
DENTS  AT  THE  ROYAL  COLLEGE  OF 
SURGEONS. 

At  a  meeting  of  Council  held  at  the  College 
on  the  13th  inst.,  Edward  Stanley,  Esq.  was 
elected  President,  and  Joseph  Henry  Green, 


131 

'  ~JC 

Esq.  and  James  Moncrieff  Arnott,  Esq.  were 
elected  Vice-presidents  of  the  College  for  the 
year  ensuing. 

The  following  gentlemen  were  admitted 
members  of  the  College  on  the  14th  inst. : — 
Messrs.  A.  Birney — R.  Wilson — H.  B.  Ro¬ 
bertson — E.  Batt — T.  English — T.Walker — 
J.  F.  Matthew — J.  W.  Crow — W.  Scott — 
E.  Ilott — J.  Conry — J.  F.  Johnson — T.  M. 
Jones. 

Admitted  on  the  17th  inst. : — Messrs.  J. 
M.  Todd — G.  M.  Young — T.  S.  Ludlow — 
G.  W.  Paternoster — T.  S.  H.  Jackman— 
J.  George — T.  Roberts — W.  C.  Lake — G. 
Smith — J.  Hinton  —  T.  B.  Rake — H.  E. 
Tumour — H.  Turner. 

apothecaries’  hall. 

Names  of  Gentlemen  who  passed  their  ex¬ 
amination  in  the  Science  and  Practice  of 
Medicine,  and  received  certificates  to  prac¬ 
tise,  on  Thursday,  13th  July,  1848. — 
Henry  Llewellyn  Williams,  Beverley — 
Robert  Edwards  Jones,  Long  Melford — 
Henry  Merrill  Williamson,  Chapel-en-le 
Frith  —  John  James  Robert  Robertson, 
Chelmsford — James  Nuttall,  Liverpool — 
Charles  Wethered,  Little  Marlow. 

obituary. 

On  the  14th  inst.,  after  five  days’  illness, 
of  typhus  fever  (caught  in  the  discharge  of 
his  professional  duties),  Joseph  Howell,  Esq., 
surgeon,  Southwark- Bridge  Road,  aged  47, 
much  and  deservedly  lamented. 


j&electtong  from  journals. 

ON  THE  AUSCULTATORY  SIGNS  OF  ANEU¬ 
RISM.  BY  DR.  BELLINGHAM. 

An  aneurismal  sac  in  any  part  of  the  body 
contains  constantly  a  certain  amount  of 
blood,  proved  by  the  collapse  of  the  tumor 
in  external  aneurism  when  pressure  is  made 
upon  the  artery  at  the  cardiac  side.  The  first 
impulse,  therefore,  must  be  partly  due  to 
the  shock  communicated  to  the  blood  con¬ 
tained  in  the  sac  by  the  column  propelled  by 
the  left  ventricle  ;  and  as  an  aneurismal  sac 
has  but  one  orifice  for  the  entrance  and 
exit  of  blood,  we  must  have  a  current  of 
blood  into  and  out  of  the  sac  at  the  same 
instant ;  that  which  enters  [expelling  that 
which  it  previously  contained.  The  sudden 
distension  of  the  sac,  which  immediately  suc¬ 
ceed  s  the  ventricular  systole,  of  course  gives  rise 
to  the  impulse,  and  the  friction  of  the  blood 
against  the  parietes  of  the  orifice  of  the  sac 
during  this  act,  generates  sound  ;  and  this 
constitutes  the  normal  first  sound  of  aneu¬ 
rism.  If  the  friction  between  the  blood  and 
the  orifice  of  the  sac  is  increased  from  cny 
cause,  a  murmur  will  be  generated,  which 


132  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY",  ETC 


will  of  course  replace  the  normal  first  sound, 
because  it  is  nothing  more  than  this  sound 
exaggerated.  The  murmur  commonly  heard 
in  these  cases  is  the  bruit  de  souffiet,  and 
whether  it  is  present  or  absent,  will  depend 
upon  several  circumstances,  such  as  the  size 
of  the  orifice  by  which  the  sac  of  the  artery 
communicates,  the  size  of  the  sac  itself, 
and  the  direction  which  it  takes  ;  and  par¬ 
ticularly  the  force  with  which  the  blood 
is  transmitted  by  the  left  ventricle  ;  the 
latter  has  a  greater  influence  upon  the  pro¬ 
duction  of  a  murmur  than  either  of  the  for¬ 
mer  ;  for  instance,  if  the  walls  of  the  left 
ventricle  are  thinned  or  much  encumbered 
with  fat,  the  systole  will  be  too  feeble  to 
generate  a  murmur  in  the  aneurism  ;  hence, 
we  see  the  reason  why  the  first  sound  of 
aneurism  of  the  arch  of  the  aorta  is  some¬ 
times  replaced  by  a  bruit  de  soufflet.  and 
why  in  other  cases  a  murmur  is  almost 
necessarily  absent. — Dublin  Medical  Press. 


BIRTHS  &  DEATHS  in  the  Metropolis 
During  the  week  ending  Saturday ,  July  15. 


Births. 
Males ....  674 
Females. .  652 


1326 


Deaths. 
Males....  462 
Females. .  468 


930 


Av.  of  5  Sum. 
Males ....  495 
Females..  477 

972 


Deaths  indifferent  Districts. 


West — Kensington;  Chelsea;  St.  George, 
Hanover  Square;  Westminster;  St;.  Martin 
in  the  Fields;  St.  James..  (Pop.  301,326)  144 
North  —  St.  Marylebone  ;  St.  Pancras  ; 

Islington  ;  Hackney . (Pop.  366,303)  168 

Central— St. Giles  and  St.  George;  Strand; 
Holborn  ;  Clerkenwell ;  St.  Luke ;  East 
London  ;  West  London  ;  the  City  of 

London  . . (Pop.  374,759)  168 

ast — Shoreditch ;  Bethnal  Green  ;  White¬ 
chapel  ;  St.  George  in  the  East ;  Stepney ; 

Poplar . (Pop.  393,247)  202 

South  —  St.  Saviour;  St.  Olave  ;  Ber¬ 
mondsey  ;  St.  George,  Southwark  ; 
Newington;  Lambeth;  Wandsworth  and 
Clapham  ;  Camberwell  ;  Rotherhitlie  ; 
Greenwich . (Pop.  479,469)  248 

Total .  930 


Causes  of  Death. 

All  Causes . 

Specified  Causes . . 

1.  .Zy»iofic(orEpidemic, Endemic, 

Contagious)  Diseases . . 
Sporadic  Diseases,  viz. — 

2.  Dropsy,  Cancer,  &c.  of  uncer¬ 

tain  seat  . . 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  . 

4.  Lungs  and  other  Organs  of 

Respiration . 

5.  Heart  and  Bloodvessels . 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion  . 

7.  Diseases  of  the  Kidneys,  &c... 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c . 

9.  Rhematism,  Diseases  of  the 

Bones,  Joints,  &c . 

30.  Skin,  Cellular  Tissue,  &c . 

11.  Old  Age . 

12.  Violence,  Privation,  Cold,  and 

Intemperance  . . . 


Av.  of 
5  Sum. 

930 

972 

928 

968 

319 

257 

44 

45 

114 

120 

58 

80 

23 

28 

54 

79 

7 

8 

10 

10 

7 

7 

1 

1 

32 

50 

15 

8 

The  following  is  a  selection  of  the  numbers  o 
Deaths  from  the  most  important  special  causes 


Small-pox  . 

34 

Measles  . 

8 

Scarlatina  . 

72 

Hooping-cough. . 

32 

Diarrhoea  . 

64 

Cholera  . 

9 

Typhus 

59 

Dropsy . 

18 

Sudden  deaths  .. 

8 

Paralysis .  19 

Convulsion .  40 

Bronchitis .  24 

Pneumonia .  22 

Phthisis . 132 

Dis.  of  Lungs,  &c.  4 

Teething .  3 


Dis.  Stomach,  &c.  6 
Dis.  of  Liver,  &c.  11 


Hydrocephalus..  35  I  Childbirth .  5 

Apoplexy........  18  Dis. of Uterus,&c.  2 


Remarks.—' The  total  number  of  deaths  was 
42  below  the  summer  average.  The  mortality 
from  scarlet  fever  has  abated.  The  deaths  from 
diarrhoea  and  cholera  are  about  equal  to  the 
weekly  summer  average. 


METEOROLOGICAL  SUMMARY. 


\ 

Mean  Height  of  Barometer .  30T3 

“  “  Thermometer®  .  64-6 

Self-registering  do.b _ max.103’8  min.  33’5 

“  in  the  Thames  water  —  68 -4  —  64* 


a  From  12  observations  daily.  b  Sun. 

Rain,  in  inches,  0'4:  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological.— The  mean  temperature  of  the 
week  was  nearly  4°  above  the  monthly  mean. 

In  the  Registrar’s  table  the  mean  weekly  tem¬ 
perature  is  marked  at  74‘6 !  The  daily  figures 
show  that  this  is  obviously  an  error  of  10°. 


BOOKS  received  during  THE  WEEK. 

La  Gazette  Mddicale,  15  Juillet. 

L’Union  Mddicale,  13,  15,  and  18  Juillet. 

British  Record  of  Obstetric  Medicine,  No.  14, 
July  15,  1848. 

Casper’s  Wochenschrift,  Nos.  25  and  26.  17  and 
24  Juin. 

Dental  Physiology  and  Surgery,  by  John  Tomes, 
Surgeon-DentTst  to  the  Middlesex  Hospital. 

Portraits  of  Diseases  of  the  Skin,  by  Erasmus 
Wilson,  F.R.S.  Fasciculus  III. 


NOTICES  to  CORRESPONDENTS. 

The  communications  of  Mr.  Turner  and  Dr. 
Renaud  will  be  inserted  in  the  following 
number. 

Mr.  H.  B.  Norman’s  case  of  Umbilical  Hernia 
will  be  inserted. 

Mr.  E.  Canton’s  second  paper  has  been  received, 
and  will  be  inserted  immediately  after  the 
publication  of  the  first. 

The  remarks  on  Ancient  Meteorology  shall  re¬ 
ceive  our  early  attention. 

Erratum.  — The  advertisement  in  our  number 
for  July  7th,  “On  the  Archetype  and  Homologies 
of  the  Vertebrate  Skeleton,”  should  have  stated 
that  the  work  is  by  Professor  Owen. 


lectures*. 


LECTURES 

ON  THE 

DISEASES  OF  INFANCY  AND 
CHILDHOOD, 

Delivered  at  the  Middlesex  Hospital. 

By  Charles  West,  M.D. 

Physician-Accoucheur  to,  and  Lecturer  on  Mid¬ 
wifery  at,  the  Middlesex  Hospital,  and  Senior 
Physician  to  the  Royal  Infirmary  for  Children. 


Lecture  XXXV. 

Intestinal  worms — their  varieties ,  symp¬ 
toms,  and  treatment. 

Diseases  of  the  urinary  organs — Inflamma¬ 
tion  of  the  kidneys  —  Albuminous  ne¬ 
phritis  —  generally  follows  one  of  the 
eruptive  fevers,  oftenest  scarlatina — its 
symptoms  —  condition  of  the  urine  — 
appearances  after  death — essential  nature 
of  the  changes  in  the  kidneys — Treatment. 
Calculous  disorders  — frequent  in  early 
life — deposits  in  the  urine  in  childhood 
almost  always  consist  of  the  lithates — 
Other  causes  of  dysuria  besides  gravel 
and  calculus — Treatment  of  dysuria  in 
early  life. 

Diabetes — True  saccharine  diabetes  very 
rare  in  early  life — Simple  diuresis  less 
uncommon  —  Symptoms  of  disordered 
health  that  attend  both  affections  — 
Treatment. 

Incontinence  of  urine  —  circumstances 
under  which  it  occurs — its  treatment. 

Our  study  of  the  diseases  of  the  digestive 
organs  would  be  incomplete  if  we  took  no 
notice  of  those  parasitic  animals  which  fre¬ 
quently  inhabit  the  alimentary  canal  in 
children.  It  will  not,  indeed,  be  necessary 
to  say  much  respecting  them  ;  for  we  know 
that  the  older  medical  writers  greatly  over¬ 
rated  their  frequency  and  importance,  when 
they  saw  the  proofs  of  their  existence  in 
almost  every  variety  of  gastric  and  intestinal 
disorder,  and  even  attributed  to  their  pre¬ 
sence  many  forms  of  serious  disturbance  of 
the  nervous  system.  Still,  they  are  in 
many  instances  the  occasion  of  considerable 
discomfort :  they  often  aggravate,  and  some¬ 
times  even  give  rise  to  disorder  of  the 
digestive  organs,  while  now  and  then  the 
irritation  excited  by  their  presence  being 
propagated  to  the  spinal  cord,  produces 
convulsions  or  other  formidable  nervous 
symptoms. 

Although  intestinal  worms  are  much 
more  common  in  early  life  than  in  adult  age, 
vet  no  species  of  them  is  peculiar  to  the 

xlii.—  10/8.  July  28,  1848. 


child,  but  they  belong  to  one  or  other  of 
the  five  sorts  ordinarily  met  with  in  the 
grown  person. 

The  ascaris  vermicularis,  or  small  thread¬ 
worm,  which  lives  principally  in  the  rectum, 
is  by  far  the  most  common  of  all  these 
entozoa,  and  is  very  troublesome,  from  the 
local  irritation  which  it  excites.  The  long 
thread- worm,  the  tricocephalus  dispar , 
appears  much  less  frequently  in  the  evacua¬ 
tions  :  it  inhabits  the  upper  end  of  the  large 
intestines,  and  in  some  cases  coexists  with 
the  presence  of  ascarides  in  the  rectum. 
When  it  is  present  alone,  I  am  not  aware 
that  it  gives  rise  to  any  unpleasant  symtom. 
The  ascaris  lumbricoides  is  of  much  less 
common  occurrence  than  the  small  thread¬ 
worm,  though  observed  more  frequently 
than  the  tricocephalus :  it  dwells  in  the 
small  intestines,  and,  sometimes  entering 
the  stomach,  is  rejected  by  vomiting.  Occa¬ 
sionally  only  one  of  these  worms  is  present, 
and  though  there  are,  therefore,  several,  vet  it 
is  not  often  that  they  exist  in  the  child  in  very 
considerable  numbers.  The  tape-worm,  of 
which  there  are  two  kinds,  the  ta-nia  solium 
and  tajnia  lata,  is  much  the  rarest  of  these 
entozoa  in  early  life,  and  is  seldom,  if  ever, 
met  with  in  children  under  seven  years  of 
age. 

Various  symptoms  have  been  said  to  indi¬ 
cate  the  presence  of  worms  in  the  intestines, 
but  most  of  them  are  of  small  value  ;  and 
nothing  short  of  actually  seeing  the  worms 
can  be  regarded  as  affording  conclusive  evi¬ 
dence  of  their  existence.  No  one  who  is  at 
all  familiar  with  the  disorders  of  early  life 
will  be  disposed  to  attach  much  weight  to 
symptoms  such  as  the  altered  hue  of  the 
face,  the  appearance  of  a  livid  circle  around 
the  eyes,  the  loss  of  appetite,  or  its  be¬ 
coming  irregular  or  capricious.  Many 
causes  besides  the  presence  of  worms  give 
rise  to  a  tumid  state  of  the  abdomen,  to 
colicky  pains,  and  to  occasional  sickness 
and  vomiting  ;  and  itching  of  the  nose  or 
anus,  though  often  present  when  the  intes¬ 
tinal  canal  is  infested  with  worms,  yet  is 
sometimes  the  occasion  of  much  annoyance 
independently  of  their  existence.  An  irre¬ 
gular  or  intermittent  pulse,  widely  dilated 
pupils,  occasional  drowsiness,  with  uneasy 
rest  at  night,  and  starting  during  sleep,  are 
evidences  of  disturbance  of  the  nervous 
system,  but  do  not  specially  indicate  the 
presence  of  worms  as  the  cause  of  such 
irritation. 

In  any  case,  however,  where  symptoms 
such  as  those  above  mentioned  make  their 
appearance,  and,  though  fluctuating  in  se¬ 
verity,  continue  for  weeks  together,  there 
exists,  in  the  absence  of  any  obvious  cause 
of  nervous  irritation,  reasonable  ground  for 
suspecting  the  presence  of  worms  ;  and  the 
evacuations  should  be  examined,  in  order  to 


134  CEREBRAL  DISTURBANCE — WORMS  IN  THE  INTESTINAL  CANAL. 


ascertain  whether  or  no  that  suspicion  is 
■well  founded.  Even  though  for  a  season 
none  should  be  discovered,  yet  fortunately 
the  treatment  which  the  general  symptoms 
would  lead  us  to  adopt  will  be  in  great  mea¬ 
sure  such  as,  if  worms  exist,  will  prove 
most  efficacious  in  producing  their  expul¬ 
sion.  The  capricious  appetite  will  induce 
us  to  regulate  the  diet  with  care ;  the  dis¬ 
ordered  and  generally  constipated  state  of 
the  bowels  will  lead  to  the  employment  of 
alteratives,  and  to  the  occasional  administra¬ 
tion  of  brisk  cathartics ;  while  the  absence 
of  febrile  symptoms  will  probably  seem  to 
warrant  the  employment  of  some  of  the 
preparations  of  iron.  These  remedies  will 
in  many  instances  not  have  been  continued 
long  before  the  appearance  of  worms  in  the 
motions  encourages  us  to  persevere  in  the 
same  treatment.  The  combination  of  ferru¬ 
ginous  preparations  with  active  purgatives 
is  a  plan  especially  effective  in  cases  where 
the  lumbricoid  entozoa  are  present,  and  is 
likewise  of  much  service  in  getting  rid  of 
the  ascarides  which  inhabit  the  rectum,  and 
in  preventing  their  reproduction.  The 
latter  worms,  however,  need  to  be  assailed 
in  their  habitation  ;  and,  from  the  circum¬ 
stance  of  their  living  in  the  lower  end  of 
the  rectum,  this  is  a  sufficiently  easy  task. 
Enemata  of  lime-water  usually  answer  the 
purpose  of  destroying  them ;  but,  should 
they  fail,  the  addition  of  some  two  drachms 
of  the  muriated  tincture  of  iron  to  the 
clyster  is  tolerably  sure  to  make  it  effective. 
In  young  children  these  ascarides  some¬ 
times  not  merely  occasion  much  itching  and 
distressing  irritation  about  the  anus,  but 
even  produce  a  troublesome  diarrhoea,  at¬ 
tended  with  considerable  tenesmus.  Under 
such  circumstances,  the  lime-water  injection 
should  be  administered  daily  for  two  or 
three  days  together ;  while,  at  the  same 
time,  small  doses  of  the  castor-oil  mixture 
every  six  or  eight  hours  will  soothe  the 
irritation  of  the  bowels.  In  female  children 
these  ascarides  sometimes  creep  up  the 
vulva,  and  not  merely  cause  much  irritation 
there,  but  sometimes  excite  a  leucorrhoeal 
discharge,  which  ceases  on  the  expulsion  of 
the  worms. 

The  alarming  symptoms  of  cerebral  dis¬ 
turbance  which  have  sometimes  been  pro¬ 
duced  by  worms  in  the  intestinal  canal  have 
resulted  more  frequently  from  the  presence 
of  the  round  worm  than  of  other  varieties  of 
these  entozoa.  This,  however,  is  not  always 
the  case  ;  and  in  the  only  instance  that  has 
come  under  my  observation  in  which  the 
occurrence  of  convulsions  seemed  clearly 
traceable  to  the  presence  of  worms  in  the 
intestines,  the  small  thread-worms  were  the 
cause  of  the  symptoms.  Apart  from  the 
knowledge  which  we  have  in  many  of  these 
cases  that  the  child  had  previously  been 


afflicted  with  worms,  there  is  nothing  in  the 
symptoms  which  could  enable  us  at  once  to 
distinguish  between  convulsions  from  this 
cause  and  those  which  result  from  some 
other  source  of  irritation  of  the  nervous- 
system.  In  most  instances,  however,  the 
child  has  passed  worms  frequently  before 
the  cerebral  symptoms  made  their  appear¬ 
ance,  and  not  improbably  was  under  treat¬ 
ment  for  the  destruction  of  these  parasites 
at  the  time  when  the  nervous  symptoms 
supervened.  Even  though  this  be  not  the 
case,  the  constipated  state  of  the  bowels 
which  is  almost  sure  to  have  preceded  the 
occurrence  of  the  convulsions,  indicates  the 
employment  of  active  purgatives — remedies 
which  in  most  instances  remove  together 
these  symptoms  and  their  cause,  although 
convulsions  apparently  induced  by  the  pre¬ 
sence  of  worms  have  sometimes  had  a  fataL 
termination. 

The  tsenia  is,  as  was  stated,  much  less 
common  in  childhood  than  after  puberty; 
and  in  the  few  cases  in  which  I  have  met 
with  it  during  early  life,  I  have  been  re¬ 
luctant  to  try  that  heroic  remedy,  turpentine 
and  castor  oil,  which  is  so  serviceable  in 
procuring  the  expulsion  of  tape-worm  in 
the  adult.  1  have  been  accustomed  to  em¬ 
ploy  the  decoction  of  the  bark  of  the  pome¬ 
granate  root  in  §j.  doses  three  times  a  day 
to  a  child  of  seven  years  old,  interrupting 
its  administration  twice  in  the  week,  in 
order  to  give  a  purgative  of  scammony  and 
calomel.  Under  this  plan,  pursued  for 
several  weeks  together,  large  quantities  of 
the  worm  have  been  voided,  and  the  children 
have  appeared  entirely  freed  from  this  very 
troublesome  parasite.  I  have  not  yet  made 
trial  of  the  administration  of  a  dose  of  the 
decoction  or  powder  of  the  pomegranate 
bark  every  hour  for  four  or  five  successive 
hours,  as  recommended  by  Mr.  Breton,* 
who  brought  the  remedy  into  notice  in  this 
country.  I  purpose,  however,  making  a 
trial  of  this  method  on  the  next  occasion 
that  may  offer,  since  the  effects  of  the 
remedy,  when  thus  administered,  appear  to 
be  surer,  as  well  as  more  speedy,  than  when 
it  is  given  at  longer  intervals. 

Closely  connected  with  the  disorders  of 
the  digestive  organs  are  those  affections  to 
which  the  tirinary  apparatus  is  liable. 
Unfortunately,  special  difficulties  attend 
their  investigation  in  early  life,  and  diffi¬ 
culties  which  it  is  least  easy  to  overcome  in 
dispensary  practice  :  hence  the  information 
which  it  is  in  my  power  to  give  you  with 
reference  to  these  diseases  is  less  complete 
than  I  could  have  desired. 

Nephritis ,  or  acute  inflammation  of  the 
substance  of  the  kidney,  is  exceedingly  rare 


*  Medico-Chirurgical  Transactions,  vol.  xi. 
p.  301. 


INFLAMMATION  OF  THE  KIDNEYS - ALBUMINOUS  NEPHRITIS.  J  35 


as  an  idiopathic  affection  in  early  life. 
MM.  Rilliet  and  Barthez,*  decline  attempt¬ 
ing  to  give  any  description  of  its  symptoms, 
on  account  of  the  very  few  instances  of  it 
that  have  come  under  their  observation, 
although  they  refer  to  some  cases  in  which 
the  congested,  swollen,  and  indurated  state 
of  the  kidneys. discovered  after  death  seemed 
to  indicate  that  those  organs  had  been  the 
seat  of  acute  inflammatory  action.  M. 
Rayerf  relates  an  instance  or  two  where  the 
presence  of  purulent  deposits  in  the  kidneys 
of  infants  a  few  days  old  gave  positive  evi¬ 
dence  of  their  inflammation  ;  but  no  symp¬ 
toms  observed  during  the  lifetime  of  these 
children  had  called  attention  to  their  urinary 
organs.  He  mentions  it,  moreover,  as  a 
disease  of  very  unusual  occurrence  in  early 
life,  and  adds,  that  though  he  has  seen 
cystitis  follow  the  application  of  a  blister  in 
early  life,  yet  even  in  those  cases  there  was 
no  sign  of  the  irritation  having  extended  to 
the  kidneys. 

Albuminous  nephritis ,  or  that  form  of 
inflammation  of  the  kidney  which  is  usualty 
met  with  in  connection  with  general  dropsy, 
is  rather  less  uncommon  as  a  primary  dis¬ 
ease,  though  in  by  far  the  greater  number 
of  cases  it  is  met  with  as  a  sequela  of  one  of 
the  eruptive  fevers,  generally  of  scarlatina. 
It  is  under  these  latter  circumstances  only 
that  it  has  presented  itself  to  my  notice, 
and  the  description  which  I  will  endeavour 
to  give  you  of  it  applies  to  the  characters 
that  it  then  assumes.  It  sometimes  sets  in 
with  symptoms  of  considerable  severity, 
but  even  then  it  has  a  great  tendency  to 
pass  into  a  chronic  state,  while  in  by  far 
the  majority  of  cases  its  attack  is  gradual, 
and  its  advance  is  slow.  The  dropsical 
symptoms  by  which  it  is  almost  always 
attended  generally  show  themselves  within 
from  a  fortnight  to  three  weeks  from  the 
appearance  of  the  rash  ;  the  face,  hands, 
and  feet,  being  affected  in  succession,  and 
fluid  being  likewise  sometimes  effused  into 
the  cavity  of  the  abdomen.  The  dropsical 
symptoms  are  generally  preceded  for  a  day 
or  two  by  the  indications  of  constitutional 
disturbance.  The  child  who  had  passed 
through  the  attack  of  fever  probably  with 
less  than  the  average  amount  of  suffering, 
and  who  for  a  few  days  had  seemed  rapidly 
advancing  to  convalescence,  begins  to  droop, 
grows  languid,  feverish,  and  restless.  The 
skin  becomes  dry  and  hot ;  the  process  of 
desquamation  is  arrested  while  still  incom¬ 
plete  ;  the  appetite  is  lost,  though  the  thirst 
is  often  considerable ;  the  bowels  become 
constipated,  and  the  urine  diminished  in 
quantity,  although  the  desire  for  voiding  it 
is  very  frequent.  After  these  signs  of  in- 

*  Op.  cit.  vol.  i.  chap.  xvi. 

t  Traits  des  Maladies  des  Reins.  8vo.  Paris, 
1839,  vol,  i.  p,  417, 


terrupted  convalescence  have  continued  for 
two  or  three  days,  or  even  longer,  the  face 
becomes  slightly  swollen,  a  puffiness  appear¬ 
ing  about  the  eyelids  in  the  morning,  which 
probably  disappears  later  in  the  day  ;  so  that 
in  many  instances  the  attention  of  the  parents 
is  not  particularly  directed  to  the  child’s  con¬ 
dition  until  oedema  has  extended  to  the  hands 
and  feet.  The  degree  of  anasarca  varies  much 
in  different  cases,  and  likewise  fluctuates  at 
different  periods  in  the  same  patient. 
Usually,  though  not  invariably,  there  is  a 
distinct  relation  between  the  degree  of 
swelling  and  the  severity  of  the  general 
symptoms ;  and  few  cases  terminate  fatally 
in  which  there  is  not  considerable  serous 
effusion  into  the  different  cavities  of  the 
body.  In  very  mild  cases,  the  febrile  dis¬ 
turbance  is  inconsiderable;  the  anasarca 
slight,  and  confined  to  the  face  ;  and  after  a 
few  days  of  poorliness,  the  kidneys  resume 
their  proper  functions,  the  anasarca  disap¬ 
pears,  and  the  child  returns  to  health.  In 
severe  cases  the  symptoms  persist  for  a 
longer  time,  and  associated  with  them  there 
are  usually  complaints  of  pain  in  the  back, 
and  evident  tenderness  in  the  lumbar  region, 
while  the  swelling  extends  to  the  cellular 
tissue  of  most  parts  of  the  body  ;  but  unless 
some  complication  should  exist,  improve¬ 
ment  generally  becomes  apparent  in  the 
course  of  a  week  or  ten  days,  and  recovery 
takes  place  slowly.  In  the  worst  cases,  the 
swelling,  after  having  undergone  many  cause¬ 
less  fluctuations,  becomes  extreme,  as  well  as 
universal  ;  the  features  are  disfigured  by  the 
dropsy,  the  legs  greatly  swollen,  and  the 
abdominal  parietes  much  infiltrated,  while 
the  skin  remains  dry  and  hot.  The  quantity 
of  water  voided  under  these  circumstances 
is  very  small  indeed,  and  the  pain  in  the 
back  is  often  very  severe.  The  chief  suffer¬ 
ing,  however,  is  referred  to  the  chest ;  the 
respiration  is  laboured  and  accelerated,  and 
the  child  is  frequently  unable  to  assume  the 
recumbent  posture,  and  is  moreover  dis¬ 
tressed  by  a  frequent,  short,  hacking  cough. 
Under  these  circumstances,  life  is  sometimes 
prolonged  for  several  days,  though  in  a  state 
of  extreme  suffering,  remedies  proving 
unable  either  to  increase  the  action  of  the 
kidneys,  or  to  relieve  the  dropsy.  Death  is 
sometimes  preceded  by  a  sudden  aggrava¬ 
tion  of  the  signs  of  disorder  of  the  respiratory 
organs,  which  put  on  all  the  painful  charac¬ 
teristics  of  oedema  of  the  lungs.  In  other 
cases  a  comatose  condition  comes  on,  such 
as  often  precedes  death  from  Bright’s  disease 
in  the  adult,  although  cerebral  symptoms  ap¬ 
pear  to  be  considerably  less  common  in  the 
child  than  in  the  grown  person.  Sometimes, 
a  temporary  improvement  takes  place,  the 
anasarca  abates,  and  the  kidneys  resume 
their  functions,  but  the  patient  dies  not  long 
afterwards  from  the  effects  of  the  pleurisy  o^- 


136  ALBUMINOUS  NEPHRITIS — APPEARANCES  AFTER  DEATH. 


pericarditis,  which  had  come  on  almost  un-  | 
noticed  during  the  acute  stage  of  the  affec¬ 
tion. 

These  symptoms  of  constitutional  distur¬ 
bance,  which  you  recognize  as  the  characte¬ 
ristics  of  inflammatory  dropsy,  are  associated 
with  changes  in  the  composition  of  the  urine, 
as  well  as  with  a  diminution  in  the  quantity 
of  the  secretion.  In  the  milder  cases  it  is 
transparent  when  passed,  though  01  a 
deeper  colour  than  natural,  and  becomes 
turbid  on  cooling,  when  it  deposits  a  more 
or  less  abundant  precipitate.  It  has  a  strong 
acid  reaction,  somewhat  exceeds  the  usual 
specific  gravity  of  healthy  urine,  is  at  first 
rendered  clear  by  the  application  of  heat, 
but  again  becomes  cloudy  as  the  albumen 
which  it  contains  is  coagulated,  and  falls 
down  in  a  flocculent  precipitate.  If  the 
attack  be  more  severe,  the  urine,  which  is 
very  scanty,  is  of  a  brown  or  smoke  colour, 
deep  red,  or  coffee-coloured,  and  throws  down 
a  deposit  chiefly  of  a  reddish  brown  colour, 
which,  however,  does  not  entirely  disappear 
when  heated,  while  albumen  is  present  in  it 
in  extreme  abundance.  An  examination 
under  the  microscope  of  the  deposit  that 
takes  place  spontaneously  in  the  urine  in 
these  cases,  discovers  not  merely  crystals  of 
the  lithate  of  ammonia,  but  blood  globules, 
often  very  little  altered,  mucus  corpuscles, 
and  epithelium  scales.  These  matters,  how¬ 
ever,  disappear  by  degrees  as  the  urine  re¬ 
gains  its  natural  appearance,  even  though  it 
may  still  be  shewn  by  chemical  reagents  not 
to  be  entirely  free  from  albumen. 

In  cases  where  death  takes  place  during 
the  progress  of  this  disease,  if  the  dropsical 
symptoms  had  not  been  very  severe,  and  the 
child  had  been  carried  off  less  by  them  than 
by  some  sudden  cerebral  symptoms  or  inter¬ 
current  serous  inflammation,  the  kidneys 
appear  to  the  naked  eye  no  otherwise 
altered  than  in  being  generally  darker  and 
more  congested  than  natural.  In  severer 
cases,  however,  in  which  death  has  resulted 
from  the  disease  itself,  and  not  from  any 
casual  complication,  the  capsule  of  the  kid¬ 
neys  strips  off  more  easily  than  natural,  and 
their  surface  presents  a  pale  colour  and  a 
mottled  appearance.  On  a  section  being 
made,  a  marked  contrast  is  observable  be¬ 
tween  the  pale,  fawn-coloured,  cortical 
structure  of  the  organs,  and  their  deeply  in¬ 
jected  tubular  part,  coupled  with  which 
their  pelvis  and  infundibula  generally  dis¬ 
play  a  greatly  increased  vascularity. 

The  use  of  the  microscope  has  of  late 
enabled  us  to  advance  a  step  further  than  we 
otherwise  could  have  done  towards  under¬ 
standing  the  pathology  of  this  disease.*  It 

*  On  this  subject  it  is  almost  needless  to  refer 
to  the  papers  by  Dr.  Johnson,  Mr.  Busk,  and 
Mr.  Toynbee,  in  vol.  xxix.  of  the  Med.  Ckir. 
Transactions,  or  to  those  by  Dr.  Johnson  and 


has  shewn  us  that  the  morbid  process  begins 
in  the  cortical  parts  of  the  inflamed  kidney, 
the  urinary  tubules  of  which  are  stimulated 
to  an  increased  production  of  their  epithelial 
lining,  or  even  to  a  pouring  out  of  solid 
fibrinous  matter  into  their  cavities.  The 
urine  carries  away  with  it  some  of  these 
matters,  and  thus  frees  the  tubules  for  a 
time ;  but  as  their  contents  are  reproduced 
in  quantities  too  large  to  be  thus  eliminated, 
some  of  the  tubules  become  plugged  and  im¬ 
pervious,  sometimes  even  so  over -distended 
that  they  give  way,  and  are  completely  de¬ 
stroyed.  Nor  is  this  all,  but  the  capillaries 
of  the  organ  necessarily  bear  a  part  in  the 
mischief.  At  first,  from  over  congestion, 
thev  become  dilated  and  varicose,  and  after- 
wards,  (in  part  probably  from  the  formation 
of  fibrinous  clots  within  them,  in  part  as 
the  result  of  a  process  of  adhesive  inflamma¬ 
tion),  they  become  obstructed  or  even  oblite¬ 
rated.  Supposing  this  morbid  process  to 
have  gone  on  to  any  considerable  extent,  the 
kidney  must  be  left  by  it  permanently  and 
irreparably  injured,  while  even  in  its  slighter 
degree  it  must  for  a  time  seriously  disturb 
the  functions  of  the  organ.  In  the  earlier 
stages  of  the  disease,  the  presence  of  albu¬ 
men  in  the  urine  is  in  part  due  to  the  actual 
escape  of  blood  from  the  over-loaded  capil¬ 
laries  of  the  kidney,  in  part  to  the  tempo¬ 
rary  suspension  of  its  functions  ;  while  if  at 
a  later  period,  when  the  urine  has  lost  its 
preternaturally  deep  colour,  and  has  regained 
much  of  its  healthy  appearance,  albumen 
should  still  exist  in  any  quantity,  there  will 
be  reason  for  apprehending  that  some  abid¬ 
ing  injury  has  been  inflicted  on  the  organ. 

In  the  case  of  the  dropsy  that  succeeds  to 
scarlatina,  although  the  convalescence  is 
often  very  tedious,  there  fortunately  does 
not  appear  to  be  much  tendency  to  the  pro¬ 
duction  of  any  serious  permanent  injury  to 
the  kidney.  The  danger  to  the  patient  in 
the  acute  stage  of  the  affection  is,  however, 
often  very  considerable,  if  the  attack  be 
severe,  for  the  function  of  the  kidney  is 
almost  entirely  suspended,  while  at  the  same 
time  the  action  of  the  skin,  that  other  great 
emunctory  of  the  system,  is  completely 
arrested.  The  blood  circulates  through  the 
vessels  laden  with  urea,  as  chemical  reagents 
easily  show ;  w'hich  the  system  unable 
to  eliminate  by  its  natural  outlets,  tries  to 
get  rid  of  by  pouring  it  out  abundantly  in 
the  serous  effusions  that  take  place  into 
the  different  cavities  of  the  body.  These 
efforts  of  nature  to  relieve  herself  not  only 
prove  unsuccessful,  but  the  effused  fluid  often 
seriously  interferes  with  the  due  performance 
of  their  functions  by  the  different  viscera ; 


Mr.  Simon,  in  vol.  xxx. ;  together  with  the  note 
appended  to  the  latter  volume  by  the  editors,  re¬ 
specting  the  labours  of  continental  observers 
in  this  field  of  inquiry. 


ALBUMINOUS  NEPHRITIS  AS  A  SEQUELA  OF  SCARLATINA 


137 


inflammation  of  the  serous  membrane  of  the 
chest  or  abdomen  very  frequently  super¬ 
venes,  and  though  this  should  not  be  the 
case,  still  the  continuance  of  life  is  not  com¬ 
patible  with  the  circulation  through  the  body 
of  blood  loaded  with  urea. 

When  this  affection  occurs  as  a  sequela  of 
scarlatina,  it  may  very  often  be  traced  to  ex¬ 
posure  to  cold  while  the  process  of  desqua¬ 
mation  was  going  on,  whereby  the  activity 
of  the  skin  has  been  checked  or  altogether 
suppressed,  or  to  the  injudicious  adoption 
of  a  tonic  or  stimulant  plan  of  treatment  at 
a  very  early  period  of  the  patient’s  convales¬ 
cence.  The  opinion  that  it  more  frequently 
follows  a  mild  than  a  severe  attack  of  scar¬ 
latina,  does  not  appear  to  have  any  better 
foundation  than  the  circumstance  that  pre¬ 
mature  exposure  to  the  air,  and  errors  of 
diet,  are  exciting  causes  much  more  likely  to 
occur  after  slight  than  after  severe  cases. 
Something,  moreover,  is  unquestionably  due 
to  the  epidemic  constitution  of  the  year,  as 
Sydenham  calls  it,  since  the  occurrence  of 
the  consecutive  dropsy  is  common  after  the 
scarlet  fever  of  one  year,  comparatively  rare 
after  the  same  disease  in  another  year. 

The  treatment  of  this  affection  is  on  the 
whoie  that  of  inflammatory  dropsy,  from 
what  cause  soever  it  may  arise.  If  it  have 
set  in  with  severity,  the  urine  being  very 
high  coloured,  extremely  scanty,  and  loaded 
with  albumen,  the  abstraction  of  blood  is 
almost  indispensable,  and  from  four  to  six 
ounces  may  be  taken  from  the  arm  of  a 
child  of  five  or  six  years  old.  It  will,  I 
believe,  seldom,  if  ever,  be  necessary  to  re¬ 
peat  the  general  depletion,  though  if  no  im¬ 
provement  follow,  and  especially  if  there  be 
pain  or  tenderness  in  the  loins,  cupping,  or 
the  application  of  leeches  in  that  situation, 
should  be  resorted  to.  At  the  same  time 
the  child  must  be  put  on  a  low  diet :  he 
must  be  kept  in  bed,  and  must  be  placed  in 
a  hot  bath  every  night,  in  order,  if  possible, 
to  excite  the  skin  to  action.  The  bowels 
must  be  kept  freely  open  ;  but  I  have  not 
found  as  much  advantage  from  the  employ¬ 
ment  of  cathartics  as  from  the  use  of 
diaphoretic  medicines.  The  tartar  emetic  is 
in  these  cases  a  very  valuable  remedy,  and 
may  be  given  in  nauseating  doses  every  three 
or  four  hours,  combined  with  the  Liquor 
Ammoniae  Acetatis.  If,  as  sometimes  hap¬ 
pens,  the  child  should  complain  of  headache, 
or  should  appear  heavy  and  drowsy,  or  if 
the  bowels  be  constipated,  Dover’s  powder 
is  inadmissible,  though  otherwise  it  may  be 
advantageously  combined  with  the  medicine, 
or  be  given  in  a  rather  larger  dose  at  bed¬ 
time.  When  by  the  employment  of  these 
means,  the  skin  has  been  excited  to  action, 
and  the  swelling,  if  not  actually  diminished, 
has  at  least  ceased  to  increase,  some  of  the 
milder  diuretics  may  be  combined  with  the 


mixture — as  the  acetate  of  potash,  the  extract 
of  taraxacum,  or  the  spirits  of  nitrous  ether, 
while  at  the  same  time,  the  dose  of  the  tartar 
emetic  may  be  reduced  ;  but  the  change  of 
the  urine  to  a  darker  colour,  or  the  increase  of 
albumen  in  it,  should  be  regarded  as  indicat¬ 
ing  the  propriety  of  discontinuing  their  use, 
and  of  returning  to  the  previous  strictly  anti¬ 
phlogistic  treatment. 

In  cases  where  little  or  no  fever  is  present, 
and  where  the  urine,  though  still  albuminous, 
is  neither  so  scanty  nor  so  high  coloured 
as  in  the  instances  just  referred  to,  while  the 
oedema  is  comparatively  slight,  a  less  vigo¬ 
rous  plan  of  treatment  may  be  adopted.  The 
child  should  still  be  kept  on  low  diet,  and 
confined  at  first  to  bed,  and  for  a  con¬ 
siderable  time  afterwards  to  its  nursery 
while  the  warm  bath  should  still  be  employed 
every  night.  Bleeding,  however,  is  unneces¬ 
sary  ;  the  tartar  emetic  need  not  be  adminis¬ 
tered,  but  saline  aperients,  so  given  as  to 
keep  up  a  somewhat  free  action  of  the  bowels 
for  several  days,  will  generally  suffice  to 
effect  a  cure.  When,  after  the  nearly  com¬ 
plete  disappearance  of  the  oedema,  and  the 
return  of  the  urine  almost  or  altogether  to  a 
healthy  state,  the  child  still  continues  pale 
and  languid,  and  feeble,  the  tincture  of  the  ses- 
quichloride  of  iron  is  the  best  tonic  that  can 
be  administered,  and  under  its  use  any  traces 
of  albumen  that  previously  existed  will  be 
altogether  removed.  Much  care  is  required 
in  restoring  the  child  to  its  usual  diet,  and 
it  should  not  be  allowed  to  go  abroad  with¬ 
out  wearing  flannel  next  its  skin ;  but  no 
case  has  come  under  my  observation  in 
which  the  continuance  of  a  morbid  state  of 
the  urine  after  apparent  convalescence  from 
this  affection  has  warranted  the  apprehen¬ 
sion  that  actual  degeneration  of  the  kidney 
had  been  produced. 

Before  leaving  this  subject,  I  must  just 
observe,  that  a  slight  degree  of  anasarca  occa¬ 
sionally  follows  an  attack  of  scarlet  fever  in 
a  weakly  child,  as  a  mere  effect  and  indica¬ 
tion  of  its  feebleness  ;  and  also  that  an  affec¬ 
tion  is  now  and  then  met  with  having  all  the 
characters  of  inflammatory  dropsy,  except 
that  the  urine  is  free  from  albumen.  This 
was  observed  in  the  dropsy  which  followed  a 
recent  epidemic  of  scarlatina  at  Berlin,*  and 
is  likewise  mentioned  by  Dr.  Henry  Kennedy 
as  having  been  the  case  in  some  instances  of 
the  secondary  dropsy  which  occurred  dur¬ 
ing  the  Dublin  epidemic  of  the  disease. f 
With  few  exceptions,  however,  it  has  been 
found  that  the  affection  is  slight  when  there 
is  no  albumen  in  the  urine  :  its  absence  being 
probably  due  to  the  congestion  of  the  kidney 


*  Described  by  Dr.  Philip,  in  Casper’s  Wochen- 
schr.  August  29,  1810. 

+  In  his  excellent  account  of  the  epidemic  of 
scarlatina  in  Dublin,  from  1834  to  1842.  12mo. 
Dublin,  1843. 


138 


CALCULOUS  DISORDERS - FREQUENCY  IN  EARLY  LIFE. 


not  having  been  so  considerabe  as  to  lead  to 
the  rupture  of  its  capillaries,  and  the  admix¬ 
ture  of  blood  with  the  urine. 

Although  most  diseases  of  the  urinary 
organs  are  less  common  in  children  than  in 
grown  persons,  yet  calculous  disorders  are 
far  more  frequent  in  early  life  than  in  adult 
age.  It  appears,  indeed,  from  some  statis¬ 
tical  data  furnished  by  Dr.  Prout,  that  out 
of  1256  patients  received  into  the  Bristol, 
Leeds,  and  Norwich  hospitals,  for  the  pur¬ 
pose  of  being  operated  on  for  stone,  500,  or 
nearly  40  per  cent.,  were  under  10  years  of 
age.  If  we  bear  in  mind  the  intimate  con¬ 
nection  that  subsists  between  the  assimilative 
and  the  excretory  functions,  it  will  not  sur¬ 
prise  us  that  in  early  life,  when  the  former, 
though  so  active,  are  so  readily  disturbed, 
the  latter  should  likewise  be  often  thrown 
into  disorder. 

Very  slight,  and  very  temporary  causes, 
indeed,  often  suffice  to  occasion  abundant 
deposits  in  the  urine  of  children,  and  these 
deposits  almost  always  consist  either  of  the 
amorphous  lithate  of  ammonia,  or  of  the 
small  reddish  brown  crystals  of  lithic  acid. 
A  trifling  cold,  or  the  slight  feverishness 
and  general  irritation  which  sometimes  at¬ 
tend  upon  dentition,  not  infrequently  pro¬ 
duce  them,  while  they  disappear  as  soon  as 
the  brief  constitutional  disturbance  subsides. 
While  it  lasts,  however,  the  condition  of  the 
child  is  often  one  of  very  considerable  suf¬ 
fering,  each  attempt  to  make  water  being 
attended  with  much  pain,  the  patient  crying 
and  drawing  up  its  legs  towards  its  abdo¬ 
men  ;  while  frequently  a  few  drops  only  of 
urine  are  voided  at  each  time.  Now  and 
then  the  suppression  of  urine  is  complete  for 
twelve,  eighteen,  or  twenty-four  hours ; 
but  this  seldom  happens  except  in  chil¬ 
dren  previously  much  out  of  health,  and 
in  whom,  under  these  circumstances,  the 
febrile  symptoms  and  the  constitutional  dis¬ 
turbance  are  very  severe,  the  bowels  usually 
constipated,  and  the  evacuations  very  un¬ 
natural  in  appearance.  But  besides  cases 
of  this  acute  kind,  which  occur  almost  ex¬ 
clusively  in  infants  in  whom  the  process  of 
dentition  is  not  yet  complete,  similar  symp¬ 
toms  are  often  observed  in  older  children, 
and  though  at  first  of  a  much  less  urgent 
character,  they  are  yet  of  more  serious  im¬ 
port,  since  they  frequently  indicate  the  exist¬ 
ence  of  a  calculus  in  the  bladder,  instead  of 
a  merely  temporary  excess  of  lithic  acid  de¬ 
posits  in  the  urine. 

In  many  instances  the  formation  of  lithic 
acid  in  the  kidneys  goes  on  without  giving 
rise  to  any  very  obvious  symptoms  ;  and  I 
have  but  rarely  seen  a  child  suffer  from  pain 
of  that  severe  character  which  in  the  adult 
not  infrequently  accompanies  the  descent  of 
a  calculus  from  the  kidney  to  the  bladder. 
Sometimes,  however,  after  frequent  attacks 


resembling  seizures  of  ordinary  colic,  a 
child  begins  to  manifest  the  symptoms  of 
stone  in  the  bladder ;  and,  under  these  cir¬ 
cumstances,  it  is  probable  that  the  previous 
attacks  of  abdominal  pain  were  due  to  the 
disordered  functions  of  the  kidneys,  rather 
than  to  any  primary  affection  of  the  intesti¬ 
nal  canal.  The  occurrence  of  colic  in  chil¬ 
dren  of  three  or  four  years  old,  indeed, 
should  always  direct  our  most  sedulous  at¬ 
tention  to  the  state  of  the  urine,  which  will 
very  often  be  found  to  deviate  widely  from 
a  healthy  condition, — frequently  to  abound 
in  lithic  acid  gravel. 

The  symptoms  of  stone  in  the  bladder  are 
much  the  same  at  all  ages :  the  pain  in 
voiding  urine,  and  immediately  afterwards, 
the  frequent  desire  to  pass  water,  the  occa¬ 
sional  abrupt  stoppage  of  the  stream  of 
urine,  and  the  irritation  about  the  penis, 
owing  to  which  the  child  keeps  its  hand 
almost  constantly  on  its  genitals,  can  hardly 
fail  to  awaken  suspicion  as  to  the  nature  of 
the  case.  Before  subjecting  the  child,  how¬ 
ever,  to  the  fright  and  pain  which  the  intro¬ 
duction  of  a  sound  into  its  bladder  is  sure 
to  occasion,  it  should  first  be  ascertained 
that  the  patient’s  sufferings  are  not  due  to 
the  prepuce  being  extremely  long  and  its 
orifice  very  narrow.  The  existence  of  that 
malformation  sometimes  prevents  the  ready 
escape  of  the  urine  ;  while  the  edges  of  the 
foreskin  becoming  irritated  and  sore,  any 
attempt  to  make  water  is  rendered  exceed¬ 
ingly  painful,  and  the  symptoms  present  a 
most  deceptive  resemblance  to  those  of  stone 
in  the  bladder.  The  presence  of  ascarides 
in  the  rectum  likewise  sometimes  produces  a 
degree  of  irritation  about  the  bladder,  which 
is  by  no  means  unlike  that  produced  by  cal¬ 
culus  ;  and  against  this  possible  source  of 
error  it  behoves  us  to  be  likewise  on  the 
watch. 

The  treatment  of  dysuria  in  early  life, 
connected,  as  the  affection  almost  always  is, 
with  an  excess  of  lithic  acid  in  the  urine,  is 
sufficiently  simple.  Those  acute  attacks 
which  come  on  during  infancy,  and  for  the 
most  part  during  the  period  of  teething,  and 
which  are  attended  with  much  fever,  with  a 
constipated  or  otherwise  disordered  condi¬ 
tion  of  the  bowels,  and  with  severe  suffering, 
obviously  call  for  antiphlogistic  and  soothing 
measures.  The  warm  bath  is  often  very 
serviceable  in  these  cases  in  relieving  the 
febrile  symptoms  ;  besides  which,  the  occa¬ 
sional  immersion  of  the  child  in  hot  water, 
as  high  as  the  hips,  soothes  the  pain  which  is 
so  apt  to  attend  upon  every  attempt  to 
empty  the  bladder.  The  bowels  should  be 
acted  on  freely  by  castor  oil ;  and  afterwards, 
no  medicine  has  appeared  to  me  to  afford  so 
much  relief  to  pain,  or  so  effectually  to  excite 
the  kidneys  to  action,  as  the  castor  oil  mix¬ 
ture  which  I  have  already  mentioned  to  you 


SIMPLE  DIURESIS  LESS  RARE  THAN  TRUE  SACCHARINE  DIABETES.  139 


several  times,  in  combination  with  small 
doses  of  liquor  potassse,  laudanum,  and  ni¬ 
trous  ether.  Barley  water,  milk  and  water, 
and  thin  arrow  root,  should  constitute  the 
child’s  nourishment  during  the  severity  of  its 
attack  ;  and  even  when  the  symptoms  are  on 
the  decline,  much  prudence  must  still  be 
exercised  in  keeping  the  child  to  a  very  mild 
and  unstimulating  diet.  It  is  generally  wise 
to  continue  the  use  of  alkalies  for  some  time 
after  the  active  symptoms  have  subsided ; 
and  small  doses  of  liquor  potassm,  either 
alone  or  in  combination  with  the  vinum 
ipecacuanhae,  may  be  given  three  or  four 
times  a  day  in  a  little  milk.  Once  or  twice 
I  have  seen  a  sudden  suppression  of  urine, 
attended  with  great  aggravation  of  the  child’s 
sufferings,  follow  after  the  existence  of  severe 
dysuria  for  two  or  three  days ;  and  have 
found  this  occurrence  to  be  due  to  the  me¬ 
chanical  obstruction  of  the  urethra  by  a 
small  calculus  which  had  become  impacted 
in  its  canal.  The  dysuria  which  is  produced 
by  the  excessive  length  of  the  prepuce  can 
be  relieved  only  by  the  removal  of  a  portion 
of  the  superfluous  foreskin  ;  while,  when  it 
is  excited  by  ascarides,  an  enema  of  liquor 
calcis,  with  a  dose  or  two  of  castor  oil,  will 
often  produce  an  immediate  cure  of  symp¬ 
toms  which  had  been  very  troublesome. 

The  treatment  of  calculus  in  the  bladder 
hardly  requires  special  notice  here  ;  but  you 
would  bear  in  mind  that  the  calculi  which 
form  in  childhood  are  just  of  that  kind  on 
which  medical  agents  are  best  calculated  to 
act ;  and  that  we  have  but  little  reason  for 
dreading  those  changes  in  the  precipitate 
thrown  down  from  the  urine  which  take 
place  in  later  life.  The  deposits  that  take 
place,  and  the  calculi  that  form  in  childhood, 
consist  almost  invariably  of  the  lithates,  and 
hence  we  may  employ  the  alkaline  carbo¬ 
nates  without  apprehension ;  and  under 
their  continued  use  I  have  seen  very  copious 
sediments  completely  and  permanently  dis¬ 
appear  from  the  urine.  Their  action,  how¬ 
ever,  is  far  too  slow  to  be  relied  on  in  any 
case  where  unequivocal  signs  are  present  of 
the  existence  of  a  stone  of  considerable  di¬ 
mensions  ;  while,  fortunately,  the  anaesthetic 
agents  which  we  now  possess,  by  depriving 
the  operation  of  lithotomy  of  the  pain  that 
once  attended  it,  have  robbed  it  of  many  of 
its  terrors. 

An  unnaturally  profuse  flow  of  urine  oc¬ 
curs  at  all  ages  as  a  temporary  symptom  in 
the  course  of  many  disorders.  Its  perma¬ 
nent  increase,  when  associated  with  certain 
changes  in  the  composition  of  the  fluid,  and 
the  presence  of  saccharine  matters  among  its 
elements,  constitutes  diabetes.  This  disease, 
although  not  common  at  any  period  of  life, 
yet  occurs  in  the  adult  sufficiently  often  for 
us  to  become  familiar  with  its  characters, 


and  to  dread  it  as  one  of  the  most  formidable 
results  of  disorder  of  the  assimilative  pro¬ 
cesses.  In  the  child,  however,  it  would  seem 
to  be  an  exceedingly  rare  affection,  for  not 
only  has  no  instance  of  it  come  under  my 
notice  at  the  Children’s  Infirmary,  but  Dr. 
Prout,  out  of  his  immense  experience  in 
diseases  of  the  urinary  organs,  states  that  he 
has  seen  but  one  instance  of  it  in  a  child  of 
five  years  old,  and  only  twelve  in  young  per¬ 
sons  between  the  age  of  eight  and  twenty 
years,  out  of  a  total  of  7 00  cases  of  diabetes.* 
Simple  diuresis,  indeed,  is  less  rare  than 
true  saccharine  diabetes  ;  and  I  have  seen 
some  instances  in  which,  coupled  with  seri¬ 
ous  gastric  and  intestinal  disturbance,  there 
was  so  considerable  an  increase  in  the  se¬ 
cretion  of  urine  as  to  constitute  a  prominent 
symptom  of  disease.  In  these  cases,  how¬ 
ever,  considerable  disorder  of  the  digestive 
organs  had  for  some  time  preceded  the  ex¬ 
cessive  flow  of  urine ;  and  Dr.  Prout  states 
that  in  the  earlier  stages  of  infantile  diuresis 
the  urine  is  loaded  with  lithates,  and  dimi¬ 
nished  in  quantity,  though,  as  the  disease 
advances,  the  quantity  of  urine  becomes 
considerably  increased ;  and  it  sometimes 
contains  albumen,  or  in  rarer  cases  yields 
signs  of  sugar.  So  far  as  my  observation 
goes,  indeed,  the  disturbance  of  the  func¬ 
tions  of  the  kidney  is  in  these  cases  purely 
secondary  and  subsidiary  to  the  gastric  and 
intestinal  disorder.  The  quantity  of  urine 
has  either  become  speedily  diminished  under 
a  due  attention  to  diet  and  the  regulation  of 
the  digestive  organs,  or  the  symptoms  have 
merged  by  degrees  in  those  of  phthisis, 
which  has  gradually  developed  itself.  My 
experience  concerning  these  affections 
amounts,  in  short,  to  this — that  whenever 
the  processes  of  digestion  and  assimilation 
are  seriously  disturbed  for  any  considerable 
time  in  early  life,  the  functions  of  the  kid¬ 
ney  are  very  apt  to  become  excessive  in  de¬ 
gree  as  well  as  disordered  in  kind.  Further, 
such  disorder  is  especially  likely  to  occur 
just  at  that  period  when  the  simple  but 
highly  animalized  food  of  the  suckling  is 
exchanged  for  the  more  varied  diet  of  the 
infant  after  weaning.  And,  lastly,  its  exis¬ 
tence  may  be  suspected,  whenever,  coupled 
with  more  or  less  indications  of  gastrointes¬ 
tinal  disorder,  there  is  a  rapidly  increasing 
emaciation,  for  which  no  adequate  cause 
appears.  It  will,  however,  often  happen, 
even  when  the  amount  of  urine  greatly  ex¬ 
ceeds  the  healthy  average,  that  the  parents 
of  an  infant  take  no  notice  of  the  circum¬ 
stance,  imagining  it  to  be  either  an  acciden¬ 
tal  and  unimportant  occurrence,  or  account¬ 
ing  for  it  as  the  natural  result  of  the  thirst, 


*  On  Stomach  and  Renal  Diseases,  5th  ed.  8vo. 
London,  1848.  P.  36,  note. 

i 


140 


TREATMENT  OF  DIABETES.  INCONTINENCE  OF  URINE. 


which  induces  the  child  to  drink  very  abun¬ 
dantly.  Hence,  unless  you  make  special 
inquiries  with  reference  to  this  point,  you 
may  remain  in  ignorance  of  a  very  important 
symptom. 

When  once  you  have  become  acquainted 
with  the  nature  of  the  affection,  its  treatment 
is  attended  by  no  particular  difficulty,  and 
if  undertaken  sufficiently  early,  will  often 
prove  successful.  The  state  of  the  bowels 
requires  most  careful  attention  :  mild  alte¬ 
ratives  are  frequently  serviceable,  but  drastic 
purgatives  are  very  unsuitable.  The  Hydr. 
c.  Greta,  in  combination  with  Dover’s  pow¬ 
der,  is  often  very  useful  in  promoting  a 
healthy  condition  of  the  evacuations ;  while 
the  Dover’s  powder  alone  is  also  beneficial 
in  calming  the  child’s  excessive  irritability, 
as  well  as  in  diminishing  the  amount  of 
urine  secreted.  Dr.  Prout  adds  a  caution, 
however,  with  reference  to  the  use  of  opiates 
in  these  cases,  as  Well  as  to  the  sudden 
withdrawal  of  fluids,  since  a  suppression 
of  urine  may  follow  the  incautious  adoption 
of  these  measures,  and  that  condition  is 
almost  sure  to  end  in  coma  and  death. 
Change  of  air  to  a  dry  and  temperate  situ¬ 
ation,  especially  on  the  sea-coast,  is  of  much 
importance,  and  the  tepid  or  warm  sea  water 
bath  is  often  beneficial ;  while  tonics  of 
various  kinds  are  generally  of  service.  The 
different  preparations  of  iron  appear  to  have 
advantages  over  other  medicines  ;  and  Dr. 
Venables,  who  was  the  first  to  call  the  atten¬ 
tion  of  the  profession  to  this  affection,  be¬ 
stows  high  commendation  on  the  phosphate 
of  iron.  Dr.  Prout  insists,  moreover,  on 
the  importance  of  a  suitable  diet,  into  which 
albuminous  matters  should  enter  freely,  in 
preference  to,  though  not  to  the  entire  exclu¬ 
sion  of,  those  which  contain  gelatine.  Milk 
should  form  a  chief  element  in  the  diet : 
while  of  farinaceous  matters,  those  are  to  be 
preferred  which  have  not  undergone  the  fer¬ 
mentative  process.  These  precautions  too 
must  be  observed,  not  for  a  short  period, 
but  until  the  child  has  for  some  time  re¬ 
gained  its  health,  since  a  slight  error  is  very 
likely  to  be  followed  by  a  serious  relapse. 

Incontinence  of  urine  is  a  very  distressing 
infirmity  from  which  children  sometimes 
suffer,  and  which  in  many  instances  is  found 
very  troublesome  to  cure.  In  most  cases 
this  inability  to  command  the  flow  of  urine 
exists  only  in  the  night-time,  but  sometimes 
it  is  present  also  by  day  ;  and  both  forms  of 
the  affection  are  met  with  in  children  of  both 
sexes  and  of  all  ages,  even  up  to  the  period 
of  puberty.  The  nocturnal  incontinence  of 
urine  is  often  associated  with  the  presence 
of  an  excess  of  lithic  acid  in  the  secretion, 
and  in  such  cases  the  first  step  towards  re¬ 
medying  the  infirmity  consists  in  correcting 
the  morbid  state  of  the  fluid.  Now  and 


then  it  appears  to  be  dependent  on  the  irri¬ 
tation  produced  by  ascarides  in  the  rectum, 
while  in  the  majority  of  cases,  so  long  as  the 
affection  is  recent,  a  connection  may  be 
clearly  traced  between  it  and  gastro-intestinal 
disorder.  If  not  remedied,  however,  all  the 
other  functions  of  the  body  may  return  to  a 
healthy  state,  while  yet  the  incontinence  of 
urine  is  perpetuated  by  a  kind  of  habit, 
which  it  is  found  very  difficult  to  break 
through. 

The  involuntary  discharge  of  urine  by 
day-time  as  well  as  at  night  is  a  still  more 
troublesome  affection.  Sometimes  there  is 
an  absolute  want  of  control  over  the  bladder, 
so  that  the  urine  is  almost  constantly  drib¬ 
bling  away  ;  while  in  other  cases  the  desire 
to  pass  water  is  distinctly  felt  at  certain  short 
intervals,  but  the  patient  is  unable  to  resist 
this  desire  even  for  a  minute.  This  affection, 
too,  is  sometimes  associated  with  a  morbid 
condition  of  the  urine ;  in  other  instances  it 
seems  to  depend  on  a  state  of  general  weak¬ 
ness  ;  while  in  some  cases  there  is  no  appa¬ 
rent  cause,  either  general  or  local,  to  which 
it  is  possible  to  ascribe  it.  Cases  of  this  last 
kind  are  of  all  the  most  troublesome ;  they 
are  sometimes  met  with  in  several  members 
of  the  same  family,  especially  in  girls,  though, 
according  to  my  experience,  the  other  more 
curable  forms  of  incontinence  are  much  more 
common  in  male  children. 

In  the  cure  of  nocturnal  incontinence  of 
urine  much  may  often  be  gained  by  attention 
to  certain  precautionary  measures ;  such  as 
limiting  the  quantity  of  drink  taken  at  the 
last  meal,  preventing  the  child  from  lying  on 
his  back  when  in  bed  (a  position  which 
seems  greatly  to  favour  the  occurrence  of  the 
accident),  and  rousing  him  from  bed  to 
empty  his  bladder  two  or  three  times  in  the 
night.  If  the  urine  be  loaded  with  lithates 
the  diet  must  be  most  carefully  regulated, 
and  medicines  must  be  given  to  restore  the 
urine  to  a  healthy  state,  and  to  ensure  the 
due  performance  of  the  functions  of  the  di¬ 
gestive  organs.  Tonics  are  often  extremely 
useful  afterwards,  and  there  is  none  from 
which  I  have  seen  so  much  benefit  as  from 
the  tincture  of  the  sesquichloride  of  iron.  At 
the  same  time,  cold  sponging  to  the  back 
and  loins  is  often  decidedly  serviceable  ;  and 
if  the  case  resist  these  milder  measures,  the 
frequent  application  of  a  blister  to  the  sacrum 
seldom  fails  to  do  great  good.  In  very  obsti¬ 
nate  cases  the  tincture  of  cantharides  is  of 
service ;  and  once  or  twice  1  have  employed 
with  advantage  large  doses  of  the  nitrate  of 
potash,  according  to  the  recommendation  of 
Dr.  Young,  of  Chester ;  but  as  a  general 
rule,  the  employment  of  these  stimulant 
diuretics  does  not  seem  desirable. 


INFLUENCE  OF  RESEARCHES  IN  CHEMISTRY  ON  THERAPEUTICS.  141 


LECTURES  ON  THE 

INFLUENCE  OF  RESEARCHES  IN 
ORGANIC  CHEMISTRY  ON 
THERAPEUTICS, 

especially  in  relation  to  the  depura¬ 
tion  OF  THE  BLOOD. 

Delivered  at  the  Royal  College  of  Physicians, 

By  Dr.  Golding  Bird,  A.M.  F.R.S. 
Fellow  of  the  College. 


Lf.cture  V. — May  5,  1848. 

Medicine  a  history  of  reaction — Solidism 
and  humor alism — Views  of  the  older 
writers — Evils  of  abstract  pathology — 
Zymotic  theory  of  disease  that  of  the 
English  fathers  of  medicine — Crisis  by 
urine — Evolution  of  poisons  by  the  urine 
— Crisis  present  although  not  easily  ob¬ 
vious — Mode  of  discovery — Excretion  of 
solids — Estimation  of— Variation  of — 
Ratio  of  to  the  ingesta — Critical  excre¬ 
tion  by  urine  in  ague — Illustrative  cases. 

Mr.  President,  —  An  elegant  modern 
political  writer  has  defined  the  history  of 
the  constitution  of  a  country  to  be  a 
history  of  reactions — a  series  of  principles 
alternately  dominant  and  forgotten,  each 
raising  its  head,  constituting  for  a  time 
the  governing  element,  and  becoming  the 
object  of  general  attention,  until  worn 
out,  it  expires,  or,  if  existing,  its  sickly 
light  is  obscured  by  the  brilliant  blaze  of  its 
successor, — still  in  turn  to  disappear  and 
die,  and  be  succeeded  by  its  predecessor, 
animating,  perhaps,  a  new  form.  The  do¬ 
minance  of  one  or  other  of  these  hypotheti¬ 
cal  views  of  state  policy  being  determined 
less  by  their  intrinsic  excellence  or  practical 
utility,  than  by  the  brilliancy  of  genius, 
exuberance  of  talent,  or  Herculean  industry 
which  may  for  the  time  distinguish  that 
man  w’ho  may  step  forth  as  the  apostle  of 
such  views, — the  man  rather  than  the  prin¬ 
ciples  he  advocates  being  the  real  object  of 
attention  :  thus  reducing  the  popularity  of 
particular  views  or  theories  to  a  sort  of  hero 
worship,  of  which  their  promulgator  or  tem¬ 
porary  supporter  is  the  object.  Without 
conceding  to  the  author  of  these  view's  a 
claim  to  be  regarded  as  an  authority  in  our 
art,  still  the  history  of  medicine  affords  a 
curious  commentary  on  these  ideas.  Per¬ 
haps  there  are  few  more  instructive  lessons 
to  be  placed  either  before  the  student  or 
practitioner,  than  a  sketch  of  the  history  of 
the  science  we  profess.  I  do  not  allude  to 
the  tale  of  its  development  from  the  pale 
lambent  flame  of  its  infancy,  through  the 
steady  but  faint  light  shining  over  it  on  the 
revival  of  letters,  up  to  its  full  effulgence  in 


these  our  days ;  but  I  allude  to  the  history 
of  the  alternate  credit  and  obloquy  accorded 
to  a  few  views  propounded  in  connection 
with  the  theory  or  practice  of  the  art  of 
healing.  Excluding  the  myriads  of  minor 
theories,  the  ingenious  cobwebs  of  an  hour’s 
existence,  a  glance  at  some,  of  more  com¬ 
prehensive  character,  will  explain  my  mean¬ 
ing.  From  the  earliest  era  of  our  art,  from 
the  time  that  the  rudest  knowledge  of 
zootomy  was  appreciated,  there  has  always 
existed  a  strong  feeling  to  refer  the  sources 
of  disease  to  one  of  two  general  causes, — 
either  to  a  lesion  of  the  solid  structures  of 
our  fabric,  or  to  an  unhealthy  character  of 
its  fluids  or  humours.  Thus  at  all  times  we 
have  had  champions  of  solidism,  and  advo¬ 
cates  of  humoralism  ;  and  it  is  no  less  curious 
than  instructive  to  observe  how  each  has,  at 
different  periods,  appeared  worn  out  and 
threadbare,  and  yet,  after  its  adversary  has 
in  its  turn  become  exhausted,  it  has,  phcenix- 
like,  risen  in  fresh  vigour  from  its  ashes. 
Each  revival  has,  however,  been  invariably 
attended  with  improvement  and  progress; 
so  that,  although  the  subjects  treated  of  re¬ 
main  the  same,  the  theories  of  the  humo- 
ralist  of  to-day  are  not  those  of  Morton  and 
Sydenham,  nor  the  views  of  the  modem 
solidist  those  of  Sanctorius  and  Boerhaave, 
and  hardly  even  these  of  Cullen.  Thus 
great  benefits  have  arisen  from  the  alternate 
popularity  of  opposing  theories,  wdien  advo¬ 
cated  by  really  able  men  ;  for  as  in  science 
in  general,  so  in  medicine  in  particular,  the 
mischief  done  by  an  advocate  of  any  parti¬ 
cular  theory,  is  in  a  ratio  to  his  bigotry  in 
its  favour,  multiplied  by  the  imperfection  of 
the  light  he  may  possess  on  the  subject. 
No  one  can  have  read  the  writings  not 
only  of  the  ancients,  but  perhaps  of  the  less 
known  fathers  of  medicine  in  our  country, 
as  Sydenham,  Morton,  Wiilis,  and  others, 
without  acknowledging  the  comprehensive¬ 
ness  of  their  views,  the  acuteness  of  their 
talents,  and  confessing  that  there  wrere  giants 
on  the  earth  in  those  days.  It  has  been 
probably  too  much  the  fashion  to  regard  our 
ancestors  as  little  better  than  a  pack  of 
noodles  in  almost  all  matters  connected  with 
applied  science,  and  to  consider  the  revival 
of  their  writings  as  the  wasting  of  so  much 
ink  and  paper  :  witness,  for  example,  the 
lavish  ridicule  cast  by  such  persons  on  that 
most  excellent  institution,  the  Sydenham 
Society,  for  reviving  one  of  the  most  elabo¬ 
rate  and  excellent  works  of  the  ancient 
writers,  the  celebrated  Paulus.  But  whilst 
I  am  anxious  to  impress  upon  all  cultivators 
of  medicine  the  propriety  of  carefully  con¬ 
sulting  the  works  of  the  older  writers,  to 
add  their  meed  of  information  to  their  own, 
I  would  not  for  an  instant  enforce  or  sup¬ 
port  a  blind  obedience  to  their  dogmata  ;  for 
if  they  were  giants,  they  moved  in  a  light 


142  ON  THE  INFLUENCE  OF  RESEARCHES  IN  ORGANIC  CHEMISTRY  ON 


just  sufficient  to  render  darkness  visible; 
and  if  we  be  pigmies  in  comparison,  we 
exist  when  the  light  of  science  shines  so 
brightly,  that  the  merest  tyro  can  recognise 
and  distinguish  objects  which  would  have 
been  invisible  to  the  more  erudite  among 
our  ancestors.  Still  I  believe  we  may  often, 
in  the  recorded  experience  of  our  predeces¬ 
sors,  find  a  long-buried  path  of  investiga¬ 
tion,  which  we  can  easily  trace  out  to  ad¬ 
vantage,  but  which  they  were  compelled  to 
abandon.  If  we  avail  ourselves  of  these 
aids,  we  become  virtually  seniors  to  our 
ancestors,  having  their  recorded  experience, 
plus  our  own  acquired  knowledge,  and, 
standing  on  a  high  elevation,  can  see  far 
enough  to  pilot  our  way  to  discoveries  un¬ 
heard  of  by  them  ;  and,  as  has  been  aptly 
said  by  an  old  writer,  that,  “  Pygmaei  gi- 
gantum  humeris  impositi,  plus  quam  ipsi 
gigantes  vident.,, 

One  great  and  characteristic  feature  of 
medical  science  in  our  era,  is  the  devotion  of 
its  cultivators  to  pathology — may  I  venture 
to  say,  to  perhaps  too  abstract  a  pathology. 
The  earlier  physicians,  deprived  of  the  light 
yielded  by  morbid  anatomy,  cultivated  more 
a  kind  of  therapeutical  empiricism.  I  can¬ 
not  help  thinking  that  the  latter  is  now  too 
much  lost  sight  of.  It  would  too  often  seem 
sufficient  for  the  physician  to  make  an  accu¬ 
rate  diagnosis,  to  detail  the  pathological  in¬ 
dications  detected  by  the  scalpel,  should  the 
death  of  the  patient  permit  such  an  investi¬ 
gation  ;  but  I  do  think  that  the  application 
of  remedies  to  the  cure  of  disease,  and  inves¬ 
tigation  into  their  mode  of  action,  is  too 
often  regarded  as  of  secondary  importance. 
Although  no  one  can  be  more  convinced  that 
a  sound  pathology  can  be  the  only  trust¬ 
worthy  guide  to  treatment,  still  I  would  urge 
on  every  member  of  our  profession  the  pro¬ 
priety  of  not  voting  therapeutics  a  bore,  as 
is  too  often  done,  but  I  would  beg  of  them 
to  recollect,  that  it  is  as  much  their  duty  to 
know  how  to  use  their  remedies  to  oppose 
disease,  as  to  point  out  its  existence.  It  is 
in  this  kind  of  excellence  that  the  expe¬ 
rienced  practitioner  exceeds  his  less  erudite 
brethren,  and,  indeed,  constitutes  the  great 
element  of  his  success  in  life.  If  subjects  of 
this  kind,  if  a  tendency  to  encourage  inqui¬ 
ries  into  the  modus  agendioi  medical  agents, 
was  a  little  more  infused  into  the  meetings 
of  our  medical  societies,  they  would  resemble 
a  little  less  than  they  now  do  a  series  of  me¬ 
ditations  on  death.  One  of  the  earliest 
treatises  on  pathology  was  aptly  entitled 
Sepulchretum,  or  grave-yard  ;  and  some¬ 
thing  like  a  sarcasm  appears  lurking  in  the 
frontispiece  of  that  celebrated  work,  when  it 
exhibits  good  old  Bonetus  penning  his  huge 
folios,  whilst  a  figure  of  death  armed  with  a 
scythe  looks  in  at  the  window,  and  with  a 


patronising  air  seems  to  cheer  the  author  in 
his  undertaking. 

I  should  not  have  offered  these  remarks, 
which  may  appear  perchance  sufficiently 
trite  and  discursive,  had  they  not  referred  in 
some  sqnse  to  that  portion  of  my  subject 
which  now  falls  under  our  notice.  In  the 
writings  of  the  older  humoralists,  we  find 
disease  referred  for  the  most  part  to  certain 
peccant  humours  the  result  of  bad  coction, 
which,  entering  the  blood,  excite  (unless 
promptly  got  rid  of)  a  sort  of  fermentation 
competent  to  the  development  of  some  form 
or  other  of  morbid  action.  This  theory, 
turned  into  language  less  quaint,  and  ex¬ 
pressed  in  terms  more  familiar,  is  identical 
with  the  most  modern  views  of  that  mass  of 
diseases  which  are  grouped  together  under 
the  term  zymotic,  from  their  supposed  de¬ 
pendence  upon  the  existence  of  a  zume  or  a 
ferment  in  the  blood.  All  the  recent  views 
emanating  from  Giessen,  and  which  for  a 
time  absorbed  everybody’s  attention,  which 
explain  diseased  action  on  the  principle  an¬ 
nounced  in  my  second  lecture,  by  referring 
it  to  the  influence  of  molecular  motion 
propagated  from  an  infinitely  small  initial 
force,  are  of  this  character.  Witness  the 
following  definition  of  the  poison  of  fever  : 
— “  Fomitem  febriferum  asseramus  esse. 
Deleterium  quid  in  spirituum  systemate 
de/etescens,  quod  fermenti  ad  instar  eos 
adoiens  atque  cestro  primum  exagitans, 
delude  Jiumoribus  secundo  quasi  momento, 
varias  mutationes  atque  qualitates  morbosas 
nobis  sensibiles  impertti."  If  it  be  in¬ 
quired  who  is  this  apparent  supporter  of  the 
views  now  so  popular,  and  so  generally  ad¬ 
mitted — who  is  this  who  talks  of  a  morbid 
poison  communicating  its  action  like  a  fer¬ 
ment  to  the  constituents  of  the  system,  set¬ 
ting  up  by  a  secondary  impulse  perceptible 
metamorphic  changes  in  the  blood,  tissues, 
and  secretions — I  answer,  that  the  author 
who  thus  announces,  and  in  a  laborious 
manner  through  a  large  work  develops  the 
now  popular  theory,  with  the  single  dif¬ 
ference  of  using  the  Latin  word  fermentum 
for  the  Greek  ^vgr],  is  at  least  free  from  the 
charge  of  plagiarism,  seeing  that  he  was 
consigned  to  the  tomb  in  this  modern  Baby¬ 
lon  some  150  years  before  the  oldest  present 
in  this  theatre  saw  the  light.  The  almost 
necessary  result  of  a  belief  in  such  an  hypo¬ 
thesis,  was  a  search  after  the  emunctory  by 
which  the  “  deleterium  quid' ’  was  got  rid 
of  from  the  system ;  and  almost  with  uni¬ 
versal  accord  the  kidneys  were  regarded  as 
the  portals  by  which,  if  not  the  poison,  at 
least  its  results  were  eliminated.  Upon  this 
belief  depends  much  that  has  been  written 
about  crisis  by  the  urine,  and  the  appear¬ 
ances  of  this  secretion  in  different  phases  of 
disease ;  and  it  is  remarkable  how  minutely 


THERAPEUTICS  IN  RELATION  TO  THE  DEPURATION  OF  THE  BLOOD.  143 


its  physical  properties  are,  in  the  absence  of 
a  knowledge  of  its  chemistry,  described  by 
the  older  writers,  although  in  this  particular 
our  ancestors  went  to  some  extent ;  for  I 
find  Dr.  Willis,  a  court  physician  in  the 
days  of  our  second  Charles,  recommending 
a  solution  of  alum  as  a  test  to  detect  in  the 
urine  morbid  changes  not  perceptible  to  the 
eye. 

To  these  critical  features  of  the  urine  the 
attention  of  our  forefathers  was  especially 
directed,  more  particularly  in  those  diseases 
which  certainly  better  bear  out  the  theory  of 
Zymosis  than  any  others — I  mean  the  whole 
class  of  fevers.  I  have  no  doubt  that  all 
who  have  perused  the  Hippocratic  writings, 
and  even  those  of  a  much  more  modern  date, 
have  been  struck  with  the  apparent  obvious 
relation  between  the  termination  of  some 
phases  of  disease,  and  a  crisis  by  urine ;  and 
have,  perhaps,  like  myself,  wondered  at  their 
not  having  observed  these  things  themselves. 
I  think,  however,  that  this  admits  of  a  ready 
explanation,  for  on  referring  to  the  history 
of  fevers  earlier  than  the  last  century  and  a 
half,  no  one  can  fail  to  notice  the  fact  of  the 
remarkable  tendency  to  periodicity  they  ex¬ 
hibit ;  indeed,  we  might  almost  doubt 
whether  a  genuine  continued  fever  was  then 
known.  The  greater  prevalence  of  malaria, 
arising  from  large  extents  of  unreclaimed 
forest-land  and  marsh,  will  explain  this,  and 
I  hope  to  produce  evidence,  ere  we  part  to¬ 
day,  that  a  genuine  crisis  is  really  indicated 
by  the  urine  in  malarious  fevers. 

The  physiological  indications  fulfilled  by 
the  urine  are  familiar  to  all :  we  know  that 
the  kidneys  pump  off  from  the  blood  all 
excess  of  water,  that  they  remove  the  meta¬ 
morphosed  products  of  effete  tissues  or 
mal-assimilated  food,  chiefly,  as  I  pointed 
out  when  I  had  the  honour  of  addressing  you 
on  Wednesday,  in  the  form  of  urea,  creatine, 
creatinine,  uric  acid,  hippuric  acid,  urox- 
anthin,  and  a  peculiar  body  abounding  in 
sulphur  ;  but  we  also  know  that  the  researches 
of  Wohler  have  shewn  something  more — 
viz.,  that  whatever  substances  exist  dis¬ 
solved  in  the  blood,  not  necessary  or  fit  for 
the  repair  of  the  structure  of  our  frame,  in¬ 
variably  escape  from  the  body  by  the  kid¬ 
neys.  The  injection  of  saline  bodies,  colour¬ 
ing  matter,  &c.,  readily  proves  the  truth  of 
Wohler’s  statement.  These  bodies  are, 
however,  often  excreted  in  a  metamorphic 
state,  and  hence  we  must  not  expect  to  find 
them  in  the  urine  in  the  state  they  entered  in 
the  blood;  thus  benzoic  acid,  hydruret  of 
salycyle,  sulphuret  of  potassium,  appear 
respectively  as  hippuric  acid,  salycylic  acid, 
and  sulphate  of  potass,  in  the  urine  ;  and  the 
evidence  I  brought  forward  on  such  changes 
in  my  second  lecture,  is,  I  hope,  not  for¬ 
gotten.  On  this  account,  if  it  be  granted 
that  in  a  given  disease  a  man  perfects  in  his 


own  body  a  septic  poison,  as  deadly,  per¬ 
haps,  as  that  of  the  puff-adder,  and  capable 
of  producing  as  malignant  effects  if  intro¬ 
duced  into  the  blood  of  a  healthy  person,— 
if  such  poison  really  exists,  and  be  ultimately 
got  rid  of  by  the  kidneys,  it  is  by  no  means 
necessary  to  find  the  urine  as  poisonous  as 
the  blood,  or  other  secretions  of  the  patient; 
as  the  septic  matter,  or  the  results  of  the 
metamorphosis  of  tissues  under  its  influence, 
will  in  all  probability  be  resolved  into  some 
of  the  now  well-recognised  elements  of  the 
urine.  Although,  indeed,  even  this  may 
occur,  as  shewn  in  the  celebrated  debauches  of 
the  Kamtschatdales — in  the  amanita  musca- 
ria.  When  this  fungus  (rare  among  them)  is 
found,  a  party  partake  of  it  with  the  gusto 
with  which  the  Highlander  swallows  his 
whisky  ;  and  they  become  very  drunk. 
Anxious,  perhaps,  to  prolong  their  convivi¬ 
ality,  no  other  amanita  can  be  found — how 
are  they  to  proceed  ?  There  is  no  difficulty, 
however,  on  this  matter,  for  they  have  dis¬ 
covered  that  the  intoxicating  element  escapes 
from  the  blood — which  it  had  entered — by 
the  kidneys ;  and  thus  a  second  day’s  de¬ 
bauch  is  economically  kept  up  by  quaffing 
their  own  urine,  which  is  made  to  replace 
the  more  elegant  but  scarcely  less  injurious 
alcoholic  stimulant  of  more  favoured  coun¬ 
tries. 

If  I  can  prove  that,  concomitantly  with  an 
enormous  increase  in  the  excretions  of  the 
kidneys,  sudden  improvement  occurs  in  a 
patient — which  change  for  the  better  does 
not  take  place  until  this  great  change  is  ob¬ 
served — I  think  it  will  be  conceded  that  I 
shall  produce  sufficient  evidence  to  shew 
that  the  observations  of  our  predecessors 
were  correct,  and  that  something  like  a  criti¬ 
cal  excretion  from  the  kidneys  does  take 
place,  at  least  in  the  diseases  which  have 
been  sufficiently  carefully  studied  in  this 
point  of  view. 

But  how  are  we  to  detect  such  a  condition, 
if  it  really  exists  ?  This  is  a  most  impor¬ 
tant  question  ;  and  since  I  have  been  able  to 
answer  it,  I  have  been  astonished  with  the 
curious  coincidences,  if  they  are  nothing 
more,  which  have  flown  from  it ;  and  I  only 
wonder  that,  even  as  a  means  of  diagnosis  as 
well  as  a  therapeutic  guide,  the  source  of 
information  I  now  hint  at  was  not  earlier 
indicated.  No  practitioner  ever  now  neglects 
glancing  at  the  appearance  of  the  urine,  and 
perhaps  noticing  its  density,  or  its  action  on 
litimus  paper,  or  even  asking  whether  the 
patient  passes  much  or  little.  But  no  ob¬ 
servation  of  this  kind  will  give  the  informa¬ 
tion  I  am  alluding  to.  In  a  paper  published 
in  the  Medical  Gazette  two  years  ago,  I 
pointed  out,  for  the  first  time,  the  impor¬ 
tance  of  determining  the  amount  of  real 
urine  passed  by  a  patient.  By  this  term 
real  urine ,  I  understand  the  solid  elements 


144  ON  THE  INFLUENCE  OF  RESEARCHES  IN  ORGANIC  CHEMISTRY  ON 


of  the  urine,  as  distinct  from  the  water  in 
which  they  are  dissolved.  Water,  although 
an  important,  is  not  an  essential  element  of 
the  urine :  it  may  be  excreted  by  other 
emunctories,  but  not  so  the  matters  dissolved 
therein  ;  these  s6em,  except  in  mere  traces, 
to  be  only  able  to  escape  from  the  body  at 
the  outlet  afforded  by  the  kidneys,  and, 
indeed,  from  a  structure  of  those  glands  dis¬ 
tinct  from  that  which  pours  out  the  water. 
In  the  paper  alluded  to,  I  pointed  out  the 
mode  of  determining  this  important  question 
at  the  bed-side,  and  hinted  at  the  results 
which  would  probably  be  obtained  by  it. 
From  that  moment  I  have  never  lost  sight  of 
the  inquiry,  and  one  among  many  of  the  re¬ 
sults  flowing  from  it  I  now  shall  bring  before 
the  notice  of  the  College. 

The  first  element  in  an  inquiry  of  this 
kind  will  be,  to  obtain  a  tolerably  accurate 
measure  of  the  quantity  of  urine  secreted  in 
twenty-four  hours.  Simple  as  this  appears, 
it  in  practice  is  attended  with  no  small  diffi¬ 
culty.  Not  only  is  it  no  easy  matter  to 
make  our  patients  quite  understand  what  we 
require,  but  the  loss  of  urine  generally 
voided  during  the  action  of  the  bowels  will 
frequently  prove  no  small  obstacle  to  our 
learning  the  exact  quantity  secreted.  By 
some  little  tact,  the  latter  difficulty  may  be 
generally  nearly  overcome,  and  the  former 
is  met  by  giving  the  patient  a  definite  and 
distinct  direction  as  to  the  time  when  he  is 
to  begin  to  collect  his  urine.  I  am  accus¬ 
tomed  to  tell  the  patient  to  pass  water  at 
noon,  and,  rejecting  the  portion  then  ex¬ 
creted,  to  collect  all  that  he  passes  up  to  the 
same  time  next  day,  when  he  will  take  care 
to  empty  his  bladder  completely.  In  this 
way,  twenty- four  hours’  secretion  may  be 
collected  and  measured.  Unnecessary  as 
these  minute  directions  may  appear,  they 
are  nevertheless  important ;  as  without  them, 
the  patient  is  almost  sure  to  collect  more 
urine  than  he  ought,  by  preserving  the  por¬ 
tions  passed  at  noon  on  the  first  day,  in 
addition  to  those  voided  on  the  succeeding  day. 

Having  thus  measured  the  amount  of 
urine  secreted  in  a  given  time,  we  are  yet  far 
from  having  any  satisfactory  information  as 
to  the  proportion  of  work  done  by  the  kid¬ 
neys  in  a  given  time,  as  far  as  their  depu¬ 
rating  functions  are  concerned  ;  the  amount 
of  fluid  in  the  renal  secretions  being  liable  to 
serious  variations,  according  to  the  quantity 
of  fluids  drank,  the  action  of  the  skin,  & c. 
Thus,  a  person  may,  under  peculiar  circum¬ 
stances,  void,  in  twenty-four  hours,  forty 
ounces  of  urine,  and  on  the  next  day  but 
twenty,  and  yet  the  amount  of  depurating 
duty  performed  by  the  kidneys  be  the  same ; 
for  the  former  bulk  of  urine,  if  of  a  density 
of  1’015,  will  contain  about  as  much  solid 
matters  as  half  that  quantity  if  of  a  specific 
gravity  of  U030. 


The  characteristic  function  of  the  organs 
under  consideration  must  undoubtedly  be 
regarded  as  the  excretion  of  highly  nitrogen  - 
ised  matters  derived  either  from  the  wear 
and  tear  of  the  animal  tissues,  or  from  im¬ 
perfectly  assimilated  food.  Therefore,  to 
obtain  a  measure  of  the  amount  of  integrity 
of  this  great  depurating  function,  we  must 
not  only  measure  the  urine,  but  calculate 
with  tolerable  accuracy  the  amount  of  solid 
matters  really  existing  in  it.  This  can,  of 
course,  be  effected  by  the  evaporation  of  a 
given  quantity  to  as  dry  an  extract  as  can 
be  obtained.  The  practical  difficulties  at¬ 
tending  this  process  are  familiar  to  every 
one  who  has  ever  performed  the  task  ;  and, 
moreover,  the  time  required  for  its  perfor¬ 
mance  would  preclude  its  being  had  recourse 
to  sufficiently  frequently  to  be  of  any  real 
service.  I  have  elsewhere  noticed  the  ob¬ 
jections  to  this  mode,  as  well  as  the  advan¬ 
tages  presented  by  the  more  rapid  and  easy 
determination  of  the  quantity  of  solids  from, 
the  specific  gravity  of  the  urine. 

Although  ready  to  admit  that  this  mode 
of  calculating  the  quantity  of  solids  is  not 
susceptible  of  rigid  accuracy,  still,  I  main¬ 
tain  that  the  total  error  existing  in  a  series 
of  observations  thus  made  will  be  far  less 
than  if  actual  evaporation  of  the  urine  was 
performed  ;  and  further,  the  large  number 
of  observations  capable  of  being  thus  made 
by  every  one,  amidst  the  fatigues  of  large 
practice,  render  it  of  infinitely  greater  value 
than  a  process  which  requires  time  and 
practical  skill  for  its  performance. 


Specific 

Gravity. 

Weight  of 

1  fluid  oz. 

.g  £ 

£  l 

O  ••—5 

Zfl  1*0 

Specific 

Gravity. 

. 

O  N 

<=> 

fa 

K 

rH  Cfl 

X 

§  l 

m  tio 
^-1 

1010 

441-8 

10-283 

1025 

448-4 

26-119 

1011 

442-3 

11-336 

1026 

448-8 

27-188 

1012 

442-7 

12-377 

1027 

449-3 

28-265 

1013 

443-1 

13-421 

1028 

449-7 

29-338 

1014 

443-6 

14-470 

1029 

450-1 

30-413 

1015 

444- 

15-517 

1030 

450-6 

31-496 

1016 

444-5 

16-570 

1031 

451-0 

32-575 

1017 

444-9 

17*622 

1032 

451*5 

33-663 

1018 

445-3 

18-671 

1033 

451-9 

35-746 

1019 

445-8 

19-735 

1034 

452-3 

35-831 

1020 

446-2 

20-792 

1035 

452-8 

36-925 

1021 

446-6 

21-852 

1036 

453-2 

38-014 

1022 

447-1  22-918 

1037 

453-6 

39-104 

1023 

447*5 

23-981 

1038 

454-1 

40-206 

1024 

448-0 

25-051 

1039 

454-5 

41-300 

A  glance  at  this  table  presents  us  with  a 
mode  of  recollecting  the  quantity  of  solids 
existing  in  urine  of  different  specific  gravi¬ 
ties,  when  the  table  is  not  at  hand  for  refer¬ 
ence — a  piece  of  short  memory  of  no  small 


THERAPEUTICS  IN  RELATION  TO  THE  DEPURATION  OF  THE  BLOOD.  145 


service  in  practice.  Thus,  if  the  specific 
gravity  of  any  specimen  of  urine  be  ex¬ 
pressed  in  four  figures,  the  two  last  will 
indicate  the  quantity  of  solids  in  a  fluid- 
ounce  of  the  urine,  within  an  error  of  little 
more  than  a  grain,  when  the  density  does 
not  exceed  1*030;  above  that  number  the 
error  is  a  little  greater.  To  illustrate  this, 
let  us  suppose  we  are  called  to  a  patient, 
the  integrity  of  the  depurating  functions  of 
whose  kidneys  we  are  anxious  to  learn. 
The  quantity  of  the  urine  excreted  in 
twenty-four  hours  amounts,  we  will  sup¬ 
pose,  to  three  pints  or  sixty  ounces,  and 
the  density  of  the  mixed  specimens  passed 
in  the  time  alluded  to  is  1*020;  now  we 
merely  have  to  multiply  the  number  of 
ounces  of  urine  by  the  two  last  figures  of 
the  specific  gravity,  to  learn  the  quantity  of 
solids  excreted;  or  60  +  20  =  1200  grains 
of  solids.  If  the  table  were  at  hand,  the 
calculation  would  be  more  rigid,  for  we 
should  then  multiply  60  by  20.79,  instead  of 
20  ;  the  product,  1247  grains,  shows  that 
by  the  former  mode  an  error  of  47  grains 
has  been  committed  ;  an  amount  not  suffi¬ 
cient  to  interfere  materially  with  drawing 
our  inductions  by  the  bedside,  and  of  course 
capable  of  immediate  correction  by  referring 
to  the  table  at  our  leisure. 

From  a  large  number  of  observations,  it 
appears  that  the  average  amount  of  work 
performed  by  the  kidneys  in  the  adult,  may 
be  regarded  as  effecting  the  secretion  of 
from  600  to  700  grains  of  solids  in  twenty- 
four  hours.  Although  certain  peculiarities 
connected  with  muscular  exercise,  regimen, 
and  diet,  as  well  as  certain  idiosyncrasies  of 
the  patient,  may  influence  this,  yet  if  we 
regard  650  as  the  average  expression  of  the 
number  of  grains  of  effete  matter  excreted 
in  twenty- four  hours  by  the  kidneys,  we 
shall  not  commit  any  very  serious  error.  In 
calculations  of  this  kind  much  latitude 
must  be  allowed,  and  it  ought  at  least  to  be 
assumed  that  the  kidneys  may  excrete  fifty 
grains  more  or  less  than  the  assumed  aver¬ 
age,  without  exceeding  or  falling  short  of 
their  proper  duty. 

I  have  in  this  as  well  as  in  the  preceding 
lectures  repeatedly  used  the  term  depuration 


of  the  blood,  and  have  referred  to  it  as  an 
expression  of  a  great  fact.  Some  few  years 
ago  it  would  have  required  no  little  courage 
to  have  even  used  this  term,  for  it  would 
have  been  by  many  regarded  as  at  least 
redolent  of  the  sibyls  of  the  wash-tub, 
among  whom  and  their  congeners  there  is 
always  an  aptness  for  referring  all  diseases 
to  the  “  blood  being  in  a  bad  state,”  or 
simply  “bad  blood,”  as  all  who  have  had 
much  to  do  with  dispensary  practice  can 
amply  testify.  Yet  so  much  favour  has  a 
modified  humoralism  gained  in  the  sight  of 
the  reflective  physician,  that  not  only  will 
such  expressions  pass  current,  but  hosts 
of  affections  are  now  regarded  as  strictly 
blood  diseases,  or  conditions  of  cacocemia — 
another  illustration  of  scarcely  any  popular 
opinmn  or  prejudice  existing  without  some 
admixture  of  truth.  Admitting  in  general 
terms  the  fact  that  the  kidneys  do  depurate 
the  blood  of  from  600  to  700  grains  of  solid 
matter  in  the  twenty-four  hours,  I  am 
anxious  to  remind  my  auditors  that  not  only 
does  this  occur  in  accordance  with  fixed 
physiological  laws,  but  that  the  proportion 
of  solids  excreted  at  particular  parts  of  the 
day  vary  according  to  the  amount  of  impure 
matters  existing,  and  present  in  the  blood. 

I  will  select  but  one  among  many  illustra¬ 
tions  which  I  have  at  hand  for  this  purpose. 
In  a  person  in  good  health,  the  bladder  was 
completely  emptied,  and  the  urine  after¬ 
wards  secreted  was  collected  the  next  day  at 
8  a.m.,  12  and  5  p.m.,  and  11|  p.m.,  the  total 
quantity  voided  being  twenty-four  ounces, 
but  a  very  small  quantity  of  fluid  having  been 
taken.  The  urine  voided  at  8  a.m.  was 
evidently  excreted  from  the  blood  indepen¬ 
dently  of  the  influence  of  the  blood,  and  may 
be  regarded  as  a  measure  of  the  quantity 
required  to  be  removed  for  the  depuration 
of  the  blood  of  the  effete  matters  entering  it 
from  the  metamorphosis  of  tissue ;  that 
passed  between  8  and  5|  contained  the 
addition  of  imperfectly  assimilated  matter 
derived  from  breakfast ;  and  that  voided  at 
1 1|  contained  the  results  of  mal-assimilations 
of  dinner.  The  table  before  you  exhibits 
the  result  of  the  analyses  of  these  speci¬ 
mens  : — 


When  passed . 

8  A.M. 

12  and  5  p.m. 

Ilf  P.M. 

Quantity . 

sviij. 

3VJ* 

5V  i’j- 

SP  •  g‘* . 

1.016 

1-020 

1*030 

Uric  acid . 

8  grains 

2*4  grains 

4*8  grains 

Urea . 

50*9  „ 

41*16  „ 

88*2  ,, 

Creatin,  animal  matter,  and ) 
Volatile  salts  ....  j 

62*46  „ 

36*78  „ 

123*72  „ 

Fixed  salts . 

18*4  „ 

44*4  „ 

35*2  „ 

We  thus  find  that  the  blood  alone  yielded  114*16  grains  in  8 1  hours. 
,,  ,,  plus  breakfast  80*34  ,,  in  9  ,, 

,,  ,,  dinner  .  .  216*72  ,,  in  64  ,, 


.146  ON  THE  INFLUENCE  OF  RESEARCHES  IN  ORGANIC  CHEMISTRY  ON 


In  this  example  we  have  merely  traced 
out  the  excretion  of  a  definite  amount  of 
matter  from  the  blood  in  health,  and  when 
the  processes  are  as  little  as  possible  inter¬ 
fered  with  ;  this  observation  bearing,  indeed, 
a  close  resemblance  to  the  interesting  ex¬ 
periments  of  Boussingault  with  ducks.  We, 
however,  will  now  pass  to  the  consideration 
of  another  illustration,  in  which  the  quan¬ 
tity  of  effete  matter  excreted  is  considerably 
increased  from  the  leaven  of  disease.  An 
illustration  also  of  another  fact,  and  a  very 
important  one,  to  which  I  have  already 
alluded — that  a  direct  ratio  exists  in  certain 
diseases  between  the  excretion  of  a  definite 
portion  of  effete  matter  from  the  blood  and 
the  amelioration  of  the  patient’s  condition, 
such  excretion  being  pro  tanto  critical.  I 
shall  now  merely  refer  to  the  amount  of 
‘‘real  urine”  excreted,  without  reference  to 
its  composition. 

Several  cases  of  ague  occurred  in  the  hos¬ 
pital  whilst  I  was  pursuing  this  inquiry,  and 
I  propose  alluding  to  some  of  these,  for  the 
purpose  of  illustrating  the  proposition  now 
announced.  I  have  chosen  ague,  in  conse¬ 
quence  of  its  origin  having  been  in  almost 
all  ages  traced  to  the  existence  of  a  poison, 
derived  from  marsh  miasm,  which  is  sup¬ 
posed  to  exert  such  an  influence  directly  on 
the  blood,  and  indirectly  on  every  part  of 
the  organism  bathed  by  that  fluid,  as  to  de¬ 
velop  the  well-known  and  characteristic 
systems  of  the  disease  in  question.  I  will 
read  the  report  of  the  case  in  the  words  of 
Dr.  Robert  Finch,  one  of  our  most  zealous 
clinical  clerks,  then  reporting  for  me. 

“  Owen  S - ,  set.  27,  by  occupation  a 

bricklayer’s  labourer,  admitted  into  Lazarus 
ward,  May  21,  1845,  under  Dr.  Golding 
Bird.  His  last  residence  was  at  Bankside  : 
before  that,  for  some  time,  at  Gravesend. 
Previous  health  good ;  says  he  has  lived 
temperately,  and  once  suffered  from  syphilis. 

Five  months  ago,  at  Gravesend,  he  first 
had  a  shivering  fit,  followed  by  the  usual 
hot  and  sweating  stages  ;  he  entered  Guy’s 
Hospital,  under  the  care  of  Dr.  Barlow,  and 
left  in  three  weeks  well.  On  April  1st,  the 
first  attack  appeared  rather  irregular  in  its 
stages,  and  to  use  his  own  expression,  he 
did  not  “  shake  out.”  The  paroxysm  re¬ 
turned  every  alternate  day,  at  about  three 
o’clock  in  the  afternoon.  In  the  previous 
illness  they  appeared  at  noon. 

On  admission,  aspect  sallow  and  melan¬ 
cholic  ;  complained  of  frequent  giddiness, 
with  a  sensation  of  dulness  and  stupor. 
Abdomen  flatulent,  painless  ;  no  appetite  ; 
bowels  confined ;  tongue  clean  and  moist. 
No  evidence  of  enlarged  spleen  or  liver. 
Urine  sp.  gr.  1'028,  depositing  pink  urates; 
contains  a  little  biliary  colouring  matter ; 
no  albumen. — Hyd.  c.  Creta,  Ipecacuanha, 
aa.  gr.  j.  ;  Ext.  Conii,  gr.  iij.  t.d.s. 


May  22. — Had  a  paroxysm  yesterday  at  3 
o’clock,  lasting  about  four  hours  ;  complains 
of  “  cold  creeping”  down  his  back.  P. 

23.  — A  paroxysm  at  3  a.m.,  lasting  not 
much  more  than  two  hours ;  bowels  act 
freely  ;  dejections  pale.  P. 

24.  — Feels  better  :  in  good  spirits.  P. 

27. — No  return  of  ague  ;  aspect  improved 

and  less  sallow ;  urine  depositing  urates, 
stained  pink  with  purpurine ;  bowels  act 
freely  ;  skin  rather  hot  and  inactive.  P. 

29. — Improving  in  health  and  spirits  ; 
complains  of  shivering  between  the  scapula. 
Urine  pink  from  purpurine,  but  not 
letting  fall  a  deposit.  —  Beeberinse  Sul- 
phatis,  gr.  j.,  ter  in  die. 

June  2. — Yesterday  at  noon  had  a  severe 
paroxysm  ;  shivered  severely  for  three 
hours,  followed  by  a  long  and  severe  hot  and 
sweating  stage ;  bowels  confined  for  two 
days.  P. — Pil.  Cal.  c.  Hyd.  iij.  hac  nocte. 

3. — Another  paroxysm,  but  not  so  severe  ; 
urine  alkaline. — Beeberinse  Sulphatis,  gr.  j. ; 
Pil.  Hyd.,  gr.  j.  t.d.s. 

5. — Another  attack  this  morning;  urine 
acid;  perspiration  neutral.  P. 

7. — Quite  well  yesterday  :  this  morning 
had  aslight  shivering  at  10  a.m.,  but  no  hot 
and  sweating  stage  ;  seems  dull  and  stupid. 
— Beeberinse  Sulphatis,  gr.  ij.  c.  Hyd.  c. 
Creta,  gr.  j.  ter  in  die. 

10. — No  return  of  ague  ;  appetite  good.  P. 

13.  —  Progressing  favourably;  has  a 
healthy  tint  of  the  whole  surface  of  the  body. 

16.  — Complains  of  a  little  giddiness, other¬ 
wise  quite  well. 

17.  — Convalescent.  Made  an  out-patient, 
and  remained  free  from  ague  as  long  as  he 
was  kept  under  notice. 

The  following  is  a  tabular  view  of  the  ex¬ 
amination  of  the  urine  of  this  patient,  from 
the  reports  of  Mr.  Howard  Johnson  : — 


Date. 

1  Fluid  ounces  of 
l  urine  in  24  hours. 

Specific  Gravity. 

i 

Action  on  Litmus. 

Weight  of  solids 
present  in  grains. 

May  23 

12 

1-028 

acid,  pink  deposits 

352 

May  26 

40 

1-020 

1  1 

828 

May  28 

35 

1-020 

acid,  no  deposit  . 

725 

May. 30 

48. 

1-020 

i  i 

1054 

May  31 

45 

1-016. 

743 

June  2 

35 

1-014 

alcaline . 

514 

June  4 

30 

1-028 

acid,  pink  deposits 

879 

June  6 

27 

1-034 

1  1 

1036 

June  7 

35 

1-013 

acid,  no  deposit  . 

436 

J  une  9 

40 

1-028 

1 1 

1172 

June  1 1 

45 

1-016 

1 1 

742 

Junel3 

40 

1-022 

1  1 

916 

June  14 

43 

1-022 

1  y 

984 

Junel6 

37 

1-027 

1 1 

1044 

THERAPEUTICS  IN  RELATION  TO  THE  DEPURATION  OF  THE  BLOOD.  147 


The  proportion  of  solids  excreted  in  a 
given  time,  is  calculated  from  the  specific 
gravity,  according  to  the  table  before  alluded 
to,  and  therefore  must  be  regarded  as  proxi- 
mately,  not  absolutely  correct. 

In  this  case  we  had  to  treat  a  patient 
who  had  been  long  immersed  in  malaria,  who 
had  suffered  from  a  previous  attack  of  ague, 
and  whose  portal  circulation  was  interfered 
with.  Although  no  enlargement  of  liver  or 
spleen  could  be  detected  by  “palpation/' 
still,  the  jaundiced  urine  and  sallow  mias¬ 
matic  melancholic  aspect  sufficiently  attested 
the  torpid  mode  in  which  the  liver  was 
carrying  on  its  functions.  This  case  hap¬ 
pened  to  be  one  of  four  admitted  on  the 
same  day ;  it  was  chosen  with  the  others  for 
the  purpose  of  testing  the  efficacy  of  Bee- 
berine,  then  recently  introduced  by  Dr. 
Maclagan,  as  an  anti-periodic  remedy.  I 
was  compelled,  however,  to  associate  it  with 
doses  of  a  mercurial  alterative,  for  the  pur¬ 
pose  of  unloading  a  probably  congested  state 
of  the  portal  system — at  all  events  of  stimu¬ 
lating  the  function  of  the  liver. 

On  looking  to  the  table  of  the  urine  it 
must  be  admitted  that  there  exists,  to  say 
the  least,  some  curious  coincidence  between 
the  free  action  of  the  kidneys,  quoad 
the  excretion  of  solids,  and  the  improve¬ 
ment  of  the  patient.  The  unusually  large 
quantity  of  solid  constituents  removed  by 
the  kidneys  of  this  patient  is  remarkable, 
and  certainly  very  unfrequent. 

Whether  this  was  owing  to  any  idiosyn¬ 
crasy,  I  have  no  means  of  knowing. 

On  referring  to  the  table,  we  find  that  on 
May  23rd,  but  352  grains  of  solids  were  re¬ 
moved  by  the  kidneys  in  24  hours ;  the 
patient’s  disease  not  having  then  shewn  any 
tendency  to  yield  to  our  remedies,  and  bile 
existed  in  the  urine  ;  the  quantity  of  solids 
increased  to  the  30th,  on  which  day  they 
reached  the  remarkable  quantity  of  1054 
grains;  on  the  31st  they  suddenly  fell  to 
743  grains;  and  in  the  succeeding  24  hours, 
the  paroxysm,  absent  for  several  days,  re¬ 
turned.  On  the  following  day,  June  2nd, 
the  urine  was  alkaline  for  the  first  time,  and 
contained  less  than  half  the  quantity  of 
solids  which  existed  four  days  previously, 
and  he  had  a  most  severe  attack  on  the 
next  day  ;  the  kidneys  became  more  ac¬ 
tive,  and  a  less  severe  attack  appeared 
on  the  7th,  when  the  solids  again  fell  to 
a  minimum  ;  after  this  time  they  were 
again  copiously  excreted,  and  the  ague  finally 
vanished. 

Mary  H — ,  set.  13  years,  admitted.  May 
23,  1845,  into  Martha  ward,  under  Dr. 
Golding  Bird.  She  was  born  at  Sheerness, 
and  had  lately  removed  to  Deptford  :  had 
scarcely  suffered  from  any  illness  before  the 


present  one.  Although  well  developed  for 
her  age  she  had  never  menstruated. 

Three  years  ago  she  first  suffered  from 
ague  of  the  quartan  type,  two  clear  days 
elapsing  between  the  attacks  :  the  paroxysm 
then  commencing  at  noon,  and  appearing 
pretty  regularly  in  spite  of  treatment  for 
two  years.  She  then  left  Sheerness,  and 
came  to  Deptford,  and  shortly  after  attended 
Guy’s  Hospital,  as  an  out-patient,  under 
Dr.  G.  Bird.  She  was  cupped  over  the 
spleen,  and  took  quinine,  so  that  in  a  month 
she  appeared  cured,  and  remained  well  for 
eight  months.  Lately  she  has  become 
emaciated;  a  month  ago  ague  again  appeared; 
still  quartan  in  type. 

On  admission,  the  skin  was  active, 
although  cold  ;  aspect  not  very  sallow,  but 
dull  and  stupid ;  pulse  quick,  although 
small  and  regular  ;  no  appetijte  ;  complains 
of  thirst,  and  occasional  bilious  vomitings. 
There  is  considerable  pain  across  the  fore¬ 
head,  and  from  her  mother’s  account  she  is 
light-headed  at  night.  On  examining  the 
abdomen,  the  spleen  can  be  felt  decidedly 
enlarged.  Urine  stated  to  be  high-coloured 
during  the  paroxysms  ;  pale  in  the  intermis¬ 
sions. 

May  24. — Had  a  paroxysm  to-day,  last¬ 
ing  from  noon  to  six  in  the  evening. — Hyd. 
c.  Creta,  gr.  ij. ;  P.  Ipecac,  gr.  j.  ter  in 
die. 

27. — Paroxysm  came  on  at  noon  as  usual, 
and  continued  seven  hours. — Beeberinse 
Sulphatis,  gr.  j.  4ta  quaque  bora.  Parox¬ 
ysms  absent. 

29. — Seems  pretty  well,  except  that  the 
skin  is  hot  and  dry.  P. 

31. — No  ague  yesterday;  skin  acting 
freely  ;  bowels  confined. — Rep.  Beeberinse 
Sulphatis. — Pil.  Hydrarg.  gr.  iij ;  Ext.  Coloc. 
Co.  gr.  vj.  alt.  nocte. 

June  3. — No  return  of  ague;  too  much 
heat  of  skin  ;  the  tongue  has  a  white  fur 
with  elongated  marginal  papillae  (strawberry 
tongue.)  —  Augeatur  dosin  Beeberinae  ad 

gr-  ij- 

7. — Going  on  well ;  tongue  the  same ; 
cheeks  flushed,  but  skin  perspires.  P. 

14. — Progressing  favourably  during  the 
week  ;  the  tongue  has  cleaned.  She  seems 
very  well.  P. 

17. — Not  so  well;  some  gastric  distur¬ 
bance,  owing  to  some  irregularity  in  food. — 
Zinci  Sulphatis,  9j.  statim. 

20. — Has  been  well  since  the  emetic. 

27. — Convalescent. 

The  following  table  presents  a  view  of 
the  patient’s  urine  whilst  under  treat¬ 
ment  : — 


148  INFLUENCE  OF  RESEARCHES  IN  CHEMISTRY  ON  THERAPEUTICS. 


Date. 

Fluid  ounces  in  24 
hours. 

Specific  Gravity. 

Action  on  Litmus. 

Weight  of  solids 

in  grains. 

May  24  .  . 

35 

1-008 

acid  .  . 

280 

May  26  .  . 

28 

1-013 

6  l. 

375 

May  28  .  . 

26 

1-020 

1C 

538 

May  30  .  . 

25 

1-024 

a 

625 

May  31  .  _ 

20 

1-022 

u 

458 

June  2  .  .  . 

30 

1-017 

u 

528 

June  6  .  .. . 

35 

1-018 

alkaline 

651 

June  7  .  . . 

30 

1-020 

acid  .  . 

621 

A  glance  at  this  table  shews  that  pari 
2)assu  with  the  patient’s  improvement  a 
gradual  increase  occurred  in  the  solids  ex¬ 
creted  by  the  kidneys.  No  ague  appeared 
after  the  blood  had  been  depurated  of  538 
grains  of  effete  matter,  on  the  28th  of  May. 
In  this  case,  unlike  the  last,  although  the 
patient  had  long  been  exposed  to  the  poison 
of  marsh  malaria,  she  did  not  suffer  any  re¬ 
lapse,  and  she  remained  well  up  to  the  pre¬ 
sent  winter,,  when  she  again  came  under  my 
care  as  an  out-patient,  with  a  very  slight 
attack  of  ague. 

I  hope  that  I  shall  not  be  misunderstood 
in  the  line  of  argument  I  have  adopted. 
Although  believing  most  completely  that 
ague  is  primarily  excited  by  the  influence 
of  a  peculiar  septic  poison  derived  from 
marsh  malaria,  I  do  not  for  a  moment  assert 
that  this  particular  poison  is  excreted  in  the 
urine  during  the  recovery  of  the  patient.  It 
is  very  probable  that  there  are  many  inter¬ 
mediate  links  in  the  chain  of  causation  be¬ 
tween  the  incubation  of  the  poison,  and  the 
development  of  the  phenomena  accompany¬ 
ing  convalescence.  The  great  effect  of  the 
malarious  poison  is  in  all  probability  essen¬ 
tially  and  primarily  exerted  upon  the 
nervous  system,  especially  on  the  organic  or 
ganglionic  structure,  which  preside  so  im¬ 
portantly  over  the  function  of  secretion. 
Thus,  all  the  secretions  elaborated  in  the 
body  become  affected  ;  and,  as  is  well  known, 
a  remarkable  tendency  to  congestion  is  ob¬ 
served  in  the  portal  circulation,  destined 
most  particularly  for  the  depuration  of 
matters  rich  in  carbon.  There  can  be  no 
doubt  that  the  unhealthy  secretions  thus 
formed,  become  active  agents  in  keeping  up 
in  the  body  the  impression  of  the  disease. 
One  of  the  great  elements  of  successful 
treatment  must  of  necessity  be  the  depura¬ 
tion  of  the  blood,  and  thus  by  freeing  the 
system  from  the  depressing  influence  of  a 
vitiated  pabulum  for  its  growth  and  nourish¬ 
ment,  allowing  the  vital  powers  to  throw  off 
the  influence  of  the  poison  which  for  a  time 


protected  them.  The  influence  of  smal 
doses  of  mercury  in  the  treatment  of  ague  is 
well  known  ;  by  a  gentle  but  persistent  ap¬ 
peal  of  this  kind  to  the  liver,  the  patient  is 
immensely  relieved,  and  his  ultimate  cure 
expedited.  Cotemporaneously  with  this, 
the  aspect  generally  becomes  less  sallow,  a 
sufficient  indication  of  the  liver  becoming 
active  in  depurating  the  blood  of  carbon. 
Then,  under  the  influence  of  that  very 
curious  class  of  remedies,  the  anti-periodic 
tonics,  the  paroxysms  become  less,  or  quite 
vanish,  whilst  ample  evidence  is  afforded 
of  the  kidneys  performing  the  important 
duty  of  filtering  from  the  blood  highly 
nitrogenised  substances,  by  the  rapidly  in¬ 
creasing  amount  of  solids  existing  in  the 
urine. 


CLINICAL  OBSERVATIONS  ON 

HIP  DISEASE. 

[continued.] 

By  B.  Phillips,  Esg.  F.R.S. 
Surgeon  to  the  Westminster  Hospital. 


Our  experience  of  the  results  of  hip  disease 
during  the  last  two  years  is  certainly  not 
very  cheering,  and  I  am  afraid  it  is  not  very 
different  from  the  experience  of  others.  It 
is  true  that  in  that  period  only  one  patient 
has  died  from  the  disease  within  these  walls, 
but  I  am  afraid  that  others  have  been  taken 
home  to  die.  Where  that  result  has  not 
occurred,  sometimes  serious  incurable  infir¬ 
mities  may  remain,  such  as  dislocation  or 
anchylosis  ;  in  a  few  cases  the  disease  has 
been  happily  subdued,  and  the  patient  has 
gradually  recovered.  Of  course  the  result 
will  depend  upon  many  circumstances.  Some 
people  think  that  the  chances  of  mischief  are 
greater  the  earlier  in  life  the  disease  is  de¬ 
veloped.  I  cannot  say  that  I  am  satisfied  of 
the  correctness  of  that  opinion.  Much  more 
will  depend  upon  the  constitution  with 
which  we  have  to  deal.  Where  the  child  is 
vigorous,  we  may  use  energetic  means  and 
subdue  the  disease ;  where  he  is  feeble,  our 
chance  of  success  is  lessened.  Again,  we 
have  much  more  chance  of  arresting  the  evil 
when  the  cause  is  accidental  than  where  it 
is  constitutional.  It  is  hardly  necessary  to 
say,  that  where  the  evil  is  of  long  standing, 
and  the  disorganisation  considerable,  that  we 
can  hardly  hope  for  complete  resolution. 

As  hip  disease  is  often  presented  in  feeble 
children,  and  as  in  many  instances  the  ap¬ 
pearances  of  a  scrofulous  constitution  are 
manifested,  it  has  been  very  much  the  prac¬ 
tice  to  subject  them  to  specific  plans  of. 
treatment ;  but  as  I  know  no  specific  for 
scrofula,  I  have  been  content  to  treat  the 
case  according  to  the  symptoms,  always 


MR.  PHILLIPS’  CLINICAL  OBSERVATIONS  ON  HIP  DISEASE.  149 
~~~  1  1  ■  -  ■  =e 


bearing  in  mind  that  a  scrofulous  cachexia  is 
a  proof  of  a  feeble  general  condition  ;  and 
that  such  means  as  tend  most  effectually  to 
improve  nutrition  are  best  adapted  for  the 
relief  of  this  state.  Of  course  the  means  to 
be  used  must  vary  with  the  case.  But  there 
is  a  medicine  upon  which  many  persons 
place  much  reliance  in  the  treatment  of  scro¬ 
fulous  diseases  affecting  joints — I  mean  cod- 
liver  oil.  I  have  made  considerable  use  of 
it,  and  certainly  in  most  cases  without  any 
obvious  benefit ;  in  many  cases  it  proved 
injurious :  it  has  deranged  the  digestive  sys¬ 
tem,  and  induced  diarrhoea.  In  a  few  cases 
it  has  seemed  to  do  much  good  ;  and  when¬ 
ever  its  effects  are  to  improve  nutrition — 
and  this  is  shewn  by  the  patient  gaining 
flesh — then  very  frequently  its  effects  upon 
the  local  disease  have  been  very  favourable. 

The  conviction  that  these  affections  will 
very  frequently  go  wrong,  and  that  only  the 
most  energetic  means  will  succeed  in  avert¬ 
ing  them,  is  as  old  as  the  time  of  Hippocrates 
(Aphor.  60) ;  and  the  great  remedy  in  use 
by  the  Greeks,  the  Romans,  and  the  Arabs, 
was  the  actual  cautery.  In  Europe,  it  was 
not  until  the  last  century  that  any  combined 
plan  of  treatment  was  properly  followed  out. 
Petit  says  of  these  cases, — rest  is  the  first 
remedy,  associated  with  repeated  bleedings, 
appropriated  to  the  strength  of  the  patient 
and  the  necessity  of  the  case,  and  topical 
stimulating  applications.  Later  surgeons 
have  reduced  the  treatment  into  a  more  syste¬ 
matic  plan ;  thus,  it  is  said  at  the  first 
period,  rest,  antiphlogistics,  and  counter- 
irritants,  with  appropriate  general  treatment, 
are  to  be  employed  ;  at  the  second  period, 
opening  abscesses,  if  they  exist,  and  favour¬ 
ing  the  formation  of  new  articulations  if 
there  be  displacement,  and  anchylosis  if  there 
be  not,  are  the  means  to  be  employed. 

A  great  impression  was  made  many  years 
ago  by  the  practice  of  Rust ;  although  few 
surgeons  in  this  country  have  had  the  courage 
to  use  the  actual  cautery  so  liberally  as  it 
was  employed  by  that  surgeon.  The  value 
of  the  remedy  has,  however,  been  so  gene¬ 
rally  admitted,  and  his  success  in  the  treat¬ 
ment  of  diseased  joints  was  said  to  be  so 
great,  that  it  is  proper  to  set  forth  his  plans 
in  this  place.  He  divided  the  disease  into 
four  stages  :  inflammation  of  the  medullary 
membrane,  ulceration,  dislocation,  after  con¬ 
sequences  ;  but  he  admitted  only  one  primi¬ 
tive  form — inflammation  of  the  internal 
periosteum.  In  the  first  stage,  he  recom¬ 
mended  that  as  soon  as  leeches  and  baths 
had  quieted  the  pains,  mercurial  frictions 
should  be  employed.  In  the  second  stage — 
that  of  elongation — he  used  the  actual  cau¬ 
tery.  In  the  third  and  fourth  periods — that 
of  suppuration — he  believed  that  a  radical 
cure  was  not  possible.  His  cauteries  were 
of  various  forms  :  some  were  radiating,  hav¬ 


ing  three  or  five  radii ;  these  radii  werf 
separated  from  each  other  to  the  extent  o 
nine  lines  or  an  inch.  For  an  adult,  the 
centre  radius  was  often  four,  and  sometimes 
five  or  six  inches  long  :  it  was  applied  along 
the  direction  of  the  sciatic  nerve ;  the 
second  was  laid  along  the  fossa,  behind  the 
great  trochanter ;  the  third  was  placed  over 
the  great  trochanter  itself ;  and  the  time  of 
contact  was  dependent  upon  the  depth  of 
ulceration  required.  When  abscesses  existed 
around  the  joint,  if  they  were  large,  he 
opened  them,  and  freely.  He  had  no  fear 
from  the  introduction  of  air  :  he  maintained 
that  it  was  not  the  action  of  the  air,  but  the 
state  of  the  part,  that  wrought  changes  in  the 
contained  fluid.  However,  to  get  rid  as  far 
as  he  could  of  that  objection,  he  used  to 
irritate  the  skin  of  the  part  in  which  the 
opening  was  to  be  made  by  passing  over  it 
the  red-hot  iron  ;  and  as  soon  as  the  tension 
it  occasioned  was  abated,  he  split  the  eschar, 
so  as  to  make  an  opening  into  the  cavity, 
and  cause  the  escape  of  pus.  He  considered 
this  the  best  means  to  procure  the  adhesion 
of  the  sides,  but  sometimes,  after  similar 
preparation,  the  escape  was  promoted  by 
seton.  Other  surgeons  prefer  moxas  to  the 
actual  cautery,  as  being  less  painful  and 
frightful. 

Sir  B.  Brodie  differed  from  Rust  in  this, 
that  he  distinguished  two  principal  forms  of 
the  disease — namely,  synovial  inflammation, 
and  ulceration  of  cartilages.  For  the  modi¬ 
fication  of  general  health,  he  recommends 
an  appropriate  treatment  ;  for  the  local 
treatment  he  advises  antiphlogistic  cata¬ 
plasms,  &c.  until  acute  symptoms  abate ; 
wrhen  they  are  abated,  he  advocates  counter¬ 
irritation  by  blisters  ;  at  a  still  later  period, 
frictions  with  stimulants,  &c.  In  the  se¬ 
cond  form  of  the  disease  he  insists  on  per¬ 
fect  repose,  and  the  horizontal  position,  to 
favour  anchylosis.  Where  issues  are  made, 
he  advises  that  they  should  be  placed  behind 
the  trochanter.  In  some  instances  much 
relief  has  been  obtained  by  placing  them 
over  the  tensor  vaginse  femoris.  Instead  of 
keeping  them  open  with  peas,  he  advises 
that  they  should  be  brushed  over  with  blue- 
stone  twice  or  three  times  a  week.  Where 
the  pain  at  the  joint  is  very  acute,  he  ad¬ 
vises  the  use  of  a  seton  in  the  groin,  over 
the  crural  nerve.  When  abscesses  are  to  be 
opened,  he  prefers  the  lancet,  and  he  keeps 
the  leg  wrapped  up  in  warm  flannels. 

Roux,  on  the  contrary,  objects  to  all  exci¬ 
tant  or  resolvent  applications,  because,  as  he 
says,  they  have  no  beneficial  effect.  Hethiuks 
blisters  are  only  fit  for  young  children. 
Some  persons  still  adhere  to  mercurials, 
externally  and  internally  ;  some  to  barium. 

Now  let  us  make  a  few  remarks  on  these 
things.  No  doubt,  if  the  state  of  the  con¬ 
stitution  can  be  improved  by  treatment,  it 


J  50  MR.  PHILLIPS’  CLINICAL  OBSERVATIONS  ON  HIP  DISEASE. 


should  be  done ;  but  this  is  often  difficult. 
I  believe  that  a  syphilitic  taint  has  not  often 
much  to  do  with  it,  although  this  opinion  is 
entertained  by  some  surgeons.  A  scrofulous 
taint  is  unhappily  often  associated  with  it ; 
but  every  surgeon  knows  how  difficult  it  is 
to  modify  it :  still,  it  should  be  attempted. 
Dzondi  believed  that  a  rheumatic  diathesis 
was  often  mixed  up  with  it.  He  placed  his 
patients  in  hot  baths,  where  the  temperature 
was  raised  as  far  as  it  could  be  borne,  and 
this  was  done  every,  or  every  other,  day ;  at 
the  same  time  administering  sudorifics,  using 
frictions,  and  wrapping  the  patients  in 
blankets.  There  are  still  two  plans  which 
have  been  warmly  advocated :  mercury,  so 
as  to  affect  the  system,  by  O’Beirne ;  and 
baryta,  by  Pirondi  and  Lisfranc.  I  have 
seen  good  effects  from  the  first,  but  I  cannot 
say  as  much  for  the  second. 

It  is,  however,  from  local  treatment  that 
we  have  most  to  hope — namely,  rest,  posi¬ 
tion,  antiphlogistics,  and  counter-irritants. 
On  the  utility  of  the  first  agent  I  think  few 
persons  have  any  doubts  :  it  is,  in  my  judg¬ 
ment,  the  most  important  element  of  all, 
no  matter  what  may  be  the  age  of  the  pa¬ 
tient  or  the  stage  of  the  disease,  and  it  must 
be  continued  long  after  all  feeling  of  dis¬ 
comfort  has  ceased.  At  the  same  time  I  am 
bound  to  say  that,  easy  as  it  would  seem  to 
he,  to  accomplish  this  object,  there  is  often 
considerable  difficulty  in  satisfactorily  carry¬ 
ing  it  out.  There  are  many  modes  of  effecting 
it :  it  may  be  done  effectually  by  means  of 
bullock’s  hide,  or  gutta  percha  moulded  on 
the  sides  of  the  pelvis  and  the  thigh.  Occa¬ 
sionally  T  have  known  the  object  to  be 
accomplished,  though  less  perfectly,  by  ap¬ 
plying  bandages  around  the  feet,  the  legs, 
and  the  thighs.  In  one  case  it  may  be 
best  accomplished  by  means  of  one  plan ; 
in  another,  by  a  different  one.  The  long 
splint  is  employed  by  some  surgeons,  but  it 
is  often  found  too  irksome  to  bear.  I  have 
known  cases  in  which  the  double-inclined 
plane  has  answered  well ;  but  if  there  be 
any  chance  of  anchylosis,  of  course  that 
position  would  not  do.  In  any  case,  if  per¬ 
fect  rest  be  not  procured,  our  object  will 
not  be  attained  ;  but  if  perfect  rest  to  the 
joint  be  so  important,  it  must  be  necessary 
to  ascertain  in  what  position  the  limb  is 
best  placed.  It  must  be  borne  in  mind 
that  in  these  cases  flexion  is  the  position 
which  the  limb  tends  to  take,  and  that  this 
flexion  disposes  the  head  of  the  femur  to 
escape  from  the  acetabulum  ;  and  there  can 
be  no  question  that,  if  anchylosis  is  to  take 
place,  the  flexed  position  would  make  the 
limb  useless.  There  is  no  doubt,  either,  that 
rotation  inwards  or  outwards  is  objection¬ 
able.  If  the  direction  be  inwards,  the  cap- 
sule  is  distended,  and  the  pressure  tends  to 
produce  softening  or  ulceration.  When  the 


thigh,  flexed  on  the  pelvis,  is  adducted  and 
rotated  outwards,  the  ligaments  within  and 
without  the  joint  are  distended  ;  but  this 
position  is  certainly  much  more  rarely  seen 
than  that  of  adduction  and  rotation  inwards. 
It  does  not  follow,  however,  that  because 
the  limb  is  extended  there  should  be  no 
tendency  to  displacement ;  for  it  would 
happen  if  it  were  at  the  same  time  adducted 
and  rotated  outwards,  or  adducted  and  ro¬ 
tated  inwards  ;  but  if  the  limb  be  extended 
and  directed  parallel  to  the  axis  of  the 
trunk,  the  point  of  the  foot  being  directed 
straight  forwards,  there  is  then  no  disten¬ 
sion  of  the  joint — no  tendency  to  sponta¬ 
neous  luxation.  Still,  I  think  any  forced 
extension  is  bad,  because  it  produces  a  pain¬ 
ful  dragging  on  the  anterior  part  of  the 
capsule.  Moderate  extension,  with  slight 
flexion  of  the  knee,  is,  I  think,  best,  and 
best  provides  for  a  useful  limb.  Great 
care  should  be  taken,  in  the  applica¬ 
tion  of  any  apparatus,  that  no  unnecessary 
pressure  is  made  on  the  trochanter ;  for 
the  evil  of  pressing  the  head  of  the  femur 
against  the  floor  of  the  acetabulum  is  in  its 
consequences  only  second  to  uncontrolled 
motion.  Constant  but  moderate  extension, 
combined  with  slight  traction,  acts  often 
most  successfully  in  controlling  pain  at  the 
joint.  When  we  have  secured  perfect  re¬ 
pose  with  the  extended  position  and  slight 
traction,  more  still  remains  to  be  done ; 
but  until  those  objects  are  properly  accom¬ 
plished,  we  cannot  hope  for  any  great 
amount  of  good  from  other  things. 

The  differences  of  opinion  which  ar*e  en¬ 
tertained  even  upon  what  may  appear  to  be 
the  most  simple  questions  of  treatment,  are 
a  sufficient  proof  how  much  remains  to  be 
done.  Lugol  says,  that,  having  observed 
the  good  that  resulted  in  scrofulous  ophthal¬ 
mia  from  exposing  the  eye  to  light,  he  de¬ 
termined  to'  try  the  effect  of  walking  in 
cases  of  diseases  of  the  joints  of  the  inferior 
extremities.  And  that  is  the  rule  he  com¬ 
monly  applies  to  all  such  cases,  and,  as  he 
believes,  with  great  success.  He  has  for 
many  years  employed  the  plan  in  conjunc¬ 
tion  with  iodurets  in  cases  of  white  swelling 
of  the  lower  limbs,  and  had  in  1844  em¬ 
ployed  it  in  at  least  300  cases.  Naturally 
enough,  he  says,  how  is  it  that  this  practice 
has  not  become  general  ?  The  answer  is 
obvious  enough  —  because,  as  an  ordinary 
plan,  it  is  repugnant  to  common  sense,  and 
because,  if  it  be  applicable  to  any  cases, 
they  are  not  at  present  discriminated. 

Among  the  means  to  which  recourse  must 
be  had  in  many  of  these  cases,  stands  pro¬ 
minently  the  use  of  antiphlogistics,  and  no 
doubt,  at  an  early  period  of  the  disease, 
and  combined  with  strict  rest,  they  may  do 
much  to  cut  it  short ;  but  they  must  be 
guardedly  proportioned  to  the  patient’s  con- 


MR.  PHILLIPS’  CLINICAL  OBSERVATIONS  ON  HIP  DISEASE.  151 


dition, — they  must  not  be  so  used  as  to  lessen 
much  the  general  powers,  or  reparation  be¬ 
comes  difficult ;  still  their  good  effects  are 
confined  simply  to  the  early  stage  of  the  dis¬ 
ease  :  they  may  be  found  useful  whenever  any 
acute  symptoms  are  developed  at  the  part, 
no  matter  at  what  period  that  may  be. 
These  means  include  blood-letting,  fomen¬ 
tations,  cataplasms,  &c.,  and  mercurial  or 
other  frictions,  which  should  not,  however, 
be  used  until  the  most  acute  symptoms  are 
abated.  Some  surgeons  are  strongly  im¬ 
pressed  with  the  value  of  mercurial  frictions, 
conjoined  with  fomentations,  and  carried  far 
enough  to  increase  the  activity  of  the  secre¬ 
tion. 

The  use  of  counter-irritants  is  a  most 
important  question,  on  which  much  diversity 
of  opinion  exists.  The  practice  is  as  old  as 
the  period  of  Hippocrates.  The  red-hot 
iron  was  the  remedy  of  the  Arabs,  as  well  as 
that  of  Rust.  There  are  surgeons  who  use 
it  early,  and  then  it  often  fails  ;  but  when 
the  disease  has  assumed  more  of  a  subacute 
or  chronic  form,  its  effects  are  often  very  re¬ 
markable  :  but  it  is  a  remedy  which  pro¬ 
duces  much  alarm  in  patients,  and  many 
practitioners  shrink  from  its  employment, 
substituting  for  it  a  not  less  painful,  though 
less  alarming  agent,  the  moxa,  by  which  a 
deep  eschar  is  made ;  and  the  resulting  ulcer 
should  be  healed  as  soon  as  possible.  When 
it  is  healed,  the  time  is  come  for  making 
another,  and  it  may  be  two  or  three  more. 
Other  surgeons  use  caustic  potash  or  caustic 
paste.  Those  things  certainly  have  one  re¬ 
commendation  over  the  actual  cautery — they 
are  neither  so  painful  nor  so  alarming  to  the 
patient  as  the  red-hot  iron  or  the  moxa. 
Some  surgeons  keep  open  the  ulcer,  so  made, 
with  peas  or  beads :  this  is  often  difficult, 
and  probably  the  issue  is  equally  efficacious, 
and  less  troublesome,  when  brushed  over 
with  caustic  potash  or  blue  stone.  Other 
surgeons  use  setons  behind  the  trochanter, 
or  over  the  tensor  vagince  femoris,  or  over 
the  crural  nerve  ;  and  there  is  no  doubt  that 
they  often  produce  a  considerable  abatement 
of  pain  ;  but  I  doubt  whether  they  exercise 
so  powerful  an  influence  over  the  disease,  as 
some  other  agents.  I  am  very  much  inclined 
to  think  that  in  many  instances  there  is  no 
counter-irritant  more  effectual  in  controll¬ 
ing  hip  disease  than  blisters,  repeated  as 
often  as  a  former  one  is  dried  up,  so  as  to 
keep  up  irritation  as  long  as  may  be  desired. 
In  my  experience,  certainly  nothing  has  had 
more  effect  than  these  have  in  lessening  pain  ; 
but  for  this  purpose  one  or  two  slight  blis¬ 
ters  are  rarely  sufficient, — they  must  be  re¬ 
newed  until  the  pain  is  dissipated.  In  a  few 
instances,  however,  I  have  found  that  they 
rather  aggravated  than  lessened  pain.  In 
such  cases  they  should  be  discontinued. 
Even  when  they  have  apparently  mastered 


the  pain,  much  caution  must  be  observed  in 
permitting  any  motion  at  the  part.  Indeed, 
it  is  always  safer  that  the  patient  should  con¬ 
tinue  in  the  horizontal  position  for  several 
weeks  after  the  pain  has  subsided,  than  to 
risk  mischief  by  early  motion.  Some  persons 
prefer  using  an  ointment  of  tartar  emetic  or 
croton  oil,  or  other  irritant,  capable  of 
producing  pustular  eruptions  on  the  skin ; 
but  they  are  often  very  inconvenient,  and  I 
have  seen  no  cause  to  prefer  them  to  simpler 
means ;  and  certainly  I  look  in  such  cases 
with  more  hopefulness  to  blisters,  than  to 
any  other  species  of  counter-irritant.  I 
know  that  many  experienced  surgeons  look 
with  much  favour  upon  issues ;  but  I  con¬ 
fess  my  own  experience  leads  me,  as  a 
general  rule,  to  employ  blisters  with  more 
confidence  than  issues.  Still,  however 
energetic  and  well  directed^  may  be  the 
means  we  have  employed  for  the  cure  of  the 
disease  in  that  earlier  stage  of  its  existence, 
it  is  certain  that  we  often  fail,  and  then  we 
have  to  do  with  the  more  formidable  train  of 
symptoms  which  characterises  the  next  stage 
in  the  progress  of  the  disease. 

Among  the  serious  complications  which 
are  observed  to  follow  upon  this  stage  of  the 
disease,  are  collections  of  purulent  fluid  ;  in 
many  instances  they  are  not  in  immediate 
contact  either  with  the  bones  or  the  joints, 
but  in  others  they  are  in  direct  connection 
with  them.  The  first  seem  to  be  owing  to 
the  extension  of  inflammatory  action  to  the 
soft  parts  at  a  certain  distance  ;  the  second, 
to  the  irritation  set  up  at  the  part  itself. 
Some  surgeons  have  rested  very  important 
principles  of  the  treatment  on  the  situation 
of  such  collections — that  is  to  say,  whether 
they  be  in  immediate  connection  with  the 
joint  or  not ;  and  in  that  view  it  is  very 
necessary  to  determine  the  exact  nature  of 
the  collection.  They  believe,  where  the  col¬ 
lection  is  external  to  the  joint,  that  early  and 
free  openings  should  be  made, — that  where 
they  are  connected  with  the  joint,  no  such 
interference  is  justifiable.  In  the  difficulty 
which  is  thus  presented,  it  becomes  essential, 
at  last,  to  treat  all  these  cases  as  if  they  were 
directly  connected  with  the  joint  or  the  bone. 
Under  ordinary  circumstances  the  abscess 
proceeds  and  makes  a  way  for  itself  to  the 
surface ; — I  say  ordinarily,  because  I  had  a 
case,  as  you  may  recollect,  not  long  ago, 
where  the  existence  of  a  collection  of  puru¬ 
lent  matter  was  established  by  the  introduc¬ 
tion  of  a  grooved  needle ;  but  it  was  ulti¬ 
mately  dissipated  under  blisters. 

The  opening  of  these  collections,  even 
when  it  happens  spontaneously,  is  not  neces¬ 
sarily  mortal,  but  it  is  often  accompanied  by 
great  constitutional  distress  :  it  is,  therefore, 
of  great  importance  that  we  should  be  satis¬ 
fied  whether  the  risk  of  mischief  be  lessened 
when  the  opening  is  artificially  made,  and 


152  MR.  PHILLIPS’  CLINICAL  OBSERVATIONS  ON  HIP  DISEASE 


•what  course  in  this  respect  it  is  best  to 
follow.  I  think  most  surgeons  are  convinced 
that  it  is  better  to  interfere  by  incision  or 
puncture,  rather  than  to  let  the  matter  bur¬ 
row,  and  perhaps  destroy  a  large  portion  of 
integuments,  which  it  is  likely  to  do  when 
left  to  itself.  Whether,  however,  the  open¬ 
ing  should  be  made  early  or  late,  is  a  point 
which  yields  in  practical  importance  to  none 
we  have  considered.  Some  say,  open  late, 
because  there  is  so  much  to  fear  from  con¬ 
stitutional  irritation.  And  if  you  open  at  all, 
how  shall  you  do  it  ?  By  large  incision  or 
small  ?  by  trochar  ?  by  caustics  ?  by  seton  ? 
It  cannot  be  so  indifferent  that  either  plan 
may  be  properly  followed.  Shall  it  be  done 
by  large  incision,  so  that  all  the  fluid  may 
be  evacuated  at  once,  and  the  parts  be  im¬ 
mediately  brought  together,  so  as  to  exclude 

as  far  as  mav  be  the  entrance  of  air  ?  Shall 
%! 

it  be  by  small  and  successive  punctures,  by 
which  air  may  be  most  effectually  excluded, 
and  the  cavity  more  gradually  relieved  ? 
Some  persons  advocate  one  course,  some 
another.  Various  modes  have  been  followed 
for  carrying  out  different  ideas  :  thus,  M.  A 
Petit  used  a  red-hot  needle,  for  the  purpose 
of  preventing  the  entrance  of  air,  and  ex¬ 
tracted  the  fluid  with  cupping  glasses  ; 
others  have  used  a  very  thin  knife  glided 
for  a  short  distance  under  the  skin ;  others 
have  used  a  very  small  trochar,  with  or 
without  an  elastic  gum  bottle  adapted  to  the 
canula ;  and  I  regard  this  plan  as  in  all  re¬ 
spects  the  best  :  but  where  the  fluid  contains 
a  large  portion  of  flaky  matter,  that  of 
course  is  not  evacuated  if  the  opening  be 
very  small :  this  fact,  however,  I  do  not 
regard  as  of  any  importance,  provided  the 
liquid  portion  comes  away. 

When  the  collection  opens  spontaneously, 
a  good  deal  of  inflammatory  action  is  some¬ 
times  set  up  in  the  membrane  of  the  cavity, 
and  the  pus  undergoes  a  great  change  ;  in 
those  instances  we  must  endeavour  to  lessen 
the  inflammation,  and  we  must  afford  every 
facility  for  the  escape  of  the  fluid.  Some 
persons  fill  the  cavity  with  warm  water,  as  a 
means  of  lessening  irritation,  which  it  is  be¬ 
lieved  is  brought  about  by  the  action  of  air 
upon  the  contained  fluid  ;  but,  in  many 
cases,  nothing  seems  to  avert  the  result  of 
the  irritation  then  set  up. 

In  many  of  these  cases,  the  head  of  the 
bone  having  left  its  proper  cavity,  increases 
by  its  presence  the  suppurative  action  ; 
and  then  it  has  become  a  question  whether 
the  head  of  the  bone  should  be  excised. 
Although  in  the  latter  stages  of  hip  dis¬ 
ease  displacements  are  by  no  means  rare, 
there  is  no  doubt  that,  by  paying  much  at¬ 
tention  to  position,  we  may  lessen  the  chance 
of  dislocation  ;  but  in  spite  of  all  our  care 
it  will  often  happen.  When  the  immediate 
consequences  of  such  displacements  have 


completely  passed  away,  and  the  irritation  is 
inconsiderable,  it  has  been  recommended 
that  attempts  should  be  made  to  replace  the 
bone  in  its  proper  cavity  ;  and  the  plan  has 
been  not  uncommonly  followed,  and  some¬ 
times  it  is  said  with  success  ;  but  in  many 
cases  the  acetabulum  is  almost  effaced,  and  re¬ 
duction  must  be  impracticable.  When  em¬ 
ployed,  extension  is  very  gradually  made  until 
the  head  of  the  bone  arrives  over  the  acetabu¬ 
lum  ;  and  then,  by  another  series  of  apparatus, 
it  is  gradually  forced  into  the  cavity.  It  must 
be  manifest,  that  only  a  few  cases  can  be 
usefully  treated  in  that  way.  If  the  head  of 
the  femur  or  the  acetabulum  have  been 
largely  injured,  no  good  can  reasonably  be 
expected  from  this  plan.  In  this  state  of 
things,  the  moveable  head  of  the  bone  may 
excite  much  irritation.  Extensive  abscesses 
may  follow,  and  be  succeeded  by  discharges 
so  profuse,  that  the  patient’s  health  com¬ 
pletely  breaks  down  ;  and  the  question  arises, 
may  the  patient’s  condition  be  improved  by 
excision  of  the  head  of  the  femur.  This  is  a 
very  serious  question,  but  it  has  often  been  de¬ 
cided  in  the  affirmative.  It  is  serious,  because 
the  question  is  so  surrounded  with  difficulty  ; 
either  the  patient  retains  some  vigour,  and 
anchylosis  is  by  no  means  impossible,  or  he 
is  so  feeble,  that  the  operation  may  be  ex¬ 
pected  to  accelerate  his  death.  It  has,  how¬ 
ever,  been  performed  many  times.  Altogether 
I  find  that  since  1743,  when  Schlichting’s 
operation  was  done,  there  are  not  less  than 
17  cases  in  which  the  operation  has  been 
performed  for  hip  disease  :  and  of  these,  ten 
have  more  or  less  completely  succeeded  ; 
life  being  preserved,  and  the  limb  being 
worth  something  ;  but  at  least  three  of  those 
cases  are  still  on  their  trial. 

Whether  the  amount  of  success  now  men¬ 
tioned  be  a  sufficient  warrant  to  have  re¬ 
course  to  this  operation,  is  the  matter  in 
question.  Certainly  the  naked  result — that 
out  of  seventeen  cases  ten  have  survived  the 
operation — would  not  operate  as  a  bar  to  its 
performance,  for  it  is  as  large  an  amount  of 
success  as  attends  the  operation  of  amputa¬ 
tion  of  the  thigh.  Therefore,  if  it  were 
assumed,  first,  that  the  operation  was  not 
performed  until  it  was  evident  that  the  pa¬ 
tient  would  probably  sink  under  the  disease; 
and  next,  that  it  is  our  first  business  to  save 
life,  no  matter  whether  with  capability  of 
usefulness  or  not ; — then  it  is  clear  that  we 
should  properly  declare  in  favour  of  the  ope¬ 
ration  :  and  probably  that  is  at  last  the  con¬ 
clusion  to  which  we  must  come.  But  if  we 
look  at  the  question  in  another  light,  and 
say  that  we  must  go  a  step  further,  and  ascer¬ 
tain  whether  we  have  done  more  than  extend 
life,  then  we  are  met  by  more  serious  diffi¬ 
culties.  In  many  of  the  cases  which  have 
survived  the  operation,  the  limb  saved  has 
been  useless ;  for  a  long  time  discharges  have 


ON  RHEUMATIC  ARTHRITIS  OF  THE  SHOULDER  AND  OTHER  JOINTS.  153 


continued,  in  consequence,  usually,  of  a  dis¬ 
eased  acetabulum ;  and  life  has  been  long 
threatened.  Still,  the  fact  remains  that  our 
mission  is  to  save  life,  without  speculating 
whether,  when  saved,  it  is  likely  to  be  use¬ 
fully  employed.  It  is  certain  that  in  these 
cases,  if  the  caries  were  limited  to  the  head 
of  the  femur,  a  speedy  cure  might  be  more 
reasonably  expected  than  is  usually  the  case  ; 
but  unless  there  be  already  displacement  of 
the  head  of  the  bone  before  operation,  we 
cannot  determine  with  any  certainty  whether 
it  be  or  not ;  and  if  we  remove  the  carious 
head  of  the  femur,  and  leave  behind  a  carious 
acetabulum,,  our  work  is  only  half  done, — 
yet  such  cases  have  recovered.  It  is  true 
that,  when  the  parts  are  exposed,  we  may 
get  away  carious  bone  from  the  acetabulum, 
but  it  is  not  less  true  that  we  may  fail  of 
removing  all.  The  material  points,  however, 
remain  :  if  there  be  no  question  that  we  may 
occasionally  save  life  by  having  recourse  to 
the  operation,  even  though  a  comparatively 
useless  limb  remain,  we  are  justified  in  per¬ 
forming  it  in  such  cases.  It  is,  however, 
important  to  determine,  if  possible,  whether 
caries  of  the  acetabulum  exists  ;  and  means 
should  be  taken  to  ascertain  this  point, 
because  it  is  an  unfavourable  feature  in  the 
case.  Still,  cases  have  succeeded  where 
such  caries  existed ;  and  therefore  Pott’s 
dictum,  that  where  there  is  caries  of  the 
acetabulum,  no  operation  should  be  done  on 
the  hip-joint,  has  less  value  than  without 
these  facts  it  would  have. 

So  long  as  the  head  of  the  femur  remains 
in  the  acetabulum,  there  is  great  difficulty 
in  determining  when  the  time  at  which  an¬ 
chylosis  may  happen  has  passed  ;  but  when 
dislocation  has  happened,  that  difficulty  has 
ceased.  So  long  as  there  is  no  dislocation, 
if  we  are  satisfied  that  the  apparatus  of  the 
joint  is  destroyed,  all  our  efforts  should  be 
directed  to  favour  anchylosis,  and  perfect 
rest  is  the  most  important  element  for  se¬ 
curing  that  object ;  and  when  it  is  likely  to 
be  accomplished,  care  must  be  taken  that 
the  position  given  may  be  that  which  is 
likely  to  make  the  limb  most  useful.  When 
anchylosis  is  incomplete,  it  may  happen  that 
by  prudent  treatment  a  certain  latitude  of 
motion  may  ultimately  be  obtained,  but  the 
greatest  care  must  be  taken  not  to  interfere 
too  early,  or  that  desideratum  may  be  de¬ 
feated. 


apothecaries’  hall. 

Names  of  Gentlemen  who  passed  their  ex¬ 
amination  in  the  Science  and  Practice  of 
Medicine,  and  received  certificates  to  prac¬ 
tise,  on  Thursday,  20th  July,  1848. — 
Charles  Walter  Poulton,  Cricklade,  Wilts 
— Henry  Tizand,  Weymouth  —  Charles 
Crowdy,  St.  John’s,  Newfoundland. 


0ngtnal  @ommumcatton£. 

ADDITIONAL  NOTES  ON  THE 

MORBID  ANATOMY,  &c.of  CHRONIC 
RHEUMATIC  ARTHRITIS 

OF  THE 

SHOULDER  AND  OTHER  JOINTS. 

By  Edwin  Canton,  F.R.C.S. 

Demonstrator  of  Anatomy  at  the  Charing  Cross 
Hospital  School  of  Medicine. 

[Concluded  from  page  115.] 


The  hand. — This  complaint  attacks 
not  unfrequently  several  joints  of  the 
hand  and  wrist,  and  we  rarely  find  it 
affecting  one  of  them  singly.  The 
young  may  be  the  subjects  of  the 
malady,  and  experience  the  local 
changes  it  induces ;  but  the  most  com¬ 
mon  victims  are  the  aged,  in  whom  its 
peculiar  ravages  are  marked  during 
life  by  that  order  of  symptoms  which 
characterises  the  disease  elsewhere 
seated  ;  whilst  enlargement  and  other 
distortion,  impeding  movement, — arti¬ 
cular  crepitus,  experienced  sometimes 
on  motion, — soft  anchylosis  or  sponta¬ 
neous  and  partial  displacement, — may 
constitute  additional  phenomena  of  the 
affection.  These  latter  morbid  condi¬ 
tions,  however,  are  not  to  be  regarded 
as  peculiar  to  the  hand  ;  for  the  disease 
often  stamps  with  like  distinct  impress 
other  diarthroses.  The  appearances 
disclosed  after  death  tally  well  with  the 
abnormal  states  observed  during  life, 
and  will  be  shortly  described. 

In  the  year  1805,  Dr.  Hay  garth  pub¬ 
lished  a  small  work  on  Acute  Rheuma¬ 
tism,  to  which  was  appended  “a  clinical 
history  of  the  nodosity  of  the  joints.” 
The  latter  affection  is  clearly  shewn,  by 
its  description,  to  be  the  one  at  present 
under  consideration.  “These  diseased 
joints,”  it  is  remarked,  “  generally 
suffer,  especially  at  night,  but  in  a  less 
degree  than  might  be  expected  from 
such  a  considerable  morbid  change: 
they  often  feel  sore  to  the  touch.  In 
one  case  the  patient  was  attacked  with 
severe  spasmodic  pains.  As  the  disease 
increases,  the  joint  becomes  distorted, 
and,  perhaps,  in  bad  inveterate  cases, 
even  dislocated.  In  a  few  patients,  a 
crackling  noise  was  perceived  in  the 


154  ON  KHEUMATIC  ARTHRITIS  OF  THE  SHOULDER  AND  OTHER  JOINTS. 


joint  when  in  motion,  particularly  in 
the  neck.  The  skin  seldom  or  never 
inflames.”  The  author  has  more  fre¬ 
quently  seen  the  complaint  in  the  hand 
than  elsewhere.  Out  of  thirty-four 
cases,  one  only  was  in  a  male ;  all  the 
patients  (two  excepted)  were  above 
forty-one  years  of  age,  and  the  most 
common  date  of  the  commencement  of 
the  disease  was  between  fifty-one  and 
sixty  years  of  age.  A  close  connection 
has,  curiously  enough,  been  traced  be¬ 
tween  the  occurrence  of  the  malady 
and  the  cessation  of  the  menses  ;  and  it 
is  stated,  “  in  some  the  nodes  appeared 
as  soon  as  the  menses  became  irregular 
— most  commonly  at  the  time  when 
they  ceased ;  in  a  few  instances  several 
years  after  this  period.” 

Of  all  the  joints  of  the  hand,  the  first 
carpo-metacarpal  is  the  one  which  I 
have  seen  to  be  most  extensively  af¬ 
fected.  In  articulations  which  are 
capable  of  the  widest  range  of  motion, 
the  disease  appears  to  cause  the  greatest 
degree  of  havoc,  and  this  is  well  exem¬ 
plified  in  a  specimen  of  the  complaint 
before  me.  Previous  to  dissection,  the 
joint  presented  all  the  characters  of  a 
dislocation  of  the  first  bone  of  the 
thumb  upwards  on  to  the  trapezium. 
The  former  could  be  readily  drawn 
downwards,  but,  in  the  absence  of 
traction,  resumed  its  former  position. 
I  found  the  ligaments  to  be  dense,  but 
lax ;  the  synovia  thick  and  plentiful ; 
the  trapezium  hollowed  out  to  the 
depth  of  half  an  inch,  with  its  upper 
margin  projecting  greatly  beyond  the 
level  of  the  lower,  and  the  interval  be¬ 
tween  the  two  an  inch.  The  cartilage 
was  almost  entirely  absent,  and  minute 
apertures  are  to  be  seen  on  the  exposed 
bone,  the  scabrous  and  irregular  margin 
of  which  is  here  and  there  studded  with 
osseous  nodules.  The  upper  end  of  the 
first  metacarpal  bone  presents  arrange¬ 
ments  closely  adapting  it  to  these 
peculiarities.  In  the  two  succeeding 
joints  of  the  thumb,  similar  evidences 
of  disease  are  to  be  seen.  No  other 
articulation  in  the  hand  is  affected. 

In  an  early  stage  of  the  complaint, 
the  portion  of  cartilage  encrusting  the 
lower  and  inner  part  of  the  articular 
surfaces  is  the  first  to  disappear  ;  and  I 
have  several  times  noticed,  that,  where 
enamel-like  deposit  has  occupied  its 
place,  the  movements  of  the  thumb 
have  been  restricted  to  adduction  and 
abduction,  in  consequence  of  the  ridges 


and  grooves  which  these  surfaces  pre¬ 
sent.  This  furrowed  condition  is  by  no 
means  uncommon  in  the  phalangeal 
joints. 

In  Cruveilhier’s  work  on  Morbid 
Anatomy,  livr.  xxxiv.  pi.  I.,  is  repre¬ 
sented  the  hand,  and  dissections  of  it, 
from  an  old  woman  of  the  Salpetriere. 
There  is  great  deformity,  and  all  the 
joints  are  affected  with  what  is  termed 
“  usure  des  cartilages.”  It  is  remarked 
of  the  case— “  La  malade  attribuait  sa 
maladie  a  un  rhumatisme  goutteux, 
dont  elle  aurait  ete  tourmentee  des  sa 
jeunesse.”  With  respect  to  the  fre¬ 
quency  of  the  occurrence  of  this  com¬ 
plaint  in  the  hand,  and  the  cause  of  it, 
the  author  observes — “  Depuis  sept  ans 
que  je  pratique  la  medecine  a  la  Salpe¬ 
triere,  j’ai  eu  occasion  de  voir  un  assez 
grand  nombre  de  fois  Ije  deplacement 
des  phalanges  consecutif  a  une  maladie 
articulaire.  Plusieurs  des  femmes  qui 
presentaient  des  alterations,  avaient  ete 
soumises  a  l’influence  du  froid  et  de 
l’humidite;  d’autres  faisaient  remonter 
cette  lesion  a  une  grossesse,  a  un  rheu » 
matisme  laiteux.  Quelques-unes,  qui 
n’avaient  subi  Faction  d’aucune  cause 
occasionelle  appreciable,  accusaient  la 
goutte.” 

“  In  the  removal  of  the  cartilage 
without  suppuration,”  says  Mr.  Adams, * 
“  in  the  substitution  for  it  of  porcelain¬ 
like  deposit,  and  in  the  surrounding 
exuberance  of  new  bone,  we  find  this 
disease  of  nodosity  of  the  joints  of  the 
fingers  resembling  accurately  the  ana¬ 
logous  affection  of  the  other  joints, 
which  has  been  supposed  to  be  the  slow 
effects  of  chronic  rheumatism.” 

The  deformity  produced  in  the  hand 
by  the  complaint  is  often  considerable, 
and  may  be  such  as  to  prevent  any 
useful  employment  of  the  part.  There 
is  at  present  a  female  in  St.  Martin’s 
Workhouse,  aged  88  years,  the  little, 
middle,  and  ring  fingers  of  whose  hand 
are  permanently  flexed  upon  the  palm. 
The  metacarpo-phalangeal  joint  of  the 
index  finger  is  considerably  swollen 
from  enlargement  of  the  ends  of  the 
bones,  and  just  above  the  articulation  is 
an  oval-shaped  collection  of  fluid.  The 
finger  at  this  part  is  fixed  in  a  state  of 
flexion,  and,  at  the  same  time,  inclined 
inwards,  somewhat  behind  the  others ; 
the  motions  of  the  two  succeeding 


*  Cyclopaedia  of  Anatomy  and  Physiology, article 
Hand. 


RHEUMATIC  ARTHRITIS  OF  THE  SHOULDER  AND  OTHER  JOINTS.  155 


joints  are  free,  as  are  those  of  the 
thumb.  The  movements  of  the  wrist 
are  performed  with  ease,  and  the  lower 
end  of  the  ulna  is  enlarged,  and  pro¬ 
jects  backwards. 

The  Spine. — I  believe  the  joints  of 
*die  vertebral  column  to  be  not  unfre- 
cuently  the  seat  of  chronic  rheuma¬ 
tism  ;  and  that  certain  appearances  of 
the  bones,  which  are  so  generally  con¬ 
sidered  as  indications  of  advanced 
years,  to  be,  in  point  of  fact,  gradually 
produced  by  this  disease  in  its  pro¬ 
gress.  In  examining  the  vertebrae  in 
the  recent  state,  we  occasionally  find 
•that  the  depth  of  the  bodies  is  dimi¬ 
nished  in  front  or  on  the  side  ;  whilst 
from  around  the  upper  and  lower  mar¬ 
gin,  osseous  matter  has  been  thrown 
out  in  greater  or  less  abundance,  and  is 
thick  at  its  origin;  but  irregular,  bevel¬ 
led,  and  thin  where  it  is  imbedded  in 
the  adjacent  ligamentous  tissue.  This 
growth  is  sometimes  compact,  or  it 
may  be  spongy,  in  texture.  I  have 
seen  the  anterior  common  ligament 
replaced  by  a  broad  bony  lamina, 
lying  in  front  of,  and  intimately  united 
with,  several  vertebrae.  Exuberant 
bone  is  not  to  be  seen  at  the  part  cor¬ 
responding  to  the  spinal  canal,  or,  at 
all  events,  not  so  placed  as  to  encroach 
upon  the  latter.  The  inter-vertebral 
substance,  when  the  bones  are  in  the 
above-mentioned  state,  will  in  general 
be  found  to  present  a  more  dense,  com¬ 
pressed,  and  brittle  condition,  than 
.natural ;  whilst  in  some  cases  the  disc 
has  disappeared,  and  the  bones  which 
it  had  separated  have  become  firmly 
anchylosed  together.  The  spine  may 
be  bent  either  to  the  right  or  left,  but, 
for  the  most  part,  the  curve  is  for¬ 
wards.  It  is  on  the  joint  surfaces  of 
the  articular  processes  that  porcella- 
nous  matter  is  most  frequently  to  be 
seen;  and  when  I  have  met  with  it, 
it  has  been  in  the  cervical  and  lum¬ 
bar  regions,  situations  in  which  mo¬ 
bility  is  enjoyed  to  a  greater  degree 
than  in  the  intermediate  part.  In  a 
vertebra  from  the  neck,  and  one  from 
the  loins,  at  present  before  me,  the 
upper  and  lower  articular  surfaces  on 
the  left  side  only  are  affected,  and 
they  are  spread  out  to  more  than  thrice 
their  natural  extent;  bony  matter  is 
plentiful  at  their  circumference,  and  a 
continuous  stratum  of  porcellanous 
matter,  presenting  a  fine  polish,  en¬ 
crusts  all  that  part  where  motion  was 


performed.  In  connection  with  the 
mention  of  this  deposit,  I  might  again 
quote  the  passage  already  cited  from 
Dr.  Haygarth’s  work: — “In  a  few  pa¬ 
tients,  a  crackling  noise  was  perceived 
in  the  joint  when  in  motion,  particu¬ 
larly  in  the  neck.”  I  possess  a -speci¬ 
men  of  a  lumbar  vertebra,  the  inferior 
articular  surface  of  which  is  wholly 
coated  with  ivory-like  deposit,  pre¬ 
senting  ridges  and  furrows,  curved 
and  concentrically  disposed  in  the  long 
axis  of  the  part. 

The  peculiarities  which  I  have  al¬ 
luded  to  in  reference  to  the  bodies  of 
the  vertebrae,  may — some  of  them,  at 
least — be  noticed  in  a  preparation  (No. 
1374)  in  the  King’s  College  Museum. 
The  description  given  of  it  is — “  Sof¬ 
tening  and  caries  affecting  the  bodies 
of  the  cervical  vertebrae.” 

An  instance  of  the  occurrence  of  this 
affection  in  the  spine  is  mentioned  by 
Dr.  Todd*  : — “Among  the  inmates  of 
the  Wandsworth  Union  is  a  poor  girl, 
aged  twenty- five,  who  is  the  most  ex¬ 
traordinary  martyr  to  this  disease  in  all 
her  joints,  even  in  those  of  the  cervical 
vertebrae .” 

Ivory -like  deposit. — A  peculiar  fea¬ 
ture  in  this  complaint  is  the  deposit  so 
commonly  seen  on  the  joint  surfaces, 
and  well  known  to  all  by  the  name  of 
porcellanous,  enamel,  or  ivory-like.  It 
replaces  cartilage,  forms  for  it  an  effi¬ 
cient  substitute,  and,  though  lacking 
the  pliancy  and  elasticity  of  the  origi¬ 
nal,  presents  both  polish  and  density, 
to  ensure  a  certain  facility  of  motion, 
and  guard  against  injury  from  friction. 
It  is  found  in  situations  where  no  car¬ 
tilage  had  previously  existed  ;  and  as 
newarticular  surfaces  are  being  formed, 
to  accommodate  a  bone  in  its  altered 
position,  a  provision  is  required  to 
maintain  freedom  of  movement  and  the 
want  supplied  by  the  presence  of  this 
material.  It  is  always  in  abundance 
where  pressure  is  greatest;  and  by 
presenting  an  even  or  furrowed  aspect, 
facilitates  enarthrodial  or  secures  gin- 
glymoid  motion.  It  will  as  readily 
clothe  bone  of  new  formation,  as  con¬ 
stitute  a  crust  upon  the  original  tissue. 
“  L’etat  eburne  des  cartilages,”  says 
Lobstein,  “  est  manifestement  un  eff'et 
de  l’arthritis  ;  une  fois  produit  il  deter¬ 
mine  de  la  rigid! te  et  des  douleurs  dans 

*  Practical  Remarks  on  Gout,  Rheumatic 
Fever,  and  Chronic  Rheumatism  of  the  Joints. 
P.  180. 


156  ON  RHEUMATIC  ARTHRITIS  OF  THE  SHOULDER  AND  OTHER  JOINTS. 


les  articulations  affect6es  et  des  cra- 
quements  dans  leur  mouvements.  Le 
poli  dont  je  parle  est  sans  doute  l’effet 
du  frottement ;  mais  la  substance 
eburnee  resulte  evidemment  du  depot 
de  la  matiere  osseuse  qui  a  envahi  et 
detruit  les  cartilages  diarthrodiaux  ;  ce 
qui  la  prouve  c’est  son  exuberance 
autour  des  surfaces  articulaires,  aux- 
quelles  elle  donne  un  rebord  saillant.” 

I  have  here  to  acknowledge  the 
kindness  of  Mr.  Quekett,  of  the  College 
of  Surgeons,  who  has  favoured  me  with 
the  following  interesting  and  original 
view  respecting  the  formation  of  this 
material : — “  On  removing  some  thin 
slices  with  a  saw,  and  making  them 
sufficiently  thin  for  the  microscope  by 
grinding  away  the  cut  surface,  I  found 
that  the  bone  was  more  than  usually 
dense,  and  that  there  was  almost  total 
absence  of  Haversian  canals,  which 
made  the  bone  more  dense  ;  this  led  me 
to  speculate  on  the  cause  of  this  por- 
cellanous  deposit.  Recollecting  that 
the  French- polisher  (when  he  wishes 
to  give  a  fine  polish  to  rose- wood,  ma¬ 
hogany,  or  any  other  woods  which 
have  an  open  grain)  first  fills  up  the 
pores  in  the  wood  with  some  wax,  or 
resinous  material,  and  then  polishes, 
whereby  a  fine  lustre  is  obtained,  it 
at  once  struck  me  that  no  bone  could 
present  this  porcellanous  appearance 
without  its  canals  were  first  filled  up  ; 
and  I  then  began  to  consider  how  this 
took  place.  In  every  bone  which  I 
examined,  having  this  deposit  upon  its 
surface,  I  invariably  found  that  in  the 
immediate  neighbourhood  of  the  depo¬ 
sit  that  there  was  an  additional  quan¬ 
tity  of  bony  matter  thrown  out ;  and  I 
considered  that  there  would  have  been 
a  similar  growth  upon  all  the  other 
parts,  had  there  been  no  friction  of  op¬ 
posed  surfaces  in  these  places — the 
exuberant  growth  being  kept  down  by 
the  friction.  The  only  other  places  in 
whicli  new  bone  could  be  deposited 
were  the  canals,  which  were  by  this 
means  filled  up,  and  the  bone  rendered 
more  dense  in  consequence,  which 
dense  bone,  being  subjected  to  constant 
friction,  became  polished,  and  hence 
the  cause  of  the  so-called  porcellanous 
deposit.” 

Displacement  of  bone. — A  peculiarity 
to  be  noticed  often  in  this  affection  is 
displacement  of  bone,  predisposed  to, 
in  some  points,  I  believe,  by  relaxation 
of  the  ligaments,  consequent  upon  the 


presence  in  the  articulation  of  an  undue 
accumulation  of  synovia,  which  be¬ 
comes  thicker,  and  of  a  deeper  yellow 
tint  than  natural ;  whilst,  in  others,  the 
removal  of  certain  fibrous  tissues,  as 
the  tendon  of  the  biceps  and  the  action 
of  surrounding  muscles,  explains  the 
cause  of  this  faulty  position. 

The  extent  to  which  displacement 
occurs  is  greatest  in  enarthrodial  joints; 
but  it  should  be  stated  that  the  term 
displacement  must  bear  a  limited  signi¬ 
fication  only,  inasmuch  as  the  joint- 
surface  of  a  bone  does  not  always  leave 
its  recipient  cavity,  which  becomes  en¬ 
larged,  whilst  the  part  corresponding 
to  it  expands,  as  seen  in  the  hip  and 
shoulder;  but,  at  the  same  time,  in  the 
latter,  from  the  loss  of  long  bicipital 
tendon  in  part,  the  humerus  shifts 
upwards,  to  articulate  with  the  under 
surface  of  the  acromion  process,  so  (hat 
the  distance  between  the  latter  part 
and  the  external  condyle  is  slightly 
diminished ;  and  the  elbow,  when 
placed  by  the  side  of  the  chest,  does 
not  extend  quite  so  low  down  as  its 
fellow.  Again,  in  the  hip  this  relative 
displacement  is  dependent  mainly  upon 
the  neck  of  the  femur  assuming  the 
horizontal  direction,  and  being  removed 
partially  or  completely  by  intersti¬ 
tial  absorption,  when  the  limb  being 
proportionably  drawn  up,  becomes 
shorter  than  its  fellow  by  an  extent 
varying  from  an  inch  to  tw’o  inches  or 
more.  The  expanded  head  of  the  bone 
is  often  so  locked  into  its  widened  ca¬ 
vity  by  circumferential  bony  growth, 
that  dislocation,  in  the  ordinary  accep¬ 
tation  of  the  term,  could  only  be  ef¬ 
fected  by  great  violence — violence, 
indeed,  which  would  more  probably 
produce  fracture  than  cause  luxation. 
The  displacement  bears  reference  to 
the  heel,  malleolus,  patella,  and  tro¬ 
chanter  major  of  the  opposite  limb ; 
whilst  the  joint  itself — so  far  as  regards 
the  correspondence  of  articular  surfaces 
— is  as  intact  as  the  opposite  one. 
Cruveilhier  terms  this  faulty  position. 
“  deplacement  consecutif.” 

A  partial  displacement,  in  the  usual 
sense  of  the  word,  may,  howrever,  oc¬ 
cur  ;  and  an  instance  has  been  cited  in 
the  case  of  Harrison,  wrhere,  on  one 
side,  was  an  incomplete  luxation  of  the 
acromial  end  of  the  clavicle. 

Loose  cartilages. — These  bodies  have 
been  noticed  in  various  articulations, 
but  the  situation  in  which  they  are 


MR.  TURNER  ON  GASTRIC  OR  GASTRO-ENTERITIC  FEVER.  ]  57 


perhaps  most  commonly  to  be  found  is 
the  knee-joint.  An  explanation  of 
their  origin  is  variously  given  by  dif¬ 
ferent  authors;  but  when  present,  in 
connection  with  chronic  rheumatic  ar¬ 
thritis,  they  seem  almost  invariably  to 
have  been  formed  as  bony  or  cartila¬ 
ginous  matter,  deposited  in  the  fibrous 
textures  around  or  within  the  joint, 
and  becoming  detached,  accommodate 
themselves  to  the  altered  form  and  re¬ 
stricted  movements  of  the  articulation. 
We  not  unfrequently  see,  in  this  affec¬ 
tion,  these  bodies  placed  in  the  sub¬ 
stance  of  the  ligaments,  or  more  or  less 
projecting  into  the  interior  of  the 
joint ;  and  sometimes  a  single  one  is 
to  be  seen  enclosed  in  a  pouch-like 
offset  of  the  synovial  membrane.  An 
example  of  this  arrangement  1  met 
with  in  the  first  carpo-metacarpal  ar¬ 
ticulation  which  had  been  attacked  by 
the  complaint  under  consideration. 
The  little  body  was  oval  in  form,  irre¬ 
gular  on  the  surfaee,  less  than  a  quar¬ 
ter  of  an  inch  in  length,  of  semi-osseous 
consistence,  and  a  grain  in  weight. 

Mr.  H.  Labatt,  in  describing  the 
appearances  found  in  this  disease  af¬ 
fecting  the  shoulder-joint,  says — “  The 
capsular  ligament,  being  divided  inter¬ 
nally  and  interiorly,  considerable  ossi- 
fic  deposit  presents  itself  in  this  direc¬ 
tion,  at  the  junction  of  the  head  and 
anatomical  neck  of  the  humerus ;  and 
projecting  into  the  joint,  but  imbedded 
in  and  evidently  connected  with  the 
tendinous  structure  of  the  subscapularis 
muscle  at  its  insertion,  is  an  osseous 
body,  rough  on  its  surface.” 

104,  St.  Martin’s  Lane, 

June  1848. 


ON 

GASTRIC  or  GASTRO-ENTERITIC 
FEVER. 

By  Charles  W.  Turner, 

Member  of  the  Royal  College  of  Surgeons,  one 
of  the  Surgeons  to  the  Dispensary,  &c.  at 
Minchinliampton. 

Within  the  last  few  years  a  peculiar 
type  of  fever  has  prevailed  in  some 
districts,  altogether  marked  by  a  diffe¬ 
rent  set  of  symptoms,  and  requiring  a 
different  treatment  from  the  fevers 
ordinarily  occurring  in  England.  The 
forms  of  fever  heretofore  prevailing  in 
our  own  climate  have  been  called 
simple,  continued,  or  typhus ;  and 
although  in  some  of  these  cases  there 


is  a  marked  irritation  of  the  gastric 
membrane,  yet  such  a  symptom  is  by 
no  means  invariably  present.  In  the 
form  of  fever,  however,  of  which  I 
am  now  speaking,  irritation  of  the 
gastric  mucous  membrane  early  de- 
velopes  itself,  and  remains  the  most 
prominent  symptom  during  the  con¬ 
tinuance  of  the  disease;  and  hence, 
gastric,  or  gastro-enteritic,  appears  to 
me  as  the  most  suitable  designation  for 
this  type  of  fever.  Some  years  ago, 
M.  Broussais  directed  the  attention  of 
the  profession  to  the  irritations  and 
inflammations,  as  particularly  affecting 
the  stomach  and  bowels  in  fever ;  and 
in  so  doing  he  has  deserved  well  of  his 
medical  brethren  :  at  the  same  time, 
there  can  be  no  doubt  but  that  he 
drove  his  inflammatory  theory  too  far, 
as  even  in  the  putrid  fevers  of  Pringle 
and  other  old  authors,  his  favourite 
gastro-entirite  alone  was  perceptible; 
indeed,  worms,  which  are  so  commonly 
found  in  the  intestines  after  death, 
were  thought  by  M.  Broussais  to  be 
produced  by  gastro-enterite.  I  cannot 
imagine  a  local  inflammation  to  be  the 
cause  of  all  fevers  ; — few  fevers  termi¬ 
nate  fatally  without  producing  organic 
changes,  and  these  changes,  for  the 
most  part,  are  the  result  of  inflamma¬ 
tion  :  again,  in  other  cases,  the  brain, 
the  lungs,  or  the  mucous  membrane  of 
the  stomach  and  alimentary  canal,  are 
unmistakeably  the  seat  of  inflammation. 
Different  epidemics  are  marked  by  a 
particular  class  of  symptoms,  influenced 
and  modified  very  materially,  as  I 
believe,  by  the  atmosphere.  The 
weather  which  prevailed  in  1846  would, 
I  should  consider,  be  highly  conducive 
to  the  development  of  fever.  It  will 
be  remembered  the  summer  of  that 
year  was  remarkable  for  the  extreme 
sultry  and  oppressive  state  of  the  at¬ 
mosphere  ;  and  it  will  not  easily  be 
forgotten  (especially  by  butchers)  with 
what  rapidity  animal  substances  be¬ 
came  tainted,  and  passed  into  a  state 
of  decomposition.  Fever  that  summer 
wTas  very  prevalent  in  many  places; — 
places  wrere  the  seat  of  fever  where 
none  had  previously  existed,  scarcely 
within  the  memory  of  man,  and 
amongst  these  places  Minchinhampton 
may  be  noted  as  one.  From  the  situa¬ 
tion  of  this  town,  it  wrnuld  be  considered 
one  of  the  very  last  places  likely  to 
be  the  seat  of  fever, — neither  hadjever 
been  known  here  for  half  a  century ,  till 


158  MR.  TURNER  ON  GASTRIC  OR  GASTRO-ENTERITIC  FEVER. 


some  few  cases  made  their  appearance 
here  at  the  end  of  1845,  and  that 
without  any  satisfactory  cause.  The 
fever  of  1845  was  of  the  simple  or 
continued  form,  not  at  all  characterised 
by  the  gastric  symptoms  so  very  ob¬ 
servable  in  the  type  of  fever  which 
prevailed  here  in  the  year  1846.  No 
case  of  fever  presented  itself  in  this 
place  until  the  end  of  June  1846,  and 
that  case  happened  in  the  person  of  a 
little  girl  who  came  from  Reading  upon 
a  visit  at  a  gentleman’s  house  in  the 
town.  The  second  case  was  that  of  the 
lady  at  whose  house  the  child  was 
visiting  :  this  was  about  three  weeks 
from  the  child’s  illness.  The  third  case 
which  occurred  was  the  gardener :  it 
then  appeared  at  the  other  end  of  the 
town,  just  where  you  might  expect — 
namely,  at  the  house  of  the  person  who 
washed  the  linen ;  one  or  two  of  the 
washerwomen  became  ill,  and  from 
.  that  time  cases  broke  out  here  and 
there,  not  only  in  the  town,  but  sur¬ 
rounding  it ;  isolated  cases  occurred 
here  and  there  in  the  countrv,  a  mile 
or  two  from  the  town,  clearly  traceable 
to  local  causes.  Indeed,  one  of  my 
worst  cases  evidently  arose  from  the 
miasma  arising  from  the  drains  and 
privies  which  were  situated  at  the  back 
of  my  patient’s  house.  This  case  oc¬ 
curred  in  the  person  of  Mr.  Simpkins, 
the  druggist,  at  the  back  of  whose 
house,  besides  a  butcher’s  heap  of 
manure,  there  also  existed  three  privies, 
all  opening  to  the  atmosphere,  the 
stench  from  which,  at  the  change  of 
weather,  he  tells  me  was  intolerable. 
No  wonder,  then,  that  the  family  oc¬ 
cupying  these  premises  should  become 
the  subjects  of  fever,  especially  if  you 
bear  in  mind  the  summer  of  1846.  I 
do  not  intend  to  offer  any  opinion  as  to 
the  cause  of  the  fever  which  prevailed 
here,  or  at  Bisley,  Fairford,  Reading, 
&c. ;  but  certain  it  is  that  no  case  of 
gastric  fever  came  under  my  notice  ; 
neither  was  there  any  case  of  fever  in 
the  town  until  the  little  girl  arrived 
from  Reading  on  a  visit. 

I  must  offer  a  remark  or  two  on  the 
case  of  Mr.  Simpkins,  and  the  accumu¬ 
lation  of  dirt  and  filth  behind  his 
house.  During  the  time  this  person 
was  labouring  under  fever  it  was  im¬ 
possible  to  ventilate  his  room,  for  it 
was  observed,  whenever  this  was  done, 
his  symptoms  were  uniformly  aggra¬ 
vated  the  next  day.  After  he  had  been 


ill  about  fourteen  days  he  became 
sufficiently  convalescent  to  be  removed 
to  another  room ;  his  mother  took  the 
opportunity  of  having  his  room  cleaned, 
and  of  opening  the  window  all  day; 
the  consequence  was,  he  had  a  restless 
night,  and  was  manifestly  worse  the 
next  day.  For  several  days  he  became 
worse,  notwithstanding  the  care  and 
the  remedies  employed.  It  was  now 
very  clear  to  me,  that  life,  with  respira¬ 
tion  of  such  an  atmosphere,  was  im¬ 
possible  ;  and  that  die  he  certainly 
would,  unless  removed.  I  had  him 
lifted  out  of  his  bed,  placed  in  a  car¬ 
riage,  and  removed  to  the  village  of 
Avening,  about  three  miles  distant:  the 
next  day  he  wTas  better,  and  he  con¬ 
tinued  to  improve  day  by  day,  com¬ 
paratively  without  the  use  of  medicine. 

My  house  is  situated  nearly  opposite 
to  Mr.  Simpkins’s,  and  my  nursery 
windows  are  at  the  top  and  front  of  the 
house.  I  think  it  very  probable  that 
the  miasma  (arising from  the  nuisances 
which  I  have  before  mentioned)  was 
the  cause  of  my  children  being  attacked 
with  this  epidemic  ;  but  it  is  possible, 
as  has  been  suggested  to  me  by  Dr. 
Forbes,  of  London,  that  I  might  myself 
have  conveyed  the  contagion  to  my 
nursery. 

I  shall  always  consider  that  Mr. 
Simpkins’s  life  was  preserved  by  his 
removal ;  and  it  is  curious  to  observe 
how  change  to  another  district  will 
suspend  the  development  of  the  attack 
of  fever,  even  after  the  fever  poison 
has  been  received  into  the  svstem.  To 
illustrate  this  I  shall  mention  a  case  or 
two.  A  milliner  came  to  me  in  con¬ 
siderable  alarm  and  anxiety,  under  the 
impression  that  one  of  her  apprentices 
was  sickening  with  fever,  and  begging 
me  to  come  down  and  see  her  imme¬ 
diately.  On  visiting  the  girl  I  found 
such  to  be  the  case ;  she  had  not  gone 
to  bed,  but  she  was  evidently  labouring 
under  the  first  symptoms  of  fever.  The 
person  said  her  business  would  surely 
be  ruined  if  her  apprentice  was  laid 
up  with  fever  in  her  house.  Under 
these  circumstances,  I  advised  her 
immediate  removal.  She  was  at  once 
conveyed  to  the  railway  station,  and 
placed  under  the  care  of  her  friends 
at  Reading ;  and  what  is  most  re¬ 
markable,  notwithstanding  fever  was 
prevailing  very  extensively  at  that 
place,  this  girl  appeared  for  two  or 
three  days  to  have  got  rid  of  her 


MR.  TURNER  ON  GASTRIC  OR  GASTRO-ENTERJTI C  FEVER. 


L  59 


threatened  attack.  After  that  time, 
however,  it  came  on,  and  she  was 
seriously  ill.  At  the  time  I  removed 
Mr.  Simpkins  to  Avening  there  was 
no  case  of  fever  in  the  village,  neither 
Rad  fever  prevailed  there  during  the 
time  I  was  acquainted  with  the  place, 
a  period  of  fourteen  years,  until  the 
autumn  of  1847:  it  then  became  the 
seat  of  fever  to  a  very  great  extent  in 
this  way,  and  has  continued  more  or 
less  to  the  present  time.  A  Mrs. 
Baxter  had  a  daughter  ill  of  fever  in 
London :  she  went  up  to  town,  and 
brought  her  sick  child  back  to  Avening 
with  her.  This  was  the  first  case  in 
the  village.  The  next  cases  were  also 
in  her  own  family.  Subsequently  the 
inmates  of  the  cottages  adjoining  be¬ 
came  affected  with  fever  ;  and  about 
the  same  time,  a  gentleman,  a  patient 
of  mine,  who  was  lodging  at  Mrs. 
Baxter’s  house,  was  seized  with  fever. 
He  was  lodging  at  Mrs.  Baxter’s  until 
his  own  house  was  prepared ;  and  on 
getting  into  his  own  house  he  had  a 
severe  illness.  This  gentleman’s  at¬ 
tack  was  of  the  same  character  as  that 
which  prevailed  at  Minchinhampton 
in  1846.  At  first  I  was  not  disposed 
to  look  upon  this  fever  as  very  infec¬ 
tious,  but  cases  soon  occurred  which 
caused  me  to  alter  my  opinion.  This 
gentleman’s  servant  took  fever,  in  con¬ 
sequence  of  waiting  upon  her  master. 
After  her  recovery  so  far  as  to  be  able 
to  remove,  she  went  to  her  friends, 
who  lived  in  Herefordshire,  where  no 
case  of  fever  of  any  kind  had  previously 
existed.  She  had  been  home,  how¬ 
ever,  but  a  very  short  time,  when  her 
aged  mother  and  her  sister  became  the 
subjects  of  fever.  In  like  manner  with 
a  servant  who  had  been  waiting  upon 
my  children  :  she  went  home  (a  dis¬ 
tance  of  four  miles),  sickened  with 
fever,  and  communicated  it  to  the  rest 
of  the  family,  her  mother  dying  of  it. 

The  symptoms  ushering  in  this  dis¬ 
ease  are — vomiting  and  bowel  com¬ 
plaint  ;  pains  in  the  back,  limbs,  and 
head;  extreme  chilliness, succeeded  by 
heat ;  and  in  many  cases,  even  at  the 
commencement,  we  had  partial  per¬ 
spirations.  The  sensorial  functions 
were  much  deranged,  and  the  brain 
seemed  to  have  lost  its  powers  as  a 
thinking  organ.  There  was  delirium, 
but  it  was  curious  to  observe,  that  if 
you  asked  a  question,  you  would  al¬ 
ways  get  a  correct  answer ;  and  this 


state  of  things  I  observed  in  the 
earliest,  and  consequently  some  of  the 
worst  cases.  The  patient  would  com¬ 
plain  of  confusion,  great  noises  in  the 
head,  and  an  entire  inability  to  collect 
his  thoughts.  In  most  cases  there  was 
deafness  ;  but  in  one  case,  where  pre¬ 
viously  for  years  there  had  been  deaf¬ 
ness,  there  was  a  morbidly  sensitive 
state  of  the  auditory  nerves,  and  the 
hearing  became  distressingly  acute  for 
a  time.  The  deafness  generally  re¬ 
mained  until  the  termination  of  the 
fever,  but  in  no  case  that  I  am  aware 
of  was  permanent  mischief  done  to  the 
organ  of  hearing.  When  the  paroxysms 
of  fever  came  on,  then  there  was  a 
great  increase  of  temperature  about 
the  head,  but  not  more  in  proportion 
to  the  other  parts  of  the  body.  The 
skin  was  very  dry  and  hot ;  the  tongue 
was  slightly  coated,  but  in  no  case 
loaded ;  the  sides  were  red,  and  the 
papillae  enlarged  and  elongated  ;  the 
pulse  never  less  than  100,  and  com¬ 
monly  150.  In  all  cases  there  was  a 
remarkably  irritable  state  of  the 
bowels,  attended  with  extreme  tender¬ 
ness  of  the  epigastrium,  and  more  or 
less  pain  over  the  whole  surface  of  the 
abdomen.  Epistaxis  was  a  very  common 
symptom.  In  most  cases  the  diarrhoea 
was  a  troublesome  symptom,  but  in 
some  cases  it  was  of  such  an  inveterate 
character  that  no  remedy  would  arrest 
it.  The  motions  frequently  contained 
but  little  faecal  matter,  and  consisted 
principally  of  flocculent  mucus,  having 
a  very  disagreeable  smell,  which  Dr. 
Evans,  of  Gloucester  (who  was  associated 
with  me  in  some  cases),  compared  to  the 
smell  of  decayed  bone.  In  other  cases 
the  evacuations  were  of  that  ochery 
character  so  commonly  attendant  on 
ulceration  of  the  small  intestines.  The 
thirst  was  very  great.  The  secretion 
from  the  kidneys  in  all  cases  quite 
natural  and  clear.  There  was  the 
usual  restlessness  of  fever,  and  in 
some  cases  great  feeling  of  sinking  and 
prostration.  This  state  of  things  con¬ 
tinued  from  fourteen  to  twenty-one 
days,  the  recovery  being  always  ex¬ 
tremely  slow,  and  the  pulse  keeping 
very  high  even  when  the  patient  is  in 
a  state  of  convalescence. 

As  this  gastric  fever  is  essentially 
different  from  the  gastro-enterite  of 
M.  Broussais,  so  also  must  be  its  treat¬ 
ment.  M.  Broussais  considers  all 
fevers  to  arise  from  irritation ;  and  he 


160  MR.  TURNER  ON  GASTRIC  OR  GASTRO-E NTERITIC  FEVER. 


further  goes  on  to  say,  “  that  every 
irritation  that  produces  fever  is  an  in  - 
flammation.”  These  views  so  regu¬ 
lating  his  practice,  the  consequence  is, 
that  in  every  form  of  fever,  and  in 
every  stage,  he  applies  leeches  to  the 
region  of  the  stomach,  or  to  the  head, 
chest,  or  extremities,  pursuing  the 
sympathetic  irritation  or  inflammation 
of  gastro-enterite  through  all  these 
different  localities,  and  this  to  the  ex¬ 
clusion  of  almost  every  other  remedy, 
save  the  most  rigid  starvation.  Such 
a  plan  of  treatment  pursued  in  a  case 
of  gastric  fever  such  as  I  have  de¬ 
scribed,  would,  I  doubt  not,  speedily 
destroy  the  patient.  The  first  con¬ 
sideration  is  to  get  rid  of  the  irritation 
of  the  stomach  and  bowels,  which  will 
best  be  accomplished  by  a  mixture  of 
chalk  and  opium,  and  a  mustard  plaster 
over  the  epigastric  region.  It  is  a 
peculiar  feature  in  this  type  of  fever, 
that  opium  is  not  only  well  borne 
from  the  very  commencement  of  the 
attack,  but  that  it  is  also  highly  bene¬ 
ficial,  which  circumstance  is  very  un¬ 
usual  in  all  cases  of  fever  that  have 
previously  come  under  my  observation. 
Not  only  is  opium  well  borne,  but  I 
have  found  it  convert  a  dry  tongue  to 
a  moist  one.  This  was  particularly 
marked  in  the  case  of  a  young  lady, 
the  daughter  of  a  thoroughly  practical 
physician  (Dr.  Davies,  of  Birmingham), 
who  was  under  my  care.  I  mentioned 
to  the  Dr.  that  my  practice  each  night 
was  to  give  my  patient  a  dose  of  Pulv. 
Ipecac.  Co.  with  Hydrarg.  c.  Greta, 
and  that  I  always  found  it  had  the 
effect  of  greatly  lessening  delirium 
when  present,  and,  at  the  same  time, 
produced  moisture  about  the  tongue 
and  fauces.  One  night  we  determined 
to  omit  the  opiate,  and  the  consequence 
was,  we  had  an  increase  of  fever,  with 
restless  night.  The  following  night 
the  powder  was  given  ;  shortly  after, 
my  patient  fell  asleep  :  after  sleep¬ 
ing  three  or  four  hours,  she  awoke, 
and  expressed  how  much  more  com¬ 
fortable  she  was,  and  that  the  dryness 
of  the  mouth  and  throat  had  gone 
away.  Such  a  state  of  things  would 
not  be  in  ordinary  cases  of  fever.  Even 
after  the  bowels  have  been  steadied, 
there  will  be  occasion,  as  I  have  before 
said,  to  give  an  opiate  at  least  once  in 
twenty-four  hours,  as  there  is  a  con¬ 
stant  disposition  to  diarrhoea.  The 
combination  I  prefer  is  that  -which  I 


before  adverted  to— viz.  the  compound 
powder  of  Ipecacuanha,  with  the 
Hyd.  c.  Creta;  this  has  the  effect  of 
quieting  the  bowels,  and  the  evacua¬ 
tions  contain  a  due  admixture  of  bile, 
which  is  not  the  case  when  the  Hyd. 
c.  Creta  is  omitted.  In  these  cases 
such  is  the  disposition  to  relaxation 
that  I  rarely  have  recourse  to  aperients, 
and  it  is  surprising  tosee  whatpurgative 
effects,  and  consequent  prostration, 
will  result  from  the  exhibition  of  a  few 
grains  of  powdered  rhubarb,  or  a  tea¬ 
spoonful  of  castor  oil.  The  great  dan¬ 
ger  to  be  apprehended  in  these  cases 
is  ulceration  of  the  small  intestine,  and 
the  indication,  therefore,  is  to  get  rid 
of  as  early  as  possible  the  irritated 
state  of  the  gastro-intestinal  mucous 
membrane:  for  this  purpose  I  have 
found  the  soothing  plan  the  best. 
Patients  bear  very  ill  the  loss  of  blood, 
and  I  think  depletion  should  never  be 
carried  further  than  the  application  of 
a  few  leeches  :  in  the  majority  of  cases 
I  found  a  blister  efficient  in  removing 
the  tenderness  of  the  epigastrium,  es¬ 
pecially  if  followed  by  warm  cloths, 
covered  or  not,  according  to  circum¬ 
stances,  with  oiled  silk.  Then  I  have 
usually  given  a  little  draught  every 
three  or  four  hours,  consisting  of  Liq. 
Ammoniae  Acet.,  with  the  Ammonia 
slightly  in  excess  if  there  be  much 
feeling  of  prostration,  or  else  a  mixture 
with  bicarbonate  of  potash.  Some¬ 
times,  in  bad  cases,  the  opiate  at  night 
was  not  sufficient  to  keep  the  bowels 
quiet :  in  tfmt  case  I  usually  threw  up 
into  the  rectum  from  twenty  to  forty 
drops  of  tincture  of  opium,  in  some  cold 
water,  which  I  always  found  successful; 
and  I  considered  it  preferable  to  ad¬ 
ministering  more  opium  internally. 
Then,  as  to  diet,  I  allowed  my  patients 
to  have  as  much  cold  water,  toast  and 
water,  rice  water,  or  milk  and  water,  as 
they  desired.  I  found  many  of  my 
patients  would  take  a  good  deal  of 
milk.  Another  feature  in  this  form  of 
complaint,  is  the  tedious  convalescence: 
in  typhus,  when  you  once  get  your 
patient  round  the  corner,  they  move  on 
steadily  and  progressively :  not  so 
here :  there  is  a  constant  disposition  to 
relapse,  and  the  digestive  organs  are 
left  in  such  a  weak  state  as  to  require 
much  care.  It  is  a  long  time  in  some 
cases  before  the  bowels  will  get  into  a 
settled  state.  Under  such  circum¬ 
stances  I  have  found  the  mineral  acids 


DR.  KENAUD  ON  CAULIFLOWER  EXCRESCENCE  OF  THE  UTERUS.  161 


serviceable,  especially  the  preparation 
of  Tr.  Ferri  Sesquichloridee. 
Minchinhampton,  July  1848. 


THE  LITERATURE,  PROBABLE 
PATHOLOGY,  &c., 

OF  CAULIFLOWER  EXCRESCENCE 
OF  THE  UTERUS. 

By  Dr.  Renaud. 


In  the  reports  of  the  Manchester 
Pathological  Society,*  I  published  a 
case  of  the  cauliflower  excrescence  of 
the  uterus,  and  then  gave  briefly  a 
detail  of  the  microscopical  appearances 
of  the  diseased  mass,  as  it  exists  prior 
to  death. 

Further  investigation  has  served  to 
convince  me  of  the  truth  of  the  state¬ 
ments  then  made  ;  and  a  reference  to 
books  has  revealed  the  exceeding 
paucity  of  information  and  detailed 
cases  accumulated  since  the  early 
beginning  of  the  present  century.  I 
now  propose  to  give  the  result  of  these 
inquiries,  hoping  they  may  be  deemed 
worthy  of  record,  when  the  fact  is  re¬ 
membered  for  how  long  a  period  cauli¬ 
flower  excrescence  of  the  uterus  re¬ 
mained  undiscovered,  and  that  at  the 
end  of  forty  years  succeeding  to  this  dis¬ 
covery,  doubts  as  to  its  real  nature 
still  remain,  which  are  as  widely  shared 
by  the  profession  as  they  are  detri¬ 
mental  to  the  public. 

Hitherto  cauliflower  excrescence  has 
been  revealed  as  an  advanced  and  con¬ 
firmed  disease  :  its  early  beginnings, 
and  its  method  of  attack,  have  passed 
unnoticed.  But,  as  every  fresh  acces¬ 
sion  of  knowledge  of  the  structure  of 
the  disease  in  its  completed  form  may 
tend  to  reveal  its  nascent  character,  it 
cannot  be  otherwise  than  right  to  in¬ 
vestigate  facts  as  they  appear,  in  hopes 
of  arriving  some  time  at  a  truthful  de¬ 
monstration. 

I  would  venture  to  define  cauliflower 
excrescence  of  the  uterus  as  a  sessile 
tumor,  lacking  sensibility,  and  possessed 
of  a  certain  degree  of  malignancy 
sufficient  to  warrant  a  belief  of  its 
being  a  species  of  soft  cancer.  That 
its  ordinary  seat  of  origin  is  at  the 
mouth  and  neck  of  the  uterus.  That 
to  the  unaided  vision,  it  greatly  resem¬ 


bles  cauliflower  or  broccoli.  That  its 
structure  is  compound,  being  made  up 
of  a  series  of  looped  capillaries  carry¬ 
ing  red  blood,  of  very  delicate  texture, 
and  bearing  a  strong  resemblance  to 
the  placental  tufts,  whose  interspaces 
are  filled  up  with  nucleated  cells  closely 
packed,  and  to  the  presence  of  which, 
its  form,  density,  and  brittleness,  are  to 
attributed.  That  these  cells  have  no  dis¬ 
tinguishable  difference  from  the  cells 
of  medullary  cancer.  That  the  tumor 
secretes  or  exudes  ordinarily  a  watery 
discharge,  for  the  most  part  inoffensive 
and  inodorous,  which  is  made  up  of 
the  serum  of  blood,  the  disintegration 
of  the  cells  just  described,  epithelium 
cells  which  are  tesselated  and  line  the 
vaginal  walls,  and  the  natural  mucus 
of  the  passages.  That  in  addition  to 
the  watery  discharge,  there  are  frequent 
losses  of  blood  and  bloody  sanies,  the 
result  of  mechanical  injury  to  the 
capillaries.  That  the  discharge,  from 
being  inodorous  and  watery,  may  be¬ 
come  highly  offensive,  and  be  muco¬ 
purulent,  or  even  wholly  consist  of  a 
ropy  mucus  ;  or  these  appearances  may 
usher  in  the  disease,  and  decline  as  it 
advances.  That  the  disease  may  or 
may  not  be  associated  with  cancer  of 
the  substance  of  the  uterus  or  sur¬ 
rounding  parts,  but,  that  when  so  asso¬ 
ciated,  the  unmixed  cancer  is  for  the 
most  part  secondary.  That  when  re¬ 
moved,  it  has  a  constant  tendency  to 
return,  and  that  at  each  return  the 
probability  is  increased  of  its  being 
found  in  company  with  secondary 
cancer  of  the  uterus.  That  its  ordi¬ 
nary  way  of  destroying  life  is  by  ex¬ 
haustion,  the  consequence  of  haemor¬ 
rhages  and  discharges  ;  but  when  as¬ 
sociated  with  cancer  of  the  uterus  and 
other  organs,  the  death  may  take  place 
independently  of  the  discharges,  e.  g. 
from  softening  and  breaking  up  of 
cancerous  masses,  &c.,  as  happens  in 
the  cases  of  those  who  die  from  malig¬ 
nant  diseases  unassociated  with  cauli¬ 
flower  excrescence.  That  its  dimen¬ 
sions  vary  from  exiguity,  to  a  size  large 
enough  to  extend  beyond  the  capacity 
of  a  relaxed  vagina,  and  grow  out¬ 
wardly.  That  its  consistency  varies  in 
proportion  to  the  amount  of  cancer 
matter  mixed  with  it. 

This  definition  wall  be  seen  to  differ 
from  any  previously  given — 1st,  in 
that  it  fixes  the  exact  structure  of  the 
tumor — 2nd,  that  it  softens  down  the 


*  Vide  Med.  Gazette,  1847,  page  1092. 


162  DR.  RENAUD  ON  CAULIFLOWER  EXCRESCENCE  OF  THE  UTERUS. 


line  of  demarcation  existing  between 
it  and  fungous  polypus  of  the  uterus — 
3rd,  that  it  makes  the  progress  and  ter¬ 
mination  of  the  disease  less  absolute. 

Literature. — To  assign  the  discovery 
of  this  disease  to  Dr.  John  Clarke, 
would  be  to  fix  the  year  1808  as  that 
in  which  the  medical  profession  first 
came  to  a  knowledge  of  it.  To  Dr. 
Clarke  exclusively  belongs  the  merit 
of  first  classifying  the  disease,  and  de¬ 
scribing  its  symptoms.  Prior  to  this 
date,  the  disease  when  seen  received 
differen  tnames.  Reports,  when  given , 
were  not.  clear,  and  a  degree  of  diffi¬ 
culty  is  experienced  in  well  defining 
the  waiter’s  meaning.  As  early  as  the 
year  1 666,  a  clear  notice  of  this  disease, 
in  a  form  modified  by  abundant  ad¬ 
mixture  with  soft  cancer,  is  detailed  in 
the  German  ephemerides,  by  one 
George  Seger,  and  is  called  a  fungous 
excrescence,  resembling  prolapsus  of 
the  uterus.  The  case,  greatly  abbre¬ 
viated  from  the  original,  is  somewhat 
as  follows: — 

"  Mary,  widow  of  David  Scott,  aged 
47  years,  and  in  the  eighth  year  of  her 
widowhood,  a  discreet  and  virtuous 
woman,  caught  cold  whilst  menstruat¬ 
ing,  and  began  to  suffer  pains  in  the 
belly.  Shortly  afterwards  a  little 
tumor  appeared  at  the  pudendum, 
which  increased  daily.  In  the  January 
of  1667,  the  substance  had  attained  to 
the  size  of  two  fists,  was  very  foetid, 
and  had  a  sphacelated  appearance.  It 
was  removed  by  operation,  and  weighed 
upwards  of  one  pound.  They  who  saw 
it  concluded  it  to  be  a  fungous  excres¬ 
cence.  A  subsequent  attempt  at  entire 
removal  was  made  by  ligature,  but  the 
woman  being  phthisical,  the  attempt 
was  abandoned,  and  she  shortly  died. 
On  inspection,  the  uterus  was  found 
sound,  and  in  its  proper  place.  The 
sphacelated  substance  was  a  fungous 
excrescence,  springing  from  theanterior 
and  major  part  of  the  neck  of  the 
uterus,  substantia  rugosa ,  spungiosa,  et 
fungosa ,  uteri  colli.” 

A  somewhat  similar  excrescence  to 
this  is  detailed  in  Burton’s  Midwifery, 
obs.  xxx.,  published  a.d.  17 51.  In 
this  instance  there  was  considerable 
consistency  of  tumor.  During  its  pro¬ 
gress,  it  was  attached  to  two  thirds  of 
the  uterine  neck,  was  insensible,  and 
poured  fourth  so  abundant  a  discharge, 
sometimes  inoffensive  and  sometimes 
devoid  of  odour,  as  “  to  wet  the  place 


she  sat  upon,  quite  through  all  her 
petticoats,  &c.”  This  tumor  was  re¬ 
moved,  and  recovery  followed. 

Dr.  Denman  seems  to  have  been 
aware  of  the  disease  so  early  as  the 
year  1788.  He  classed  all  polypi  as 
fungous  excrescences  of  different  den¬ 
sities  ;  and  he  warned  parties  against 
their  removal  when  the  uterus  too 
was  diseased.  He  also  drew  a  distinc¬ 
tion  between  sessile  and  pediculated 
polypi.  Moreover,  in  1808,  Dr.  Denman 
further  stated  his  opinion,  in  presence 
of  the  members  of  the  Med.  Chir.  So¬ 
ciety,  that  a  large  cauliflower  excres¬ 
cence  of  the  os  and  cervix  uteri  could 
not  be  operated  on  without  increasing 
the  miseries  of  the  patient,  and  even¬ 
tually  shortening  her  life;  and  for  the 
reason  that  it  is  so  incorporated  with 
the  os  and  cervix  that  it  is  not  possible 
to  say  where  the  original  part  ends, 
and  where  the  disease  begins. 

It  was  on  the  4th  of  July  of  this 
same  year  (1808)  that  Dr.  John  Clarke 
read  a  paper  before  the  members  of  the 
Med.  Chir.  Society,  the  object  of  which 
was  to  give  an  account  of  a  disease  not 
hitherto  described,  as  far  as  he  knew, 
by  any  writer  on  the  diseases  of  the 
female  organs  of  generation,  or  in  any 
book  on  morbid  anatomy,  though  it 
was  far  from  being  uncommon.  Dr. 
Clarke  gave  the  name  of  cauliflower 
excrescence,  meaning  thereby  to  dis¬ 
tinguish  the  disease  from  cancer — a 
distinction  that  at  the  present  day 
should  be  received  with  caution,  by 
reason  of  the  more  wide  range  now 
assigned  to  cancerous  diseases,  through 
an  improved  knowledge  of  pathology 
and  the  more  general  use  of  the  micro¬ 
scope. 

Dr.  Clarke  observed  that  women  of 
all  ages  are  attacked  indiscriminately 
with  the  disease,  and  that  he  never 
met  with  an  instance  where  it  did  not 
terminate  fatally ; — that  it  emaciates 
and  destroys  the  patient  through  the 
discharge,  which  he  never  saw  to  be 
purulent,  although  he  sometimes  found 
mucus  in  it.  In  proof  of  his  anxiety 
to  cure  the  disease,  we  find  him  remov¬ 
ing  an  excrescence  by  ligature,  but  his 
patient  shortly  after  died  of  cancer  of 
the  uterus. 

In  1816  Dr.  Canella  treated  a  case  of 
excrescence  of  the  uterine  neck,* 
which  commenced  on  the  anterior  la- 


*  London  Med.  and  Phys.  Journal,  vol.  xviii. 


DR.  RENAUD  ON  CAULIFLOWER  EXCRESCENCE  OF  THE  UTERUS.  163 


bium,  as  a  rapidly  growing  and  soft 
pediculated  cancerous  fungus.  The 
anterior  lip  was  removed  in  the  De¬ 
cember  of  1816.  In  April  1817,  a  sessile 
cancerous  excrescence  formed  on  the 
posterior  lip,  and  was  similarly  re¬ 
moved.  In  May,  1818,  new  vegeta¬ 
tions  were  discovered  forming  an 
unequal  lobulated  fungus.  These  were 
attacked  and  destroyed  with  caustic, 
after  continuing  the  applications,  at 
intervals,  for  four  months.  The  patient 
was  supposed  to  be  cured,  but  she  died 
in  1820  of  cancer  of  the  uterus. 

By  turning  to  M.  Levret’s  paper, 
published  a.d.  1819,  in  the  Mem.  de 
l’Academie  de  Chirurgie,  it  will  be 
found  that  whilst  he  makes  no  express 
mention  of  cauliflower  excrescence,  he 
speaks  of  twovarieties  of  uterinepolypi, 
or  “  vivaces,”  which  he  considers  in¬ 
curable.  The  one  is  digitated,  the 
other  in  a  single  mass,  semi-globular, 
filling  the  vagina,  and  rendering  the 
uterus  more  or  less  painful.  He  viewed 
them  as  vegetations  of  uterine  ulcers, 
and  concluded  that  operations  by  liga¬ 
ture  were  useless,  by  reason  of  its  being 
impossible  to  destroy  the  immediate 
cause  of  the  fungosities.  He  describes 
these  vivaces  as  either  lacking  a 
covering  membrane,  or  possessing  one 
too  fine  for  discrimination.* 

Dr.  Blundell  wrote  on  this  disease  in 
his  Lectures,  published  in  1828,  stating 
that  it  is  a  malignant  efflorescent  ex¬ 
crescence,  sometimes  seated  on  parts 
that  have  undergone  little  change  of 
structure,  and  sometimes  on  an  indu¬ 
rated  scirrhous  mass  ; — that  the  foetor 
of  the  discharge  is  not  equally  certain 
with  that  of  other  malignant  growths  : 
clearly  inferring  by  this  remark  that 
he  did  not  consider  the  inodorous  and 
colourless  discharge  essential  to  the 
disease  in  all  cases. 

During  this  same  year  (1828)  a  me¬ 
moir,  by  M.  Avenal,  appeared  in  the 
pages  of  the  Revue  Medicale,  entitled 
— “  On  the  Treatment  of  Cancerous 
Affections  of  the  Neck  of  the  Uterus, 
and  on  its  amputation  in  particular.” 
Without  naming  cauliflower  excres¬ 
cence,  M.  Avenal  describes  a  “fungous 
and  carcinomatous  degeneration”  of 
the  neck  of  the  uterus,  bleeding  on  the 
slightest  touch,  soft,  grey,  and  brittle, 


*  I  have  given  Levret’s  description  of  the  ses¬ 
sile  variety  of  the  “  vivaces,”  and  must  leave  it 
an  open  question  whether  they  be  cauliflower 
growths  or  not. 


a  portion  of  which  may  be  easily  de¬ 
tached  by  the  finger.  In  the  two  cases 
he  has  given,  the  symptoms  are  per¬ 
fectly  in  accordance  with  those  of  cauli¬ 
flower  excrescence;  and  the  diseased 
mass  was  in  each  removed  by  excision. 

M.  Nauche’s  work  on  diseases  of 
women  appeared  in  1819.  He  makes 
no  specific  mention  of  this  disease,  but 
warns  operators  to  be  cautious  in  the 
removal  of  all  polypoid  growths,  for 
that  some  were  cancerous. 

In  1831  Sir  C.  Clarke’s  book  appeared 
on  Diseases  of  Females.  Here  an 
opinion  is  advanced  that  the  tumor  is 
covered  over  with  a  fine  membrane, 
from  which  the  secretion  is  poured  out, 
and  that  bleeding  only  takes  place 
\yhen  this  membrane  is  injured  that 
innumerable  small  arteries  terminate 
on  this  membrane,  and  act  as  exha- 
lents  ; — that  the  tumor  is  insensible, 
and  attached  solely  to  the  os  uteri, 
wholly  or  in  part;— that  the  resem¬ 
blance  between  cauliflower  excrescence 
and  the  foetal  placenta  is  so  strong, 
that  they  differ  only  in  name — or,  in 
other  words,  they  are  each  a  distended 
set  of  blood-vessels.  Another  work  on 
diseases  of  women,  by  Dr.  Gooch,  ap¬ 
peared  in  1831.  He  seemed  disposed 
to  include  the  vivaces,  fungus  polypus, 
and  cauliflower  excrescence,  in  one 
category;  and  even  asserted  that  he  had 
known  the  disease  to  spring  from  the 
fundus  of  the  uterus.  He  viewed  it  as 
a  fungus  Kmmatodes. 

In  1834  M.  Lisfrane  gave  an  opinion 
that  the  vegetations  and  soft  fungous 
tumors  of  the  neck  of  the  uterus  are 
not  originally  cancerous,  but  have  a 
tendency  to  become  so  at  a  later  period. 

Madame  Boivin,  in  the  same  year 
(1834),  classed  the  disease  as  fungous 
cancer,  and  very  analogous  to  the  vi¬ 
vaces  of  Levret. 

Two  years  afterwards  (1836)  Dr. 
Davies  wrote  a  precisely  similar  opi¬ 
nion. 

I  find  no  exact  mention  made  of  this 
disease  in  the  Dictionnaire  de  Medecine. 
In  speaking  of  vesiculo- vascular  poly¬ 
pus,  it  is  described  as  liable  to  be  con¬ 
founded  with  fungosities  springing 
from  the  excoriated  or  ulcerated  neck 
of  the  uterus;  and  the  inference  is 
drawn  that  such  fungi  may  originate 
in  this  form  of  polypus.  In  the  article 
“  Cancer,”  in  this  same  Dictionary, 
and  arranged  under  the  fourth  variety 
of  the  primitive  forms  of  cancer  of  the 


164  DR.  RENACJD  ON  CAULIFLOWER  EXCRESCENCE  OF  THE  UTERUS. 


neck  of  the  uterus,  viz.  where  it  com¬ 
mences  with  a  partial  or  general  tume¬ 
faction  of  the  neck,  which  is  difficult 
of  diagnosis,  and  liable  to  be  con¬ 
founded  with  inflammatory  engorge¬ 
ment,  it  is  stated  that,  when  confirmed, 
it  produces  in  some  persons  encepha- 
loid  cancer,  and  in  others  fungous 
cancer  (cancer  fongeux  sanguin*) 
The  author  then  goes  on  to  state,  that 
according  as  the  vascular  or  encepha- 
loid  element  predominates,  so  accord¬ 
ingly  will  the  aneemic  state  be  brought 
about :  in  the  one  case  by  constant 
bleedings  following  the  most  trifling 
exercise ;  or,  in  the  other,  the  same 
breaking  up  of  constitution  will  result 
from  the  draining  away  of  an  enor¬ 
mous  quantity  of  sanies,  slightly  con¬ 
sistent,  almost  colourless,  and,  it  may 
be,  less  foetid  than  the  sanious  dis¬ 
charges  of  other  varieties  of  cancer. 
If,  after  gathering  these  facts  together, 
the  passage  that  immediately  follows 
be  added — viz.  that  this  form  of  cancer 
attacks  much  more  slowly  the  body  of 
the  uterus  and  adjacent  parts — a  mo¬ 
derately  graphic  account  will  be 
framed  of  cauliflower  excrescence  in 
the  modified  forms  in  which  it  is 
found  to  exist. 

In  1840,  Dr.  Simpson  wrote  that  he 
believed  this  disease  to  be  an  erectile 
tumor  in  its  early  stage,  or  simple  vas¬ 
cular  sarcoma,  with  a  tendency  to 
become  the  seat  of  carcinomatous  or 
encephaloid  tumor. 

Three  _ writers  appeared  in  1843 — 
Dr.  Ashwell,  Dr.  Lever,  and  Dr.  An¬ 
derson.  Dr.  Ashwell  defines  cauli¬ 
flower  excrescence  of  the  os  uteri  as  a 
morbid  growth,  consisting  of  minute 
ramifications  of  arteries,  connected  by 
a  flocculent  tissue,  and  covered  with  a 
secreting  membrane,  having  a  granu¬ 
lated  surface,  bleeding  on  being  slightly 
handled,  and  almost  constantly  pour¬ 
ing  forth  a  watery  discharge;  varying 
in  size,  nearly  painless,  and  proving  its 
malignancy  by  returning  after  removal 
either  by  knife,  ligature,  or  caustic. 
Dr.  Ashw'ell  saw  seven  or  eight  cases, 
all  of  wffiich  proved  fatal. 

Dr.  Lever  adds  nothing  to  the  in¬ 
formation  already  extant  at  the  time 
of  his  writing.  He  gives  a  clear  and 


*  To  those  who  desire  to  know  the  exact  mean¬ 
ing  attached  to  the  “  tumeurs  fongeux  sanguin” 
by  French  authors,  the  “  Voyage  a  Londres,” 
by  M.  ltoux,  in  1814,  or  the  surgical  work  of 
M.  Brescliet,  may  be  recommended. 


concise  history  of  the  disease,  believes 
it  to  be  malignant,  and  follows  the 
treatment  recommended  by  Sir  Charles 
Clarke.  Dr.  Lever  met  with  three 
cases  out  of  three  hundred  and  fifty  of 
uterine  cancer. 

Dr.  Anderson  examined  the  growth 
microscopically.  From  the  character 
of  the  cells,  he  did  not  hesitate  to  con¬ 
sider  it  as  a  variety  of  cerebri  form  or 
encephaloid  disease.  He  differed  in 
opinion  from  Sir  C.  Clarke  and  others 
in  the  belief  of  a  fine  vascular  mem¬ 
brane  being  spread  over  the  surface  of 
the  tumor.  In  his  opinion,  the  tumor 
consists  of  parallel  plates  of  a  w'hitish 
matter,  separated  from  each  other  by 
reddish  lines,  which  he  concludes  to 
be  .blood-vessels  ramifying  over  the 
fine  laminae  of  a  membrane,  every¬ 
where  dipping  complexedly  into  the 
tumor,  beautifully  vascular,  and  very 
thin.  He  could  not  distinguish  the 
course  and  distribution  of  the  capilla¬ 
ries,  but  entertained  no  doubt  of  the 
wdiitish  cell  substance  being  formed 
from  the  vascular  membrane. 

Mr.  Heming,  in  1844,  gave  testimony 
in  favour  of  a  malignant  origin  to  this 
disease ;  and  Dr.  Montgomery  did  like¬ 
wise  in  1846. 

In  1846,  also,  Dr.  Walshe’s  w7ork  on 
Cancer  appeared.  He  feels  undecided 
about  the  nature  of  cauliflower  ex¬ 
crescence,  but  believes  it  to  be  none 
other  than  a  modification  of  encepha¬ 
loid. 

In  1847,  Mr.  Lee’s  work  appeared 
on  Tumors  of  the  Uterus.  In  that 
part  w7hich  treats  of  califlow7er  excres¬ 
cence,  he  concludes,  after  running 
over  the  evidence  of  Dr.  and  Sir  C. 
Clarke,  that  the  disease  is  traceable  to 
no  cause,  but  that  it  is  not  malignant. 
He  agrees  with  Dr.  Montgomery  con¬ 
cerning  the  variableness  of  density  of 
the  tumor;  thinks  it  liable  to  be  repro¬ 
duced  ;  examined  its  minute  anatomy, 
and  declared  it  to  be  free  from  a  com¬ 
mon  investing  membrane;  that  numbers 
of  nucleated  cells  exist  in  its  structure, 
and  that  the  mass  swarms  with  blood- 
corpuscles  and  cells,  but  that  the  course 
and  distribution  of  the  blood-vessels 
could  not  be  distinguished  with  suffi¬ 
cient  accuracy  ;  that  the  tumor  bears 
a  resemblance  to  macerated  placenta, 
but  a  much  more  close  resemblance  to 
the  fronds  of  some  sea-weeds;  that  the 
tumor  has  a  membrane  highly  vascular 
for  a  basis,  and  that  this  membrane 


FEVER  IN  WESTMINSTER.  REPORT  OF  SANITARY  COMMISSION.  165 


has  the  power  of  forming  from  the 
blood  a  whitish  cell  substance,  which 
is  deposited  on  a  layer  around  it ;  that 
the  discharge  comes  from  the  vessels  ; 
that,  although  the  tumor  is  in  itself 
insensible,  the  patients  are  themselves 
variably  sensible  to  pain  in  the  neigh¬ 
bouring  parts ;  that  a  cautious  prog¬ 
nosis  should  be  given  ;  and  that  several 
instances  were  on  record  where  the 
disease  had  not  reappeared  after  entire 
removal. 

In  Mr.  Syme’s  Pathology,  lately 
published,  is  the  history  of  a  case  ope¬ 
rated  on,  which  was  considered  to  be 
cured  ;  but,  as  the  woman  left  hospital 
eleven  days  after  the  operation,  there 
may  reasonably  enough  exist  some 
doubt  as  to  the  permanence  of  the 
cure.  Mr.  Syme’s  opinion  is,  that 
cauliflower  excrescence  is  not  malig¬ 
nant. 

[To  be  continued.] 


NECESSITY  OF  COMBINING  COMPARATIVE 
AND  HUMAN  ANATOMY  IN  TEACHING. 

From  my  own  experience  as  a  teacher,  I 
have  no  hesitation  in  expressing  my  con¬ 
viction,  that  no  one  circumstance  has  tended 
so  much  to  cramp  the  mind  of  the  student 
in  respect  to  one  of  the  most  essential  of 
his  pursuits,  than  the  practice,  till  late  years 
universal,  and  even  now  but  too  general,  of 
introducing  him  to  whatever  knowledge  he 
may  attain  to  in  the  science  of  organization, 
through  the  exclusive  portals  of  human 
anatomy,  where  all  is  so  elaborate,  modified, 
and  therefore  obscure.  On  the  other  hand, 
there  is  such  an  unbroken  chain  of  connexion 
linking  together  the  various  classes  of  organs 
in  the  animal  series,  and  the  successive  ad¬ 
ditions  and  developments  proceed  by  such 
short  steps,  that  the  observer  is  conducted 
from  simple  to  compound,  much  in  the  same 
way  as  the  geometrician  is  led  certainly,  but 
almost  imperceptibly,  from  the  primitive  and 
self-evident  axiom  to  the  final  demonstration 
of  a  complex  proposition.  It  is  thus  that 
while  the  student  is  obtaining  a  practical 
acquaintance  with  facts  essential  to  the  due 
comprehension  of  the  human  formation,  he 
is  at  the  same  time  acquiring  that  inductive 
frame  of  mind,  which  will  be  of  invaluable 
aid  in  a  science  like  that  of  medicine,  where 
the  phenomena,  however  arbitrary  they  may 
seem  to  be,  observe,  on  the  whole,  a  regular 
and  definite  sequence. — Mr.  Grainger’s 
Hunterian  Oration. 


MEDICAL  GAZETTE. 


FRIDAY,  JULY  28,  1848. 


Our  readers  may  remember  that  a  few 
months  since,  rumours  were  in  circula¬ 
tion  that  a  malignant  fever  had  sud¬ 
denly  appeared  in  Westminster,  and 
had  caused  great  mortality.  The 
origin  of  this  fever  was  ascribed  to  the 
opening  of  some  foul  drains  and  cess¬ 
pools,  for  the  purpose  of  testing  the 
efficacy  of  certain  disinfecting  pro¬ 
cesses.  The  subject  was  mentioned 
in  Parliament,  and  so  much  popular 
feeling  was  manifested  on  the  occasion, 
that  Government  resolved  to  institute 
an  inquiry  into  the  facts.  The  result 
of  this  inquiry  is  now  before  the  public, 
in  the  shape  of  a  third  report  from  the 
Metropolitan  Sanitary  Commission; 
and  it  is  satisfactory  to  know'  that  the 
statements  circulated  in  the  public 
journals  respecting  the  origin  and  mor¬ 
tality  of  the  Westminister  fever,  are 
gross  exaggerations. 

We  learn  from  this  report,  that  there 
were  only  thirty-six  persons  attacked 
w  ith  the  fever ;  but  it  is  remarkable 
that  thirty-two  of  them  w7ere  attacked 
wnthin  the  short  period  of  eleven  days. 
There  w7ere  only  five  deaths,  three 
among  the  scholars,*  and  twro  among 
the  inhabitants.  We  subjoin  a  sum¬ 
mary  of  the  results  at  which  the  Com¬ 
missioners  have  arrived  : — 

“  After  having  devoted  to  the  exami¬ 
nation  of  the  circumstances  attendant 
on  the  fever  that  has  occurred  in  this 
small  locality,  an  extent  of  labour  that 
might  have  sufficed  to  investigate  the 
sanitary  condition  of  a  large  mass  of  the 
population,  wre  have  found  on  the 
w7hole — That  whereas  it  has  been 
stated  that  fever  broke  out  immediately 

*  Dr.  Fincham  states  that  only  two  of  the 
scholars  died  from  the  fever. 


166  FEVER  IN  WESTMINSTER.  REPORT  OF  SANITARY  COMMISSION. 


after  the  cleansing  of  the  cesspools,  the 
fact  is  found  to  he  that  eight  weehs 
elapsed  between  the  emptying  of  the 
last  cesspool  and  the  first  case  of  fever — 
a  period  which,  according  to  the  predo¬ 
minant  medical  testimony,  puts  out  of 
the  question  that  operation  as  an  ex¬ 
citing  cause  of  fever,  even  if  it  had 
been  performed  in  such  a  manner  as  to 
evolve  large  quantities  of  noxious  gases, 
instead  of  by  a  method  which  produces 
incomparably  less  effluvia  than  any 
process  heretofore  known.  That 
whereas  it  has  been  stated  that  the 
fever  was  of  an  entirely  newT  type,  such 
as  had  never  been  seen  or  observed 
before  in  that  or  any  other  place ;  the 
fact  appears  to  be  that  the  type  is  one 
well  known  and  recognized  as  preva¬ 
lent  for  years  past  in  that  very  locality 
and  neighbourhood,  as  well  as  in  all 
other  parts  of  the  metropolis.  That 
whereas  it  was  stated  that  fever  was 
entirely  unknown  before  in  the  place 
in  question,  the  fact  appears  to  be  that 
fever  had  occurred  there  the  year 
before,  and  also  in  1846,  as  testified  by 
Dr.  Basham,  and  cases  had  occurred  in 
former  years  ;  and,  although  no  regular 
record  has  been  preserved,  there  is  good 
reason  to  believe  that  epidemics  have 
from  time  to  time  occurred  there,  and 
that  there  has  been  no  such  entire  pre¬ 
vious  exemption  as  reputed.  That 
whereas  it  was  represented  that  there 
was  an  excess  of  fever  cases  in  the 
Westminister  district  after  the  cleans¬ 
ing  operations,  it  appears,  from  parti¬ 
cular  inquiries  in  the  places  cleansed, 
that  there  has  been  a  decided  reduction 
in  the  sickness  experienced,  and 
throughout  the  district  a  less  amount  of 
sickness  than  previously.  That  where¬ 
as  it  has  been  stated  that  an  offen¬ 
sive  smell  was  perceived  in  the  school, 
produced  by  the  filling  up  of  a  cesspool 
that  had  been  cleansed  some  weeks 
before, — the  fact  is  found  to  be  that 
this  particular  cesspool  gave  out  no  un¬ 


usual  smell  on  that  occasion,  but  that 
the  smell  complained  of  probably  arose 
from  the  emanations  given  off  from  a 
large  cesspool  which  had  never  been 
cleansed  at  all,  and  which  communi¬ 
cated  with  the  whole  line  of  a  foul 
sewer  passing  directly  under  the  school ; 
the  evaporating  surface  of  this  sewer, 
as  far  as  it  has  been  possible  to  explore 
it,  which  is  only  through  a  compara¬ 
tively  small  part  of  its  course,  being 
estimated  at  2,000  feet,  or  more  than 
four  times  the  surface  of  the  18  cess¬ 
pools  emptied  in  the  early  part  of  the 
year.  That  the  course  of  the  disease 
followed  very  exactly  the  line  of  this 
sewer,  which  communicates  by  direct 
openings  with  several  of  the  houses 
where  fever  broke  out,  passes  directly 
under  the  school  and  the  dormitory,  is 
in  close  proximity  with  nearly  all  the 
houses  in  which  fever  occurred,  and  is 
in  so  foul  a  state  that  the  officers  of 
the  Metropolitan  Sewers  Commis¬ 
sioners,  accustomed  as  they  are  to 
such  examinations,  were  absolutely 
unable  to  proceed  along  it  beyond  a 
certain  point,  so  that  beyond  that 
point  it  still  remains  unexplored.  That 
the  public  sewers  of  the  neighbour¬ 
hood  were  comparatively  clear  of  de¬ 
posit,  and  gave  off  but  a  very  small 
amount  of  effluvium.  That  if  the  pri¬ 
vate  drains  and  the  large  branch  sewer, 
which  were  by  mistake  surcharged 
with  the  soil  from  the  cesspools,  had 
been  perfectly  cleared  out  when  the 
cesspools  were  emptied,  the  probable 
source  of  the  extraordinary  sickness 
and  mortality  would  have  been  re¬ 
moved,  and  the  health  of  the  inha¬ 
bitants  in  general  as  certainly  pro¬ 
moted  as  the  health  of  the  porter  of 
the  cloisters  and  his  family  seems  to 
have  been  improved  by  the  emptying 
and  filling  up  of  the  cesspools  under¬ 
neath  his  house.  That  the  probability 
of  the  recurrence  of  a  similar  visita¬ 
tion  will  be  diminished  to  the  extent 


THE  ASIATIC  CHOLERA.  STATE  OF  HEALTH  OF  THE  METROPOLIS.  167 


that  the  cleansing  of  the  present  house 
drains  and  branch  sewers,  and  their 
substitution  by  a  perfect  drainage 
apparatus,  are  completed ;  excepting 
always  the  more  remote  and  accidental 
emanations  from  adjacent  districts  that 
may  remain  uncleansed,  from  which  it 
may  be  difficult  entirely  to  protect  the 
school  or  the  Abbey-precinct.” 

This  inquiry  has  not  only  proved 
that  there  was  no  ground  for  imputing 
the  production  of  this  fever  to  Dr. 
Buckland’s  disinfecting  processes,  but 
it  has  shewn  the  paramount  importance 
of  having  a  perfect  system  of  drainage 
and  sewerage.  Thus  we  learn  that 
the  fever  closely  followed  the  line  of 
the  foul  sewer,  and  that  the  houses  in 
which  the  disease  occurred  were  in 
close  proximity  to  it ;  while  the  evi¬ 
dence  of  one  witness  shews  that  there 
was  a  perceptible  improvement  in  the 
health  of  his  family  so  soon  as  the 
cleansing  operations  were  completed, 
and  the  cesspools  adjoining  his  house 
were  filled  up. 

The  necessity  of  a  permanent  Sani¬ 
tary  Board  for  determining  all  ques¬ 
tions  connected  with  the  production 
and  diffusion  of  disease  in  the  metro¬ 
polis,  is  strikingly  shown  by  this 
report.  By  putting  an  end  to  false 
rumours,  and  tracing  disease  to  its 
real  source,  it  serves  to  inspire  that 
confidence  which  is  one  of  the  strongest 
preservatives  against  the  attacks  of 
epidemics. 


We  have  no  further  authentic  accounts 
of  the  westward  progress  of  the  cho¬ 
lera.  It  appears  that  on  the  8th  inst. 
the  number  of  cases  in  St.  Petersburgh 
amounted  to  3790,  and  the  fresh  cases 
on  that  day  were  853.  The  deaths 
were  574.  On  the  9th  July,  the  num¬ 
ber  of  patients  attacked  with  cholera 
amounted  to  3897.  Up  to  the  1st 
inst.  the  attacks  were  3474,  and  the 


deaths  1682.  This  is  equivalent  to  a 
mortality  of  48*4  per  cent. 

Reports  have  been  circulated  that 
Diarrhoea  and  Cholera,  in  a  severe 
form,  are  becoming  prevalent  in  the 
metropolitan  districts;  but,  by  a  re¬ 
ference  to  the  weekly  table  of  deaths, 
these  are  proved  to  be  unfounded. 
The  state  of  health  in  the  metropolis, 
as  indicated  by  the  rate  of  mortality, 
has  undergone  a  gradual  improvement 
since  the  commencement  of  the  sum¬ 
mer  trimestrial  period.  Thus,  the 
total  deaths  were  in  the  week  ending 

July  1st  .  .  .  1100 
„  8th  .  .  .  970 

„  15th  .  .  .  930 

The  weekly  deaths,  based  on  an 
average  of  five  summers,  are  972 : 
hence  on  the  total  mortality  there  is 
no  indication  of  any  unhealthy  condi¬ 
tion  of  the  atmosphere.  The  diseases 
which  often  acquire  a  special  malig¬ 
nancy  at  this  season  are  diarrhoea  and 
cholera ;  and,  with  respect  to  the 
mortality  from  these  diseases,  the 
Registrar’s  table  furnishes  us  with  the 
following  facts.  The  deaths  from 
Diarrhoea  were  in  the  week  ending 

Under  5  yrs.  old. 

July  1st  .  .  42,  including  34 
„  8th .  .  57  ,,  51 

„  15th  .  .  64  „  58 

The  weekly  summer  mortality  from 
diarrhoea  is  no  less  than  66:  hence, 
since  the  commencement  of  the  sum¬ 
mer  quarter,  the  deaths  from  this  dis¬ 
ease  have  not  even  reached  the  sum¬ 
mer  average.  It  will  be  remarked, 
too,  that  a  very  large  proportion  of 
the  deaths  from  this  cause  have  oc¬ 
curred  among  infants  and  young  chil¬ 
dren. 

The  deaths  from  Cholera  were  in 
the  week  ending 

Under  5  yrs.  old. 

July  1st  .  .  6,  including  2 

„  8th  .  .  7  „  5 

„  15th  .  .  9  „  6 


168 


ON  RECENT  ADVANCES  IN  THE  PHYSIOLOGY  OF 


The  average  number  of  weekly 
deaths  from  this  cause  is  7,  which  has 
been  only  once  passed  within  the  last 
three  weeks.  Out  of  the  22  registered 
deaths  from  this  disease  occurring 
among  a  population  of  two  millions, 
13  have  occurred  among  infants  and 
young  children. 

The  state  of  public  health  is  so  far 
highly  satisfactory.  There  is  not  the 
slightest  ground  for  the  assertion  that 
we  have  yet  among  us  those  disordered 
states  of  the  alimentary  canal  which 
are  said  to  be  the  precursors  of  Asiatic 
Cholera.  On  the  contrary,  they  are 
less  fatal  than  the  quinquennial  ave¬ 
rage  would  lead  us  to  expect ;  while 
the  greater  number  of  deaths  are  re¬ 
corded  in  the  period  of  infancy.  Ad¬ 
mitting  that  the  Registrar-General’s 
table  shews  the  mortality,  and  not  the 
morbility ,  of  a  population,  there  is  no 
reason  to  believe  that  diarrhoea  and 
cholera  are  more  prevalent  than  they 
have  been  for  several  preceding  sum¬ 
mers  ;  and  it  is  at  any  rate  certain 
that  when  the  cypher  of  mortality  does 
not  rise  in  consequence  of  their  preva¬ 
lence,  we  have  no  reason  to  complain 
of  the  metropolis  being  in  an  unhealthy 
state. 

Since  the  above  remarks  were 
written  we  have  received  the  Re¬ 
gistrar-General’s  return  for  the  week 
ending  on  Saturday  last.  From  this 
it  appears  that  there  has  been  a  very 
sudden  increase  in  the  number  of 
deaths.  This  is  chiefly  due  to  the 
increased  fatality  of  diseases  of  the 
zymotic  class.  The  deaths  from  diar¬ 
rhoea  were  94,  but  of  these  the  very 
large  proportion  of  82  occurred  among 
infants.  The  fatal  cases  of  cholera 
were  21,  of  which  11,  or  more  than  50 
per  cent.,  occurred  among  children 
under  the  age  of  five  years.  The  deaths 
from  scarlatina  were  no  less  than  90, 
to  a  summer  average  of  37 ;  but  of  the 


90  deaths,  87  were  among  young  chil¬ 
dren.  Although  the  return  of  the  last 
week  is  more  unfavourable  than  the 
returns  of  the  three  preceding  weeks, 
there  is  nothing  to  indicate  the  exis¬ 
tence  of  a  virulent  epidemic  among 
the  adult  population — i.  e.,  in  that 
class  which  is  the  most  exposed  to  the 
attacks  of  Asiatic  cholera. 


Recent  Advances  in  the  Physiology  of 
Motion ,  the  Senses,  - Generation ,  and 
Development.  By  William  Baly, 
M.D.  F.R.S.  «fec.,  and  William 
Senhouse  Kirkes,  M.D. ;  being  a 
Supplement  to  the  Second  Volume 
of  Professor  Muller’s  Elements  of 
Physiology.  8vo.  pp.  132.  London  : 
Taylor  and  Walton,  1848. 

Drs.  Baly  and  Kirkes  have  done  good 
service  to  Physiology,  by  the  publica¬ 
tion  of  the  supplementary  volume  nowr 
before  us.  In  a  science  which  is 
making  such  rapid  advances  by  the 
aid  of  chemistry  and  the  microscope, 
it  becomes  important  to  record  occa¬ 
sionally  the  degree  of  progress  made. 
A  volume  like  this,  enables  the  pos¬ 
sessor  of  Muller’s  Elements  to  bring 
up  his  knowledge  to  the  present  time; 
and  it  puts  it  in  the  powrer  of  all  pro¬ 
fessional  men,  to  make  themselves 
acquainted  with  the  most  recent 
discoveries  in  one  of  the  most  inter¬ 
esting  departments  of  medical  science. 
How  changed  is  the  aspect  of  physio¬ 
logy  since  the  not  very  remote  period, 
when  “  Richerand’s  Elements”  was 
the  class-book  in  the  medical  schools 
of  the  United  kingdom  !  The  perusal 
of  this  supplement,  shows  that  the 
microscope  has  completely  revolu¬ 
tionized  the  science.  We  are  carried 
from  the  external  forms  of  organs  into 
the  structure  of  the  minutest  fibres, — 
the  development  of  cells,  and  those 
other  physical  changes  of  the  body,  on 
which  the  building  up  of  the  animal 
system  depends.  All  is  laid  bare, — wre 
become  familiar  with  structures  inac¬ 
cessible  to  the  scalpel  of  the  anatomist; 
but  in  spite  of  this  apparent  obstacle, 
they  are  described  with  the  same 


MOTION,  THE  SENSES,  GENERATION,  AND  DEVELOPMENT.  J  6  9 


facility,  as  if  they  were  visible  to  the 
unassisted  eye. 

The  title  shews  that  this  is  a  work 
of  a  fragmentary  kind,  i.  e.  without  fol¬ 
lowing  any  particular  order  or  arrange¬ 
ment,  it  furnishes  the  reader  with  a 
knowledge  of  recent  progress.  It  em¬ 
braces  in  a  small  space,  numerous 
observations,  well  selected  and  judi¬ 
ciously  compared,  on  the  physiology 
of  Motion,  the  Senses,  Generation,  and 
Development.  The  following  extracts 
will  show  the  manner  in  which  the 
authors  have  treated  the  subject;  and 
the  numerous  references  in  each  para¬ 
graph,  will  prove  that  much  time  and 
labour  have  been  spent  in  the  selection 
and  collation  of  the  facts  :  — 

“  The  rigidity  of  muscles  after  death. — 
Much  has  been  written  of  late  on  the 
subject  of  the  post-mortem  rigidity  of 
muscles,  though  in  addition  to  what  was 
stated  by  Professor  Muller,  few  new  facts  of 
importance  have  been  obtained,  beyond  some 
W'hich  tend  to  confirm  the  general  opinion, 
that  the  rigidity  is  dependent  upon  an  actual 
contraction  of  the  muscular  tissue,  and  that 
it  does  not  occur  until  the  muscles  have  lost 
their  irritability,  or  their  power  of  con¬ 
tracting  on  the  application  of  ordinary 
stimuli.  Among  other  facts  in  proof  of  the 
latter  of  these  circumstances,  it  has  been 
observed  by  Dr.  Gierlichs,  that  in  frogs,  in 
whom,  as  in  other  reptiles,  the  muscular 
irritability  is  very  persistent,  the  rigor 
mortis  is  often  not  established  for  three  or 
four  days  after  death  ;  that  in  birds,  on  the 
other  hand,  whose  muscular  irritability, 
endures  but  a  short  time  after  death,  the 
post-moitem  rigidity  ensues  quickly.  Addi¬ 
tional  proof  also  has  been  procui'ed,  both  by 
Dr.  Gierlichs  and  other  observers,  that  all 
circumstances  which  cause  a  speedy  ex¬ 
haustion  of  muscular  irritability,  induce  an 
early  occurrence  of  the  cadaveric  rigidity, 
while  conditions  by  which  the  disappearance 
of  the  irritability  is  delayed,  are  succeeded 
by  a  tardy  onset  of  this  rigidity. 

“  The  rigidity  of  voluntary  muscles,  from 
being  the  most  evident,  has  attracted  most 
attention,  and  the  phenomenon  has,  until 
lately,  been  described  solely  in  relation  to 
this  class  of  muscles  ;  but  sufficient  evidence 
has  now  been  accumulated  to  warrant  the 
conclusion,  that  the  involuntary  muscles  also 
are  affected  by  a  post-mortem  rigidity,  which 
is,  in  all  essential  respects,  comparable  with 
that  seated  in  the  voluntary  muscles.  And 
this  is  true,  not  merely  with  regard  to  those 
involuntary  muscles  which,  such  as  the 
blood  and  lymphatic  hearts,  are  constructed 
of  striped  fibres,  but  also  with  regard  to  the 
tissues  composed  of  unstriped  fibres,  such 


as  the  muscular  coat  of  the  intestines,  and 
the  contractile  coat  of  blood-vessels  and  of 
the  large  excretory  ducts.  The  observations 
of  Dr.  George  Budd,  and  of  Mr.  Paget,  have 
proved  this  in  the  case  of  the  heart ;  and  the 
occurrence  of  the  rigidity  in  the  digestive 
canal  has  been  shewn  by  Valentin,  who 
found  that  if  a  graduated  tube  be  connected 
with  a  portion  of  intestine  taken  from  a 
recently  slain  animal,  filled  with  water  and 
tied  at  the  opposite  end,  the  water  will  in  a 
few  hours  rise  to  a  considerable  height  in 
the  tube,  owing  to  the  contraction  of  the 
intestinal  walls.  The  contraction  of  the 
blood-vessels  after  death  was  observed  by 
John  Hunter,  and  is  now  regarded  as  a  well 
established  fact,  and  one  by  which  the  empty 
state  of  the  arterial  system  after  death  is  in 
great  measure  explained” — (p.  9). 

On  Ventriloquism  we  find  the  follow¬ 
ing  observations  : — 

“  Ventriloquism.. — The  general  correct¬ 
ness  of  Professor  Muller’s  account  of  the 
probable  mode  of  production  of  this  peculi¬ 
arity  of  the  human  voice,  has  been  confirmed 
by  M.  Colombat,  who  states  that  by  con¬ 
tinually  practising,  in  a  manner  somewhat 
similar  to  that  pointed  out  by  Professor 
Muller,  he  was  enabled  to  obtain  consider¬ 
able  skill  in  the  production  of  this  variety  of 
voice.  The  essential  mechanical  parts  of  the 
process  consist  in  taking  a  full  inspiration, 
then  keeping  the  muscles  of  the  chest  and 
neck  fixed,  and  speaking  with  the  mouth 
almost  closed,  and  the  lips  and  lower  jaw  as 
motionless  as  possible,  while  air  is  very 
slowly  expired  through  a  very  narrow  glottis; 
care  being  taken  also,  that  none  of  the  ex¬ 
pired  air  passes  through  the  nose.  But,  as 
observed  by  Professor  Muller,  much  of  the 
ventriloquist’s  skill  consists  in  deceiving 
other  senses  than  hearing” — (p.  11). 

It  has  been  hitherto  supposed  that 
the  human  eye,  unlike  that  of  certain 
animals,  was  not  luminous  in  the  dark, 
but — 

“  Mr.  Gumming  has  found  that  the  human 
eye,  when  observed  under  favourable  circum¬ 
stances,  appears  almost  as  luminous  as  the 
eye  of  the  cat,  dog,  and  other  animals  pro¬ 
vided  with  atapetum,  to  which  this  luminous 
appearance  has  been  hitherto  supposed  to  be 
limited.  For  the  purpose  of  observing  this 
in  the  human  subject,  the  person  whose  eye 
is  to  be  examined  should  be  placed  in  a  dark 
room,  four  or  five  feet  from  the  half-closed 
door,  with  his  face  towards  a  light  held  at  an 
equal  distance  outside  the  door.  By  such  a 
contrivance  the  reflection  may  usually  be 
perceived  by  an  observer  standing  between 
the  screen  and  the  light,  and  occupying  a 
position  as  near  as  possible  to  the  direct  line 
between  the  source  of  the  light  and  the  eye 


170 


ON  RECENT  ADVANC  £  TN  THE  PHYSIOLOGY  OF 


examined.  It  varies  in  appearance  from  a 
red  livid  glare  to  a  bright  golden  red  or 
burnished  brass  tint.  In  some  individuals 
the  phenomenon  is  much  more  manifest  than 
in  others  ;  and  in  all,  the  brilliancy  of  the 
reflection  is  proportionate  to  the  intensity  of 
the  light  used  in  the  experiment” — (p.  15). 

The  most  important  additions  are 
undoubtedly  on  the  Physiology  of 
Generation.  Considerable  care  has 
evidently  been  bestowed  upon  this 
part  of  the  Supplement ;  and  the 
authors,  in  assigning  to  each  observer 
his  proper  share  of  merit,  have  suc¬ 
ceeded  in  comprising  within  a  small 
space  a  large  amount  of  valuable 
information.  They  have  picked  out 
the  corn  and  thrown  away  the  chaff: — 
this  is  exactly  the  kind  of  winnowing 
of  facts,  which  will  suit  readers  engaged 
in  practice.  They  may  desire  to  know 
what  has  been  done  in  this  department 
of  physiology  since  they  were  students, 
what  progress  has  been  made  during 
their  Rip-van-Winkle  slumber;  but 
may  be  altogether  indisposed  to  wade 
through  British  and  Foreign  periodicals 
for  the  purpose  of  satisfying  their 
curiosity.  Here  they  will  find  the 
information  required :  and  if  in  the 
abridged  form,  the  contents  of  the 
Supplement  should  not  satisfy  them, 
the  references  are  so  given  that  they 
may  readily  seek  for  more.  We  are 
particularly  pleased  with  that  portion 
of  the  section  on  Generation  which 
refers  to  the  Discharge  of  ova  from  the 
Ovaries.  Much  of  the  mystery  which 
hung  over  this  subject  a  few  years  since, 
is  here  dispelled.  Full  justice  is  done 
to  the  researches  of  Bischoff,  Raci- 
borski,  and  Ritchie,  in  reference  to  the 
production  of  Corpora  lutea ;  but  we 
do  not  find  any  notice  of  the  observa¬ 
tions  of  Dr.  Knox  published  in  this 
journal  in  1843.  According  to  Bischoff, 
the  discharge  of  an  ovum  always  gives 
rise  to  the  formation  of  a  corpus 
luteum;  “  but  most  of  the  recent  writers 
on  the  subject,  including  Paterson, 
Lee,  Ritchie,  Raciborski,  Deschamps, 
and  Renaud,  maintain  as  regards  the 
human  female,  that  a  ‘  true  and  fully 
formed  corpus  luteum,’  is  met  with 
only  where  an  ovum  has  been  im¬ 
pregnated,  and  consequently  that  such 
a  body  is  a  sure  evidence  (proof?)  of 
previous  impregnation.”  (51)  The 
great  question  upon  which  physio¬ 
logists  have  so  long  entertained  con¬ 
flicting  opinions,  therefore,  turns  upon 


this  : — What  is  a  true  and  fully  formed 
corpus  luteum,  and  how  is  it  to  be 
defined  and  recognized  ?  We  are 
informed  that — 

“  The  corpus  luteum  of  the  human  female 
differs  from  that  of  the  domestic  quadruped, 
in  being  of  a  firmer  texture  and  having  more 
frequently  a  persistent  cavity  at  its  centre, 
and  in  the  stelliform  cicatrix  which  remains 
in  the  cases  where  the  cavity  is  obliterated, 
being  proportionally  of  much  larger  bulk. 

The  following  are  the  more  obvious  pheno¬ 
mena  of  its  formation  : — First,  the  Graafian 
follicle  which  is  about  to  discharge  its  con¬ 
tents,  becomes  very  vascular,  then  its  walls 
lose  their  transparency,  and  a  very  thin  layer 
of  soft  yellowish  matter  appears  in  them. 
When  the  follicle  bursts,  this  yellowish 
deposit  increases.  It  does  not,  however, 
usually  form  mammillary  growths  projecting 
into  the  cavity  of  the  follicle,  and  never 
protrudes  from  the  orifice,  as  is  the  case  in 
other  mammalia.  It  maintains  the  character 
of  a  uniform,  or  nearly  uniform  layer,  which 
is  thrown  into  wrinkles  in  consequence  of 
the  contraction  of  the  external  tunic  of  the 
follicle.  After  the  orifice  of  the  follicle  has 
closed,  the  growth  of  the  yellow  substance 
continues  during  the  first  half  of  pregnancy, 
till  the  cavity  is  reduced  to  a  comparatively 
small  size,  or  is  obliterated ;  in  the  latter 
case,  merely  a  white  stelliform  cicatrix  re¬ 
maining  in  the  centre  of  the  yellow  body” — 
(p.  52). 

With  this  description  of  the  produc¬ 
tion  of  a  corpus  luteum,  we  may 
proceed  to  consider  how  far  its  physical 
characters  will  allow  us  to  express  an 
©pinion  as  to  whether  it  is  or  is  not 
the  result  of  impregnation. 

“  There  is  reason  to  believe  that  under 
normal  circumstances  the  rupture  of  a 
Graafian  follicle  and  the  discharge  of  an 
ovum  at  the  period  of  menstruation  is  at¬ 
tended  with  that  change  in  the  tunic  of  the 
follicle  which  constitutes  the  first  step  in  the 
formation  of  the  corpus  luteum.  For 
amongst  the  descriptions  given  by  writers  of 
ruptured  Graafian  follicles  found  in  virgins 
and  other  menstruating  women  who  could 
not  have  been  recently  impregnated,  there 
are  several  in  which  it  is  distinctly  stated 
that  a  layer  of  yellow  substance  existed  in 
the  walls  of  the  follicle ;  and  in  other  in¬ 
stances,  bodies  resembling  in  structure  the 
corpora  lutea  of  pregnant  women,  have  been 
found  in  the  ovaries  of  females  who  had 
menstruated  at  some  distance  of  time,  and 
who  had  not  been  pregnant.  But  the  layer 
of  yellow  matter  in  the  recently  ruptured 
follicle  was  in  such  cases  very  thin,  and  the 
yellow  body,  though  in  all  other  respects 
similar  to  the  corpus  luteum  of  a  pregnant 


MOTION,  THE  SENSES,  GENERATION,  AND  DEVELOPMENT.  171 


woman,  was  of  much  smaller  size.  It 
appears,  therefore,  that  the  development  of 
the  corpus  luteum  does  not  proceed  so  far 
in  the  menstruating  woman  as  in  animals  in 
heat.  The  reason  of  this  inferior  degree  of 
development  of  the  corpus  luteum  in  the 
woman,  in  comparison  with  that  in  quadru¬ 
peds,  is  easily  conceivable  ;  the  excitement 
of  the  ovaries  and  the  whole  sexual  system 
being  undoubtedly  far  greater  in  the  female 
quadruped  in  the  state  referred  to,  than  it 
usually  is  in  the  human  female  at  the  period 
of  menstruation.  The  degree  of  vascular 
excitement  in  the  generative  organs  attending 
the  process  of  mensti’uation  is  moreover 
liable  to  great  variety.  It  may  sometimes 
be  only  just  sufficient  to  cause  the  rupture 
of  the  follicle,  and  not  adequate  to  the  pro¬ 
duction  of  yellow  substance  by  an  organic 
change  in  its  tunic.  In  this  way  we  may 
account  for  the  fact  that  in  the  greater 
number  of  the  descriptions  of  ruptured 
Graafian  follicles  observed  in  unimpregnated 
women,  no  mention  is  made  of  the  existence 
of  a  yellow  deposit  in  the  walls  of  the  follicle. 
The  follicles  thus  destitute  of  yellow  sub¬ 
stance  when  collapsed,  would  form  the 
corpora  albida  of  Dr.  Ritchie.  On  the 
other  hand  we  must  admit  that  when  great 
excitement  attends  menstruation,  the  forma¬ 
tion  of  the  corpus  luteum  may  go  on  more 
rapidly  and  continue  for  a  longer  period,  and 
that  under  these  circumstances  the  resulting 
yellow  body  may  be  of  considerable  size. 

If,  in  addition  to  the  foregoing  facts  and 
considerations,  the  varieties  in  size  of  the 
corpora  lutea  formed  during  pregnancy  are 
borne  in  mind,  it  will  be  seen  that  cases  can 
seldom  occur  where  the  mere  presence  of 
one  of  those  bodies  can  be  taken  as  a  proof 
of  previous  impregnation.  The  following 
practical  rules,  however,  seem  to  be  deducible 
from  the  facts  detailed. 

1.  A  corpus  luteum,  in  its  earliest  stage 
(that  is  a  large  vesicle  filled  with  coagulated 
blood,  having  a  ruptured  orifice,  and  a  thin 
layer  of  yellow  matter  in  its  walls),  affords 
no  proof  of  impregnation  having  taken  place. 

2.  From  the  presence  of  a  corpus  luteum, 
the  opening  of  which  is  closed,  and  the 
cavity  reduced  or  obliterated,  only  a  stellate 
cicatrix  remaining,  also  no  conclusion  as  to 
pregnancy  having  existed  or  fecundation 
having  occurred  can  be  drawn,  if  the  corpus 
luteum  be  of  small  size,  not  containing  as 
much  yellow  substance  as  would  form  a  mass 
the  size  of  a  small  pea. 

3.  A  similar  corpus  luteum  of  a  larger 
size  than  a  common  pea,  would  be  strong 
presumptive  evidence,  not  only  of  impregna¬ 
tion  having  taken  place,  but  of  pregnancy 
having  existed  during  several  weeks  at  least ; 
and  the  evidence  would  approximate  more 
and  more  to  complete  proof  in  proportion 


as  the  size  of  the  corpus  luteum  was  greater’ r 
-(p.  57). 

From  these  conclusions,  itwillbe  seen 
that  the  evidence  which  was  formerly 
considered  conclusive,  is  in  truth  only 
presumptive.  A  corpus  luteum  formed 
during  menstruation  under  great  ex¬ 
citement,  may  be  as  large  as  another 
formed  in  some  cases  during  preg¬ 
nancy  :  hence,  unless  we  know  of  the 
conditions  and  circumstances  under 
which  the  female  was  placed,  it  is 
utterly  out  of  our  power  by  a  mere 
examination  of  the  ovary,  to  determine 
the  true  from  the  false  body.  As  the 
distinction  is  proved  to  be  only  relative 
and  arbitrary,  it  appears  to  us  that 
these  terms  should  be  henceforth 
abolished. 

The  connection  of  fecundation  with 
the  menstrual  function  is  thus  de¬ 
scribed  :  — 

“Assuming,  now,  that  the  theory  of  the 
discharge  of  ova  periodically  at  the  times  of 
menstruation,  and  exclusively  at  those  times, 
is  correct,  as  it  certainly  is  highly  probable, 
the  question  next  presents  itself, — how  long 
after  the  extrusion  of  the  ovum  from  the 
ovary,  or  how  long  after  the  cessation  of  the 
menstrual  discharge,  is  fecundation  possible. 
The  passage  of  the  ovum  from  the  ovary  to 
the  uterus  occupies,  M.  Bischoff  says,  three 
days  in  the  rabbit,  and  four  or  five  days  in 
ruminants,  and,  therefore,  probably  eight  or 
ten  days  in  the  human  female.  M.  Bischoff 
believes  that  the  ovum  escapes  from  the 
Graafian  follicle  at  the  time  when  the  men¬ 
strual  discharge  is  about  to  cease,  and  he  is 
of  opinion,  that  in  order  to  be  fecundated,  it 
must  be  acted  on  by  the  semen  while  it  is  in 
the  Fallopian  tube.  From  these  data,  then, 
he  infers  that  sexual  connection,  to  be 
fruitful,  must  take  place  within  eight  or 
twelve  days  from  the  cessation  of  the  men¬ 
strual  discharge.  Raciborski  thinks  the  time 
more  limited.  Out  of  sixteen  women  who 
gave  him  such  information  as  enabled  him  to 
determine  the  time  of  fecundation,  there  was 
only  one  in  whom  this  occurred  so  late  as 
ten  days  after  the  cessation  of  the  menstrual 
flux  ;  and  in  this  one  the  menses  had  been 
suddenly  arrested  several  days  before  their 
usual  time  of  cessation,  so  that  the  extrusion 
of  the  ovum,  M.  Raciborski  thinks,  did  not 
take  place  till  about  two  days  prior  to  the 
act  of  sexual  intercourse,  to  which  it  owed 
its  fecundation.  M.  Raciborski  relates 
several  cases  which  seem  to  shew  that  im¬ 
pregnation  may  result  from  sexual  coitus 
taking  place  one  or  two  days  before  the 
period  of  menstruation.  In  one  of  these 
cases  the  menses  did  not  appear  at  all ;  in 


172 


ON  RECENT  ADVANCES  IN  THE  PHYSIOLOGY  OF  MOTION,  ETC. 


three  others  they  continued  an  unusually 
short  time” — (p.  59). 

We  are  elsewhere  informed  that 
Naeg-ele  is  accustomed  to  reckon  the 
duration  of  pregnancy  at  nine  months 
and  eight  days  from  the  last  menstrual 
period,  and  in  normal  cases  he  has, 
according  to  his  own  statement,  never 
been  wrong.  This  is  unquestionably 
a  strong  ground  for  believing  that  the 
discharge  of  ova  is  confined  to  the 
periods  of  menstruation,  and  that 
females  are  sterile  during  the  inter¬ 
vening  time. 

The  subjoined  extract  will  serve  to 
throw  some  light  on  the  curious  ques¬ 
tions  connected  with  sexual  malfor¬ 
mations.  It  is  here  demonstrated  that 
at  one  period  of  uterine  life,  the 
rudimentary  sexual  organs  are  the 
same  in  the  male  and  female,  and  a 
slight  turn  in  the  order  of  development, 
at  this  period,  determines  the  sex. 
A  small  irregularity  in  the  process  of 
development  will  thus  render  the  being 
an  androgynus  or  androgyna. 

“  Rudimentary  Uterus  in  the  Male. — In 
the  account  given  by  Professor  Muller  of  the 
mode  in  which  the  sinus  urogenitalis  of  the 
early  embryo  is  subsequently  divided  into 
two  portions — pars  urinaria,  and  pars  geni¬ 
talis,  it  is  stated  that  while  the  former  is 
converted  into  the  urinary  bladder,  the  latter 
is  transformed  into  the  vesiculae  seminales  in 
the  male,  and  into  the  uterus  in  the  female. 
In  relation  to  this  subject  an  interesting  fact 
has  been  discovered  by  Professor  E.  H. 
Weber ;  namely,  that  in  the  males  of  several 
mammiferous  animals  which  he  examined, 
and  in  man,  the  organ  analogous  to  the 
female  uterus  which  is  formed  in  the  embryo, 
persists  in  a  more  or  less  developed  state, 
throughout  the  whole  of  adult  life.  In  man 
this  rudimentary  uterus  exists  in  the  form  of 
a  somewhat  oval  vesicular  body  imbedded  in 
the  substance  of  the  prostate  gland  :  a 
portion  of  it  projects  as  a  narrow  ridge  along 
the  middle  of  the  lower  surface  of  the  pros¬ 
tatic  portion  of  the  urethra,  and  is  com¬ 
monly  known  as  the  caput  gallinaginis  or 
verumontanum.  That  it  is  a  hollow  body, 
and  has  no  communication  with  the  prostate, 
may  be  shewn  by  inflating  it  with  air.  Very 
commonly  the  orifice  of  this,  which  Weber 
calls  the  male  uterus,  remains  patent,  and 
may  be  discerned  on  the  middle  line  of  the 
urethra  between  the  openings  of  the  two 
ejaculatory  ducts  ;  sometimes  it  is  very 
narrow,  and  in  a  few  cases  is  even  entirely 
closed.  The  male  uterus  is  still  more  mani¬ 
fest  in  the  beaver,  where  it  is  found  enclosed 
within  a  fold  of  the  peritoneum,  and  situated 
between  the  urinary  bladder  and  the  rectum, 


exactly  in  the  position  occupied  by  the 
uterus  in  the  female  beaver  :  in  the  male, 
also,  as  in  the  female,  this  organ  is  two¬ 
horned.  Likewise  in  the  male  rabbit  a  rudi¬ 
mentary  uterus  exists  and  occupies  the  same 
situation  as  the  fully  developed  organ  of  the 
female.  The  vasa  deferentia  open  into  the 
lower  part  of  this  male  organ,  just  as  their 
analogues  the  Fallopian  tubes  open  into  the 
upper  part  of  the  female  uterus.  It  has 
also  been  found  by  Weber  that  the  walls  of 
this  rudimentary  uterus  possess  distinct 
muscular  fibres,  and  moreover  that  when 
mechanically  or  electrically  irritated  they 
contract  and  manifest  distinct  peristaltic 
movements. 

In  the  newly-born  rabbit,  the  organs  of 
generation,  both  external  and  internal,  so 
closely  resemble  each  other  in  the  two  sexes, 
that  it  is  only  possible  to  distinguish  the 
male  from  the  female  by  the  manner  in 
which  the  vasa  deferentia  differ  from  the 
Fallopian  tubes.  A  male  rudimentary 
uterus  has  also  been  found  by  Weber,  in  the 
dog,  cat,  sow,  and  horse.  In  the  three 
former  animals  the  orifice  of  the  uterus 
usually  appears  closed :  but  in  the  horse,  as 
in  man,  it  is  frequently  found  open. 

The  permanent  existence  of  a  rudimentary 
uterus  in  the  male,  accounts  satisfactorily, 
in  Weber’s  opinion,  for  the  presence  of  a 
large  uterus  in  the  so-called  male  herma¬ 
phrodites  of  the  human  subject :  such  a 
uterus  is  of  course  only  the  vesicuia  pro- 
statica,  or  rudimentary  uterus,  in  a  more 
fully  developed  state” — (p.  112). 

After  considering  development  in 
reference  to  organs,  tissues,  and  cells, 
the  work  is  closed  by  some  interesting 
remarks  on  the  development  of  the 
blood.  In  order  to  render  the  explana¬ 
tions  clear,  wood  engravings  are 
throughout  interspersed  with  the 
remarks. 

We  think  highly  of  the  practical 
utility  of  this  supplementary  volume. 
To  those  who  possess  Muller’s  Ele¬ 
ments  it  is  indispensable, — to  others, 
who  have  not  this  useful  work,  it  will 
be  found  most  serviceable  in  giving 
them  at  a  small  expense  an  insight 
into  the  recent  progress  of  physiology. 
It  would  be  well  if  this  practice  of 
publishing  Supplements  to  standard 
works  on  medical  science  were  more 
frequently  adopted  :  as  it  is,  a  large 
work  on  an  important  branch  of  medi¬ 
cal  science,  is  exposed  to  the  risk  of 
the  doctrines  contained  in  it  becoming 
obsolete  before  another  edition  is  re¬ 
quired,  and  it  is  thus  apt  to  lose  its 
position  in  medical  literature  as  a  work 
of  authority. 


ON  THE  CONSUMPTION  OF  OPIUM.  IMPORTATION  OF  CHOLERA.  173 


A  Practical  7'reatise  on  the  Diseases 
peculiar  to  Women ;  illustrated  by 
Cases,  Sfc.  By  Samuel  Ash  well, 
M.D.  Member  of  the  Royal  College 
of  Physicians,  &c.  3d  edition,  8vo. 
pp.  772.  London  :  Highley,  1848. 

There  are  few  medical  works  which 
have  reached  a  third  edition  in  so  short 
a  period  of  time  as  that  of  which  we 
have  now  to  announce  the  publication. 
This  is  not  merely  due  to  the  repu¬ 
tation  of  the  author  as  an  obstetric 
physician,  but  to  the  practical  character 
of  the  work  itself.  The  diseases  of 
females  have  hitherto  formed  a  sort  of 
appendix  to  works  on  practical  mid¬ 
wifery  ;  but  it  is  obvious  that  so  com¬ 
prehensive  a  subject  can  be  fairly 
treated  only  in  a  distinct  volume;  and 
the  very  rapid  sale  of  two  editions  of 
this  wTork  furnishes  a  clear  proof  of  the 
high  value  attached  by  the  profession 
to  Dr.  Ash  well’s  labours. 

Having  already,  within  a  compara¬ 
tively  recent  period,  given  a  full  notice 
of  the  contents  of  this  volume,  it  is 
unnecessary  for  us  to  reopen  the  sub¬ 
ject.  The  short  space  which  has 
elapsed  since  the  publication  of  the 
second  edition,  has  not  rendered  many 
additions  necessary.  The  size  of  the 
volume  is  therefore  but  little  altered. 
Wecan safely  recommend  Dr.  AshweiPs 
treatise  as  an  admirable  guide  either  to 
assist  the  practitioner  or  to  inform  the 
student. 


(Pomgponfccnte. 


ON  THE  CONSUMPTION  OF  OPIUM  IN 
ENGLAND. 

Sir, — In  your  number  of  the  X6th  uit., 
I  observe  an  allusion  to  the  quantity  of 
opium  consumed  in  England,  which  is  ac¬ 
companied  by  a  remark  or  two  that  it  is 
reported  that  “  the  inmates  of  our  work- 
houses  are  given  to  the  practice  of  opium  - 
eating;”  and  also  that  “the  so-called 
temperance  principles  may  have  tended  to 
increase  the  demand  for  this  drug.”  In 
reply,  allow  me  to  observe  that  it  is  ex¬ 
tremely  improbable  that  the  inmates  of  our 
workhouses  should  be  addicted  to  this  bane¬ 
ful  practice  ;  for  if  there  was  no  other  argu¬ 
ment  against  the  assumption,  the  fact  of  the 
financial  inability  of  paupers  must  render  it 
all  but  certain  that  the  expense  of  pro¬ 
curing  this  deleterious  drug  would  alone 
preclude  these  unfortunate  creatures  from 


consuming,  in  any  material  degree,  so 
costly  an  article.  Still  less  is  it  probable 
that  the  spread  of  “  the  so-called  tem¬ 
perance  principles’^-  can  in  any  degree  have 
“  tended  to  increase  the  demand  for  this 
drug for  I  am  fully  convinced  that  the 
very  “  principles”  which  go  to  establish  the 
practice  of  “  temperance,”  have  equally 
operated  to  expose  the  highly  objectionable 
nature  of  all  narcotic  substances  ;  and 
amongst  the  teetotallers,'  as  a  body,  you 
will  find  a  large  amount  of  information  as 
to  the  physiological  actions  of  all  intoxicat¬ 
ing  agents,  which,  I  regret  to  say,  is  not 
possessed  by  a  very  large  proportion  of  me¬ 
dical  men,  too  many  of  whom  are  in  the 
habit  of  using  alcoholic  liquors  without  much 
knowledge,  and  with  even  less  considera¬ 
tion,  of  their  nature  and  properties  ;  and  I 
am  of  opinion  that,  to  the  spread  of  “  tem¬ 
perance  principles,”  we  are  indebted  for 
some  of  the  most  striking  ameliorations  in 
the  health,  morals,  and  social  condition  of 
the  community.  It  is  to  be  lamented, 
therefore,  that  the  medical  profession  should 
afford  so  little  countenance  to  the  greatest 
discovery  of  modern  times — viz.  that  all 
spirituous  and  fermented  liquors  are  unne¬ 
cessary  to  persons  in  health  ;  that  they  do 
not  strengthen  and  invigorate  the  system  ; 
and  that  they  may  be  relinquished  altoge¬ 
ther,  not  only  without  any  disadvantage, 
but  with  absolute  benefit. 

Thomas  Beaumont. 

Bradford,  July  17,  1848. 

P.S. — I  may  add,  that  the  true  expla¬ 
nation  of  the  enormous  consumption  of 
opium  is  to  be  found  in  the  almost  incredible 
quantity  which  is  employed  by  druggists  in 
the  preparation  of  those  vile  and  deleterious 
compounds  which  are  sold  under  the  names 
of  “  Godfrey’s  cordial,”  “  Dalby’s  carmi¬ 
native,”  &c.  &c.  &c. 


CASES  OF  PLACENTA  PR.EVIA  AND  HOUR¬ 
GLASS  CONTRACTION. 

Case  of  placenta  praevia  in  which  the  pla¬ 
centa  was  expelled  by  the  natural  efforts  of 
the  uterus,  before  the  birth  of  the  child  : — 

Mary  Cobb  was  taken  in  labour  on  the 
afternoon  of  the  24th  of  February ;  upon 
the  midwife’s  arrival  she  found  the  os  uteri 
considerably  dilated,  and  an  unusual  pre¬ 
sentation,  the  precise  nature  of  which  she 
did  not  understand.  After  waiting  an  hour, 
“  something  came  down”  into  the  vagina, 
and  was  expelled  by  the  uterus.  She  then 
discovered  it  to  be  the  placenta. 

The  head  of  the  child  immediately  pre¬ 
sented,  and  the  labour  terminated  in  an  hour 
after  the  expulsion  of  the  placenta :  the 
child  was  still-born.  The  uterus  did  not 
contract  well,  and  I  was  called  in,  the  mid¬ 
wife  thinking  there  was  another  child. 


174  ALLEGED  IMPORTATION  OF  CHOLERA.  CHOLERA  IN  RUSSIA. 


Pressure  upon  the  abdomen  expelled  a  great 
deal  of  coagulated  blood,  and  the  woman  re¬ 
covered  without  an  untoward  symptom. 

Case  2. — Hour-glass  contraction  of  the 
uterus  previous  to  delivery. 

On  Saturday  morning  last,  July  8th,  had 
been  in  attendance  for  some  hours  upon 
Mrs.  Abbey,  when  she  directed  my  attention 
to  the  unusual  state  of  her  abdomen  :  upon 
placing  my  hand  thereon,  could  distinctly 
feel  a  decided  contraction  across  the  middle 
of  the  uterus,  leading  one  to  believe  that 
there  were  two  children,  one  in  that  part  of 
the  organ  which  was  above  the  umbilicus, 
and  one  certainly  below,  as  the  head  could 
be  felt  per  vaginam.  The  neck  between  the 
two  portions  did  not  seem  much  thicker  than 
a  man’s  wrist.  The  pains  continued  for 
many  hours  without  much  progress  ;  they 
then  suddenly  ceased.  The  head  was 
brought  away  by  the  vectis,  the  body  soon 
following.  No  hemorrhage. 

The  cord  could  now  be  traced  into  the 
upper  part  of  the  uterus  (through  the  neck), 
which  now  evidently  contained  the  placenta, 
and  which  was  obliged  to  be  removed,  to¬ 
gether  with  some  coagulated  blood,  by  the 
introduction  of  the  hand.  It  was  adherent 
to  the  upper  and  left  portion  of  the  uterus. 
The  woman  is  doing  well,  although  the 
uterus  diminishes  very  slowly  in  size,  and  the 
contraction  in  the  middle  is  still  distinctly 
to  be  felt.  Yours  truly, 

Benj.  Dulley. 

Wellingborough,  July  17,  1848. 


JMctucal  Untelltgence* 


ALLEGED  IMPORTATION  OF  CHOLERA. 

The  following  inquiry  was  made  in  the 
House  of  Commons  on  Tuesday  evening 
relative  to  the  alleged  importation  of  cho¬ 
lera  : — 

Mr.  Wyld  wished  to  call  the  attention  of 
the  Government  to  a  statement  which  ap¬ 
peared  in  the  papers.  It  was  said  that  the 
English  brig  Marion,  Captain  John  Beal, 
anchored  off  Malmo  on  the  8th  of  July, 
having  taken  a  cargo  of  wheat  at  Cronstadt 
14  days  before.  It  was  ascertained  that  the 
captain  had  arrived  sick  on  board  at  Cron¬ 
stadt,  and  died  with  symptoms  of  cholera  ; 
one  of  the  crew  had  also  been  taken  ill,  but 
recovered  again.  It  was  now  supposed  that 
that  vessel  had  arrived,  or  would  soon  ar¬ 
rive,  in  this  country. 

Mr.  Labouchere  was  sorry  his  noble  friend 
the  First  Commissioner  of  Woods  and 
Forests  was  not  in  his  place,  because  he 
was  in  constant  communication  with  the 
Lords  Commissioners  of  the  Privy  Council 
on  the  subject,  for  the  purpose  of  devising 


means  to  prevent  the  arrival  of  that  dreadful 
scourge  in  this  country,  and  by  which  its 
progress  might  be  arrested. 

THE  ASIATIC  CHOLERA  IN  RUSSIA. 

Among  the  persons  attacked  by  the  cholera 
at  Jassy  are  the  Prince  Stourdza  and  all  his 
family.  Letters  from  Moscow  of  the  3d 
announce  that  the  cholera  has  begun  to  de¬ 
cline  in  that  city.  A  letter  from  Konigs- 
berg,  of  the  13th,  states  that  several  inha¬ 
bitants  of  the  city  had  been  attacked  with  a 
violent  diarrhoea,  bearing  symptoms  ana¬ 
logous  to  cholera,  and  that  some  had  died. 

The  cholera  is  rapidly  approaching  to¬ 
wards  Hungary  and  Bukovine.  A  letter, 
dated  Galacz,  the  24th  of  June,  states — 
With  the  beginning  of  this  month  the  cho¬ 
lera  made  its  appearance  here,  and  increased 
much  about  the  12th  ;  the  first  day  after 
that,  197,  the  second,  186  persons  fell  sick, 
of  whom  36  and  32  died  in  the  course  of 
the  two  days.  On  the  following  days  the 
number  attacked  by  the  sickness  was  230  ; 
it  was  observed  that  on  an  average  one-third 
died.  On  the  20th  it  raged  worse  still, 
and  67  persons  have  fallen  victims  daily 
since  then.  In  the  cities  where  it  rages, 
the  people  desert  their  houses  and  encamp 
on  the  open  field  ;  thus  Giurgewo  is  entirely 
depopulated.  The  sickness  reigns  likewise 
at  Silistria,  Turtukay,  Popica,  Sistowa, 
Widyr,  and  at  Werszerow,  on  the  frontiers 
of  Wallachia.  Also  at  Galacz,  where  it  has 
reappeared  since  the  15th,  and  has  taken  a 
worse  character;  up  to  the  8th  of  June, 
285  persons  have  fallen  sick,  and  101  died 
at  Ibrailow,  containing  a  population  of 
18,000  souls.  At  Jassy,  until  the  23d  of 
June,  from  31  to  40  daily  fell  sick,  of  whom 
about  two  died ;  from  that  place  it  has 
spread  all  over  the  country.  It  is  remark¬ 
able  that  the  sickness  has  not  been  increasing 
on  the  side  of  the  Danube,  which  extends 
into  Bulgaria,  except  at  one  place  called 
Maczyn.  More  remarkable  still  it  is  that 
the  sailors  on  the  Danube  have  been  entirely 
free  from  it.  At  Moscow,  1,724  persons 
have  fallen  sick,  and  728  died  between  the 
13th  and  20th  of  June  :  besides  many  other 
districts  visited  by  the  cholera,  it  is  princi¬ 
pally  the  district  of  Jaroslaw  which  has 
been  violently  attacked  by  it ;  likewise  the 
town  of  Tichwin,  in  Novgarod,  has  suffered 
much.  It  has  just  broken  out  at  Niko- 
lajew,  in  Cherson,  and  in  the  quarantine  at 
Odessa,  where,  since  the  beginning  of  May. 
many  lives  have  been  lost  in  the  vessels ; 
the  city  of  Odessa  is,  however,  free  from  it. 
In  Sweden  a  quarantine  of  five  days  has 
been  ordered  to  be  kept  by  all  vessels  which 
arrive  from  Southern  Finnland  and  Han- 
goudd.  For  this  reason  the  steamers  Stol- 
lursten  and  Prince  Metternich  have  delayed 
their  departure  for  Stockholm, 


STATISTICS  OF  AMPUTATIONS. 


175 


At  Constantinople  the  cholera  continues 
to  make  great  havoc  in  all  parts  of  the 
capital,  and  also  in  some  villages  situated  on 
the  Bosphorus. 

THE  GLOUCESTERSHIRE  MEDICAL  AND  SUR¬ 
GICAL  ASSOCIATION. 

At  a  Special  General  Meeting  of  the  mem¬ 
bers  of  the  Gloucestershire  Medical  and  Sur¬ 
gical  Association,  held  at  Cheltenham,  on 
the  20th  day  of  July,  1848,  “  to  take  into 
consideration  the  proposals  for  a  measure  of 
Medical  Reform,  lately  published,  as  result¬ 
ing  from  a  conference  of  parties  representing 
the  Metropolitan  Corporations  and  the 
General  Practitioners,  and  intended  as  the 
basis  of  an  Act  of  Parliament  for  the  regula¬ 
tion  of  the  profession,”  Thomas  Wright, 
Esq.  President,  in  the  Chair,  the  following 
resolutions  were  carried  unanimously  : — 

1.  — That  the  Charter  granted  to  the  Col¬ 
lege  of  Surgeons  in  1843,  forms  an  insur¬ 
mountable  obstacle  in  the  path  of  Medical 
legislation,  and  that  no  attempt  to  adjust  by 
Act  of  Parliament  the  difficulties  of  this  sub¬ 
ject  can  be  successful  or  satisfactory  until 
the  injustice  perpetrated  by  that  obnoxious 
measure  be  done  away  with. 

2.  — That  the  Colleges  of  Physicians  and 
Surgeons  if  rightly  organized,  are  quite  suffi¬ 
cient  for  the  requirements  of  the  profession 
in  this  country,  and  that  the  proposed  crea¬ 
tion  of  a  new  corporation  for  the  enrolment 
of  the  General  Practitioners  is  uncalled  for  by 
any  necessity,  and  that  such  new  institution 
would  be  alike  injurious  to  the  intei'ests  of 
the  profession  and  the  public. 

3.  — That  the  parties  undertaken  to  appear 
on  the  part  of  the  General  Practitioners  in 
the  conferences  which  have  led  to  the  pro¬ 
posal  of  a  new  corporation,  have  no  title 
whatever  to  be  considered  as  representing 
the  views  and  opinions  of  that  great  body  of 
the  profession. 

4.  — That  this  association  pledges  itself  to 
oppose,  by  all  means  in  its  power,  the  adop¬ 
tion  of  any  legislative  measures  which  may 
tend  to  perpetuate  the  injustice  inflicted  upon 
the  Members  of  the  College  of  Surgeons  by 
the  Charter  of  1843. 

5.  — That  a  Memorial  be  forwarded  to  the 
Secretary  of  State,  and  a  Petition  be  pre¬ 
sented  to  the  House  of  Commons,  embody¬ 
ing  the  foregoing  resolutions  ;  and  that  a 
Committee  be  appointed  for  the  purpose  of 
drawing  up  such  Memorial  and  Petition,  and 
giving  publicity  to  the  proceedings  of  the 
meeting. 

J.  W.  Wilton,  F.R.C.S.,  Hon.  Sec. 

CITY  OF  LONDON  HOSPITAL  FOR  DISEASES 
OF  THE  CHEST. 

The  following  gentlemen  have  been  ap¬ 
pointed  the  medical  officers  of  the  above 
charity  :  —  Consulting  physicians,  Drs. 


Babington  and  Jeaffreson  ;  consulting  sur¬ 
geon,  Mr.  Aston  Key;  ordinary  physicians, 
Drs.  Peacock,  Bentley,  and  Allen  Williams. 

NUMBER  OF  STUDENTS  IN  THE  MEDICAL 
SCHOOLS  OF  FRANCE  AND  SPAIN. 

It  appears  from  official  documents,  that  the 
number  of  medical  students  in  the  schools 
and  colleges  of  France  is  1875,  of  whom 
there  are  in  the  faculty  of  Paris  800,  in  that 
of  Montpellier  175,  and  of  Strasburg  77. 
The  remainder  are  pretty  nearly  equally  dis¬ 
tributed  among  twenty  other  minor  schools 
in  the  provinces.  In  Spain,  with  a  much 
smaller  population  than  France,  the  number 
of  medical  students  is  said  to  be  much 
greater.  Thus,  in  Madrid  there  are  1100, 
and  in  the  united  schools  of  Barcelona,  Cadiz, 
and  Santiago,  there  are  no  less  than  400, 
making  a  total  of  1500  students. 

THE  PROFESSORSHIP  OF  SURGERY  AT  UNI¬ 
VERSITY  COLLEGE. 

It  is  reported  that  Mr.  Arnott,  surgeon  of 
the  Middlesex  Hospital,  has  been  appointed 
Surgeon  to  the  North  London  Hospital,  and 
Professor  of  Surgery  in  University  College. 

MEDICAL  APPOINTMENTS  UNDER  THE 
FRENCH  REPUBLIC. 

Dr.  Archambault  of  Mareville,  has  been 
appointed  to  succeed  Dr.  Foville  as  Director 
and  Medical  Superintendent  of  the  Lunatic 
Asylum  of  Charenton.  The  displacement 
of  Dr.  Foville,  reflects  disgrace  upon  the 
Provisional  Government. 

UNIVERSITY  OF  EDINBURGH. 

Dr.  Bennett  has  been  elected  Professor 
of  the  Institutes  of  Medicine  in  the  Univer¬ 
sity  of  Edinburgh,  in  the  room  of  Dr.  Allen 
Thompson,  who  has  been  appointed  Pro¬ 
fessor  of  Anatomy  in  the  University  of 
Glasgow. 

ROYAL  COLEGE  OF  SURGEONS. 

Gentlemen  admitted  Members  on  the  21st 
inst.  : — W.  N.  Price — R.  S.  Harvey — T. 
Leeson — A.  B.  Jones — C.  H.  Gamble — 
E.  E.  Phippen  —  J.  W.  Harper — J.  W. 
Trotter — O.  H.  Jennings — G.  J.  Knight — 
J.  Sturdy — T.  Limbery. 

Admitted  on  the  24th  inst.  : — G.  W. 
Peake—  D.  D.  Murphy — G.  F.  Trimnell — 
E.  J.  Lazarus — H.  Eales — G.  E.  Driver — 
C.  C.  Piper — R.  C.  Smyth — T.  B.  Knott. 


STATISTICS  OF  AMPUTATIONS. 

Dr.  Fenwick,  in  an  elaborate  paper  on  the 
influence  of  age,  sex,  and  other  conditions, 
on  the  fatality  of  surgical  operations,  makes 
the  following  remarks  respecting  amputa¬ 
tions. 

It  will  be  advisable  in  persons  between  20 
and  30  years  of  age  labouring  under  incurable 


176  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY,  ETC, 


diseases  of  the  joints,  to  delay  the  perform¬ 
ance  of  amputation  so  long  as  the  strength  and 
othercircumstances  of  the  patient  will  permit, 
instead  of  resorting  at  an  early  period  to 
the  operation,  on  account  of  there  being  but 
little  prospect  of  a  natural  recovery.  In 
that  time  of  life  which,  in  amputations  for 
diseased  joints  of  the  extremity,  is  most 
fatal — viz.  from  30  to  50  years  of  age — 
we  find  also,  that  an  amputation  succeeds 
better  if  the  disease  has  existed  from  one  to 
five  years,  than  if  the  operation  be  performed 
at  an  earlier  stage  of  the  disease.  Thus,  of 
eight  cases  in  which  the  illness  had  existed 
only  one  year,  three  died,  or  one  in  every 
2*6  ;  whereas,  of  eight  who  had  suffered 
from  the  diseased  joint  from  one  to  five  years, 
only  two  perished  or  one  in  four.  Only 
two  cases  were  operated  upon  who  were 
above  60  years  of  age ;  in  both,  the  disease 
was  of  long  standing,  and  in  both  the  opera¬ 
tion  was  successful. — Edinburgh  Monthly 
Journal,  1848. 


BIRTHS  &  DEATHS  in  the  Metropolis 


During  the  week  ending  Saturday,  July  22. 


Births. 
Males ....  695 
Females. .  614 


1309 


Deaths. 
Males....  567 
Females..  529 

1096 


Av.  of  5  Sum. 
Males ....  495 
Females..  477 


972 


West — Kensington;  Chelsea;  St.  George, 
HanoverSquare;  Westminster;  St.  Martin 
in  the  Fields;  St.  James  ..  (Pop.  301,326)  152 
North— St.  Marylebone  ;  St.  Pancras  ; 

Islington  ;  Hackney . (Pop.  366,303)  232 

Central— St. Giles  and  St. George;  Strand; 
Holborn;  Clerkenwell ;  St.  Luke;  East 
London ;  West  London  ;  the  City  of 

London  . (Pop.  374,759)  227 

ast — Shoreditch  ;  Bethnal  Green  ;  White¬ 
chapel  ;  St.  George  in  the  East ;  Stepney ; 

Poplar . (Pop.  393,247)  242 

South  — St.  Saviour;  St.  Olave  ;  Ber¬ 
mondsey  ;  St.  George,  Southwark  ; 
Newington;  Lambeth;  Wandsworth  and 
Clapham  ;  Camberwell ;  Rotherhithe  ; 
Greenwich . (Pop.  479,469)  243 

Total .  1096 


Causes  of  Death. 

All  Causes . 

Specified  Causes . . 

1.  ^t/»io(«c(orEpidemic,Endemic, 

Contagious)  Diseases . . 
Sporadic  Diseases,  viz. — 

2.  Dropsy,  Cancer,  &c.  of  uncer¬ 

tain  seat  . 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  . 

4.  Lungs  and  other  Organs  of 

Respiration . 

5.  Heart  and  Bloodvessels . 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion  . 

7.  Diseases  of  the  Kidneys,  &c.. . 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c . 

9.  Rhematism,  Diseases  of  the 

Bones,  Joints,  &c . 

30.  Skin,  Cellular  Tissue,  &c . 

11.  Old  Age . 

12.  Violence,  Privation,  Cold,  and 

Intemperance . ! 


1 

Av.  of 
5  Sum. 

1096 

972 

1092 

968 

390 

257 

54 

45 

112 

120 

65 

80 

54 

28 

65 

79 

14 

8 

10 

10 

6 

7 

2 

1 

34 

50 

36 

8 

The  following  is  a  selection  of  the  numbers  of 
Deaths  from  the  most  important  special  causes: 


Small-pox  .  31 

Measles  .  15 

Scarlatina  .  90 

Hooping-cough..  24 

Diarrhoea  .  94 

Cholera  .  21 

Typhus  .  70 

Dropsy .  7 

Sudden  deaths  . .  7 

Hydrocephalus . .  24 
Apoplexy .  25 


Paralysis .  10 

Convulsion .  51 

Bronchitis .  28 

Pneumonia .  18 

Phthisis . 140 

Dis.  of  Lungs,  &c.  10 

Teething .  7 

Dis.  Stomach,  &c.  6 
Dis.  of  Liver,  &c.  15 

Childbirth .  3 


Dis.ofUterus,&c.  5 


Remarks.— The  total  number  of  deaths  was 


124  above  the  weekly  summer  average,  indicating 
a  very  sudden  and  large  increase  above  the  deaths 
of  the  preceding  week. 


METEOROLOGICAL  SUMMARY. 


Mean  Height  of  Barometer .  29‘74 

“  “  Thermometer1  .  62*5 

Self-registering  do.b - max.  96-  min.  33*5 

“  in  the  Thames  wrater  —  68'5  —  65*8 

a  From  12  observations  daily.  b  Sun. 


Rain,  in  inches,  *41 :  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological.—' The  mean  temperature  of  the 
week  was  1*5  above  the  mean  of  the  month  (61°). 


BOOKS  RECEIVED  DURING  THE  WEEK. 

Report  of  the  Medical  Cases  treated  in  the 
Liverpool  Northern  Hospital.  By  James 
Turnbull,  M.D.  &c. 

Casper’s  Wochenschrift,  No.  27,  July  1,  1848. 

Journal  de  Chimie  Mddicale,  No  VII.  Juillet. 

Annales  d’Hygifene  Publique  et  de  MMecine 
Legale,  Juillet  1848. 

Comptes  Rendus,  Nos.  1  and  2,  3d  and  10th  July. 

Hygiene  of  the  Navy.  Some  Suggestions  on  the 
Construction  and  Management  of  Pumpwrells 
as  necessary  to  the  Preservation  of  Health  on 
board  Ship. 

Report  of  the  Committee  of  the  Convention  of 
Poor  -Law  Medical  Officers. 

***  This  will  be  noticed  in  our  next  number. 

Eighth  Annual  Report  of  the  Registrar-General 
of  Births,  Deaths,  and  Marriages  in  England. 
Folio. 

The  Philosophy  which  shows  the  Physiology  of 
Mesmerism  and  explains  the  Phenomenon  of 
Clairvoyance,  by  T.  H.  Pasley. 


NOTICES  to  CORRESPONDENTS. 

The  letter  of  Mr.  Wetherfield  will  be  inserted  in 
the  following  number. 

Dr.  Brookes’s  communication  has-been  received, 
and  will  have  early  insertion. 

Mr.  Lonsdale’s  paper  has  been  postponed  until 
next  week. 

Received.— Mr.  H.  Lee— Messrs.  Braddon  and 
White. 


fttmtJot!  iHe&ttal  ©alette. 


177 


^Lectures* 


COURSE  OF  SURGERY, 
Delivered  in  the  years  1846  and  1847, 

By  Bransby  B.  Cooper,  F.R.S. 

Surgeon,  and  Lecturer  on  Surgery  at  Guy’s 
Hospital. 


Lecture  XXXIV. 

SURGERY  OF  REGIONS. - CONTINUED. 

Thoracic  region.  Anatomical  relations. 
Sternal  region.  Congenital  malformation 
—  case.  Absorption  of  sternum  from 
abscess — case.  Venereal  nodes  on  ster¬ 
num.  Trephining  sternum.  Infra-clavicu- 
lar  region.  Abscesses  in.  Tying  subcla¬ 
vian  artery.  Seat  of  aneurism  of  arteria 
innominata.  Lateral  regions  of  the  chest 
distorted  by  spinal  disease — by  empyema. 
Paracentesis  thoracis.  Puncturing  the 
pericardium.  Dorsal  region  of  the  chest. 
Steatomata.  Spina  bifida.  Distortion 
of  the  spine.  Diaphragmatic  region. 
Penetrating  wounds.  Wounds  of  dia¬ 
phragm.  Superior  region  of  the  chest. 
Abnormal  condition  of  the  thymus  gland. 
Fatal  character  of  deeply  penetrating 
wounds  in  any  part  of  the  chest. 
Abdomen.  Importance  of  its  viscera. 
Anatomical  relations.  Division  into  re¬ 
gions.  Contents  of  each  region.  Inter¬ 
nal  abdominal  fascia.  Injuries  to  the 
abdomen.  Mere  contusion  of  parietes — 
case.  Wounded  parietes — cases.  Pro¬ 
trusion  of  viscera.  Viscera  wounded. 

The  Thoracic  Region. 

The  cavity  of  the  thorax  is  situated  between 
the  cervical  region  and  the  abdomen  :  it  con¬ 
tains  the  organs  of  respiration,  and  their  in¬ 
vesting  membranes,  the  pleurae ;  the  heart 
with  its  envelope,  the  pericardium  ;  and  the 
mediastina  with  their  contents. 

The  thorax  has  a  direct  internal  com¬ 
munication  above  with  the  neck,  and  below 
with  the  abdomen,  for  the  continuation  and 
transmission  of  org:  ns  from  one  of  these  re¬ 
gions  to  the  other. 

In  the  anterior  or  sternal  subdivision  of 
this  region,  the  following  are  the  principal 
considerations  that  present  themselves  to  the 
surgeon  : — Being  situated  precisely  in  the 
mesian  line,  it  is  very  liable  to  congenital 
malformations,  and  is,  indeed, sometimesbifid 
through  almost  its  whole  extent,  leaving  only 
a  soft  tissue  between,  through  which  the  ac¬ 
tion  of  the  heart,  is  distinctly  to  be  felt. 

J 

The  bifid  formation  of  the  ensiform  carti¬ 
lage  is  very  common  ;  and  I  have  also  met 
with  cases  in  which  the  structure  was  so  in- 

xlii.— 1079.  Aug.  4,  1848. 


|  verted  as  to  form  a  deep  substernal  fossa. 
A  gentleman  once  called  upon  me  complain¬ 
ing  of  constant  disposition  to  vomit  imme¬ 
diately  after  having  taken  a  meal  or  drunk  a 
large  draught :  being  in  other  respects,  how¬ 
ever,  in  perfect  health.  As  I  was  not  able 
to  discover  from  the  history  of  the  case  any 
premonitory  symptoms  that  could  indicate 
the  cause  of  the  disorder,  I  was  led  to  ex¬ 
amine  the  abdomen,  to  ascertain  if  there  ex¬ 
isted  any  tumor  or  other  abnormal  condition, 
which  could  produce  the  effect  I  have  de¬ 
scribed.  Upon  exposing  the  person  of  the 
patient,  I  was  at  once  struck  with  the  pecu¬ 
liar  form  of  the  termination  of  the  sternum, 
and  I  at  first  thought  it  might  have  been 
produced  by  a  blow,  but  the  patient  in¬ 
formed  me  that  it  had  existed  from  his  birth. 
From  the  extent  of  the  depression,  and  its 
interference  with  the  functions  of  the  stomach, 
the  case  was  one  of  considerable  interest, 
and  I  therefore  sent  the  patient  to  my 
neighbour  Dr.  Burn,  that  he  might  examine 
him.  Dr.  Burn  agreed  with  me,  that  the 
symptoms  could  only  be  attributed  to  the 
malformation,  although  many  authors  have 
denied  that  inversion  of  the  sternum  ever 
produces  any  effect  upon  the  stomach. 

The  sternum  is  sometimes  absorbed, 
from  the  internal  pressure  produced  by 
abscess  or  glandular  enlargement  within  the 
anterior  mediastinum  ;  if  the  pressure  arise 
from  abscess,  the  matter  may  ultimately  dis¬ 
charge  itself,  but  the  tumor  may  be  mistaken 
for  aneurism  from  the  impulse  it  receives  from 
the  heart’s  action.  A  medical  student  once 
called  upon  Sir  Astley  Cooper,  to  request 
his  opinion  upon  a  pulsating  tumor  under 
the  sternum,  which  had  been  pronounced  by 
several  eminent  members  of  the  profession 
to  be  aneurism  of  the  aorta.  Sir  A.  Cooper 
soon,  however,  relieved  his  fears,  inform¬ 
ing  him  that  the  tumor  was  nothing  more 
than  an  abscess  in  the  mediastinum,  and 
that  the  pulsation  depended  upon  its  pres¬ 
sure  upon  the  heart.  An  incision  was  imme¬ 
diately  made  in  the  skin,  and  as  the  matter 
had  already  made  its  way  through  the  ster¬ 
num,  it  was  readily  evacuated,  and  in  three 
months  the  patient  had  perfectly  recovered. 
The  remains  of  the  thymus  gland  may  some¬ 
times  undergo  abnormal  change,  and  press¬ 
ing  upon  the  aorta  and  pulmonary  vessels, 
produce  urgent  symptoms  very  difficult  to 
diagnose. 

Venereal  enlargements  often  occur  in  the 
region  of  the  sternum,  producing  distinct 
nodes ;  the  specific  cause  can  only  be  arrived 
at  by  an  accurate  knowledge  of  the  history 
of  the  case,  or  the  existence  of  concomitant 
syphilitic  symptoms,  such  as  sore  throat  or 
venereal  blotches.  Under  these  circum¬ 
stances  alterative  remedies  are  of  course  in¬ 
dicated. 

To  assist  nature  in  the  removal  of  carious 


178  LATERAL  REGIONS  OF  THE  CHEST  DISTORTED  BY  SPINAL  DISEASE 


portions  of  the  sternum,  or  to  evacuate  the 
pus  in  abscess  of  the  anterior  mediastinum, 
it  is  sometimes  advisable  to  employ  the  tre¬ 
phine  ;  and,  indeed,  this  method  of  pro¬ 
cedure  has  been  recommended  by  French 
surgeons  for  the  evacuation  of  the  fluid  in 
hydro-  pericarditis. 

Fractures  of  the  sternum,  and  dislocations 
of  the  sterno-clavicular  diarthrosis,  have 
already  been  described  :  it  is,  however,  in 
this  region  that  the  deformities  resulting 
from  these  accidents  would  be  obvious. 

On  either  side  of  the  mesian  line,  at  the 
upper  portion  of  the  chest,  and  immediately 
under  the  clavicle,  is  placed  a  transverse  de¬ 
pression,  which  may  be  designated  the  infra- 
clavicular  region.  In  this  space  deep-seated 
abscesses  may  form,  and  so  surround  the  sub¬ 
clavian  vessels  as  to  render  the  evacuation 
of  the  pus  dangerous,  unless  due  precaution 
be  taken  :  it  is  very  frequently  the  case,  that 
matter  forms  in  this  region  in  phlebitis  result¬ 
ing  from  injury  to  the  hand  in  dissection  ; 
and  this  is  usually  attributed  to  the  absorp¬ 
tion  of  a  morbid  poison,  but  is,  I  am  more 
inclined  to  believe,  most  frequently  the  re¬ 
sult  of  a  peculiar  constitutional  condition  of 
the  individual.  It  is  in  this  region  that, 
under  some  circumstances,  surgeons  recom¬ 
mend  the  operation  of  applying  a  ligature 
around  the  subclavian  artery  for  axillary 
aneurism,  instead  of  securing  it  above  the 
clavicle,  as  I  have  already  described.  I 
cannot  myself  see  in  what  circumstances  this 
operation  can  be  preferred.  I  will,  however, 
gentlemen,  describe  to  you  the  method  by 
which  it  may  be  performed.  The  patient 
is  placed  recumbent,  and  the  shoulders 
somewhat  raised  by  a  pillow  ;  the  arm  on  the 
side  of  the  disease  is  then  brought  to  a  right 
angle  with  the  body,  so  as  to  put  the  pecto- 
ralis  major  muscle  on  the  stretch.  A  hollow 
may  then  be  felt  between  the  upper  edge  of 
this  muscle  and  the  clavicular  attachment  of 
the  deltoid  ;  and  in  the  centre  of  this  hollow 
an  incision  is  to  be  made  three  inches  in 
length,  commencing  at  the  clavicular  attach¬ 
ment  of  the  pectoralis  major,  and  being  con¬ 
tinued  outwards  nearly  parallel  with  the 
clavicle  ;  this  incision  should  only  divide  the 
skin  and  the  dense  subcutaneous  cellular 
tissue.  After  the  incision  is  made,  the  arm 
is  lowered  to  the  side,  when  from  the  i-elaxa- 
tion  of  the  muscles  and  skin,  the  wound  may 
be  widely  opened,  and,  as  soon  as  the  blood 
is  sponged  away,  a  strong  shining  fascia 
is  seen  at  the  bottom  :  it  is  termed  the 
coraco-costal  fascia,  and  is  next  to  be 
divided  with  great  caution,  when  the  sub¬ 
clavian  vein  will  be  exposed.  The  vein  is  to 
be  carefully  separated  from  its  fascial  con¬ 
nections,  and  on  being  gently  drawn  down¬ 
wards,  the  subclavian  artery  itself  will  be 
seen.  An  aneurismal  needle  armed  with  a 
ligature  may  now  be  easily  passed  beneath 


the  artery  from  below  upwards,  and  the 
ligature  secured. 

At  the  point  of  junction  of  the  right  infra- 
clavicular  with  the  sternal  region,  the  pulsa¬ 
tory  motion  communicated  in  aneurism  of 
the  arteria  innominata  may  be  detected  :  this 
vessel  has  in  some  instances  been  tied  for 
aneurism,  but  it  becomes  highly  important 
in  such  cases  to  ascertain  that  the  arch  of 
the  aorta  itself  is  not  implicated  in  the  dis¬ 
ease,  and  this  is  sometimes  not  easily  deter¬ 
mined  with  certainty.  I  shall  not  describe 
the  operation  of  tying  the  arteria  innominata, 
until  I  treat  specifically  of  aneurism,  as  there 
are  numerous  abnormal  phenomena,  sympto¬ 
matic  of  the  physical  condition  of  this  vessel, 
which  cannot,  as  in  aneurism  of  the  more 
superficial  arteries,  be  ascertained  by  ex¬ 
ternal  examination  alone. 

The  lateral  regions  of  the  chest  are  often 
rendered  unsymmetrical  by  distortions  of  the 
spine,  which  produce  projections  on  one 
side,  and  corresponding  depressions  on  the 
other.  In  speaking  of  rickets,  I  have 
already  mentioned  the  treatment  to  be 
adopted  in  these  cases.  Projection  of  the 
ribs  on  one  side  may  also  proceed  from  a 
collection  of  fluid  in  the  cavity  of  the  chest ; 
these  cases  fall  more  frequently,  however, 
under  the  care  of  the  physician,  until  the 
surgeon  is  called  upon  to  perform  the  ope¬ 
ration  of  paracentesis  thoracis  to  evacuate 
the  fluid.  I  shall  therefore  describe  this 
operation  to  you,  gentlemen.  The  patient 
may  be  placed  either  in  the  recumbent  or 
sitting  posture,  according  to  his  constitutional 
powers,  and  the  trocar  is  to  be  introduced  in 
the  intercostal  space  between  the  eighth  and 
ninth  rib,  close  to  the  superior  edge  of  the 
lower,  and  about  two  inches  anterior  to  its 
angle.  The  object  of  this  choice  of  po¬ 
sition  for  the  opening  is  to  avoid  the  in¬ 
tercostal  artery  which  runs  along  the  in¬ 
ferior  edge  of  the  rib  from  the  angle  to  the 
cartilage,  and  is  therefore  protected  in  this 
locality,  while  posterior  to  the  angle  no  cer¬ 
tain  point  can  be  indicated  in  which  there  is 
not  the  liability  to  injure  the  artery. 

Puncturing  the  pericardium  in  hydro¬ 
pericarditis  has  been  sometimes  recom¬ 
mended  in  the  left  intercostal  space  between 
the  third  and  fourth  ribs.  The  opening 
must  be  made  two  inches  from  the  sternum, 
for  the  purpose  of  avoiding  the  internal 
mammary  artery.  This  is  an  operation  but 
rarely  had  recourse  to,  in  consequence  of  the 
great  difficulty  of  ascertaining  with  any  cer¬ 
tainty  the  actual  presence  of  fluid  within 
the  membrane,  and  from  the  danger  of 
wounding  the  heart,  if  none  be  present.  I 
defer  speaking  of  the  surgery  connected  with 
the  mammary  region,  until  I  treat  of  the 
diseases  of  the  breast,  which  in  itself  consti¬ 
tutes  so  important  a  subject  as  to  deserve 
distinct  consideration. 


DIAPHRAGMATIC  REGION.  SUPERIOR  REGION  OF  THE  CHEST.  179 


Connected  with  the  posterior  or  dorsal 
region  of  the  neck,  there  are  but  few 
points  of  surgical  importance,  as  the 
only  structures  entering  into  its  com¬ 
position  are  the  cutaneous  and  muscu¬ 
lar  coverings  to  the  posterior  extremities  of 
the  ribs  and  dorsal  vertebrae,  and  that  por-  ' 
tion  of  the  spinal  marrow  contained  within 
them.  The  subcutaneous  cellular  tissue,  from 
its  laxity  to  allow  of  the  free  motion  of  the 
scapulae,  and  the  muscles  belonging  to  them, 
is  frequently  subjected  to  a  morbid  growth 
of  fat,  constitituting  steatomatous  tumors ; 
and  in  this  situation  they  are  frequently  so 
adherent  to  the  fascia,  as  to  require  in  their 
removal  careiul  dissection  from  that  tissue  : 
to  secure  the  healing  of  the  wound,  the 
upper  extremity  on  the  affected  side  should 
be  confined  to  the  trunk,  so  as  to  prevent 
motion  from  interfering  with  the  reunion. 

The  vertebrae  of  this  region  are  sometimes 
affected  in  children  by  the  disease  termed 
spina-bifida  :  this  abnormal  condition  results 
from  an  arrest  in  development,  and  not  from 
actual  disease.  The  deficiency  in  nutrition 
is  found  principally  in  the  laminae  of  bone 
constituting  the  arch  of  the  vertebrae,  which 
not  uniting  posteriorly  to  join  the  spinous 
process,  the  medulla  spinalis  is  at  this 
point  unprotected,  and  protrusion  of  the 
spinal  cord  and  membrane  results.  This 
condition  is  more  frequent,  however,  in  the 
lumbar  than  in  the  dorsal  region.  Sir  Astley 
Cooper  many  years  ago  recommended  punc- 
tux-e  of  these  tumors  for  the  evacuation  of 
the  fluid  they  contained,  and  in  some  few 
cases  a  permanent  cure  has  been  effected  by 
this  operation,  although  the  statistical  ac¬ 
counts  of  its  results  cannot  be  said  to  lead 
to  a  favourable  prognosis.  The  distortions 
of  the  spine  in  this  region  in  case  of  rickets, 
is  productive  of  great  alteration  in  the  form 
of  the  chest,  appearing  as  if  diminishing  the 
capacity  of  that  cavity,  but  in  point  of  fact 
a  compensating  influence  is  generally  in  ope¬ 
ration  to  maintain  the  actual  dimensions  of 
the  space  necessary  to  the  free  action  of  the 
lungs.  To  prove  how  much  the  position  of 
the  ribs  is  accommodated  to  this  condition, 
you  will  find  that  if  a  lung  becomes  adherent 
to  the  mediastinum  as  the  result  of  pres¬ 
sure,  from  an  accumulation  of  pus  within 
the  pleura,  however  the  ribs  may  have 
been  projected  by  its  presence,  soon  after 
the  fluid  has  been  evacuated  they  become  de¬ 
pressed  so  as  to  present  a  convexity  inwards, 
to  fill  up  the  vacuity  which  the  adherent 
lung  is  no  longer  capable  of  occupying. 

The  inferior  or  diaphragmatic  region  of 
the  chest  appertains  much  more  to  internal 
diseases  than  to  physical  injury  ;  it  may, 
however,  be  the  subject  of  lesion  from 
penetrating  wounds,  in  which  the  viscera 
of  the  chest  or  abdomen,  or  both,  way  be 


implicated.  This  accident  is  obviously  to 
be  ascertained  only  by  the  train  of  symptoms 
resulting  from  the  altered  junction  of  the 
organ.  The  diaphragm  may  sometimes  be 
ruptured  by  a  blow  without  any  external 
lesion  :  distension  of  the  abdomen  from  any 
cause  would  of  course  produce  a  liability  to 
this  accident. 

A  patient  was  brought  into  Guy's  Hospi¬ 
tal  who  had  received  a  severe  blow  on  the 
abdomen,  unattended,  however,  by  external 
wound  ;  there  was  no  collapse,  but  he  com- 
plainedof  severe  cramp  and  spasm-like  kind  of 
pain  deeply  seated  in  the  epigastrium,  attended 
with  a  short  snatching  kind  of  breathing, 
as  if  a  rib  were  broken,  which  was  considered, 
from  his  symptoms,  to  be  the  case.  The 
dresser,  Mr.  Day,  applied  a  bandage  around 
his  thorax,  which  gave  him  considerable 
relief ;  he  was  also  bled,  and  small  doses  of 
tartarized  antimony,  combined  with  a  neu¬ 
tral  salt,  were  exhibited.  The  patient  re¬ 
mained  much  in  the  same  state  for  about  ten 
days  ;  he  then  became,  the  subject  of  occa¬ 
sional  sickness  after  eating  ;  his  countenance 
was  anxious,  and  he  died  three  weeks  after 
the  accident.  Upon  a  post-mortem  exami¬ 
nation,  it  was  found  that  the  diaphragm  had 
been  ruptured  on  the  left  side,  extending 
from  its  muscular  into  its  tendinous  struc¬ 
ture  ;  the  stomach  had  also  become  adherent 
to  the  edges  of  the  opening,  which  accounted 
for  the  sickness. 

Owing  to  the  contiguity  of  the  pleurae  to 
the  upper,  and  that  of  the  peritoneum  to  the 
under  surface  of  the  diaphragm,  inflamma¬ 
tory  attacks  frequently  extend  themselves 
from  one  of  these  splanchnic  membranes  to 
the  other,  producing  great  difficulties  in  the 
diagnosis  ;  these  have,  however,  to  be  con¬ 
tended  with  by  the  physician  rather  than  the 
surgeon. 

The  superior  boundary  of  the  chest  is 
entirely  osseous,  and  constitutes  an  opening 
for  the  transmission  of  organs,  the  important 
functions  of  which  are  in  great  measure 
secured  by  the  solidity  of  the  circumscribed 
opening,  and  by  the  peculiar  arrangement  of 
the  cervical  fascia,  which  is  continued  from 
the  region  of  the  neck  into  the  thorax.  The 
chief  surgical  points  relating  to  this  locality 
have  already  been  mentioned  in  describing 
those  of  the  supra- sternal  fossa;  it  may, 
however,  be  remarked,  that  in  children  the 
thymus  gland  becomes  sometimes  abnormally 
enlarged*  extending  upwards  in  front  of  the 
trachea,  occasionally  even  as  high  as  the 
thyroid  gland.  If,  under  these  circum¬ 
stances,  it  becomes  necessary  to  perform  the 
operation  of  tracheotomy,  great  difficulty 
would  be  experienced  from  the  presence  of 
the  abnormal  growth  ;  indeed,  owing  to  the 
shortness  of  the  neck  and  comparative  depth 
of  the  trachea  in  young  children,  laryngotomy 


180 


THE  ABDOMEN — IMPORTANCE  OF  ITS  VISCERA 


should  always  be  preferred  to  tracheotomy 
wherever  it  is  admissible. 

Any  reference  to  the  pathology  of  the 
chest  beyond  that  I  have  already  made  in 
describing  the  injuries  it  may  sustain  in  frac¬ 
ture  of  the  ribs,  would,  I  believe,  gentlemen, 
somewhat  exceed  my  province;  for  the 
changes  produced  in  the  function  of  the  or¬ 
gans  it  contains,  by  the  pressure  of  effusions, 
and  the  mode  of  obtaining  a  diagnosis  by 
auscultation  and  percussion,  are  subjects 
that  belong  especially  to  the  physician.  Very 
similar  phenomena  result,  however,  in  aneu¬ 
rism  of  the  aorta  ;  but  this  is  a  subject  to 
which  I  must  again  refer  in  its  proper  place. 
Deeply  penetrating  wounds  in  the  chest  are 
generally  so  fatal  in  their  character,  owing 
to  the  vital  importance  of  the  organs  ex¬ 
posed  to  injury,  that  death,  particularly  in 
wounds  of  the  heart  or  aorta,  is  almost  in¬ 
stantaneous. 

THE  ABDOMEN. 

No  region  of  the  body  possesses  equal 
interest  with  this  in  the  eyes  of  the  surgeon. 
The  number,  magnitude,  and  great  import¬ 
ance  of  the  organs  contained  in  the  cavity  of 
the  abdomen, — their  susceptibility  to  morbid 
action, — their  extensive  sympathies, — the 
varying  and  complex  phenomena  that  attend 
their  different  diseases,-— the  frequency  and 
danger  of  injury  to  them, — and  the  impor¬ 
tance  and  difficulty  in  operating  in  this  lo¬ 
cality,  all  combine  to  command  the  strictest 
attention  on  the  part  of  the  medical  practi¬ 
tioner. 

In  a  physiological  point  of  view  we  should 
be  almost  justified  in  including  the  thorax 
with  the  abdomen  under  one  common  name 
and  description.  In  mammalia,  it  is  true,  the 
diaphragm  constitutes,  for  the  mere  anato¬ 
mist,  a  definite  boundary  between  the  two 
cavities,  but  to  the  physiologist  and  compara¬ 
tive  anatomist  this  separation  appears  arbi¬ 
trary  and  incomplete,  for  not  only  does  the 
skeleton  possess  no  traces  of  this  boundary 
line, — not  only,  moreover,  do  we  find  the 
separation  less  and  less  complete  in  other 
classes  of  the  vertebrate  animals  (so  that  in 
many  of  them  the  lungs  and  heart  are  in 
immediate  contact  with  the  organs  of  diges¬ 
tion), — not  only  do  we  find  in  all  animals  an 
uninterrupted  continuity  in  part  of  the 
viscera  of  the  two  regions,  but,  finally,  we 
notice  that  the  very  partition  which  in  the 
living  man  separates  these  cavities,  does 
itself  in  reality  belong  equally  to  both,  and 
is  equally  subservient  to  their  respective 
functions.  Taking,  then,  this  view  of  the 
subject,  which,  indeed,  physiology  so  amply 
warrants,  we  might  advantageously  contem¬ 
plate  the  hollow7  of  the  trunk  as  one  great 
visceral  cavity,  considering  all  its  parts  and 
organs,  its  apparatus  of  sensibility,  of  se¬ 
cretion,  and  even  of  motion,  as  all  alike 


concerned  in  the  one  great  purpose  of  main¬ 
taining  the  integrity  of  the  blood ;  for 
while  the  viscera  which  more  particularly 
belong  to  the  lower  compartment  regulate 
the  renovation  of  that  fluid  with  regard  to 
quantity ,  constantly  repairing  the  waste 
which  occurs  in  assimilation  and  secretion, 
those  of  the  upper  compartment — the  lungs 
especially — have  the  function  of  renewing 
that  peculiar  quality  of  the  blood  by  which 
it  is  rendered  an  appropriate  source  of  vitality 
to  the  whole  living  organismus.  It  is  inte¬ 
resting,  also,  in  connection  with  this  general 
view  of  the  subject,  to  compare  the  mecha¬ 
nical  contrivances  in  the  upper  and  lower 
portions  of  this  great  cavity, — to  notice  how 
differently  they  are  constructed  in  order  to 
facilitate  the  action  of  the  different  organs 
which  they  respectively  contain,  and  to  con¬ 
trast  the  rigid  walls,  and  almost  uniform 
capacity  of  the  one,  with  the  yielding  parietes 
and  distensible  cavity  of  the  other, — the 
thorax  being  comparatively  limited  as  to  the 
quantity  of  air  it  is  destined  to  receive  in 
the  function  of  respiration,  while  the  abdo¬ 
men  is  capable  of  adapting  itself  both  to  the 
varying  quantity  of  food  ingested,  to  the  dis¬ 
tension  in  gravid  uterus,  accumulation  of  gas 
in  the  intestines,  fluid  in  ascites,  and  in  re¬ 
tention  of  urine. 

The  abdomen,  separately  considered,  is 
placed  between  the  thorax  and  the  lower 
opening  of  the  pelvis ;  it  is  bounded  above 
by  the  diaphragm  and  the  four  inferior  ribs, 
to  which  that  muscle  is  principally  attached; 
below,  by  the  ossa  innominata  and  the  mus¬ 
cles  that  fill  up  the  pelvic  openings ;  behind, 
by  the  lumbar  vertebrae  and  muscles  of  the 
loins ;  and  laterally  by  the  four  inferior  ribs 
and  abdominal  muscles.  Its  external  surface 
presents  an  oval  form,  and  anteriorly  as  well 
as  posteriorly,  it  is  symmetrically  divided 
by  a  raphe,  which  is  in  no  part  of  the  body 
more  distinctly  marked  than  in  this  region. 
The  abdomen  is  convex  on  its  anterior  sur¬ 
face  to  an  extent  differing  according  to  the 
various  epochs  of  life,  and  subject  to  changes 
from  the  condition  of  its  external  organs. 

This  cavity  is  naturally  divided  into  an 
anterior,  two  lateral,  and  a  posterior  aspect; 
but  for  physiological,  pathological,  and  surgi¬ 
cal  purposes,  and  to  enable  us,  indeed,  topo¬ 
graphically  to  describe  accurately  the  relative 
position  of  its  contents,  it  has  been  found 
useful  arbitrarily  to  subdivide  it  into  the  fol¬ 
lowing  regions :  first,  by  drawing  a  line 
from  the  extremity  of  the  last  rib  on  one 
side  to  that  on  the  other ;  and  a  second  line 
from  the  anterior  and  superior  spinous  pro¬ 
cess  of  the  ilium  to  that  on  the  opposite  side. 
Thus  we  divide  the  abdomen  into  three  dis¬ 
tinct  portions,  which  must  not  be  considered 
as  a  superficial  division  only,  but  as  extend¬ 
ing  in  a  continuous  horizontal  plane  imme¬ 
diately  through  the  cavity.  The  space  be- 


EFFECTS  RESULTING  FROM  WOUNDS  AND  INJURIES  OF  ABDOMEN.  181 


tween  the  upper  line  and  the  chest  is  termed 
the  epigastrium,  and  contains  the  principal 
organs  of  chymification  and  chylification. 
The  intermediate  or  central  space  is  termed 
the  umbilical  region,  and  contains  a  large 
proportion  of  the  intestinal  canal  and  the 
kidneys  ;  while  the  lower  space,  termed  the 
Jiypogastrium,  lodges  and  protects  the  re¬ 
mainder  of  the  intestines,  part  of  the  urinary 
organs,  and  the  internal  organs  of  genera¬ 
tion.  Even  this  arrangement  has  not,  how¬ 
ever,  been  considered  sufficiently  definite  to 
localize  with  precision  the  various  organs,  and 
a  further  subdivision  is  resorted  to,  by  draw¬ 
ing  a  vertical  line  on  either  side,  from  the 
junction  of  the  cartilage  of  the  eighth  with 
the  seventh  rib  downwards,  to  a  point 
slightly  external  to  the  spine  of  the  pubes. 
These  two  lines  necessarily  subdivide  each  of 
the  regions  already  spoken  of  into  three 
parts :  the  superior  or  epigastric  region  is 
thus  subdivided  into  a  central  portion, 
termed  the  scrobiculus  cordis ,  and  two  late¬ 
ral,  termed  the  right  and  left  hypochondriac 
regions.  The  middle  region,  in  the  centre, 
retains  the  name  of  umbilical,  but  its  lateral 
portions  are  called  the  right  and  left  lumbar 
regions.  The  inferior  division,  or  hypo- 
gastrium  in  the  centre,  is  distinguished  as 
the  pubic,  while  its  lateral  portions  are 
termed  the  iliac  regions. 

Such  a  subdivision  of  a  continuous  surface 
may  at  a  first  glance  appear  useless  and 
arbitrary  ;  but  a  little  reflection  will  shew 
how  much  the  diagnosis  will  be  facilitated  in 
diseases  of  the  abdominal  viscera  by  these 
means,  and  also  how  advantageous  it  must 
be  to  the  surgeon  in  contemplating  the  ex¬ 
tent  of  injury  inflicted  by  penetrating 
wounds,  and  in  performing  the  numerous 
operations  that  appertain  to  the  abdomen,  to 
have  the  various  viscei’a  thus  localized,  as  it 
were,  externally. 

Between  the  muscular  parietes  of  the 
abdomen  and  the  peritoneum  is  placed  a 
fascia,  which  may  be  designated  the  internal 
abdominal  fascia ;  the  different  parts  of  this 
membrane  have,  however,  been  named  ac¬ 
cording  to  the  muscles  with- which  it  is  in 
contact ;  but  1  consider  this  plan  as  pro¬ 
ductive  of  considerable  confusion. 

This  abdominal  fascia  is  projected  from 
the  interior  with  every  vessel  and  nerve  that 
perforates  the  walls  of  the  abdomen :  the 
spermatic  cord  in  the  male,  the  round  liga¬ 
ment  in  the  female,  the  crural  vessels,  are  all 
furnished  with  prolonged  sheaths  of  this 
membrane,  which  tend  to  constrict  the 
openings  by  which  these  structures  issue 
from  the  abdomen,  and  by  this  constric¬ 
tion  prevent  the  protrusion  of  the  viscera 
themselves  from  their  natural  cavity ;  but 
whenever  or  wherever  such  a  protrusion 
occurs,  the  protruding  viscus  is  invariably 
covered  by  this  fascia — an  anatomical  fact 


which  is  highly  important,  from  the  relation 
it  bears  to  hernia. 

I  shall  now  enter  into  the  consideration  of 
the  effects  resulting  from  the  wounds  and 
injuries  to  which  the  parietes  of  the  abdomen 
are  obnoxious,  and  shall,  in  conformity 
with  the  general  usage  of  authors  upon  this 
subject,  divide  it  into  the  following  heads  : — 
lstly,  Simple  contusions  of  the  abdominal 
parietes;  2dly,  Wounds  of  the  parietes; 
3dly,  Wounds  combined  with  protrusion  of 
the  viscera  ;  4thly,  Wounds  of  the  parietes 
and  viscera  ;  and  lastly,  Laceration  of  the 
viscera  without  solution  of  continuity  of  the 
parietes. 

In  the  first  class  of  injuries,  viz.  simple 
contusion,  no  effect  is  usually  produced 
beyond  the  mere  pain  inseparable  from 
the  accident,  requiring  nothing  more  than 
rest  and  strict  dietetic  observance  to  restore 
the  patient  to  health.  Not  that  this  fortu¬ 
nate  result  always  occurs  :  in  some  few  cases, 
indeed,  it  is  authentically  recorded  that  a 
slight  blow  of  the  epigastrium  has  caused  im¬ 
mediate  death  without  any  apparent  cause 
being  discovered  upon  post-mortem  examina¬ 
tion.  In  such  cases  death  has  been  attributed 
by  some  pathologists  to  an  effect  produced 
upon  the  centre  of  the  great  sympathetic 
nerve,  owing  to  the  relaxed  condition  of  the 
abdominal  muscles,  which  were  unprepared 
at  the  moment  to  offer  protective  resistance 
to  the  applied  force.  In  other  cases  a  con¬ 
dition  of  collapse  results,  which  may  render 
it  extremely  difficult  to  form  a  just  diag¬ 
nosis  of  the  extent  of  the  injury  sustained. 
Under  such  circumstances  it  is  right,  gen¬ 
tlemen,  to  withold  your  decision,  both  as 
to  treatment  and  prognosis,  until  the  reac¬ 
tion  has  occurred  ;  and  perhaps  it  may  be 
necessary  to  administer  warmth  or  even 
slight  stimuli  to  the  patient,  to  produce  the 
desired  effect ;  and  only  upon  the  early 
restoration  of  reaction,  and  the  absence  of 
relapse,  can  the  surgeon  judge  whether  the 
injury  consist  in  simple  contusion  or  is 
complicated  by  internal  lesion.  If,  when 
reaction  takes  place,  the  pulse  denotes  in¬ 
ordinate  force,  and  the  temperature  of  the 
body  is  abnormally  raised,  active  antiphlo¬ 
gistic  means  should  be  had  recourse  to,  to 
prevent  the  liability  to  subsequent  perito¬ 
nitis,  which  is  as  much  to  be  dreaded  as  the 
immediate  effects  of  the  injury.  Abstraction 
of  blood,  rest,  and  a  perfectly  flexed  state  of 
the  abdominal  muscles,  are  the  means  to  be 
employed  to  prevent  this  tendency  to  in¬ 
flammation  ;  for  it  must  be  considered  as  a 
serious  error  on  the  part  of  any  surgeon  to 
permit  in  such  a  case  inflammatory  symp¬ 
toms  to  manifest  themselves,  and  be  com¬ 
pelled  to  employ  as  a  remedy  those  means 
which  he  ought-  to  have  used  as  a  preventive. 
The  immediate  effects  produced  by  a  blow 
will  depend  in  great  measure  upon  the  par- 


182 


LACERATION  OF  THE  ABDOMINAL  MUSCLES. 


ticular  region  in  which  it  has  been  inflicted, 
and  the  disturbance  to  the  functions  of  any 
organ  in  that  region  would  sufficiently  con¬ 
stitute  the  diagnosis,  and  indicate  the  proper 
treatment. 

Laceration  of  the  abdominal  muscles  may 
occur  from  a  blow  on  the  abdomen  :  blood 
may  be  extravasated,  or  subsequent  ab¬ 
scesses  may  result ;  each  of  these  effects 
would  necessarily  lead  to  protracted  surgical 
treatment,  the  diagnosis  of  the  nature  of  the 
injury  being  formed  from  the  concomitant 
symptoms  which  occurred. 

2dly.  When  the  parietes  of  the  abdomen 
are  wounded  either  by  laceration  or  incision, 
but  the  wound  is  not  attended  by  the  pro¬ 
trusion  of  viscera,  there  is  little  difference  in 
the  treatment  than  that  already  recom¬ 
mended,  excepting  that  in  the  lacerated 
wound  the  parts  are  to  be  supported  so  as 
to  diminish  the  extent  of  surface  to  be 
healed  by  granulation  ;  while  in  the  incised 
wound  the  edges  are  to  be  brought  into 
perfect  apposition,  and  maintained  by 
suture,  to  promote  the  rapid  adhesion  of 
the  surfaces  ;  but  in  both  cases  the  abdo¬ 
minal  muscles  must  be  kept  perfectly  re¬ 
laxed.  It  is  very  important,  in  wounds  of 
the  abdomen,  to  diminish  the  extent  of  the 
cicatrix  as  much  as  possible,  as,  if  it  is 
large,  the  parietes  of  the  abdomen  are  pro- 
portionably  weakened,  and  the  patient  ren¬ 
dered  liable  to  subsequent  hernia.  In 
wounds  of  the  abdomen  inflicted  by  a  cutting 
instrument,  it  is  often  difficult  to  ascertain 
whether  any  internal  viscus  is  injured  : 
the  surgeon  should,  however,  avoid  ex¬ 
ploration  by  the  probe,  as  he  may  inflict 
more  injury  than  had  been  sustained  in  the 
original  accident.  If,  however,  from  col¬ 
lapse  or  any  other  urgent  symptom,  it  ap¬ 
pears  probable  that  the  intestine  is  wounded, 
the  edges  of  the  wound  should  not  be  se¬ 
cured  with  great  exactness,  but  a  sufficient 
opening  left  to  admit  of  the  exit  of  faecal 
matter  ;  abstaining  also  from  the  use  of  pur¬ 
gatives,  although  other  antiphlogistic  means 
may  be  required  after  reaction  has  once 
been  completely  established.  If  it  should 
prove  that  the  intestine  has  not  been  in¬ 
jured,  the  external  wound,  which  was  at 
first  intentionally  left  partially  open,  should 
be  closed,  and  reparation  promoted  as  ra¬ 
pidly  as  possible. 

A  sailor  was  admitted  into  Accident 
ward  in  1836,  in  consequence  of  an  incised 
wound  he  had  received  while  “  skylarking” 
with  a  shipmate.  The  wound  was  of  three 
inches  in  extent,  situated  in  the  right  iliac 
region,  and,  upon  examination,  it  seemed 
not  to  have  opened  the  abdominal  cavity. 
The  patient,  however,  being  in  a  state  of 
partial  collapse,  probably  from  loss  of  blood, 
the  edges  of  the  incision  were  not  imme¬ 
diately  brought  into  very  close  adaptation. 


Reaction,  however,  soon  took  place,  and 
immediately  after  the  bowels  had  been 
opened,  without  any  indication  of  their 
having  been  injured,  the  wound  was  com¬ 
pletely  closed,  and  it  healed  most  rapidly 
without  the  occurrence  of  a  single  bad 
symptom. 

A  drover  was  admitted  in  Stephen’s 
ward  about  five  years  ago,  who  had  been 
gored  by  an  ox,  the  horn  having  entered 
just  below  Poupart’s  ligament,  and  extended 
three  or  four  inches  into  the  abdominal 
parietes.  The  patient  was  at  first  collapsed, 
and  he  was  obliged  to  have  stimuli  before 
reaction  took  place,  which  being  established, 
antiphlogistic  remedies  were  administered, 
and  poultices  and  fomentations  were  applied 
to  the  wound.  The  latter  was  a  long  time 
granulating,  in  consequence  of  repeated 
abscesses  ;  but  he  ultimately  recovered. 

3dly.  When  the  viscera  protrude  through 
the  wound  in  the  abdomen,  a  new  considera¬ 
tion  arises  as  to  the  fitness  of  the  protruded 
viscus  to  be  returned  into  its  natural  cavity : 
it  is  necessary,  therefore,  to  examine  whe¬ 
ther  it  is  wounded  by  the  instrument  which 
produced  the  injury  in  the  abdomen,  or 
whether  it  has  undergone  any  change  during 
the  period  it  may  have  been  exposed  to  the 
influence  of  external  agents,  and  whether  it 
be  constricted,  from  the  smallness  of  the 
opening  through  which  it  has  protruded. 
Let  us  suppose  that  the  intestine  has 
not  been  penetrated,  and  that  it  is  in  a  fit 
state  to  be  returned  to  its  natural  situation. 
The  restoration  should  be  effected  as  quickly 
as  possible,  the  wound  through  the  parietes 
being  enlarged,  if  necessary,  to  facilitate 
the  reduction  of  the  protruded  part.  The 
edges  of  the  wound  are  then  to  be  brought 
together  and  retained  by  suture  ;  then  treat¬ 
ing  the  accident  as  in  the  second  class  of 
injuries  to  the  abdomen,  to  which  it  is, 
indeed,  reduced.  Should  any  doubt  exist 
in  the  mind  of  the  surgeon  as  to  the  pro¬ 
priety  of  returning  the  intestine  into  the 
abdomen,  either  from  its  altered  colour, 
abnormal  coldness,  loss  of  elasticity,  or  any 
other  prominent  change  in  its  physical  or 
vital  properties,  the  surgeon  has  then  duly 
to  weigh  in  his  mind  the  probable  chances 
of  the  reparation  of  the  part,  considering 
equally  the  constitutional  powers  of  the 
patient  and  the  actual  conditions  of  the 
parts  themselves.  If,  upon  mature  reflec¬ 
tion,  any  doubt  should  still  remain  on  his 
mind,  I  think  it  better,  as  a  general  prin¬ 
ciple,  to  return  the  intestine  into  its  cavity, 
as  it  is  there  placed  under  the  most  favoura¬ 
ble  circumstances  for  the  restoration  of  its 
vital  energies. 

Caution  must,  however,  be  observed  when 
the  return  of  the  intestine  is  determined 
upon,  care  being  taken  to  leave  the  in¬ 
jured  portion  as  near  as  possible  to  the 


PROTRUSION  OF  VISCERA.  VISCERA  WOUNDED. 


183 


wound  through  the  parietes  ;  so  that,  should 
hature  fail  in  her  attempt  at  reparation, 
an  exit  for  the  contents  of  the  intestine 
may  be  secured.  Such  a  difficulty  in  deter¬ 
mining  on  the  propriety  of  returning  a 
morbidly  changed  viscus  into  the  abdomen 
often  occurs  in  the  operation  for  hernia ; 
and  I  have  frequently  experienced  it,  but 
can  faithfully  say  that  I  have  scarcely  ever 
had  to  regret  the  determination  to  return 
the  intestine,  although  frequently  to  regret 
having  left  it  in  the  hernial  sac.  After  the 
intestine  has  been  returned  without  any 
signs  of  collapse,  but,  on  the  contrary, 
perhaps  followed  by  symptoms  of  increased 
arterial  action  (indicated  by  hard  or  small 
pulse),  leeches  should  be  applied  upon  the 
abdomen,  and  sudorifics  and  very  small 
doses  of  calomel  with  opium  prescribed  ; 
purgative  medicines  should,  however,  be 
avoided  for  several  days,  as  a  perfect  state 
of  rest  of  the  intestine  is  most  likely  to 
promote  restoration  to  its  natural  condi¬ 
tion. 

There  are  many  cases  on  record  of  viscera 
which  had  protruded  through  incised  wounds 
of  the  abdomen,  being  returned  into  their  na¬ 
tural  cavity  without  any  urgent  symptoms 
having  supervened.  I  have  met  with  several 
such  cases  in  my  own  practice ;  and  the  late 
Mr.  Morgan  used  to  relate  a  case  of  a  boy 
at  Tottenham,  who  received  a  wound  in  the 
abdomen,  through  which  the  intestines  were 
protruded  :  the  child  placed  the  protruded 
viscus  in  his  pinafore,  and  walked  some 
distance  to  a  surgeon,  who,  having  carefully 
cleansed  the  bowel  from  a  quantity  of  ad¬ 
hering  dust,  replaced  it  in  the  abdomen, 
sewed  up  the  wound  by  the  twisted  suture, 
and  in  a  comparatively  short  time  restored 
the  boy  to  perfect  health. 

When  the  omentum  only  is  protruded,  if 
it  has  been  exposed  sufficiently  long  for 
adhesion  to  have  taken  place  at  the  internal 
edges  of  the  wound  ;  or  if,  from  the  small¬ 
ness  of  the  opening,  there  is  any  difficulty 
in  returning  the  protruded  portions  ;  or, 
thirdly,  if  the  omentum  has  undergone  any 
abnormal  change,  I  consider  it  better  that 
it  should  be  left  to  slough,  rather  than  that 
it  should  be  returned  into  the  abdomen  ; 
and  I  have  seen  cases  terminate  most  suc¬ 
cessfully  under  this  plan  of  treatment, 
adopting  the  same  means  as  have  already 
been  described  to  prevent  subsequent  peri¬ 
tonitis.  When  it  is  decided  to  leave  the  pro¬ 
truding  omentum  out  of  the  abdomen, 
poultices  should  be  applied  to  it ;  and  when 
it  is  in  a  complete  state  of  slough,  a  ligature 
may  be  placed  around  it,  to  promote  sepa¬ 
ration  ;  but  before  the  disorganisation  is 
complete,  it  is  better  not  to  remove  it  either 
by  ligature  or  knife,  as  the  former  may  tend 
to  produce  peritonitis,  and  the  latter  to 
cause  heemorrhage. 


Such  accidents  as  I  have  mentioned  have 
been  known  frequently  to  occur,  in  which 
the  peritoneal  cavity  has  been  opened,  re¬ 
sulting  both  from  accident  and  operation, 
and  without  any  ultimate  injurious  results  : 
hence  it  has  been  inferred  by  some  that  the 
great  danger  generally  attached  to  lesion  of 
the  peritoneum  is  overrated.  The  surgeon 
should,  however,  hesitate  before  he  arrives 
at  such  a  conclusion  ;  learning,  from  the 
result  of  the  operation  for  strangulated 
hernia,  how  much  more  frequently  the  cause 
of  failure  depends  upon  subsequent  inflam¬ 
mation  of  the  peritoneum  than  upon  any 
morbid  change  which  the  intestine  itself  may 
have  undergone.  It  is  true  that  in  the  re¬ 
moval  of  the  ovaria — an  operation  that  has 
lately  been  frequently  performed  —  many 
cases  have  proved  successful,  notwithstand¬ 
ing  the  extensive  lesions  of  this  membrane  ; 
but,  in  my  opinion,  these  results  involve  the 
question  whether  the  peritoneum  has  not 
undergone,  from  the  pressure  of  the  tumor, 
such  morbid  alteration  as  completely  to 
change  its  specific  character,  and  to  prevent 
that  accession  of  inflammation  to  which  the 
healthy  peritoneum  under  injury  is  so 
prone.  It  sometimes  happens  that  cases  of 
protruded  viscera  through  wounds  in  the 
parietes  of  the  abdomen  prove  fatal  when 
the  immediate  manifestations  of  injury  are 
not  sufficient  to  account  for  such  a  termina¬ 
tion.  In  these  cases  death  is  no  doubt 
generally  the  effect  of  concomitant  injury  to 
more  distant  vital  parts,  as  the  following 
instance  will  illustrate  : — 

About  two  years  since,  a  man  was 
brought  into  Guy’s  Hospital,  in  consequence 
of  very  severe  injuries  which  he  had  received 
while  in  the  act  of  stealing  lead  from  the 
top  of  a  brewery,  from  which  he  fell.  Upon 
examination,  it  was  found  that  he  had  torn 
open  an  old  scrotal  hernia,  and  that  a  conside¬ 
rable  quantity  of  intestine  had  protruded,  and 
had  remained  exposed  for  nearly  an  hour ; 
one  of  his  thighs  was  also  broken,  and  his 
left  shoulder  dislocated.  The  intestine  was 
immediately  returned  into  the  cavity  of  the 
abdomen,  and  the  edges  of  the  wound 
brought  together  by  the  uninterrupted 
suture  ;  the  fractured  thigh  was  placed  in 
splints,  and  the  dislocated  shoulder  reduced, 
which  was  accomplished  with  much  more 
than  usual  facility,  in  consequence  of  the 
state  of  collapse  of  the  patient  from  his  ab¬ 
dominal  injury.  His  pulse  being  feeble,  the 
surface  of  his  body  cold,  and  his  respiration 
difficult,  julep  ammon.  was  administered, 
and  bottles  of  hot  water  applied  to  his  feet, 
for  the  purpose  of  producing  reaction,  which 
was  no  sooner  effected  than  pain  in  the  ab¬ 
domen  came  on,  for  which  leeches  were  ap¬ 
plied,  and  calomel  with  opium  given,  for 
the  purpose  of  allaying  his  pain ;  all  the 
symptoms,  however,  rapidly  increased  in 


184 


dr.  todd’s  clinical  observations  on  paralysis. 


urgency,  and  in  fifteen  hours  after  his  ad¬ 
mission  he  died. 

Upon  examination  of  his  body,  it  was 
found  that  he  had  been  the  subject  of  severe 
peritonitis,  demonstrable  from  the  quantity 
of  coagulable  lymph  which  was  poured 
out ;  the  portion  of  intestine  which  had  pro¬ 
truded  had  not  been  ruptured,  nor  were 
there  any  signs  by  which  it  could  be  known 
from  the  rest  of  the  intestines,  but  from  a 
slight  degree  of  thickening,  probably  from 
its  frequent  descent  into  the  old  hernial  sac. 
The  diaphragm  w~as  found  ruptured,  and  a 
considerable  portion  of  the  stomach  pro¬ 
truded  into  the  chest — a  circumstance  of 
which  there  was  no  suspicion  from  the 
symptoms  during  life. 


CLINICAL  LECTURE 
ON 

PARALYSIS, 

Delivered  at  King's  College  Hospital, 

By  R.  B.  Todd,  M.D.  F.R.S. 
Physician  to  the  Hospital. 

(Reported  by  Mr.  S.  J.  A.  Salter,  A.Iy.C.) 


Lecture  II. 

In  my  last  lecture,  gentlemen,  I  stated  to 
you  the  principal  causes  capable  of  pro¬ 
ducing  paralysis,  and  called  your  attention 
to  three  cases  then  in  the  hospital,  in  one  of 
which  the  paralysis  depended  on  the  pre¬ 
sence  of  lead  in  the  system  ;  in  the  second 
it  was  caused  by  a  local  injury  to  the  nerves 
of  the  upper  extremity  by  a  fractured 
clavicle,  or  rather  the  treatment  which  was 
adopted  in  curing  it ;  and  the  third  was  one 
of  hysterical  hemiplegia.  All  of  these  have 
now  left  the  hospital,  one  much  improved, 
the  second  but  slightly  so,  and  the  third 
quite  cured. 

I  purpose  now  to  speak  of  some  cases  of 
paralysis  which  have  their  origin  in  disease 
of  the  brain.  A  prominent  feature  of  this 
kind  of  paralysis  is  its  one-sidedness,  con¬ 
stituting  that  which  is  called  hemiplegia ,  or 
paralysis  of  one  side  of  the  body  from  dis¬ 
ease  of  the  opposite  half  of  the  brain. 

The  first  case  to  which  I  shall  refer  is  that 
of  Thomas  Hardwick,  aged  49,  a  smith,  of 
temperate  habits.  This  man  was  first  at¬ 
tacked  eight  weeks  ago  with  pain  in  the 
region  of  the  left  parietal  bone  ;  this  was 
followed  by  dimness  of  vision,  and  often  dou¬ 
ble  vision.  These  symptoms  continued  a 
month,  and  he  then  had  what  he  calls  rigors , 
affecting  the  right  arm  and  leg,  which  were 
probably  convulsive  movements  of  those 
limbs.  These,  he  says,  “  turned  to  erysi¬ 
pelas,  ”  and  were  followed  by  loss  of  power 
in  this  leg,  and  afterwards  in  the  arm. 


On  his  admission  be  was  suffering  from 
pain  in  the  left  side  of  the  head  ;  there  was 
loss  of  power,  affecting  both  the  right  arm 
and  leg,  and  loss  of  sensation  in  the  arm  ; 
the  loss  of  power  was  greater  in  the  arm 
than  in  the  leg.  In  walking,  he  drags  the 
right  leg  at  the  same  time  that  he  lifts  it 
from  the  ground,  by  inclining  the  trunk  to 
the  opposite  side. 

The  contrast  between  the  movement  of 
the  paralysed  leg  in.  this  case  and  in  the 
case  of  hysterical  paralysis  to  which  I  re¬ 
ferred  in  the  last  lecture,  is  very  striking. 
In  this  case  the  leg  is  lifted  from  the 
ground  ;  but  in  the  hysterical  case  it  is 
dragged  along  as  if  dead,  without  the 
slightest  attempt  to  lift  it.  As  both  patients 
are  now  in  the  house,  you  have  abundant 
opportunity  of  observing  and  contrasting 
the  different  kind  of  movement  in  each. 

The  paralysed  limbs  exhibit  considerable 
rigidity  of  the  muscles  ;  this  becomes  par¬ 
ticularly  obvious  in  the  arm  when  an  at¬ 
tempt  is  made  to  extend  the  forearm  upon 
the  arm,  the  biceps  becoming  rigid,  as  if  it 
resisted  extension.  This  resistance  on  the 
part  of  the  biceps  to  the  complete  extension 
of  the  forearm  upon  the  arm  is  often  the 
only  mark  of  any  irritated  condition  of  the 
nerves  or  muscles  of  the  palsied  limb. 
While  the  limb  is  quiescent,  the  muscles 
are  soft  and  relaxed ;  but  the  moment  ex¬ 
tension  is  attempted,  the  biceps  becomes 
firm  and  resisting.  The  extending  force 
excites  the  biceps  by  reflexion,  when  there 
is  even  the  slightest  excitement  in  the  nerves 
of  the  affected  limb. 

There  is.  also  in  this  case  palsy  of  the 
l  ight  side  of  the  face,  denoted  by  hanging  of 
the  cheek,  and  by  paralysis  of  the  buccinator 
muscle.  The  movements  of  the  eyes  pre¬ 
sent  a  very  peculiar  appearance  :  they  are 
constantly  directed  downwards,  with  a  con¬ 
vulsive  action  of  the  depressing  muscles. 
When  desired  to  open  his  eyes,  or  direct 
them  in  any  way,  by  means  of  a  strong 
voluntary  effort,  this  movement  of  the  eye¬ 
balls  becomes  more  excited,  and  is  accom¬ 
panied  by  very  marked  convulsive  twitch* 
ings.  In  consequence,  no  doubt,  of  these 
irregular  movements,  vision  is  sometimes 
double ;  the  pupils  are  unequal,  the  right 
being  larger.  These  symptoms  clearly  in¬ 
dicate  some  irritative  disease  affecting  the 
third  pair  of  nerves,  either  in  their  course  or 
at  their  origin.  You  will  observe  that  in 
this  case  the  power  over  the  orbicular 
muscle  of  the  eyelids  has  not  been  at  all 
impaired,  indicating  that  the  portio  dura 
of  the  seventh  pair  of  nerves  is  untouched. 
In  general,  in  cases  of  hemiplegic  paralysis, 
the  tongue  deviates  to  the  paralysed  side. 
This  case  was  an  apparent,  though  not  a 
real,  exception  to  this  rule  ;  for  the  tongue 
deviated  to  the  sound  side.  On  careful 


DR.  TODD  S  CLTNICAL  OBSERVATIONS  ON  PARALYSIS. 


185 


examination,  however,  it  was  found  that 
certain  projecting  teeth  in  the  lower  jaw 
diverted  the  course  of  the  tongue  from  its 
ordinary  channel  into  a  deviation  to  the 
right  side ;  and  the  case  illustrates  the 
remarks  which  I  made  on  this  subject  in 
mv  last  lecture. 

Now  the  points  in  this  case  which  served 
for  the  foundation  of  a  diagnosis  were,  first, 
the  existence  of  pain  ;  next,  the  occurrence 
of  paralysis  on  the  opposite  side  to  the  pain  ; 
and,  lastly,  the  irregular  movements  of  the 
eyeballs,  and  the  double  vision. 

The  existence  of  fixed  pain  in  the  head  in 
general  indicates  intra-cranial  irritation. 
Pain  in  the  head  may  be  situate  in  the  course 
of  some  of  the  nerves  of  the  scalp,  over  the 
brow,  or  across  the  forehead,  or  in  the 
temple,  or  spreading  upon  the  parietal  bone, 
or  at  the  vertex.  Pain  in  these  situations  is 
apt  to  shift,  or  intermit,  or  sometimes  it 
gives  the  sensation  of  a  nail  being  driven 
into  the  head — the  clavus  hystericus.  When 
pain  exhibits  such  characters  as  these,  it  is 
not  indicative  of  any  mischief  going  on 
within  the  skull,  but  rather  is  symptomatic 
of  deranged  digestion,  or  of  some  constitu¬ 
tional  disturbance,  or  of  a  hysterical  or  hypo¬ 
chondriac  state,  or  it  is  the  result  of  debility 
or  exhaustion  ;  but  where  the  pain  is  fixed 
in  its  situation,  as  in  this  case,  and  varies 
only  in  intensity,  and  not  in  locality,  it  can 
only  be  referred  to  intra-cranial  irritation, 
such  as  probably  would  arise  from  disease 
of  the  membranes,  or  of  some  superficial 
parts  of  the  brain.  Disease  of  the  corpus 
striatum,  or  of  the  optic  thalamus,  does  not 
generally  produce  pain,  which  is  distinctly 
referrible  to  a  particular  spot.  When  dis¬ 
ease  of  these  parts  occurs,  it  either  causes 
no  pain  at  all,  or  a  dull  heavy  pain,  which 
the  patient  cannot  localise  ;  unless,  indeed, 
the  pia  mater  in  connection  with  them  be 
extensively  diseased.  If  the  dura  mater,  or 
the  arachnoid,  or  the  pia  mater,  become  the 
seat  of  disease,  then  pain  is  produced,  and 
the  patient  refers  it  to  a  point  which  very 
nearly  corresponds  to  the  site  of  the  morbid 
lesion :  hence  such  pain  as  our  patient 
suffers  may  be  looked  upon  as  indicating 
rather  a  superficial  than  a  deep-seated 
lesion. 

Another  important  symptom  under  which 
this  man  laboured  was  dimness  of  vision, 
which  also  assumed  the  form  of  double 
vision.  This  symptom,  although  it  often 
occurs  independently  of  cerebral  lesion, 
ought,  nevertheless,  to  excite  the  suspicion 
of  such  lesion,  and  more  especially  if  there 
be  at  the  same  time  any  affection  of  the 
muscles  of  the  eyeball. 

The  paralysis  in  this  case  is  of  that  kind 
which  generally  depends  on  cerebral  lesion, 
its  one-sided  character  denoting  a  cerebral 
rather  than  a  spinal  origin  :  at  the  same 


time,  you  must  bear  in  mind,  as  I  pointed 
out  in  my  last  lecture,  that  a  similar  form  of 
paralysis  may  take  place,  as  the  result  of 
hysteria,  where  th^re  is  no  appreciable 
lesion  at  all.  In  th:aj  case  it  is  plain  that 
the  paralysis  is  nof  the  hysterical  kind, 
because  the  face  is  affected,  and  also  because 
the  mode  of  moAvig  the  leg  is  essentially 
different  from^ jstbf  the  hysterical  palsy; 
the  patient  k-  -,,  rdf  the  male  sex,  which  is 
very  much  #.  liable  to  these  hysterical 
affections. 

The  parts  of  the  brain,  die  lesion  of  which 
is  most  apt  to  produce  hemiplegia,  are 
the  corpus  striatum  and  the  optic  thalamus, 
and  the  most  frequent  lesions  of  them  are 
softening,  a  clot,  or  abscess.  It  is  remark¬ 
able  that  lesion  of  the  optic  thalamus  should 
produce  nearly,  or  precisely,  the  same  effects 
as  lesion  of  the  corpus  striatum.  This  is 
probably  explained  by  the  intimate  union  of 
the  two  bodies,  so  that  neither  can  be 
affec:ed  without  the  other  participating  in 
the  morbid  influence;  but  if  the  optic 
thalamus  be  the  part  diseased,  the  corpus 
striatum  will  suffer  more  in  consequence 
than  the  optic  thalamus  would  if  the  corpus 
striatum  were  the  seat  of  lesion,  because  of 
the  great  size  and  extensive  connections  of 
the  optic  thalamus,  and  the  smaller  size  and 
more  limited  connections  of  the  corpus 
striatum.  Disease  also  in  the  immediate 
vicinity  of  these  parts  will  cause  paralysis ; 
but  if  the  lesion  be  situated  quite  near  the 
surface  of  either  hemisphere  of  the  brain, 
and  be  not  of  such  a  nature  as  to  produce 
pressure,  there  will  be  no  paralysis. 

A  clot,  or  an  abscess,  or  a  tumor,  in  the 
centre  of  the  centrum  ovale,  will  not  produce 
paralysis  if  it  do  not  cause  pressure,  or  in¬ 
terfere  materially  with  any  of  the  fibres  of 
the  corpus  striatum. 

Another  condition  capable  of  producing 
hemiplegia  is  inflammatory  or  other  disease 
of  the  membranes.  The  dura  mater  cannot 
suffer  long  from  inflammatory  disease  with¬ 
out  implicating  the  arachnoid  or  pia  mater. 
When  you  get  inflammation  of  these  mem¬ 
branes,  you  have  effusion  of  lymph  or  of 
pus,  which,  as  it  increases,  causes  pressure 
on  the  surface  of  the  brain,  which  is  then 
extended  to  the  corpus  striatum  and  optic 
thalamus,  and  thence  results  the  paralysis. 

If  some  of  the  deeper- seated  parts,  such 
as  the  crura  cerebri,  are  affected,  we  also 
have  paralysis  ;  because  the  crura  cerebri,  as 
the  bond  of  union  between  the  corpora 
striata  and  spinal  cord,  form  a  part  of  the 
great  centre  of  volition.  Disease  of  the 
cerebellum  or  its  crura,  provided  it  be  deep- 
seated,  will  also  produce  hemiplegia  ;  this 
is  probably  due  to  the  connection  which  is 
formed  between  the  hemispheres  of  the  cere¬ 
bellum  and  the  fibres  of  the  pyramids  in  the 
pons  Yarolii. 


186 


DR.  TODD’S  CLINICAL  OBSERVATIONS  ON  PARALYSIS. 


Now,  in  the  case  of  Hardwick,  the  first 
symptoms  were  those  of  irritation,  produc¬ 
ing  convulsive  movements  of  the  right  side  ; 
and  these  were  followeds-by  incomplete  para¬ 
lysis  of  the  limbs.  ts  slow  access  of  the 
paralysis,  following  ms  of  irritation, 

gives  us  some  clue  t,j  the  nature  of  the  ex¬ 
citing  lesion.  These  pheromena  are  pre¬ 
cisely  such  as  one  would  etu<>ct,  where  the 
lesion  consisted  in  infl<ltrilou.\on  of  the 
membranes  of  the  brain,  accL.npanied  by 
effusion  of  lymph.  In  the  first  Aages  of  the 
inflammatory  affection  you  would  have  irri¬ 
tation,  and  consequently  convulsive  move¬ 
ments  ;  and  in  a  later  stage,  where  the 
lymph  came  to  be  effused,  we  should  have 
pressure  and  paralysis  ;  but  as  the  pressure 
was  not  excited  immediately,  but  only  indi¬ 
rectly,  upon  the  centre  of  volition,  the  para¬ 
lysis  would  be  incomplete. 

A  very  interesting  and  important  feature 
in  the  paralysis  in  this  case  is  the  accom¬ 
panying  spastic  or  rigid  state  of  the  muscles. 
This  rigidity,  according  to  my  experience,  if 
it  supervene  early  in  the  paralytic  seizure, 
or  simultaneously  with  the  paralysis,  indi¬ 
cates  irritative  disease  within  the  cranium. 
It  is  not  uncommon,  however,  to  meet  with 
cases  in  which  there  has  been  very  com¬ 
plete  paralysis,  with  perfect  resolution  of  the 
muscles ;  but  after  a  time  these  muscles 
slowly  become  rigid,  the  fingers  become 
flexed,  and  sometimes  firmly  pressed  against 
the  palm  of  the  hand,  the  hand  bent  upon 
the  fore-arm,  and  the  fore-arm  upon  the 
arm,  with  a  tense  and  spastic,  although 
wasted  condition,  of  the  muscles.  This 
late  form  of  muscular  rigidity  you  must 
carefully  distinguish  from  the  early  one, 
inasmuch  as  the  former  indicates  that  there 
has  been  loss  of  substance  in  the  brain,  and 
that  the  cicatrix  is  undergoing  contraction. 

You  will  meet,  in  practice,  four  different 
conditions  of  the  muscles  in  paralytic  limbs 
in  different  cases.  The  first  differs  scarcely 
at  all  from  that  of  the  healthy  muscles  ;  the 
muscles  exhibit,  perhaps,  less  firmness,  and 
are  less  excitable  by  the  galvanic  stimulus, 
when  the  paralysing  lesion  is  not  of  an  irri¬ 
tative  kind.  A  second  condition  presents 
complete  relaxation  of  the  muscles :  they  are 
soft,  imperfectly  nourished,  and  waste  with 
wonderful  rapidity  ;  so  that  under  a  paralysis 
of  a  few  days’  duration  the  size  of  the  limb 
experiences  a  very  marked  diminution.  In 
these  muscles  there  is  very  little  excitability 
to  the  galvanic  stimulus — sometimes  almost 
none.  This  is  the  most  complete  condition 
of  paralysis,  in  the  strict  sense  of  that  term, 
and  it  is  sometimes  accompanied  with  pheno¬ 
mena  which  denote  a  depressed  state  of  the 
general  nutrition  of  the  limb  :  the  pulse  in 
the  large  arteries  of  that  side  is  weaker  ; 
there  is  sometimes  more  or  less  of  oedema, 
especially  if  the  limb  be  kept  in  a  dependent 


position ;  and  the  heat  of  the  limb  is  imper 
fectly  maintained.  Some  of  these  cases  ge 
well ;  others  continue  paralysed,  although 
the  general  health  of  the  patient  improves, 
and  the  muscles  become  wasted  to  mere 
membranes  ;  others,  again,  continue  para¬ 
lysed,  but  the  muscles  gradually  assume  a 
condition,  the  third  condition  to  which  I 
wish  to  call  your  attention — one  of  contrac¬ 
tion  and  rigidity,  the  flexor  muscles  always 
exhibiting  this  state  to  a  greater  degree  than 
the  extensors.  The  muscles  are  still  wasted, 
but  they  are  stretched  like  tense  cords  be¬ 
tween  their  origins  and  insertions.  The 
biceps  in  the  arm,  and  the  hamstring  mus¬ 
cles  in  the  thigh,  project  beneath  the  skin 
like  tense  membranes.  This  condition  is  due 
to  a  chronic  shortening  of  the  muscles  them¬ 
selves  :  they  are  tense,  but  not  firm  nor 
plump  ;  it  is  undoubtedly  a  form  of  muscular 
atrophy,  and  is  accompanied  with  feebleness 
of  circulation  and  coldness  of  the  limb.  A 
fourth  condition  is  illustrated  by  our  present 
case.  The  muscles  suffer  very  little,  or  not 
at  all,  in  their  nutrition  ;  the  paralysis  is  sel¬ 
dom  complete  ;  and  the  muscles  are  either 
constantly  firm  and  rigid,  or  become  so  on 
the  slightest  movement  of  the  limb.  In 
these  cases  there  is  more  or  less  of  an  exal¬ 
tation  of  nutrition, — the  circulation  in  the 
limb  is  vigorous,  and  its  heat  is  not  below 
the  standard  of  the  other  limb  ;  and  it  is 
frequently  more  excitable  by  galvanism  than 
the  corresponding  muscles  on  the  other  side. 

I  must  beg  your  particular  attention  to 
these  various  states  in  which  the  muscles  of 
paralytic  limbs  are  found.  You  may  draw 
practical  inferences  from  them  of  great 
value  in  treatment :  when  the  early  condi¬ 
tion  of  rigidity  is  present  your  patient  will 
bear  localbleeding  or  local  counter-irritation, 
or  both,  with  advantage  ;  and  will  derive 
benefit  from  them,  provided  other  symptoms 
do  not  contraindicate  them.  The  state  of  com¬ 
plete  relaxation  affords  no  indication  for  the 
use  of  antiphlogistic  measures,  but  on  the 
contrary,  in  many  of  the  cases  in  which  it 
occurs  it  should  be  regarded  as  affording  a 
contrary  indication.  As  to  that  condition 
in  which  the  muscles  assume  the  contracted 
state  gradually,  and  some  time  after  the 
paralytic  seizure,  I  wish  much  it  were  in  my 
power  to  suggest  some  means  of  arresting  it. 
Some  slight  benefit  is  gained  by  subjecting 
the  limb  to  frequent  extension  at  stated 
periods  in  the  day  :  this  I  believe  will  retard 
the  contraction,  so  long  as  it  is  diligently 
persisted  in  ;  but  when  it  has  been  laid  aside 
the  contraction  will  go  on  just  as  if  the  ex¬ 
tension  had  never  been  employed.  The  case 
is  analogous  to  that  of  stricture  in  the  ure¬ 
thra,  or  the  cicatrix  after  a  burn,  which  ex¬ 
hibit  a  remarkable  tendency  to  contract, 
requiring  in  the  former  case  the  long-con¬ 
tinued  use  of  the  bougie,  and  in  many 


DR.  TODU’S  CLINICAL  OBSERVATIONS  ON  PARALYSIS. 


187 


instances  its  frequent  employment  through- 
out  the  entire  life  of  the  patient.  In  both 
instances,  indeed,  I  believe  I  am  correct  in 
saying  that  surgeons  have  hitherto  failed  in 
finding  any  means  to  check  effectually  the 
tendency  to  contraction. 

I  may  add  that  long-continued  and  forcible 
extension  of  the  limb  gives  rise  to  conside¬ 
rable  pain  when  the  muscles  are  in  the 
state  of  chronic  contraction — pain  so  severe 
that  the  patient  cannot  bear  the  extension 
for  any  length  of  time. 

But  to  recur  to  the  case  of  Hardwick. 
From  the  various  symptoms  I  have  detailed 
to  you  I  have  been  led  to  the  following 
diagnosis  in  this  case  —  namely  that  the 
lesion  is  of  an  inflammatory  kind,  —  that 
it  is  principally  and  primarily  meningeal; 
so  far  I  can  speak  without  hesitation,  but 
in  determining  the  precise  locality  more 
difficulty  is  experienced  ;  I  have  no  doubt, 
however,  that  it  is  so  situated  as  to 
affect  the  optic  and  third  pair  of  nerves ; 
and  from  the  seat  of  the  pain,  which 
the  man  has  always  referred  to  the  left 
parietal  bone,  I  should  assign  as  its  locality 
the  dura  mater,  and  the  other  membranes  in 
the  vicinity  of  the  anterior  and  inferior  angle 
of  that  bone;  thence  the  disease  has  extended 
perhaps  along  the  fissure  of  Sylvius,  and  thus 
it  has  come  to  involve  the  optic  and  third 
pair  of  nerves.  It  must  be  obvious  to  you, 
however,  that  the  disease  might  readily  have 
set  up  first  in  the  pia  mater,  and  may  have 
involved  the  origins  of  these  nerves  through 
some  other  parts  of  the  brain,  producing 
precisely  the  same  train  of  symptoms. 

The  treatment  adopted  in  this  case  has 
been  chiefly  counter-irritation  to  the  scalp 
by  tartar  emetic  ointment,  and  the  use 
of  mercury.  These  remedies  have  pro¬ 
duced  no  good  effect ;  the  patient’s  intelli¬ 
gence  and  memory  are  becoming  affected, 
and  I  fear  that  the  hemispheres  of  the  brain 
are  getting  involved,  either  by  extension  of 
disease  or  by  pressure.  It  is  not  improbable 
that  ere  long  we  shall  have  the  opportunity 
of  ascertaining  how  far  the  diagnosis  is 
correct  or  otherwise. 

The  second  case  is  that  of  Catherine 
Williams,  who  is  aged,  as  she  says,  50,  but 
looks  at  least  65  :  she  has  been  long  addicted 
to  habits  of  intemperance.  She  states  that 
she  has  been  suffering  from  pain  of  the  head 
for  four  months,  and  also  from  pain  in  her 
limbs :  the  pain  in  the  head  is  not  at  all 
fixed,  and  it  has  also  been  accompanied  by 
drowsiness.  She  is  a  thin,  pale,  ill-nourished 
woman,  and  looks  like  one  who  drank  more 
than  she  ate. 

The  week  before  her  admission  she  com¬ 
plained  of  severe  pain  and  numbness  in  the 
left  hand  and  arm  :  this  was  probably  of  the 
nature  of  a  subjective  sensation,  due  to  an 


affection  of  the  nerves  at  their  central  ex¬ 
tremity,  and  not  at  their  periphery.  Affec¬ 
tions  of  this  kind  not  unfrequently  depend 
on  disease  of  the  brain ;  sometimes,  how¬ 
ever,  they  are  confined  to  the  trunk  of  the 
nerve,  and  are  strictly  of  a  neuralgic  cha¬ 
racter.  In  this  case,  however,  the  headache 
and  the  drowsiness  distinctly  point  to  a 
cerebral  affection. 

Previous  to  her  present  attack  coming  on, 
it  appears  that  she  had  been  working  very 
hard,  and  drinking  in  proportion.  One 
morning,  whilst  at  breakfast,  she  suddenly- 
lost  the  use  of  the  left  arm  and  side  of  the 
face,  and,  on  attempting  to  get  up,  fell  to 
the  ground  :  in  the  evening,  the  leg  on  the 
same  side  became  paralysed ;  the  paralytic 
seizure  was  not  accompanied  either  by  ster- 
tor,  or  by  loss  of  consciousness.  On  ad¬ 
mission,  two  days  after  this  seizure,  we 
found  this  woman  completely  hemiplegic  on 
the  left  side,  with  the  most  perfect  resolu¬ 
tion  of  all  the  muscles ;  the  facial  palsy 
was  also  complete,  and  there  was  deviation 
of  the  tongue  to  the  left  side.  The  muscles 
of  the  paralysed  limbs  were  wasted,  and 
there  was  a  slightly  oedematous  state.  On 
examining  the  heart,  we  found  a  loud  sys¬ 
tolic  bellows  sound — indicative  of  an  imper¬ 
fect  action  of  the  mitral  valve — allowing  of 
regurgitation  through  the  mitral  orifice ; 
affording  one  of  many  examples  of  the  asso¬ 
ciation  of  cerebral  with  cardiac  disease. 
From  her  habits  and  age,  it  seems  probable 
that  the  mitral  disease  is  due  to  atheroma¬ 
tous  deposits  on  or  in  the  valve;  and  simi¬ 
lar  deposits  will  also  probably  be  found  in 
the  arteries  of  other  parts  of  the  body,  and  in 
thoseof  the  brain, affecting  the  vesselsperhaps 
on  one  side  more  than  those  on  the  other. 

In  this  case  the  paralysis  seems  justly  re¬ 
ferable  to  disease  of  the  brain  ;  the  patient 
is  long  past  the  hysterical  age,  and  the 
paralysis  has  all  the  characters  of  that  pro¬ 
duced  by  lesion.  The  lesion  is  not  menin¬ 
geal,  because  there  are  no  symptoms  of  irri¬ 
tation,  and  because  the  paralysis  supervened 
suddenly,  and  was  complete.  We  must 
look  for  the  cause  of  it  in  the  substance  of 
the  brain,  and  I  should  be  led  to  locate  it 
either  in,  or  in  the  immediate  vicinity  of,  the 
corpus  striatum,  or  of  the  optic  thalamus, 
as  these  are  the  parts  most  frequently 
affected  in  such  cases,  and  as  lesion  of  both 
or  of  either  of  them,  but  especially  of  the 
corpus  striatum,  gives  rise  to  the  most  com¬ 
plete  paralysis. 

When  the  attack  took  place,  there  was  no 
stertor  or  loss  of  consciousness  :  this  shows 
that  the  paralysing  lesion,  whatever  it  may 
have  been,  caused  no  pressure  on  the  brain, 
nor  any  great  shock  to  that  organ.  The 
lesion,  therefore,  did  not  arise  probably 
from  effused  blood,  but  rather  from  some  de¬ 
generation  of  the  cerebral  matter  itself — 


188 


DR.  todd’s  clinical  observations  on  paralysis. 


such  as  white  softening  ;  and  this  is  a  form 
of  lesion  which  very  frequently  occurs  in  a 
subject  so  ill-nourished  as  our  patient,  whose 
blood  is  poor,  many  of  whose  arteries  are  un¬ 
doubtedly  in  a  diseased  condition,  and  whose 
heart,  from  the  extensive  regurgitant  dis¬ 
ease  of  the  mitral  valve,  is  not  capable  of 
supplying  the  brain  with  its  due  amount  of 
blood. 

IVly  diagnosis  of  this  case,  therefore,  is, 
that  there  has  been  white  softening  of  the 
brain,  situated  at  the  parts  which  I  have  al¬ 
ready  named  ;  this  softening  has  probably 
existed  for  some  time  without  any  distinct 
symptoms,  when  suddenly  some  of  the  fibres 
giving  way,  paralysis  followed  wdth  equal 
suddenness.  It  is  neither  impossible  nor 
unlikely  that  some  small  clots  may  exist  in 
the  white  softened  substance,  produced  by 
rupture  of  some  small  vessels  not  of 
sufficient  size  to  produce  pressure. 

The  case  has  been  treated  upon  this  view 
of  its  nature.  Indeed,  the  constitutional 
state  of  the  patient  afforded  no  indication 
for  any  other  mode  of  treatment  but  that 
which  would  contribute  to  support  and  up¬ 
hold.  There  is,  however,  but  very  little 
hope  that  any  mode  of  treatment  will  be 
permanently  beneficial,  the  whole  nutrient 
function  of  the  patient  seems  so  seriously 
impaired  :  yet  it  appears  very  unlikely  her 
vital  powers  will  long  enable  her  to  struggle 
against  the  distressing  influence  of  the  cere¬ 
bral  disease. 

I  shall  conclude  this  lecture,  by  calling 
your  attention  to  the  influence  of  electricity 
on  the  paralysed  limbs,  in  each  of  the  cases 
which  I  have  narrated. 

Most  of  you  have  frequently  witnessed  the 
trials  with  electricity  made  on  these  patients, 
and  can  bear  me  out  in  the  statements  I 
shall  make.  I  may  first,  however,  call  to 
your  recollection  the  doctrine  of  Dr.  Mar¬ 
shall  Hall,  that,  when  the  influence  of  the 
brain  upon  a  limb  has  been  withdrawn,  the 
irritability  of  the  musclesof  that  limb  becomes 
considerably  augmented,  and  that,  therefore, 
in  hemiplegic  paralysis,  the  muscles  of  the 
paralysed  limb  are  more  excitable  by  the 
galvanic  stimulus,  than  those  of  the  sound 
limb.  The  results  of  my  experiments  have 
led  me  to  a  somewhat  different  conclusion 
from  that  of  Dr.  Hall ;  and  I  would  refer 
you  to  an  account  of  these  experiments  pub¬ 
lished  in  the  last  volume  of  the  Medico- 
Chirurgical  Transactions.  If,  however,  I 
have  ventured  to  express  a  difference  of 
opinion  from  Dr.  M.  Hail,  I  can  truly  say 
that  I  have  no  wish  to  treat  with  disrespect 
any  views  which  he  may  have  put  forward ; 
but  I  cannot  shrink  from  stating  what  I  be 
lieve  to  be  the  truth,  even  though  it  be  at 
variance  with  previously  received  opinions, 
however  eminent  the  authority  by  which  they 
may  be  sanctioned. 


My  experiments  led  me  to  arrange  cases 
of  hemiplegic  paralysis  in  three  classes,  ac¬ 
cording  to  the  manner  in  which  the  electrical 
stimulus  affects  the  paralytic  limbs.  In  the 
first  class,  to  which  belongs  the  vast  majority 
of  the  cases,  the  paralytic  limb  was  acted 
upon  by  electricity  very  slightly  or  not  at 
all,  and  in  every  instance  to  a  less  degree 
than  the  sound  limb.  In  the  second  class 
of  cases,  no  perceptible  difference  existed  as 
to  the  effects  of  electricity  on  the  two  limbs  : 
these  were  cases  of  recent  paralysis,  the  cause 
of  which  was  not  of  a  depressing  nature.  In 
the  third  class,  the  electricity  produced  a 
greater  effect  on  the  paralysed  limb  than  on 
the  sound  limb  ;  the  difference,  however, 
was  never  very  great,  and  such  cases  are  not 
numerous  :  in  all  of  them  the  paralysis  was 
accompanied  by  recent  rigidity  of  the  mus¬ 
cles. 

Now,  of  the  two  cases  which  we  have  been 
describing,  we  found  that  in  the  man  Hard¬ 
wick,  electricity  produced  more  effect  on  the 
paralysed  limbs  than  on  the  sound  limbs ; 
and  in  this  case  you  will  recollect  there  is 
muscular  rigidity.  After  the  patient  had 
been  some  time  in  the  hospital,  the  paralysis 
became  more  complete,  and  the  muscles  less 
rigid,  and,  in  the  same  proportion,  their  ex¬ 
citability  to  the  galvanic  stimulus  also  dimi¬ 
nished. 

In  the  second  case — the  woman  Williams, 
electricity  produced  scarcely  any  contrac¬ 
tions  in  the  paralysed  limbs,  whilst  it  caused 
distinct  but  somewhat  feeble  contractions  in 
the  sound  ones ;  and  you  will  remember 
that  we  applied  electricity  in  this  caSe,  not 
only  by  the  electro-magnetic  machine,  but 
also  by  the  simple  galvanic  trough,  making 
use  of  a  small  trough,  consisting  of  a  few 
pairs  of  plates,  and  also  a  large  trough  con¬ 
sisting  of  a  hundred  pairs  of  plates ;  and 
whether  we  employed  the  frequently  inter¬ 
rupted  current,  as  in  the  electro-magnetic 
machine,  or  the  continuous  current  of  the 
galvanic  trough,  the  same  results  were  ob¬ 
tained. 

The  conclusions  to  which  I  have  arrived 
upon  this  subject  are,  that  when  the  para¬ 
lysed  limbs  exhibit  an  early  spastic  or  rigid 
state  of  the  muscles,  as  in  the  case  of  Hard¬ 
wick,  they  will  be  more  excitable  by  elec¬ 
tricity  than  the  sound  limbs  ;  but  if  the  para¬ 
lysis  be  accompanied  by  a  state  of  complete 
resolution  of  the  muscles,  the  sound  limb  is 
most  excitable  to  the  galvanic  stimulus,  and 
the  paralysed  limb  is  scarcely  at  all  to  be 
excited  :  in  the  latter  case,  the  nerves  of  the 
paralytic  limb  are  in  a  depressed  condition  : 
in  the  former  they  are  in  an  irritated  condi¬ 
tion  ;  and  the  different  effects  of  electricity 
in  the  two  cases  will  depend  on  the  difference 
of  cause  of  the  paralysis  ; — if  the  paralysing 
lesion  be  irritative,  the  paralytic  limb  will 
be  more  excitable  by  the  galvanic  stimulus  ; 


ENLARGEMENT  OF  THE  ABDOMEN  IN  CHILDHOOD. 


189 


if,  on  the  other  hand,  it  be  depressing,  the 
paralytic  limb  will  be  less  excitable;  and 
thus  this  difference  in  the  effect  of  electri¬ 
city  on  the  two  limbs,  may  serve  to  guide 
us  in  our  diagnosis,  and  we  may  conclude 
that  the  lesion  is  irritative  or  depressing,  ac¬ 
cording  as  the  paralytic  limb  is  more  or  less 
excitable  by  the  galvanic  stimulus. 


LECTURES 

ON  THE 

DISEASES  OF  INFANCY  AND 
CHILDHOOD, 

Delivered  at  the  Middlesex  Hospital. 

By  Charles  West,  M.D. 

Physician- Accoucheur  to,  and  Lecturer  on  Mid¬ 
wifery  at,  the  Middlesex  Hospital,  and  Senior 
Physician  to  the  Iloyal  Infirmary  for  Children. 


Lecture  XXXYI. 

Abdominal  tumors.  Enlargement  of  ab  do  - 
men  not  always  the  result  of  actual  dis¬ 
ease — causes  to  which  it  may  be  due. 
Abdominal  tumors — from  enlargement  of 
the  liver — by  simple  hypertrophy — by 
hydatid  growths — by  malignant  disease — 
from  malignant  disease  of  the  kidney — 
from  enlargement  of  the  spleen— from 
psoas  abscess.  Cases  in  illustration. 
Infantile  syphilis — its  symptoms — charac¬ 
ters  of  the  syphilitic  cachexia — tendency 
of  the  symptoms  to  return  after  apparent 
cure — its  treatment. 

Among  the  anatomical  peculiarities  of  early 
life  none  is  more  remarkable  than  the  great 
size  of  the  abdomen,  as  contrasted  with  the 
undeveloped  state  of  the  thorax,  on  the  one 
hand,  and  of  the  lower  extremities,  on  the 
other.  Though  most  striking  in  the  new¬ 
born  infant,  it  still  continues  to  a  great  de¬ 
gree  during  the  whole  of  the  first  years  of 
childhood  ;  nor  does  it  altogether  disappear 
until,  with  advancing  age,  the  pelvis  en¬ 
larges,  the  spinal  column  acquires  its  proper 
curvature,  the  limbs  gain  their  due  develop¬ 
ment,  and  the  chest  expands  in  a  measure 
commensurate  with  the  demands  made  upon 
the  thoracic  viscera  for  the  vigorous  per¬ 
formance  of  their  functions. 

The  anxiety  of  non-professional  persons  is 
often  needlessly  excited  by  the  large  size  of 
the  abdomen  in  childhood,  while  those  even 
who  are  conversant  with  medicine  do  not 
always  bear  in  mind  the  very  different 
causes  to  which  an  increase  of  its  bulk  may 
be  due.  It  will,  therefore,  I  think,  be  no 
waste  of  time  to  notice  briefly  the  circum¬ 
stances  under  which  enlargement  of  the  ab 
domen  may  occur  in  childhood,  and  to  give 
you  what  little  information  I  may  be  able  to 


furnish  with  reference  to  those  diseases 
which  occasion  distinct  abdominal  tumors. 

The  size  of  the  abdomen  sometimes  ap¬ 
pears  preternaturally  large,  wholly  indepen¬ 
dent  of  any  disorder  of  the  general  health, 
but  as  the  result  of  a  child’s  growth  and 
development  having  gone  on  slowly,  so  that 
its  body  retains  its  infantine  proportions  but 
little  altered  at  the  age  of  two  or  three  years. 
If,  as  often  happens,  this  tardy  development 
should  be  associated  with  feeble  health,  with 
a  somewhat  impaired  performance  of  the 
digestive  functions,  and  with  a  constipated 
condition  of  the  bowels,  flatus  is  almost  sure 
to  collect  in  the  intestines,  and  the  enlarge¬ 
ment  of  the  abdomen  is  thus  rendered  still 
more  considerable.  With  such  a  state  of 
health,  too,  some  of  the  minor  degrees  of 
rickets  are  often  associated ;  and  even 
though  no  serious  deformity  mark  the  exist¬ 
ence  of  the  disorder,  yet  to  its  influence  are 
due  the  undeveloped  chest  and  the  small 
pelvis;  while  the  contracted  and  misshapen 
thorax,  which  is  produced  by  the  advance  of 
the  disease,  makes  the  abdominal  enlarge¬ 
ment  appear  still  more  striking,  and  causes 
the  child,  according  to  MM.  Rilliet  and 
Barthez’  apt  comparison,  to  resemble  the 
toy  tumblers  which  Italian  image  boys  sell 
about  the  streets. 

In  cases  such  as  have  been  referred  to, 
you  will  save  yourselves  and  your  patient’s 
friends  much  needless  anxiety,  if  you  bear 
in  mind  that  tabes  mesenterica  is  exceedingly 
rare  before  five  years  of  age,  while  this  con¬ 
dition  of  general  abdominal  enlargement  is 
met  with  chiefly  between  the  commencement 
and  the  end  of  the  first  dentition.  Further, 
you  will  find  that,  under  these  circumstances, 
the  abdomen  is  perfectly  soft  and  painless  ; 
you  will  learn  that  no  symptom  of  tubercle 
has  shewn  itself ;  while,  if  you  strip  the 
child,  which  in  doubtful  cases  you  ought  to 
do,  you  will  probably  see  more  or  less  dis¬ 
tinct  indications  of  the  action  of  rickets, 
either  in  deforming  the  skeleton,  or  in  dis¬ 
ordering  its  proportions. 

Enlargement  of  the  abdomen  is  a  much 
more  frequent  attendant  on  tubercular  peri¬ 
tonitis  than  on  me.^enteric  disease.  The 
tense  and  tympanitic  and  painful  state  of  the 
abdomen,  the  sensation  of  adhesion  between 
the  abdominal  walls  and  the  subjacent  viscera, 
the  loss  of  flesh,  tlxe  frequently  recurring 
diarrhoea,  the  febrile  symptoms,  and  the 
more  or  less  well-marked  indications  of  tu¬ 
bercular  disease  which  attend  it,  usually 
stamp  the  nature  of  the  affection  too  clearly 
for  the  attentive  observer  to  fall  into  error. 

But  besides  these  cases  (and  some  others 
the  nature  of  which  is  too  obvious  for  it  to 
be  necessary  to  dwell  on  them  here),  in 
which  there  is  a  general  enlargement  of  the 
abdomen,  there  are  others  in  which  its  in¬ 
crease  of  size  is  mainly  due  to  the  presence 


CAUSE  OF  ENLARGEMENT  OF  THE  LIVER. 


19(T 


of  a  distinct  and  well-defined  tumor.  A 
good  many  instances  of  this  sort  have  come 
under  my  notice  at  different  times,  though, 
as  often  happens  in  dispensary  practice,  the 
number  of  them  is  but  small  in  which  I 
have  had  the  opportunity  of  watching  the 
affection  to  its  close,  and  of  confirming  or 
correcting  by  an  examination  after  death  the 
diagnosis  formed  during  the  life-time  of  the 
patient. 

One  not  very  uncommon  cause  of  abdo¬ 
minal  tumors  is  enlargement  of  the  liver , 
which  sometimes  undergoes  a  very  great  in¬ 
crease  of  its  bulk  without  any  obvious  rea¬ 
son,  and  even  unattended  with  any  serious 
disturbance  of  the  general  health.  I  re¬ 
member  a  little  girl,  abouHO  years  old,  who 
was  received  into  St.  Bartholomew’s  Hospi¬ 
tal  on  account  of  very  great  enlargement  of 
her  abdomen.  She  looked  very  pale,  and 
the  distension  of  the  superficial  veins  of  her 
chest  and  abdomen,  and  the  livid  congestion 
of  her  face,  shewed  that  there  existed  some 
serious  obstacle  to  the  circulation.  Her  ab¬ 
domen  had  been  gradually  enlarging  for 
many  months,  and  at  the  time  of  her  admis¬ 
sion  into  the  hospital  the  margin  of  the 
liver  was  distinctly  traceable  below  the  um¬ 
bilicus  ;  her  bowels  were  habitually  consti¬ 
pated,  but  the  evacuations  were  natural  in 
appearance,  and  the  child  was  well  nourished, 
cheerful,  and  active,  being  but  little  annoyed 
by  her  great  size.  I  saw  her  again  two 
years  afterwards,  and  her  condition  was  then 
quite  unaltered.  Similar  cases,  of  what  I 
believe  to  have  been  simple  hypertrophy  of 
the  liver,  have  since  come  under  my  notice. 
For  the  most  part  they  were  associated  with 
very  obvious  indications  of  a  scrofulous 
habit,  but  on  one  occasion  only  was  there 
any  serious  disturbance  of  the  general  health  ; 
the  child  in  that  instance  suffering  from  very 
severe  diarrhoea,  which  had  succeeded  a 
state  of  somewhat  obstinate  constipation. 

I  once  met  with  a  hydatid  tumor  of  the 
liver  in  a  girl  aged  13§  years,  in  whom  two 
years  and  a  half  previously  a  swelling  had 
begun  to  form  #t  her  right  side,  without  any 
sign  of  general  indisposition,  though  the 
subsequent  increase  of  the  growth  had  been 
attended  with  occasional  attacks  of  severe 
pain.  At  the  time  of  my  seeing  her  she  had 
gone  through  a  variety  of  treatment,  which 
consisted  chiefly  in  leeching  and  the  inunc¬ 
tion  of  iodine  ointment,  without  any  benefit ; 
but  her  general  health  was  good,  although 
she  was  small  for  her  age.  On  removing 
her  dress,  the  lower  part  of  her  chest  and 
the  upper  part  of  her  abdomen  were  much 
enlarged  by  a  growth,  the  lower  margin  of 
which  could  be  felt  a  little  above  the  umbi¬ 
licus,  and  which  seemed  larger  on  the  right 
than  on  the  left  side.  At  this  time  the  cir¬ 
cumference  of  her  chest,  on  a  level  with  the 
nipple,  was  25|  inches,  and  25  inches  four 


inches  lower  down  ;  but  three  years  and  a 
half  later,  and  a  short  time  before  her  death, 
she  measured  32  inches  at  the  former,  and 
33  at  the  latter  point.  Even  when  I  first 
saw  her,  the  respiratory  murmur  ceased  to 
be  audible  on  a  level  with  the  nipple,  and 
the  cavity  of  the  chest  became  still  more  en¬ 
croached  on  with  the  advance  of  the  disease. 
Fluctuation  was  distinctly  perceptible  over 
nearly  the  whole  of  the  tumor  in  the  chest 
as  well  as  in  the  abdomen,  and  continued 
so  during  the  whole  of  the  patient’s  life.  It 
was  in  May  1840,  that  the  patient  first  came 
under  my  notice,  and  no  change  whatever 
took  place  in  her  condition  until  February 
1842.  At  that  time,  after  severe  pain  in 
the  tumor  had  been  experienced  for  several 
days,  a  fresh  growth  made  its  appearance,  of 
about  the  size  of  a  breakfast-cup,  to  the  left 
of  the  umbilicus  and  a  little  above  it.  In 
July  following  the  patient  began  to  lose 
flesh,  her  appetite  failed,  and  she  began  to 
suffer  frequent  attacks  of  palpitation.  At 
this  time,  and  often  subsequently,  the  child 
complained  of  pain  and  numbness  extending 
down  the  right  arm.  Notwithstanding  the 
progressive  increase  of  the  tumor,  the  pa¬ 
tient’s  health  continued  tolerably  good  for 
the  succeeding  seventeen  months,  though 
she  grew  but  little,  and  no  sign  of  approach¬ 
ing  puberty  appeared.  In  the  middle  of 
December  1843,  symptoms  of  gastric  disor¬ 
der  shewed  themselves ;  the  child  suffered 
much  from  flatulence,  had  occasional  diar¬ 
rhoea,  severe  pain  in  her  abdomen,  great 
feverishness,  and  her  mind  wandered  a  little 
at  night.  The  skin  grew  jaundiced,  and  the 
water  became  very  high  coloured  ;  while  the 
attacks  of  pain,  chiefly  referred  to  the  epi¬ 
gastrium,  sometimes  were  so  severe  that  the 
patient  fainted  from  their  intensity.  Slight 
cough  came  on,  and  for  three  wreeks  before 
death  she  was  unable  for  a  moment  to  as¬ 
sume  the  recumbent  posture.  Her  strength 
gradually  failed,  and  she  died  on  Jan.  28, 
1844,  during  an  unusually  severe  attack  of 
pain. 

On  opening  the  abdomen,  from  which  a 
gallon  and  a  half  of  transparent  yellow  serum 
escaped,  the  enormously  large  liver  was 
brought  into  view.  It  reached  down  to 
somewhat  below  the  false  ribs  on  the  left 
side,  not  quite  so  low  on  the  right,  and  ex¬ 
tended  upwards  on  the  left,  pushing  the  dia¬ 
phragm  before  it  to  rather  above  the  upper 
margin  of  the  second  rib,  and  on  the  right 
side  to  a  little  above  the  level  of  the  third. 
This  enlargement  seemed  made  up  of  the 
left  lobe,  for  the  right  lobe,  rather  dark  but 
otherwise  healthy,  was  found  pushed  down¬ 
wards  by  it  into  the  right  flank.  The  sur¬ 
face  of  the  enormously  enlarged  left  lobe  was 
of  a  pale  colour  :  on  making  an  incision  into 
it,  it  was  found  to  have  formed  a  sac,  the 
parietes  of  which  were  about  a  third  of  an 


MALIGNANT  DISEASE  OF  THE  LIVER — OF  THE  KIDNEY. 


191 


inch  thick,  containing  a  gallon  of  viscid  yel¬ 
low  fluid,  and  a  number  of  hydatids  of  a 
large  size.  The  sac  itself  appeared  to  be 
formed  by  the  parent  hydatid,  the  parietes 
of  which  were  firmly  adherent  to  the  sub¬ 
stance  of  the  liver.  At  the  anterior  edge  of 
the  right  lobe  of  the  liver,  just  to  the  right 
of  the  gall-bladder,  was  a  yellowish  white 
tumor  of  the  size  of  a  walnut,  which,  on 
being  cut  into,  was  seen  to  be  composed  of 
dead  and  shrivelled  hydatids ;  they  were 
folded  together,  one  within  the  other,  like 
the  coats  of  an  onion,  except  that,  in  order 
to  reduce  the  space  they  occupied  as  much 
as  possible,  they  were  plicated.  The  two  or 
three  outer  layers  had  begun  to  be  the  seat 
of  cretaceous  deposits.  The  gall-bladder 
contained  a  little  pale  fluid  bile. 

The  lungs  were  healthy,  though  much 
compressed.  The  valves  of  the  heart  were 
quite  healthy,  but  the  pericardium  was  uni¬ 
versally,  and  in  some  parts  very  firmly  ad¬ 
herent  to  its  substance,  the  result,  doubtless, 
of  inflammation,  which  most  likely  came  on 
at  the  time  when  the  child  began  to  com¬ 
plain  of  palpitation  of  the  heart.  The  other 
viscera  were  quite  healthy. 

1  have  once  seen  the  liver  in  the  child 
the  seat  of  malignant  disease  of  the  fungoid 
kind,  in  the  progress  of  which  the  organ 
acquired  a  very  large  size.  The  affection 
was  attended  by  vague  indications  of  abdo¬ 
minal  disease,  in  which  there  was  nothing 
that  pointed  specially  to  any  one  viscus, 
while  the  morbid  growth,  having  originated 
from  the  under  surface  of  the  right  lobe  of 
the  liver,  was  supposed,  from  the  relations 
which  it  presented,  to  be  due  to  enlarge¬ 
ment  of  the  mesenteric  glands.  The  patient 
was  a  little  boy,  who  was  eight  months  old 
when  the  first  indication  of  disordered  health 
appeared,  in  diarrhoea,  fretfulness,  and  loss 
of  flesh  and  appetite  ;  and  at  the  age  of  nine 
months  his  mother  noticed  some  solid 
masses  in  the  abdomen,  though  from  the 
commencement  of  his  illness  his  belly  had 
been  hard  and  rather  tender.  The  child 
lived  to  the  age  of  one  year  ;  and  for  the 
last  six  weeks  of  his  life,  during  which  time 
I  had  the  opportunity  of  watching  him,  he 
suffered  from  diarrhoea,  which  was  occa¬ 
sionally  very  profuse.  He  became  extremely 
emaciated,  and  his  skin  assumed  an  exceed¬ 
ingly  sallow  colour ;  but  the  evacuations, 
though  relaxed,  were  often  natural.  No  hae¬ 
morrhage  took  place  from  the  intestines,  and 
the  urine  was  found  to  be  perfectly  natural 
whenever  it  was  tested.  During  the  last 
month  of  his  life  he  had  a  slight  cough  and 
wheezing  respiration ;  but  death  seemed 
due  to  the  constant  diarrhoea  and  the  severe 
pain  which  the  child  suffered,  his  exhaus¬ 
tion  being  doubtless  in  great  measure  the 
consequence  of  the  blood  which  should  have 
nourished  his  body  being  diverted  to  supply 


the  enormous  mass  of  fungoid  disease  of  the 
liver. 

During  the  six  weeks  that  the  child  was 
under  my  observation,  his  abdomen  in¬ 
creased  from  21  to  25  inches  in  circum¬ 
ference,  and  the  tumor,  the  surface  of  which 
was  uneven,  was  always  much  larger  on 
the  left  than  on  the  right  side.  It  turned 
out,  however,  on  an  examination  after  death, 
that  the  left  lobe  of  the  liver  was  almost 
completely  healthy,  but  that  it  had  been 
driven  up  under  the  ribs  by  the  enlarged 
right  lobe  ;  that  part  of  the  organ  was  con¬ 
verted  into  a  soft,  white,  brain-like  matter, 
intermingled  with  which  were  portions  of  a 
firmer,  highly  vascular,  fibro-cellular  sub¬ 
stance.  The  disease,  in  short,  consisted  of 
a  mixture  of  carcinoma  medullare  and  car¬ 
cinoma  fasciculatum.  A  few  deposits  of 
medullary  cancer,  one  of  them  as  big  as  a 
walnut,  existed  also  in  the  right  lung,  but 
the  other  viscera  were  healthy. 

Malignant  disease  of  the  kidney  is  ano¬ 
ther  occasional  cause  of  abdominal  tumor  in 
children,  and  of  this  I  have  met  with  two 
instances.  The  first  occurred  in  a  boy,  who 
died  at  the  age  of  two  years  and  ten  months  ; 
and  the  second  in  a  girl,  who  was  little  more 
than  six  years  old  at  death.  In  the  former 
case,  at  the  same  time  that  the  child  became 
languid  and  fretful,  his  abdomen  was  ob¬ 
served  to  be  enlarging.  For  a  few  days  in 
the  early  part  of  his  illness  he  was  reported 
to  have  passed  bloody  urine,  but  this  symp¬ 
tom  did  not  recur  during  the  subsequent 
progress  of  the  disease.  In  proportion  as 
his  abdomen  increased  in  size,  he  became 
more  and  more  emaciated :  he  had  occa¬ 
sional  attacks  of  diarrhoea,  but  nevertheless 
his  appetite  continued  craving,  and  it  was 
not  till  ten  months  after  the  first  symptom 
had  been  noticed,  that  the  child  died  ex¬ 
hausted.  In  the  case  of  the  girl  the  disease 
ran  a  much  more  rapid  course,  and  death 
took  place  in  ten  weeks  from  the  appearance 
of  the  first  symptom.  She  was  attacked 
with  feverishness,  gastric  disorder,  and  occa¬ 
sional  vomiting,  which  had  not  continued 
more  than  a  week  when  her  mother  noticed 
a  tumor  in  the  abdomen.  When  these 
symptoms  came  on,  the  child  was  well 
nourished,  but  she  lost  flesh  rapidly  in  pro¬ 
portion  as  her  abdomen  increased  in  size ; 
her  evacuations  were  often  very  unnatural, 
but  at  no  time  was  there  either  diarrhoea  or 
haematuria.  Towards  the  end  of  her  life 
she  became  very  fretful,  and  seemed  occa¬ 
sionally  to  suffer  severe  pain  in  the  abdo¬ 
men  ;  but  her  death  took  place  suddenly, 
and  without  any  sign  of  her  health  being 
worse  than  it  had  appeared  for  some  days 
before.  In  one  case  the  left,  in  the  other 
the  right  kidney,  was  the  seat  of  the  disease : 
the  local  symptoms  were  very  similar  in 
both  instances,  and  consisted  in  the  presence 


I 


192  ENLARGEMENTS  OF  THE  SPLEEN.  INFANTILE  SYPHILIS. 


of  a  solid  tumor  occupying  the  lumbar 
region,  and  extending  from  the  spine  across 
the  abdomen  towards  the  opposite  side,  and 
reaching  upwards  beneath  the  ribs,  and 
downwards  towards,  and  in  the  first  case 
even  into  the  pelvis.  On  examining  the 
body  after  death,  the  nature  of  the  disease 
was  seen  in  both  instances  to  be  precisely 
the  same,  being  a  mixture  of  cerebriform 
matter  and  of  the  peculiar  structure  of  fun¬ 
gus  hsematodes,  while  in  both  the  kidney 
was  considerably  bigger  than  the  head  of  an 
adult. 

In  this  country,  and  especially  in  the 
neighbourhood  of  London,  where  the  se¬ 
verer  forms  of  intermittent  fever  seldom 
occur,  we  do  not  often  meet  with  those 
enlargements  of  the  spleen  which  are  com¬ 
mon  enough  even  among  young  children  in 
malarious  districts.  The  only  instance  of 
it  which  I  have  had  the  opportunity  of  ob¬ 
serving:  was  presented  by  a  little  girl,  six 
years  and  a  half  old,  who  lived  at  Fernando 
Po  from  the  age  of  two  years  and  a  half, 
having  had  dysentery  at  three  years  old, 
and  frequent  attacks  of  fever  subsequently. 
The  enlargement  of  her  spleen  had  first  be¬ 
come  apparent  at  five  years  of  age  ;  and  when 
I  first  saw  her,  a  few  weeks  after  her  return 
from  Africa,  it  had  attained  so  considerable 
a  size  that  her  abdomen  measured  twenty- 
one  inches  and  a  half  in  circumference.  The 
spleen  in  this  case  reached  from  under  the 
ribs  quite  down  into  the  pelvis,  and  for¬ 
wards  as  far  as  the  mesial  line  of  the  abdo¬ 
men.  Independently  of  the  patient’s  his¬ 
tory,  which  in  a  case  of  this  kind  would  be 
of  itself  sufficient  to  prevent  an  erroneous 
diagnosis,  the  relations  of  the  swelling  were 
characteristic ;  for,  although  situated  at  the 
side  of  the  abdomen,  it  did  not  extend  back¬ 
wards  into  the  lumbar  region  so  as  to  fill  it 
up  completely,  as  an  enlarged  kidney  would 
do,  but  a  considerable  interval  existed  be¬ 
tween  the  posterior  margin  of  the  tumor  and 
the  vertebral  column. 

Lastly,  before  dismissing  the  subject  of 
abdominal  tumors,  I  must  warn  you  of  the 
possibility  of  mistaking  the  swelling  formed 
by  a  psoas  abscess  for  that  produced  by  en¬ 
largement  of  the  kidney.  When  psoas  ab¬ 
scess  occurs  in  young  children,  its  early 
stages  may  readily  be  overlooked,  partly 
because  the  patient  is  unable  to  describe 
those  vague  sensations  of  uneasiness  in  the 
loins  by  which  it  is  attended, — partly  be¬ 
cause  impairment  or  loss  of  the  power  of 
walking  is  so  common  a  result  of  indisposi¬ 
tion  of  any  kind  that  no  inquiry  may  be 
made  after  any  special  cause  for  its  occur¬ 
rence.  The  gradual  failure  of  the  health, 
the  loss  of  flesh,  and  the  occasional 
disturbance  of  the  bowels,  are  symptoms 
that  attend  upon  various  disorders  of 
the  abdominal  viscera,  and  that  present 


nothing  pathognomonic  of  any.  The  tumor, 
like  that  formed  by  enlargement  of  the  kid¬ 
ney,  occupies  the  lumbar  region,  projecting 
forwards  into  the  abdomen  ;  while  fluctua¬ 
tion  in  the  abscess  is  often  so  obscure  as  to 
be  scarcely,  if  at  all,  perceptible.  The 
tumor  of  psoas  abscess,  however,  reaches 
less  high  up  in  the  abdomen  than  that  formed 
by  enlargement  of  the  kidney ;  its  contour 
is  usually  more  circular,  less  oval ;  and  the 
tenderness  over  it  is  in  general  greater  than 
in  cases  of  malignant  disease  of  the  kidney. 
As  the  affection  advances,  and  the  matter 
gravitates  into  the  thigh  or  points  in  the 
lumbar  region,  its  nature  becomes  clearly 
manifest ;  but  though,  as  far  as  the  final 
issue  of  the  case  is  concerned,  an  error  of 
diagnosis  is  of  but  little  import,  it  is  yet 
very  desirable  for  our  own  reputation  that 
we  should  not,  at  any  period,  have  fallen 
into  a  mistake  as  to  its  nature. 

According  to  the  plan  which  we  proposed 
to  follow  in  this  course  of  lectures,  there 
remains  for  us  now  to  study,  in  conclusion, 
the  febrile  diseases  of  infancy  and  childhood. 
There  is  one  affection,  however,  too  impor¬ 
tant  to  be  passed  over  in  silence,  although  it 
cannot  be  assigned  to  any  of  those  classes 
into  which,  for  convenience  sake,  we  dis¬ 
tributed  the  diseases  of  early  life.  I  pro¬ 
pose,  therefore,  to  devote  the  remaining  half 
hour  of  to-day  to  the  study  of  infantile 
syphilis,  and  to  defer  till  to-morrow  the 
consideration  of  the  fevers  and  exanthemata. 

Syphilis,  as  it  occurs  in  the  infant,  presents 
many  important  differences  from  the  charac¬ 
ters  which  it  presents  in  the  adult,  nor  is  there 
in  this  anything  to  excite  our  surprise,  if  we 
bear  in  mind  the  very  different  circumstances 
under  which,  in  the  two  cases,  the  poison 
infects  the  organism.  In  the  adult  the  mani¬ 
festations  of  the  disease  are  almost  always 
the  result  of  the  direct  inoculation  of  the 
system  with  the  venereal  virus.  In  the 
child,  infection  by  that  mode  seldom  occurs. 
The  supposition,  once  generally  entertained, 
that  an  infant  becomes  affected  with  syphilis 
in  consequence  of  its  body  being  brought, 
during  the  time  of  its  birth,  into  contact 
with  venereal  sores  upon  the  mother’s  geni¬ 
tals,  is  now  deservedly  regarded  as  alto¬ 
gether  erroneous.  The  infection  of  a  child 
by  sucking  the  breast  of  a  syphilitic  nurse 
is  an  unusual  occurrence ;  and  in  by  far  the 
greater  number  of  cases  the  infant  has  con¬ 
tracted  the  disease  in  the  womb,  although 
its  indications  comparatively  seldom  shew 
themselves  until  at  least  fourteen  days  after 
birth.  In  many  of  these  cases  the  mother 
has,  during  her  pregnancy,  been  the  subject 
of  primary  syphilis,  or  if  not,  has  presented 
well-marked  secondary  symptoms ;  and 
under  either  of  these  conditions  we  can 
understand  that  her  infected  blood  may 
deteriorate  that  of  her  infant,  and  give  rise 


SYMPTOMS  OF  INFANTILE  SYPHILIS. 


to  consequences  more  or  less  analogous  to 
those  from  which  she  has  recently  suffered 
herself.  Cases,  however,  are  now  and  then 
met  with  in  which  the  venereal  taint  appears 
to  have  been  derived  entirely  from  the  father, 
the  mother  not  having  suffered,  either  before 
or  during  her  pregnancy,  either  from  primary 
or  secondary  symptoms,  although  she  has 
given  birth  to  an  infant  affected  with  all  the 
characteristic  marks  of  syphilitic  disease. 

Through  whichever  of  these  media  the 
infant  becomes  infected  with  syphilis,  symp¬ 
toms  of  the  same  kind  appear,  though  there 
is  no  invariable  order  in  which  they  shew 
themselves  ;  and  coryza  is  its  earliest  indi¬ 
cation  in  one  case,  a  cutaneous  eruption  in 
a  second,  ulceration  about  the  corners  of 
the  mouth  in  a  third.  When  we  consider 
the  frequency  with  which  abortion  or  prema¬ 
ture  labour  appears  to  be  due  to  the  influence 
of  the  syphilitic  poison,  it  might  naturally 
he  expected  that  cases  should  be  by  no  means 
unusual  in  which  infants  at  the  moment  of 
their  birth  should  present  evidences  of  the 
venereal  taint.  This,  however,  is  very 
seldom  the  case, — so  seldom,  indeed, ^hat  I 
do  not  remember  to  have  met  an  instance  of 
it;  neither  has  any  come  under  the  notice  of 
M.  Trousseau,  of  Paris,*  whose  appoint¬ 
ment  at  the  Hopital  Necker  in  that  city 
gives  him  most  ample  opportunities  for  ob¬ 
serving  the  diseases  of  early  infancy.  Chil¬ 
dren,  although  infected  with  syphilis,  and  in 
whom  the  signs  of  the  disease  speedily  shew 
themselves,  are  yet  generally  well  nourished, 
and  apparently  in  good  health,  at  the  time 
of  birth.  This,  too,  is  observed  to  be  the 
case  even  where'  the  mother  has  suffered 
severely  from  secondary  symptoms, — has 
already  aborted  frequently,  or  has  given  birth 
prematurely  to  dead  children  whose  cuticle 
was  peeling  off — a  condition  regarded,  and 
probably  with  justice,  as  an  effect  of  the 
venereal  poison.  When,  however,  she  at 
length  produces  a  living  child,  there  is 
nothing  for  the  first  two  or  three  weeks  after 
its  birth  to  distinguish  it  from  the  offspring 
of  the  most  healthy  parents.  After  the 
lapse  of  that  time  the  first  symptom  of  dis¬ 
ease  shews  itself ;  and  most  commonly  this 
is  nothing  more  than  the  occurrence  of  a 
degree  of  snuffling  with  the  child’s  breath¬ 
ing,  and  slight  difficulty  in  sucking, — the 
signs,  in  short,  of  ordinary  coryza.  Now 
and  then,  as  I  stated  some  days  ago,f  no 
other  indicationof  syphilisappears,  but  never¬ 
theless  the  coryza  does  not  yield  until  after 
the  child  has  been  brought  under  the  influ¬ 
ence  of  mercurial  remedies, — a  fact  which 
would  serve  to  shew  that  although  unaccom¬ 
panied  with  other  signs  of  venereal  taint, 

*  See  his  very  valuable  memoir  on  Infantile 
Syphilis,  in  the  Archives  G^n.  de  Mfklecine  for 
October  1847. 

t  In  Lecture  XV.,  Med.  Gaz.  vol.  xl.  p.  867. 


]  93 


the  snuffles  of  young  infants  are  sometimes 
produced  by  that  cause.  In  the  majority  of 
instances,  however,  the  coryza  does  not  con¬ 
tinue  long  without  characteristic  signs  of 
disease  appearing  about  the  nostrils  them¬ 
selves,  and  without  syphilitic  eruptions 
breaking  out  upon  the  surface  of  the  body. 
The  mucous  membrane  of  the  nostrils  se¬ 
cretes  a  yellow  ichorous  matter,  sometimes 
slightly  streaked  with  blood,  which  drying, 
obstructs  the  opening  of  the  nostrils,  and 
renders  breathing  and  sucking  very  dis¬ 
tressing  to  the  child.  The  voice,  too, 
before  long  becomes  affected,  and  assumes  a 
peculiar  hoarse  tone,  which  has  been  not 
inaptly  compared  to  the  sound  of  a  child’s 
penny  trumpet,  and  which,  when  you  once 
have  heard  it,  you  will  at  once  recognize  as 
almost  pathognomonic  of  syphilis.  This 
change  of  voice  depends  no  doubt  on  the 
affection  of  the  throat,  which  you  will  often 
see,  in  common  with  the  interior  of  the 
mouth,  to  be  red  and  shining,  and  to  present 
many  superficial  ulcerations.  The  skin  of 
the  upper  lip  over  which  the  discharge  from 
the  nostrils  runs,  often  becomes  excoriated, 
or  if  not  it  assumes  a  peculiar  yellowish 
brown  colour,  like  the  hue  of  a  faded  leaf. 
Should  the  disease  be  unchecked,  large 
patches  of  the  skin  upon  the  face  and  fore¬ 
head  put  on  this  appearance,  which  seems 
due  to  a  kind  of  staining  of  the  part,  un¬ 
accompanied  with  any  other  alteration. 
Both  lips  before  long  become  affected :  a 
number  of  minute  perpendicular  fissures 
take  place  in  them,  which  bleed  whenever 
the  infant  sucks  ;  and  small  ulcerations 
appear  at  either  angle  of  the  mouth.  It 
generally  happens,  however,  before  these 
effects  of  the  disease  have  become  very 
obvious  about  the  mouth,  that  the  skin  in 
various  parts  presents  appearances  equally 
characteristic.  Though  not  limited  to  any 
situation,  the  eruption  of  syphilis  usually 
makes  its  appearance  about  the  buttocks  and 
nates,  in  the  form  of  small,  circular,  shining 
spots  of  a  coppery  red  colour,  having  a 
slightly  shining  surface,  and  disposed  to 
become  somewhat  tough  at  their  centre  from 
the  desquamation  of  the  epidermis  in  that 
situation.  The  spots  in  the  neighbourhood 
of  the  anus  often  degenerate  into  small,  soft, 
spongy  ulcerations,  with  a  slightly  elevated 
base ;  the  margins  of  the  anus  become  fis¬ 
sured  just  in  the  same  way  as  the  edges  of 
the  lips  had  done ;  and  the  skin  about  Jhe 
scrotum  and  along  the  inside  of  the  thighs 
grows  red,  sore,  cracked,  shining,  and  de¬ 
nuded  of  its  epidermis.  The  eyes  grow 
weak,  the  margins  of  the  eyelids  sore,  and 
a  scanty  adhesive  puriform  secretion  is 
poured  out  from  the  Meibomian  glands, 
attended  with  but  little  redness  of  the  con¬ 
junctiva.  Sometimes,  too,  the  hair  of  the 
head  drops  off,  as  small,  red,  sometimes 


J  94 


SYMPTOMS  OF  INFANTILE  SYPHILIS — ITS  TREATMENT. 


slightly  elevated  spots,  extend  over  the 
scalp. 

The  child  is  generally  by  this  time  reduced 
to  the  last  stage  of  weakness  and  attenuation, 
but  even  when  the  disease  proves  fatal,  it 
does  not  as  in  the  adult  affect  the  bones.  I 
have  chanced,  indeed,  to  see  one  instance  of 
destruction  of  the  bony  palate  from  this  cause 
in  an  infant  of  a  few  months  old,  but  so 
rare  is  the  occurrence,  that  the  late  Mr. 
Colles  of  Dublin,*  notwithstanding  his  im¬ 
mense  experience,  states  that  he  had  never 
observed  it.  Should  life  be  prolonged  after 
the  disease  has  reached  an  advanced  stage, 
its  further  manifestations  consist  in  the  for¬ 
mation  of  small  pustules  about  the  mouth, 
especially  upon  the  lower  lip  and  chin, 
which  destroy  the  cutis,  and  leave  the  sur¬ 
face  after  they  have  healed  much  scarred  by 
their  cicatrices.  The  epidermis,  too,  in 
some  bad  cases  peels  off  the  hands  and  feet : 
it  generally  becomes  thickened  to  a  kind  of 
crust,  like  that  which  forms  on  the  hand  in 
psoriaris  palmaria,  and  then  cracking,  falls  off 
in  patches,  leaving  the  skin  fissured,  and 
sometimes  deeply  ulcerated  at  the  bend  of 
the  wrist  or  at  the  flexures  of  the  fingers  and 
toes.  The  new  and  delicate  epidermis  in  its 
turn  undergoes  a  similar  thickening,  and  be¬ 
comes  detached  in  the  same  manner,  or  else 
it  continues  white  and  thin,  but  shrivelled, 
and  looking  like  the  sodden  and  wrinkled 
skin  of  a  washerwoman’s  hand,  and  peeling 
off  in  little  fragments,  leaves  the  cutis,  es¬ 
pecially  at  the  tip  of  the  fingers  and  toes, 
red,  and  bleeding  slightly,  even  on  the 
gentlest  touch. 

Although  such  are  the  effects  that  may  flow 
from  infantile  syphilis  when  it  runs  its  course 
unchecked,  it  yet  happens  but  rarely  that  we 
meet  in  any  case  with  all  the  symptoms  that 
have  just  been  described.  Most  serious 
constitutional  disturbance  is  associated  with 
the  local  mischief,  and  the  child  often  falls  a 
victim  to  the  former,  when  the  outward 
signs  of  syphilitic  disease  are  yet  compara¬ 
tively  slight.  It  wastes  rapidly,  it  suffers 
from  sickness,  or  its  bowels  become  much 
purged  :  it  is  constantly  fretful  and  uneasy  ; 
the  advance  of  ossification  is  arrested ;  the 
head  feels  soft,  and  the  anterior  fontanelle  is 
large  :  circumstances  which  sometimes  lead 
to  the  suspicion  that  chronic  hydrocephalus 
has  come  on,  though  if  the  poison  of  syphilis 
should  be  eradicated  from  the  system,  the 
subsequent  complete  recovery  of  the  patient 
shows  that  no  serious  cerebral  disease  had 
existed.  In  children  affected  by  this  syphi¬ 
litic  cachexia,  not  only  are  the  loss  of  flesh, 
and  that  withered  aspect  which  gives  to  in¬ 
fancy  the  appearance  of  old  age,  very  re¬ 
markable,  but  also  the  bloodless  state  of  the 


*  Practical  Observations  on  the  Venereal  Dis¬ 
ease.  8vo.  London,  1837,  p.  271. 


conjunctiva,  and  the  yellow,  waxen  hue  of 
the  skin,  like  that  of  a  person  who  has  been 
reduced  to  the  most  extreme  degree  of  anae¬ 
mia.  Even  in  children  who  have  survived 
their  earliest  infancy,  and  in  whom  the  dis¬ 
ease,  though  not  completely  eradicated,  has 
yet  been  kept  in  check,  the  colour  of  the  skin 
continues, and  seems, indeed,  to  bean  almost 
pathognomonic  sign  of  the  affection  from 
which  they  are  suffering. 

When  imperfectly  cured,  too,  other  indica¬ 
tions  of  the  disease  remain  besides  the  im¬ 
pairment  of  the  general  health,  the  loss  of 
flesh,  and  the  peculiar  colour  of  the  skin,  or 
at  least,  if  not  constantly  present,  they  show 
themselves  from  time  to  time,  reappearing 
at  uncertain  intervals,  without  there  being 
any  fresh  cause  for  their  manifestation. 
Such  symptoms  are  the  return  of  the  small 
copper-coloured  spots,  which,  however, 
seldom  reappear  in  considerable  numbers; 
the  general  loss  of  hair ;  the  existence  of  a 
slight  degree  of  coryza ;  the  appearance  of 
one  or  two  soft,  tubercular  elevations,  with 
ulcerated  summits  about  the  organs  of  gene¬ 
rations,  or  the  outbreak  of  a  very  severe  and 
unmanageable  intertrigo.  In  other  instances, 
there  are  few  local  signs  of  the  disease 
beyond  the  occurrence  of  small  ulcerations 
at  each  angle  of  the  mouth,  or  the  develop¬ 
ment  of  large  soft  condylomata  at  the  verge 
of  the  anus,  or  in  a  few  instances  the  for¬ 
mation  of  exceedingly  troublesome  ulcera¬ 
tions,  having  a  slightly  elevated  base,  between 
the  fingers  and  the  toes,  which  last  appear¬ 
ances  seem  to  belong  to  the  tertiary  rather 
than  to  the  secondary  consequences  of  syphi¬ 
litic  disease. 

The  duration  of  the  disease,  and  the  modein 
which  it  proves  fatal,  vary  in  different  cases  ; 
for  while  death  sometimes  takes  place  speedily 
under  the  first  outbreak  of  its  symptoms,  life 
is  in  the  other  instances  prolonged  for  seve¬ 
ral  months.  In  cases  of  this  latter  kind 
the  more  marked  signs  of  the  disease  recede 
for  a  time,  either  spontaneously  or  under 
medical  treatment,  but  the  evidences  of  the 
syphilitic  cachexia  continue,  the  child  never 
regains  it  health,  glandular  enlargements 
take  place,  and  it  either  dies  phthisical,  or 
else  drags  out  a  miserable  existence  until 
some  intercurrent  disease,  as  pneumonia  or 
diarrhoea,  supervenes  and  destroys  it. 

But  though  the  consequences  of  infantile 
syphilis  are  so  serious,  if  it  be  either  let  alone 
or  inefficiently  treated,  a  fatal  result  seldom 
takes  place  if  remedies  be  employed  before 
the  syphilitic  cachexia  has  become  fully  esta¬ 
blished,  and  if  treatment ,  when  once  began, 
is  perseveringly  continued  for  some  time 
after  the  complete  disappearance  of  every 
symptom.  This,  indeed,  sometimes  implies 
the  continuance  of  treatment  for  two  or  even 
three  months  ;  for  so  long  as  any  symptoms 
remain,  be  it  only  a  slight  spot  of  eruption, 


DR.  RENAUD  ON  CAULIFLOWER  EXCRESCENCE  OF  THE  UTERUS.  195 


or  a  small  condyloma  about  the  anus,  the 
suspension  of  remedies  would  be  certainly 
followed  by  the  reappearance  of  the  whole 
train  of  symptoms.  Even  after  the  appa¬ 
rent  cure  of  the  affection,  it  is  not  wise 
hastily  to  omit  all  medicines,  since,  just  as  in 
the  adult,  the  symptoms  have  a  great  ten¬ 
dency  to  recur. 

Mercury  in  some  form  or  other  appears 
to  be  indispensable  to  the  cure  of  this  affec¬ 
tion.  It  has  been  recommended  by  some 
writers  not  to  administer  it  directly  to  the 
child,  but  to  content  ourselves  with  bringing 
the  mother’s  system  gently  under  the  mer¬ 
curial  influence,  and  to  cure  the  infant 
through  this  medium.  In  some  slight  cases 
this  may  suffice,  and  in  almost  all,  the  cure 
of  the  infant  is  materially  expedited  by  the 
administration  of  the  remedy  to  its  mother ; 
but  I  think  that  as  a  general  rule,  it  is  ex¬ 
pedient  to  give  mercury  likewise  to  the 
child.  I  prefer  the  Hydrargyrum  cum  Creta 
to  any  other  form  of  the  remedy,  and  should 
give  it  in  doses  of  a  grain  twice  a  day  to  a 
child  of  six  weeks  old,  continuing  it  with 
two  or  three  grains  of  chalk  if  the  bowels 
were  disturbed  at  the  time  of  commencing 
the  treatment,  or  if  they  became  so  during 
its  continuance.  I  have  never  found  it 
seriously  disagree,  though  sometimes  it  causes 
sickness,  in  which  case  small  doses  of  calo¬ 
mel,  or  of  the  solution  of  corrosive  sublimate, 
may  be  substituted  for  it.  The  former  of 
these  preparations,  however,  is  apt  to  occa¬ 
sion  diarrhoea,  while  the  latter  has  not  sel¬ 
dom  disappointed  me  by  not  seeming  to  do 
much  good.  In  some  cases,  whatever  be 
the  form  of  mercurial  employed,  its  pro¬ 
tracted  use  occasions  such  great  irritability 
of  the  stomach,  that  we  are  compelled  to 
discontinue  the  remedy.  Usually,  the  child 
becomes  able  to  take  it  again,  after  a  pause 
of  two  or  three  days  ;  but  if  this  should  not 
be  the  case,  we  must  leave  it  off,  and  con¬ 
tent  ourselves  with  ordering  a  scruple  of 
mercurial  ointment  to  be  rubbed  into  the 
thighs  or  the  axillae  twice  a  day. 

As  a  local  application  to  the  sores,  the 
black  wash  usually  agrees  better  than  any 
thing  else,  but  the  large,  soft  condylomata, 
which  form  about  the  anus,  often  require 
to  be  touched  with  the  solid  nitrate  of  silver. 
It  very  often  happens  that  as  the  syphi¬ 
litic  symptoms  disappear,  the  health  of 
the  child  becomes  perfectly  restored  under 
the  use  of  no  other  remedy  than  mercury. 
If  this  be  not  the  case,  however,  some  tonic 
medicine  or  other  must  be  given.  If  the 
bowels  be  disordered,  the  Liquor  Cinchonse, 
or  the  extract  of  bark  given  either  by  itself 
or  combined  with  the  extract  sarsaparilla, 
will  be  found  very  useful.  If  there  be  no 
gastric  or  intestinal  irritation,  minute  doses 
of  iodide  of  potass  may  be  given  in  combina¬ 
tion  with  the  extract  of  sarsaparilla ;  but  if 


the  syphilitic  cachexia  be  well  marked,  and 
the  child  have  suffered  long  from  syphilis, 
or  have  had  frequent  returns  of  symptoms  of 
the  disease,  no  remedy  has  appeared  to  be 
so  serviceable  as  the  iodide  of  iron,,  which 
may  be  given  in  the  form  of  the  syrup,  and 
in  most  cases  taken  by  the  child  very  readily, 
and  is  seldom  found  to  disagree. 


©rtginal  ©ommuntcattons. 

THE  LITERATURE,  PROBABLE 
PATHOLOGY,  &c., 

OF  CAULIFLOWER  EXCRESCENCE 
OF  THE  UTERUS. 

By  Dr.  Renaud. 

(Concluded  from  page  165.) 


Until  very  lately,  the  great  mass  of 
evidence  collected  went  very  much  in 
favour  of  the  cancerous  origin  of  cauli¬ 
flower  excrescence.  From  the  litera¬ 
ture  of  the  subject  up  to  the  present 
day,  it  must  have  appeared  obvious, 
that  much  greater  latitude  has  been 
allowed  to  the  constitution  of  the  dis¬ 
ease,  than  was  assigned  it  by  Dr.  J. 
Clarice.  Dr.  Blundell  especially  has 
taken  a  comprehensive  and  most 
philosophical  view  of  the  subject.  I 
would  wish  in  particular  to  call  atten¬ 
tion  to  the  case  recorded  by  Dr.  Canella, 
where  the  disease  commenced  on  the 
anterior  lip  of  the  uterus,  somewhat 
after  the  manner  of  the  pediculated 
vivaces  described  by  Levret ;  returned 
on  the  posterior  lip,  as  a  sessile  poly¬ 
pus  of  the  same  author;  re  appeared 
around  the  os  uteri  as  cauliflower  ex¬ 
crescence  ;  and  finally  destroyed  the 
patient  under  the  form  of  scirrhus  of 
the  uterus.  When  all  the  minute 
shades  of  difference  arc  introduced,  the 
proximity  of  the  disease  to  fungus 
heematodes  is  very  striking;  but  that  a 
real  difference  exists  in  the  minute 
arrangement,  of  parts  I  shall  hope  to 
show  you. 

The  term  “  cancer”  is  so  characte¬ 
ristic  in  a  general  sense  of  the  word,  yet 
so  ill  to  be  defined  when  taken  in  de¬ 
tail,  that  the  greatest  discrepancies  yet 
exist  as  to  the  exact  meaning  of  the 
word.  In  1808,  we  find  Dr.  Clarke 
fabricating  a  new  name  for  this  dis¬ 
ease  (cauliflower  excrescence)  of  the 


190  DR.  RENAUD  ON  CAULIFLOWER  EXCRESCENCE  OF  THE  UTERUS. 


uterus,  because  he  wished  to  dis¬ 
tinguish  it.  from  cancer.  In  1809, 
Mr.  Wardrop,  in  his  work  on  Fungus 
Hsematodes,  wrote  that  although  fun¬ 
gus  had  some  analogy  to  cancer,  yet  it 
could  not  be  considered  a  disease  aris¬ 
ing  from  the  same  morbid  alteration  of 
structure  ;  whereas  M.  Dupuytren,  in 
his  Cliniques  Chirurgicales,  expressly 
designates  the  hsematoid  fungus  as  the 
association  of  medullary  cancer  with 
the  rectile  vascular  tumor  in  differ¬ 
ing  and  varying  proportions.  In  1810, 
Dr.  Denman  adopted  a  similar  precau¬ 
tion  in  his  treatise  on  cancer:  “if,” 
said  he,  “  different  diseases  have  gone 
under  the  appellation  of  cancer,  the 
points  of  resemblance  and  difference 
ought  to  be  strongly  delineated,  and  no 
position  admitted  as  irrefragable,  how¬ 
ever  great  the  authority  with  which  it 
may  be  made,  without  submitting  it  to 
the  most  accurate  and  severe  examina¬ 
tion.” 

I  quote  these  opinions,  to  show  with 
how  much  qualification,  and  allowance 
for  prevailing  opinion,  we  ought  to  re¬ 
ceive  the  statements  of  authors  with 
respect  to  the  cancerous  nature  of  this 
disease.  Neither  can  1  doubt  that  Dr. 
J.  Clarke,  in  1808,  i.  e.  some  months 
before  his  paper  appeared  on  cauli¬ 
flower  excrescence,  detailed  a  case  of 
this  disease,  but  that  from  the  combina¬ 
tion  of  hard  tumors  of  the  uterus,  and 
a  greater  quantity  of  cancer  matter  ex¬ 
isting  in  the  excrescence  than  is  com¬ 
monly  proportionate  to  the  vascular 
apparatus,  he  was  led  to  doubt  the  pro¬ 
priety  of  affixing  to  it  its  proper  name. 
It  is  described  as  a  soft  spongy  tumor 
issuing  from  the  os  uteri,  tender  in  con¬ 
sistence,  and  readily  separable  in  its 
parts,  discharging  bloody  water  and 
coagula,  removed  by  ligature,  but  re¬ 
turning  and  causing  death  by  exhaust¬ 
ing  discharges. 

Jn  order,  however,  the  more  clearly 
to  be  understood,  I  would  briefly  enu¬ 
merate  the  appearances  which  I  con¬ 
ceive  necessary  to  the  constitution  of 
cancer.  It  is  not  sufficient  for  the  es¬ 
tablishment  of  a  diagnosis  to  say  that 
cancer  grows  by  cells  ;  for  the  same 
holds  good  in  the  fat  cells  of  fatty 
tumors,  in  the  fibre  cells  of  fibrous 
tumors.  There  must  be  certain  fixed 
and  unvarying  cell  formations  in  a  can¬ 
cerous  tumor,  to  constitute  a  diagnosis  ; 
not  one  cell  of  an  exact  shape,  but  one 
or  more  varieties  of  that  cell  formation. 


From  the  great  variety  of  forms 
assumed  by  cancer  cells,  Yogel  comes 
to  the  conclusion  that  there  is  no  such 
thing  as  a  distinctive  cancer  cell;  and 
consequently  from  observing  a  single 
cell  under  the  microscope,  it  is  impos¬ 
sible  to  discern  with  accuracy  whether 
it  is  cancerous  or  not;  but  that  on  ex¬ 
amining  a  mass  of  these  cells  we  can 
often  decide  with  certainty  whether 
they  be  cancer  cells  or  not,  from  the 
varieties  which  they  present. 

Amongst  the  unvarying  elements  of 
cancer,  other  formations,  which  may  be 
destined  accidental,  may  or  may  not  be 
found.  Of  the  certain  elements  are — 
1.  Cells  of  a  spherical,  elliptical,  irre¬ 
gular  or  caudate  shape,  each  contain¬ 
ing  one  or  more  nuclei,  and  these  nuclei 
frequently  developing  nucleoli,  in  their 
turn  to  perform  the  functions  of  the 
parent  cell,  when  it  may  have  suffered 
disintegration.  2.  A  fluid  or  pabulum, 
cut  of  which  these  cells  are  eliminated. 
3.  Granular  particles.  Of  the  accidental 
elements,  are— 1.  Fat  globules.  2. 
Compound  granular  corpuscles  or  in¬ 
flammatory  globules  of  gluge,  the  con¬ 
sequence  of  irritative  inflammation. 
3.  Various  salts  and  crystals.  On  the 
neutral  ground,  i.  e.  not  quite  absolute, 
nor  altogether  accidental,  I  would 
place  the  fibre  cells,  which,  although 
constantly  found  in  cancers,  are  yet 
proper  to  healthy  tissues,  and  do  but 
seem  to  form  a  basis  or  scaffolding  on 
which  the  malignant  matters  build 
themselves  up.  True  cancer  elements, 
in  whatever  variety  they  may  exist,  are 
classed  as  heterologous,  altogether 
foreign  to  the  body  in  health. 

I  have  preferred  giving  the  elemen¬ 
tary  principles  of  which  cancer  is  made 
up,  to  attempting  an  eloquent  defini¬ 
tion  of  the  disease,  which,  however 
worded,  is  always  liable  to  one  or  more 
objections.  For  the  rest,  the  density  of 
the  tumor  will  always  be  found  to  be 
great  or  not,  according  to  the  ever- 
varying  amount  of  fibre  which  may  be 
associated  with  it,  and  in  some  mea¬ 
sure  in  proportion  to  the  resistance 
offered  to  its  spread  by  surrounding 
parts. 

Cancer,  for  the  most  part,  grows  at 
the  expense  of  the  natural  tissues, 
which  are  either  converted  or  absorbed, 
and  their  places  occupied.  I  have  said 
“ for  the  most  part,”  because  fungoid 
cancers  on  free  surfaces  frequently 
grow  to  a  goodly  size  without  affecting 


DR.  RENAUD  ON  CAULIFLOWER  EXCRESCENCE  OF  THE  UTERUS.  197 


the  tissues  on  which  they  are  implant¬ 
ed.  Arguing  thus  for  the  cancerous 
origin  of  cauliflower  excrescences,  it 
does  not  appear  that  there  need  be  any 
transmutation  of  the  natural  tissues  of 
the  uterus,  but  rather  that  a  new  for¬ 
mation  has  origin  within  the  fibres  of 
the  uterus,  which  serve  it  as  a  nidus, 
and  into  which  it  penetrates,  but 


which,  in  course  of  time,  it  may  de¬ 
stroy  or  displace.  This  new  formation, 
I  am  of  opinion,  is  a  compound  of 
tufted  capillaries,  the  exact  counterpart 
of  those  which  go  to  form  the  human, 
placenta,  and  of  nucleated  cells  answer¬ 
ing  to  the  description  given  of  cancer 
cells.  That,  as  the  capillary  loops 
elongate,  so  do  the  cancer  cells  grow  ; 


Minute  Anatomy  of  Cauliflower  Excrescence  of  the  Uterus. 


and  in  this  particular  it  is  that  a  dis¬ 
ease  really  cancerous  differs  in  the 
arrangement  of  parts  from  the  ordinary 
minute  anatomy  of  cancers.  The  or¬ 
ganized  vascular  tufts  of  cauliflower 
excrescence  are  widely  different  from 
the  arrangement  of  blood-vessels  in 
other  forms  of  cancer, —  from  the  ex- 
travasated  patches  of  fungus  hsema- 
todes,  which  arise  from  a  simple  exten¬ 
sion  and  bursting  of  vessels  proper  to 
the  body  in  health;  or  from  the  rami¬ 
fications  of  small  arteries  and  veins 
along  the  fibrous  septa  of  true  scirrhus. 
In  the  cauliflower  excrescence  the 
tufts  of  looped  capillaries  dip  down  in 
every  direction  into  the  substance  of 
the  tumor,  constituting  much  of  its 
absolute  size  during  life,  and  account¬ 
ing,  in  part,  for  the  inordinate  shrink¬ 
ing  the  mass  undergoes  after  death, — 
for  the  coats  of  these  capillaries  being 
very  thin,  the  more  watery  parts  of  the 
blood  find  a  ready  exit  through  them, 
and  flow  forth  from  the  body  through 
the  pudendal  outlet. 

They  who  object  to  cauliflower  ex¬ 
crescence  being  a  malignant  disease, 


may  feel  disposed  to  urge  that  it  and 
cancer  may  coexist,  and  yet  be  inde¬ 
pendent  the  one  of  the  other,  in  the 
same  manner  that  ovarian  cystic  tu¬ 
mors  may  be  in  themselves  benign, 
but  in  progress  of  growth  have  soft 
cancer  ingrafted  on  one  or  more  loculi 
as  an  accidental  circumstance.  Were 
such  the  fact,  it  is  highly  improbable 
that  the  vascular  interspaces  of  cauli¬ 
flower  excrescence  should  be  filled  up 
with  closely  packed  cells,  precisely 
analogous  to  those  that  go  to  constitute 
cerebriform  cancer;  and  that  the  capil¬ 
lary  blood-vessels  should  elongate 
themselves  more  and  more  without 
having  some  specific  purpose  to  fulfil. 
This  would  be  arguing  contrary  to 
nature.  Or  again,  Dr.  Hodgkin  laid 
down  five  characteristics  of  malignant 
disease  to  serve  in  the  place  of  a  defi¬ 
nition.  These  are — adjacent  lesion, 
form  of  ulcer,  glandular  enlargement, 
occurrence  of  similar  lesion  in  other 
parts,  and  constitutional  affection. 
Four  out  of  the  five  characters  are 
common  to  cauliflower  excrescence, 
with  other  malignant  formations. 


198  DR.  RENAUD  ON  CAULIFLOWER  EXCRESCENCE  OF  THE  UTERUS. 


Assuming  the  first  of  these  five — 
viz.,  adjacent  lesions — to  be  as  little 
liable  as  any  to  objection,  then  it  fol¬ 
lows  that  as  cauliflower  excrescence 
does  frequently  give  rise  to  alterations 
of  structures  in  the  immediate  neigh¬ 
bourhood  of  the  spot  primarily  affected, 
it  may  be,  and  probably  is,  malignant 
on  this  principle.  Nor  will  the  fact 
that  alterations  of  surrounding  struc¬ 
tures  may  accompany  other  tumors 
besides  those  which  are  considered 
malignant,  militate  in  aught  against 
this  view  of  the  disease,  because  any 
doubts  of  the  real  nature  of  the  pro- 
pinqual  changes  that  may  have  existed 
during  life  have  been  again  and  again 
dispelled  by  post-mortem  examinations. 
Nay,  to  altogether  reverse  the  case,  it 
by  no  means  follows  that  because  the 
disease  may  be  removed  by  excision  or 
ligature,  or  the  patient  may  die,  and 
the  surrounding  parts  either  are  not  at 
all,  or  not  perceptibly,  departed  from 
the  natural  arrangement,  that  the 
disease  should  not  be  malignant,  seeing 
how  often  the  more  common  forms  of 
cancer,  in  particular  organs,  confine 
themselves  exclusively  to  those  organs, 
and  cause  death  without  producing 
secondary  cancers  in  remote  parts,  or 
contaminating  those  most  nearly  ap¬ 
proached. 

It  should  not,  however,  be  forgotten 
that  encephaloid  cancer  has  a  great 
tendency  to  unite  itself  with  vascular 
tumors  ;  and  there  appear  three  ways 
in  which  this  conjunction  may  deter¬ 
mine  : — 

1.  The  vascular  structure  may  be 
added  to  the  encephaloid. 

2.  The  encephaloid  may  be  super- 
added  to  the  vascular. 

3.  They  may  be  simultaneous  in 
origin. 

Of  the  second  way,  or  where  the  en¬ 
cephaloid  seems  added  to  the  vascular, 
the  vivaces  of  Levret  seem  an  apt 
illustration  :  readily  bleeding  when 
touched,  and  seeming  to  consist  essen¬ 
tially  of  newly-formed  capillaries 
springing  from  an  ulcerous  surface, 
and  very  readily  reproduced  when  de¬ 
stroyed,  but  when  reproduced,  more 
liable  to  return  with  cancer  than  with¬ 
out  it.  Naevi,  aneurism  by  anastomosis, 
or  morbid  erectile  tissue,  are  further 
examples,  and  subject  alike  to  inordi¬ 
nate  and  unrepressed  development 
when  an  increased  determination  of 


blood  takes  place  towards  the  region 
of  the  body  in  which  they  are  situated 
(Hodgkin,  p.  272)  ;  and  possess  a  re¬ 
markable  proneness  to  become  the 
seat  of  malignant  disease.  There 
seems  also  a  probability,  bordering 
upon  demonstration,  that  cauliflower 
excrescence  takes  origin  from  one  of 
these  combinations  of  vascular  tissue 
with  cancer,  but  to  which  of  the  three 
there  is  as  yet  no  evidence  to  shew. 

Sir  C.  Clarke  has  remarked,  that 
“  perhaps  some  small  arteries  near 
the  os  uteri  may  undergo  that  morbid 
dilatation  of  their  coats  which  is  ana¬ 
logous  to  aneurism  in  the  larger 
trunks ;”  and  he  then  puts  the  ques¬ 
tion — “  may  such  a  state  of  blood¬ 
vessels  exist  at  the  time  of  birth,  re¬ 
main  concealed  in  early  life,  and  be 
developed  at  that  period  at  which, 
blood  rushes  with  greater  force,  and 
in  greater  quantity,  to  enlarge  the 
organs,  and  render  them  fit  for  the 
performance  of  new  duties?”  But  as 
these  questions,  in  order  to  be  answered, 
would  imply  either  a  rudimentary  form 
of  this  disease  in  every  uterus,  or  a 
manifest  departure  from  the  general 
integrity  of  the  organs  of  the  body 
when  newly  formed,  it  seems  unlikely 
that  this  speculation  should  be  just. 
Were  the  evioence  of  the  return  of  the 
disease  after  complete  excision  of  the 
cervix  more  certain,  the  question 
would  at  once  receive  a  negative  an¬ 
swer.  In  Mr.  Lee’s  case  of  excision 
the  disease  was  reproduced,  but  it  ap¬ 
pears  a  small  portion  of  the  cervix  re¬ 
mained  uncut  away. 

Having  given  a  reason  why  I  believe 
cauliflower  excrescence  may  be  con¬ 
sidered  cancerous,  from  direct  demon¬ 
stration  and  indirect  reasoning,  I  may 
draw  attention  to  the  opinions  of 
authors,  as  seen  in  the  statistical  table, 
from  which  it  will  appear  how  greatly 
the  evidence  for  its  malignancy  pre¬ 
ponderates.  By  reference  to  the  column 
entitled  “  Supposed  cause,”  it  will 
be  seen  with  how  little  confidence  in 
this  country  the  idea  of  a  syphilitic 
origin  for  the  disease  has  been  received. 
The  married  and  unmarried,  and  par¬ 
ties  of  all  ages  and  established  pru¬ 
dence,  are  alike  the  subjects.  Sir  C. 
Clarke  spoke  very  ably  on  this  part  of 
the  subject,  and  was  decidedly  of 
opinion  that  the  disease  was  not  trace¬ 
able  to  any  syphilitic  cause;  neverthe¬ 
less,  M.  Boivin  concluded  him  to  be 


DR.  RENAUD  ON  CAULIFLOWER  EXCRESCENCE  OF  THE  UTERUS  199 


wrong  in  rejecting  the  possibility  of 
such  an  origin,  concluding  that  syphilis 
may  induce  chronic  metritis,  and  after¬ 
wards  cancerous  disease  of  the  os  uteri. 
In  reply  to  this  supposition,  for  it  is 
merely  an  unsupported  conjecture,  the 
assertion  from  Sir  C.  Clarke  again 
stands  opposed  :  “  that  common  pros¬ 
titutes  are  by  no  means  more  liable  to 
it  than  any  similar  number  of  women 
in  different  stations  of  life ;  for  the 
disease  arises  as  often  in  the  strong 
and  robust  as  in  the  weak  ;  in  persons 
who  live  in  the  country,  and  in  those 
who  inhabit  large  towns ;  in  those 
whose  situation  in  life  oblige  them  to 
labour,  as  well  as  those  who,  from  their 
rank  in  society,  sometimes  consider 
themselves  privileged  to  become  use¬ 
less  members  of  it.” 

It  is  quite  possible  syphilis  may  be 
one  of  many  predisposing  causes,  and 
I  know  myself  one  case  wherein  several 
abortions  occurred  indirectly  through 
former  syphilis  having  predisposed  the 
uterus  to  congestion  and  irritability, 
which  in  the  end  took  on  the  cauli¬ 
flower  variety  of  disease. 

This  statistical  table  (see  page  200) 
comprises  nearly  all  the  well-authenti¬ 
cated  and  completed  cases  with  which 
I  have  been  enabled  to  meet,  and  is 
proof,  if  any  proof  be  wanted,  of  the 
necessity  for  a  further  accumulation  of 
careful  records  of  this  disease. 

Treatment. 

The  treatment  resolves  itself,  first, 
into  operation  with  intent  to  cure, 
either  by  ablation  of  the  cervix  uteri, 
ligature  around  the  base  of  the  tumor, 
or  by  caustics  locally  applied  ;  se¬ 
condly,  into  a  palliative  treatment,  with¬ 
out  intent  to  cure,  but  with  intent  to 
prolong  life,  reduce  pain,  and  render 
more  endurable  the  miseries  that  in 
this  disease  so  thickly  bestrew  the 
passage  to  the  grave. 

That  the  cervix  uteri  may  be  excised 
with  moderate  safety  to  the  patient 
has  been  long  proved  by  the  surgery 
of  M.  Lisfranc,  who  performed  the 
operation  some  ninety-nine  times  for 
various  disetises,  and  with  recovery  to 
the  major  part  of  his  patients.  I 
merely  quote  the  fact,  without  one 
word  of  comment ;  nevertheless,  erring 
on  the  cautious  side,  I  have  omitted 
to  introduce  M.  Lisfranc’s  name  into 
the  statistical  table.  If,  therefore, 


cauliflower  excrescence  be  found  im¬ 
planted  on  the  os  uteri,  and  there  be 
no  wide-spread  induration  of  the 
cervix,  or  enlargement  of  the  body  of 
the  uterus,  neither  any  ovarian  tumors, 
there  is  very  good  reason  to  expect 
that  excision  of  the  cervix  uteri  will 
be  attended  with  present  relief  to  the 
patient,  and,  at  the  same  time,  afford 
her  a  probable  chance  of  recovery. 
From  evidence  already  in  possession, 
it  would  appear  that  the  chances  are 
greatly  in  favour  of  a  return  of  disease 
to  the  uterus  or  appendages  in  the 
form  of  cerebri  form  cancer.  Dr.  Simp¬ 
son  has  nevertheless  recorded  a  case 
of  this  disease  on  which  he  ope¬ 
rated  by  excising  the  uterine  neck  so 
successfully,  that  five  years  afterwards 
the  woman  remained  in  good  health, 
and,  in  the  interval,  had  given  birth  to, 
and  suckled,  three  healthy  children. 
Dr.  Montgomery  also  had  a  case  of 
this  disease,  for  the  cure  of  which  he 
had  removed  the  cervix,  and  the  wo¬ 
man  remained  well  at  the  time  of 
writing— viz.  three  years  after  the  ope¬ 
ration. 

The  more  common  practice,  as  being 
the  more  easy  of  adoption,  and  the  less 
attended  with  dangerous  consequences, 
has  been  the  passing  a  ligature  as  near 
round  the  base  of  the  tumor  as  the 
peculiarity  of  its  shape  will  admit. 
This  operation  does  not  appear  to  be 
attended  with  any  common  risk  to 
life,  and  the  greatest  inconvenience  to 
be  expected  from  it  is  the  foetor  of  dis¬ 
charge,  and  sphacelus  consequent  upon 
the  tedium  of  separation.  Accordingly 
as  the  tumor  is  more  or  less  dense,  and 
the  ligature  aptly  applied,  will  be  the 
duration  of  time  necessary  to  the  com¬ 
plete  separation  of  the  parts.  Twelve 
days  may  be  allowed  as  a  maximum 
time  for  the  accomplishment  of  this 
purpose,  and  three  or  four  days  a  mini¬ 
mum.  On  the  ligature  coming  away, 
the  parts  may  be  allowed  to  remain 
quiet,  or  corroding  substances  applied 
to  the  cervix  of  the  uterus,  with  intent 
the  more  completely  to  destroy  the 
root.  Amongst  the  best  of  these  will 
be  found  the  potassa  fusa,  nitrate  of 
silver,  fluid  nitrate  of  mercury,  or  plain 
nitric  acid.  All  or  any  of  the  fore¬ 
going  may  be  directly  applied  to  the 
neck  of  the  uterus,  through  the  spe¬ 
culum,  with  the  most  complete  im¬ 
punity. 


Tabular  view  of  twenty -three  recorded  cases  of  Cauliflower  Excrescence  of  the  Uterus . 


200  DR.  RENAUD  ON  CAULIFLOWER  EXCRESCENCE  OF  THE  UTERUS. 


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DR-  RENAUD  ON  CAULIFLOWER  EXCRESCENCE  OF  THE  UTERUS.  201 


A  third  method  of  destroying  the 
excrescence  is  by  means  of  caustic 
substances  applied  to  it  twice  or  three 
times  a  week.  For  this  purpose  the 
solid  nitrate  of  silver,  or  a  very  strong 
solution,  may  be  used,  and  used  freely. 
If  the  tumor  be  large,  as  much  as  a 
quarter  of  an  inch  of  caustic  may  be 
melted  down  on  its  surface,  and  within 
its  interstices;  or  I  have  allowed  as 
much  as  a  drachm  or  two  of  the  strong 
solution  to  infiltrate  into  the  tumor 
through  the  speculum.  This  treat¬ 
ment,  when  regularly  continued,  does 
not  fail  shortly  to  develop  the  root  of 
the  fungus;  and  thus,  by  cutting  off 
the  mass  of  the  disease,  reduces 
the  wasting  discharges,  and  gives 
the  patient  time  to  rally.  I  would 
prefer  this  plan  of  treatment  to  liga¬ 
ture,  because  it  gives  no  more  annoy¬ 
ance,  perhaps  less,  to  the  patient 
than  it;  and,  moreover,  does  away 
with  the  offensiveness  of  the  dis¬ 
charges,  besides  being  a  more  gradual 
process. 

Taking  a  view  of  the  disease  as  can¬ 
cerous,  one  grave  objection  mayposibly 
apply  to  the  ligature  and  caustics  in 
common — viz.  that  the  same  malignant 
action  being  repressed  on  a  free  sur¬ 
face,  will  have  a  corresponding  ten¬ 
dency  to  repeat  itself  within  the  tissues 
of  the  part  on  which  it  is  implanted, 
and  spread  itself  by  simple  extension, 
or  be  found  as  secondary  cancerous 
masses  in  remote  parts  of  the  body. 
Thu  s,  while  a  real  good  may  appear  to 
be  effected  on  one  part,  a  more  than 
corresponding  evil  may  be  ingrafted 
on  another. 

With  regard  to  the  operation  of  com¬ 
plete  excision  of  the  cervix,  the  same 
rule  will  apply  as  that  in  force  con¬ 
cerning  haematoid  fungus,  viz.  the 
complete  ablation  of  the  diseased  part, 
— an  operation  the  performance  of 
which,  under  favourable  circumstances, 
would  appear  always  just,  on  the  prin¬ 
ciple  of  obtaining  a  present  good, 
rather  than  delaying  for  fear  of  a  con¬ 
tingent  evil.  It  is  true  that  excision 
of  the  os  and  cervix  uteri  has  fallen 
into  much  disrepute,  and  for  the  reason 
probably  that  numbers  of  such  opera¬ 
tions  have  been  performed  unneces¬ 
sarily,  injudiciously,  and  not  seldom 
for  the  removal  of  mere  functional  en¬ 
gorgements  capable  of  cure  by  thera¬ 
peutic  means. 

After  any  of  these  operations,  it 


would  seem  politic  to  have  recourse  to 
occasional  local  abstractions  of  blood, 
and  to  place  the  patient  on  a  long 
course  of  alterative  medicines,  recom¬ 
mending,  in  addition,  pure  air,  mode¬ 
rate  exercise,  and  cheerful  associa¬ 
tions. 

From  the  great  length  to  which  the 
paper  has  already  prolonged  itself,  I 
pass  over  the  consideration  of  pallia¬ 
tive  medicines,  which  are  useful  in  this 
form  of  disease,  in  common  with  other 
foreign  growths  from  these  parts,  and, 
in  conclusion,  have  to  hope  I  may 
have  been  enabled  to  place  the  disease 
on  a  more  sure  basis,  and  that  future 
attempts  at  its  treatment  may  be  made 
with  more  certainty  as  to  purpose,  and 
with  a  degree  ot  success  proportionate 
to  its  gravity;  so  that,  on  the  one 
hand,  inordinate  expectations  may  be 
repressed,  and,  on  the  other,  too 
melancholy  forebodings  may  be  dis¬ 
couraged. 


CASE  OF 

UMBILICAL  HERNIA, 

COMPLICATED  WITH,  AND  PROBABLY 
CAUSED  BY, 

P  H  Y  M  O  S  I  S. 

OPERATION  OF  CIRCUMCISION  FOLLOWED 
BY  A  CURE  OF  THE  HERNIA. 

By  H,  Burford  Norman,  F.R.C.S. 

Surgeon  to  the  St.  Marylebone  and  Blenheim 
Street  Dispensaries,  and  to  the  Western  Oph¬ 
thalmic  Institution. 


The  following  case  has  appeared  to 
me,  and  to  some  of  my  professional 
friends  to  whom  I  have  named  it,  to 
possess  much  interest.  (  may  venture, 
therefore,  to  suppose  that  its  recital  will 
not  prove  uninteresting  to  those  readers 
of  the  Medical  Gazette  generally 
who  may  be  engaged  in  the  study  or 
practice  of  surgery.  So  far  as  I  know, 
it  is  unique;  and  as  a  solitary  observa¬ 
tion  I  record  if,  in  order  to  direct  atten¬ 
tion  to  the  point  of  practice  involved. 
I  would  not  wish  to  make  too  much  of 
the  result  of  that  practice,  but  would 
submit  the  case  as  it  is,  and  for  as 
much  as  it  is  worth,  to  the  conside¬ 
ration  of  my  professional  brethren. 

Case.— On  the  4th  of  December  last, 
J.  B.,  a  fine  healihy-looking  little  boy, 
eet.  18  months,  was  brought  for  my  ad¬ 
vice  to  the  Marylebone  Dispensary,  in 


202  CASE  OF  UMBILICAL  HERNIA  COMPLICATED  WITH  PHYMOSIS. 


consequence  of  being  the  subject  of 
umbilical  hernia,  the  existence  of  which 
had  been  noticed  by  his  mother  some 
weeks.  She  felt  sure  that  the  tumor 
was  not  congenital,  but  had  very  little 
positive  knowlege  of  its  commence¬ 
ment,  or  whether  the  number  of  weeks 
it  had  existed  might  amount  to 
months.  She  had  on  this  account  no 
idea  to  what  she  might  attribute  the 
tumor,  and  had  adopted  no  means  for 
its  cure. 

The  hernia,  when  I  saw  it,  was  of 
the  size  of  a  large  nutmeg,  or  between 
that  and  a  walnut :  it  was  very  readily 
reduced,  and  shewed  no  great  dispo¬ 
sition  to  return,  remaining  in  the  ab¬ 
domen  whilst  the  child  wTas  quiet,  but 
being  protruded  with  violence,  and  of 
increased  size,  on  the  child’s  crying 
and  struggling  whilst  I  examined 
him. 

On  directing  my  inquiries  to  the 
probable  or  possible  causes  of  the 
malady,  I  was  led  first  to  investigate 
the  respiratory  functions.  With  them 
all  appeared  well.  Respiration  was 
easy,  and  altogether  natural.  The 
child  neither  was  at  the  time,  nor  had 
previously  been,  the  subject  of  cough. 

In  the  digestive  functions  there  ap¬ 
peared  to  be  equally  little  fault.  The 
bowels  were  said  to  be  regular,  and  the 
appetite  good.  The  tongue  was  clean. 
The  child  was  in  good  condition,  and 
had  not  been  subject  to  diarrhoea  or 
constipation.  He  was  frequently 
noticed  to  pick  his  nose  and  anus,  but 
had  never  voided  ascarides. 

On  inquiring  into  the  state  of  the 
urinary  organs  and  functions,  I  found 
that  the  child  made  water  very  fre¬ 
quently,  that  he  appeared  to  be  in  pain 
in  the  perineum  whilst  doing  so,  as 
indicated  by  his  seeming  uneasy,  and 
putting  his  hand  there  during  the  act, 
— that  the  urine  was  voided  more 
slowly,  and  apparently  with  greater 
exertion  and  straining  than  natural, — 
that  the  child  was  frequently  noticed 
to  play  with  the  penis,  and  to  pull 
about  the  prepuce.  He  had  never 
passed  bloody  urine,  and  was  as  active 
as  other  children  of  his  age. 

The  prepuce  I  found  on  examination 
very  long,  and  its  orifice  so  narrow  and 
unyielding  that  I  could  not  pass  a 
probe  into  it,  much  less  expose  the 
glans  penis.  Here,  it  seemed  to  me, 
was  a  state  of  things  which  in  all  pro¬ 
bability  had  occasioned  the  hernia, 


and  the  propriety  of  removing  the  pre¬ 
puce  by  circumcision  suggested  itself 
to  my  mind  as  an  efficient  and  suitable 
remedy  ;  and,  supposing  this  was  not 
the  case,  at  least  1  thought  it  desirable 
and  right  to  remove  a  cause  of  so  great 
obstruction  to  the  due  passage  of  the 
urine,  which  was  already  by  this  effect 
creating  much  inconvenience,  and 
which  might,  by  its  continuance,  occa¬ 
sion  still  more  serious  urinary  disease 
— possibly  calculus  of  the  bladder. 
Again  there  was  no  harm  to  be  appre¬ 
hended  from  the  operation,  and  it 
would  in  all  probability  require  to  be 
performed  at  a  later  period  of  life, 
when  it  would  be  on  all  accounts  a 
more  serious  matter.  These  things 
having  been  represented  to  the  parents, 
they  readily  assented  to  the  operation ; 
and,  an  aperient  powder  having  been 
prescribed,  the  next  day  but  one  was 
fixed  for  doing  it. 

6th. — The  bowels  were  freely  opened 
yesterday  and  to-day.  and  the  child 
appeared  in  a  very  fit  state  for  the 
operation.  A  little  chloroform  was 
administered  on  a  sponge,  and  in  a 
few  seconds  the  child  was  in  a  state  of 
complete  repose.  He  was  then  held 
in  a  convenient  position  on  his  mother’s 
lap,  and  the  prepuce  being  drawn  for¬ 
wards,  was  grasped  gently  between 
the  blades  of  polypus  forceps  by  Mr. 
Matthews,  the  Apothecary  of  the  Dis¬ 
pensary,  who  assisted  me.  I  then 
sliced  off  with  a  bistoury  that  portion 
of  the  prepuce  which  was  on  the  distal 
side'of  the  forceps,  and  consisted  only 
of  the  skin  forming  its  free  margin. 
The  forceps  being  opened,  the  skin 
became  retracted  behind  the  glans, 
leaving  the  mucous  membrane  entire 
covering  it.  A  slit  was  then  made  in 
the  membrane,  and  a  director  having 
been  passed  under  it,  it  was  divided  in 
its  whole  length  to  its  reflection  from 
the  penis.  There  was  then  much 
trouble  experienced  in  separating  the 
prepuce  from  the  glans,  in  consequence 
of  the  close  adhesions  formed  between 
their  adjacent  surfaces.  This  accom¬ 
plished,  two  cuts  with  the  scissors, 
commencing  at  the  base  of  the  longi¬ 
tudinal  incision,  and  extending  from 
each  side  to  the  frsenum  itself,  de¬ 
tached  the  portion  of  the  prepuce  to 
be  removed,  and  finished  the  operation. 
There  was  very  little  haemoirhage.  No 
attempt  was  made  to  bring  the  mucous 
and  cutaneous  edges  of  the  divided 


TREATMENT  OF  FRACTURE  OF  THE  THIGH-BONE  IN  INFANTS.  203 


prepuce  together :  a  fold  of  wet  lint 
formed  the  only  dressing. 

7th. — A  little  hsetnorrhage  occurred 
in  the  night,  and  was  arrested  by  cold 
water;  the  glans  swollen  and  red; 
dry  coagula  sticking  to  the  wound. 
The  penis  to  be  enveloped  in  a  bread- 
and-wat.r  poultice. 

8th. — The  orifice  of  the  urethra  be¬ 
came  plugged  in  the  night  with  the 
secretions  of  the  wound,  and  produced 
retention  of  urine,  to  the  alarm  of  the 
parents  and  distress  of  the  child.  The 
obstruction  was  removed  by  a  small 
catheter,  and  the  urine  passed  readily. 
From  this  time  cicatrization  went  on 
steadily,  and  was  complete  at  the  end 
of  three  weeks.  There  was  no  return 
of  the  hernia  after  the  operation,  and 
he  was  constantly  under  my  observa¬ 
tion  for  two  months  :  at  first  in  conse¬ 
quence  of  an  attack  of  pemphigus,  and 
subsequently  of  bronchitis.  It  is  re¬ 
markable  that  the  rupture  should  not 
have  returned  during  the  violent  cough 
accompanying  the  latter  disease,  which 
in  its  latter  stage  approached  more  to 
the  violent  and  convulsive  character  of 
hooping-cough. 

I  have  seen  the  child  this  day,  July 
12th — seven  months  since  the  opera¬ 
tion.  'He  has  remained  perfectly  free 
from  the  hernial  tumor. 

Remarks. — It  is  perhaps  impossible 
to  say  how  much  the  perfect  rest  ob¬ 
served  by  the  little  patient  after  the 
operation,  in  consequence  of  the  sore¬ 
ness  of  the  penis,  and  how  much  the 
operation  itself,  by  removing  an  ob¬ 
struction  of  the  urinary  passage,  which 
necessitated  frequent  and  unnatural 
exertion  of  the  abdominal  muscles, 
had  to  do  'with  the  happy  result  as 
relates  to  the  hernia.  But  I  think  it 
quite  fair  and  reasonable  to  suppose 
that  the  latter,  at  least ,  had  the  larger 
share;  whilst,  if  this  be  allowed,  it  is 
entitled,  in  fact,  to  the  whole  credit, 
because  it  wTas  the  means  of  enforcing 
the  former.  It  may  be  objected  that 
the  cure  was  spontaneous;  and  it  must 
be  admitted,  I  think,  that  the  umbilical 
ruptures  of  young  children  do  often 
obtain  such  a  happy  end.  From  a 
single  observation,  I  would  anxiously 
endeavour  to  avoid  any  hasty  and  un¬ 
warranted  deduction.  Still,  I  think  it 
by  no  means  a  stretch  of  imagination 
to  believe  that  in  this  case  the  opera¬ 
tion  and  the  subsidence  of  the  tumor 
do  stand  in  the  relation  of  cause  and 


effect.  Should  I  again  meet  with  such 
a  concurrence  of  circumstances,  I 
should  again  adopt  a  similar  practice; 
and  I  should  esteem  it  a  favour  on  the 
part  of  any  reader  of  these  remarks 
who  might  meet  with  such  a  case,  if  he 
would  permit  me  to  see  it  with  him, 
and,  if  disposed  to  try  the  practice,  he 
would  allow  me  the  opportunity  of 
watching  the  case  with  him,  or  would 
communicate  to  me  the  result. 

3,  Duchess  Street,  Portland  Place, 

July  12  th,  1848. 


ON  THE 

TREATMENT  OF  FRACTURES  OF 
THE  THIGH-BONE  IN  INFANTS, 

IN  THE  FLEXED  POSITION. 

By  Edward  F.  Lonsdale. 


W hen  fracture  of  the  thigh-bone  occurs 
in  infants  or  in  very  young  children, 
it  is  by  no  means  an  easy  matter  to 
prevent  shortening  of  the  limb,  owing 
to  the  difficulty  of  maintaining  the 
correct  apposition  of  the  two  portions 
of  bone.  This  difficulty  all  surgeons 
of  any  experience  in  the  treatment  of 
fractures  must  have  met  with.  My 
attention  has  been  more  particularly 
directed  to  the  subject  lately,  from 
many  cases  having  come  under  my 
care  at  the  Orthopsedic  Hospital,  as 
well  as  two  in  private  practice,  the 
children  having  been  brought  for  the 
treatment  of  existing  lameness,  in  all 
of  which  there  was  shortening  of  one 
limb,  owing  to  the  thigh-bone  having 
been  fractured  at  a  former  period,  and 
to  the  want  of  proper  care  in  preserv¬ 
ing  the  correct  apposition  of  the  bone 
during  the  treatment.  On  examining 
the  limb  carefully,  the  cause  of  the 
shortening  was  found  to  be  owing  to 
the  extreme  curve  forwards  of  the 
shaft  of  the  femur,  and  not  to  the 
lower  portion  being  drawn  up  behind 
the  upper  (which  is  generally  the 
cause  of  the  shortening  in  adults). 
The  result,  however,  is  the  same — 
namely,  the  approximation  of  the  knee 
to  the  hip-joint,  and  a  consequent 
diminution  in  the  length  of  the  whole 
limb. 

The  cause  of  this  increased  arch  in 
the  bone  depends  on  the  difficulty  of 
keeping  the  upper  end  from  tilting 
upwards,  and  of  bringing  the  lower 
portion  into  the  same  line  with  it. 


204  TREATMENT  OF  FRACTURE  OF  THF  THIGH-BONE  IN  INFANTS. 


The  bone  then  unites  in  an  angle, 
causing  the  whole  thigh  to  appear 
curved  forwards;  for  in  the  majority  of 
cases,  as  already  stated,  there  is  no 
retraction  of  one  portion  behind  the 
other.  In  adults  this  evil  is  guarded 
against  by  the  employment  of  the  in¬ 
clined  plane  ;  but  in  infants  or  very 
young  children  this  apparatus  cannot 
be  employed,  for  there  is  the  absence 
of  sufficient  weight  in  the  pelvis  and 
body,  as  well  as  the  difficulty,  if  not 
impossibility,  of  keeping  the  child  in 
the  horizontal  position — points  essen¬ 
tial  to  secure  its  action,  and  to  pre¬ 
serve  the  correct  line  of  apposition  of 
the  two  portions  of  bone. 

The  treatment  generally  followed 
for  these  cases,  and  the  one  that  I  have 
hitherto  employed  myself,  is  to  keep 
the  limb  in  the  extended  position,  by 
using  long  lath  splints,  extending  from 
the  hip  down  to  the  foot.  (I  am  con¬ 
vinced  that  short  ones,  applied  to  the 
thigh  only,  cannot  keep  the  ends  of  the 
bone  in  apposition.)  The  splint  in  the 
front  should  be  the  longest,  and  be 
made  to  pass  up  before  the  hip-joint  as 
high  as  the  crest  of  the  ilium.  A  thick 
pad  is  placed  on  the  upper  portion  of 
the  thigh-bone.  Great  pressure,  how¬ 
ever,  is  required  to  insure  the  effectual 
action  of  the  splints,  as  well  as  the 
necessity  of  keeping  the  child  in  the 
horizontal  position,  a  position  that  is 
difficult  and  irksome  in  infants,  more 
particularly  during  nursing. 

Meeting*  with  these  difficulties,  I 
turned  my  attention  to  the  possibility 
of  treating  these  cases  by  the  flexed 
position,  and  have  been  enabled  to  do 
so  by  the  following  simple  means, 
which,  in  the  case  of  a  child  twelve 
months  old,  recently  under  my  care, 
answered  most  satisfactorily  ;  the  cor¬ 
rect  apposition  of  the  ends  of  the  bone 
being  preserved  at  the  same  time  that 
the  position  of  the  child  was  less  con¬ 
strained  and  awkward. 

I  employ  two  narrow  long  strips  of 
sheet  iron,  an  inch  wide,  and  thin 
enough  to  allow  of  being  easily  bent  at 
any  angle  required,  though  sufficiently 
thick  to  bear  the  weight  of  the  limb 
without  yielding.  They  are  applied  as 
follows:— The  child  is  placed  on  its 
back,  and  an  assistant  holds  the  limb 
in  a  position  so  as  to  flex  the  hip  and 
knee  joints,  the  angle  of  flexion  being 
similar  to  that  employed  when  the 
inclined  plane  is  used  for  adults.  The 


two  thin  iron  splints  are  then  bent  at 
angles  corresponding  to  the  hip,  knee, 
and  ankle-joints,  to  adapt  themselves 
to  the  limb,  in  the  position  in  which  it 
is  being  held  by  the  assistant.  An 
important  point  to  attend  to  is,  the 
proper  length  of  the  splint.  The  upper 
one  should  be  long  enough  to  pass  up 
in  front  of  the  hip-joint,  to  lie  flat  on 
the  lower  part  of  the  abdomen,  and  to 
extend  down  over  the  instep  to  the 
toes.  The  back  one  should  extend  up 
behind  the  buttock,  being  curved  to  fit 
its  shape,  as  high  as  the  posterior 
margin  of  the  crest  of  the  ilium,  and 
long  enough  to  extend  down  behind 
the  heel  to  the  sole  of  the  foot.  If  the 
two  splints  are  bent  at  proper  angles, 
to  correspond  with  the  shape  and  posi¬ 
tion  of  the  hip,  knee,  and  ankle  joints, 
they  will,  when  firmly  bound  to  the 
limb,  keep  it  in  the  position  required, 
which  is  one  that  most  favours  the 
correct  apposition  of  the  ends  of  the 
bone,  by  relaxing  all  the  muscles.  The 
limb  must  of  course  be  evenly  rolled 
before  applying  the  splints,  and  the 
splints  themselves  be  padded.  The 
upper  ends  of  the  splints  are  to  be 
firmly  fixed  to  the  pelvis,  by  passing 
the  bandage  many  times  round  them, 
and  occasionally  reversing  the  direc¬ 
tion  of  the  bandage  round  the  ends  of 
the  splints  themselves,  to  prevent  them 
being  displaced  laterally. 

82,  Guilford  Street,  Russell  Square, 

July  20,  1848. 


NATURE  OF  THE  VITAL  FORCES  NOT  MORE 
OBSCURE  THAN  THAT  OF  THE  PHYSICAL 
FORCES. 

If  we  may  judge  by  the  tone  of  argument 
assumed  by  some  of  those  who  have  written 
on  the  subject,  it  might  be  supposed  that  all 
the  difficulties  attendant  on  the  investigation 
of  natural  phenomena  were  connected  with 
those  of  life ;  whereas  the  reality  is  that  we 
know  just  as  much  of  the  vital  forces  as  we 
do  of  the  physical.  "Who,  for  instance, 
knows  anything  of  the  nature  of  light,  of 
heat,  of  electricity  ?  or  who  can  assign  their 
intimate  relations  with  the  material  sub¬ 
stances  necessary  to  their  manifestation. 
But,  as  the  want  of  this  knowledge  has  been 
no  barrier  to  the  successful  investigation  of 
the  conditions,  laws,  and  effects  of  these 
subtle  physical  forces,  so  the  absence  of  all 
acquaintance  with  the  abstract  character  of 
the  vital  powers  need  be  no  obstacle  to  the 
most  searching  examination  of  the  question 
now  before  us. — -Mr.  Grainger's  Hunterian 
Oration. 


REPORT  OF  THE  COMMITTEE  OF  POOR-LAW  MEDICAL  OFFICERS.  205 


MEDICAL  GAZETTE. 


FRIDAY,  AUGUST  4,  1848. 

Our  space  will  not  allow  us  to  reprint 
the  whole  of  the  lengthy  Report  which 
has  been  forwarded  to  us  by  the  Com¬ 
mittee  of  the  Convention  of  Poor  Law 
Medical  Officers,  but  the  subject  is  of 
sufficient  importance  to  claim  a  brief 
analysis.  This  will  probably  meet  the 
wishes  of  the  Committee,  whose  dis¬ 
interested  efforts  we  are  desirous  of 
aiding ;  and  we  are  certain  that  it  will 
be  more  acceptable  to  our  contributors. 
The  members  of  the  Committee  have 
long  worked  assiduously,  and  we  are 
glad  to  find  they  have  at  length  brought 
their  labours  to  a  practical  conclusion. 
The  evils  of  the  present  system  have 
been  clearly  exposed,  the  remedies  have 
been  suggested,  and  it  now  only  re¬ 
mains  for 'the  Legislature  to  sanction 
these  by  an  act  which  shall  hence¬ 
forth  secure  a  proper  degree  of  relief  to 
the  pauper,  and  a  just  remuneration  to 
the  medical  practitioner.  It  is  easy 
to  perceive  from  this  report,  that  the 
Committee  have  had  to  contend  with 
numerous  obstacles  in  the  profession 
itself.  Every  practitioner  connected 
with  a  Union,  has  naturally  enough 
been  inclined  to  consider  his  own  case 
as  special,  and  one  or  peculiar  hardship; 
but  it  is  clear  that  no  amelioration  in  the 
present  system  could  be  made,  until  all 
these  unities  had  become  amalgamated. 
In  this  the  Committee  appear  to  have 
succeeded,  and  have  wisely  brought 
before  Government,  only  the  more  pro¬ 
minent  grievances  which  affect  the 
medical  officers  as  a  body.  In  carry¬ 
ing  out  their  proceedings,  they  have 
been  guided  by  certain  resolutions 
passed  at  the  Convention.  These  may 
be  summarily  stated  as  follows  : — • 

“1.— That  the  highest  qualification 
of  a  cultivated  mind,  and  professional 


capability,  with  great  expenditure  of 
time  and  physical  strength,  are  per¬ 
petually  called  into  operation  through 
the  Poor  Law  Surgeon  for  the  benefit 
of  the  sick  poor  ;  that  the  present  sys¬ 
tem  is  so  essentially  faulty,  that  the 
surgeon  is  invariably  unfairly  dealt  by, 
and  the  sick  poor  are  more  or  less  in¬ 
jured. 

“  2. — That  the  payment  given  by 
Boards  of  Guardians  is  utterly  out  of 
proportion  to  the  duties,  exertions,  and 
expenses  which  devolve  on  the  Medical 
Officer,  as  well  as  to  the  advantages 
conferred  on  the  suffering  paupers. 

“3. — That  to  remedy  these  grievances 
the  Convention  pledges  itself,  by  its 
standing  Committee,  to  use  the  most 
persevering  and  temperate  means,  to 
collect  and  digest  information  on  the 
subject ;  to  memorialize  the  Secretary 
of  State  for  the  Home  Department,  and 
the  Poor  Law  Board,  and  to  communi¬ 
cate  with  the  Colleges  of  Surgeons  and 
Physicians,  and  other  influential  and 
corporate  medical  bodies.” 

To  elicit  available  information  from 
a  large  body  of  men  constantly  and 
laboriously  occupied  in  practice,  was 
obviously  no  easy  task.  Nevertheless, 
returns  were  received  from  434  Unions, 
comprising  805  Medical  Districts,*  a 
very  fair  proportion,  and  large  enuugh 
to  justify  an  appeal  to  the  Government, 
as  from  the  whole  body.  The  neces¬ 
sity  for  removing  from  Boards  of  Guar¬ 
dians,  the  power  of  controlling  the  pay¬ 
ment  of  medical  officers,  is  plainly 
shewn  in  the  following  extract  from  the 
report : — 

“  By  several  of  the  returns,  it  ap¬ 
pears,  that  on  the  issuing  of  the  order 
of  the  Commissioners  for  the  allowance 
of  Extras,  several  of  the  Boards  of 
Guardians,  for  the  purpose  of  evading 
it,  reduced  the  Salaries  of  the  Medical 
Officers — others  (a  few  only)  gently 
constrained  the  medical  officers  to  com¬ 
pound  for  all  extras,  by  a  small  fixed 
addition  to  the  annual  salary; — whilst 
others  have  systematically  and  rigo¬ 
rously  evaded  it,  by  peremptory  instruc¬ 
tions  to  the  Relieving  Officer  to  send  all 

*  We  think  the  Committee  would  have  done 
Wisely  to  have  appended  to  this  part  of  their  Re¬ 
port,  a  table  of  the  total  number  of  Unions,  dis¬ 
tricts,  and  medical  officers,  under  the  adminis¬ 
tration  of  the  Poor  Law. 


206 


POOR-LAW  MEDICAL  RELIEF - 


cases  of  accident,  or  cases  requiring 
surgical  operations,  to  the  Hospitals  to 
which  the  Board  subscribes.  This  is 
much  complained  of,  not  on  account  of 
the  mere  loss  to  the  Medical  Officer 
of  the  fees,  but  for  the  injury  and 
risk  suffered  by  the  patient  during  the 
removal — sometimes  in  carts  over  bad 
roads,  for  many  miles.” 

This  fact  deserves  the  special  atten¬ 
tion  of  the  President  of  the  Poor  Law 
Board.  The  argument  for  the  existence 
of  “local  control,”  is  very  good  in 
theory,  but  it  fails  when  practically  ap¬ 
plied.  It  is  incredible  that  such  an 
unfair  system  of  evading  the  orders  of 
the  Commissioners  should  be  tolerated. 

Out  of  465  returns,  there  were  362 
opposed  to  the  plan  of  payment  per 
case;  while  out  of  466,  there  were  no 
less  than  428  who  approved  of  the  sys¬ 
tem  of  payment  by  a  fixed  salary,  based 
upon  the  number  of  cases  attended  and 
the  mileage.  Of  424  returns,  there  were 
351  who  approved  of  payment  by  a  fixed 
salary,  founded  upon  the  number  of  po¬ 
pulation  and  area,  to  be  determined  by 
the  Commissioners.  The  large  majority, 
therefore,  approve  of  the  plan  of  fixed 
salaries  ;  they  allege  that  if  payment 
per  case  be  adopted,  the  Guardians, 
Overseers,  and  Relieving  Officers,  in 
their  anxiety  to  keep  down  the  ex¬ 
penses,  would  refuse  orders  for  medical 
relief  in  all  but  the  most  serious  and 
dangerous  cases;  and  thus  the  great 
majority  of  the  paupers  would  be  utterly 
unable  to  procure  medical  advice  until 
their  sickness  had  become  desperate, 
and  entirelv  disabled  them.  In  addi- 
tion  to  this,  “  the  few  cases  for  which 
orders  would  be  given,  would  be  of  the 
most  serious,  and  none  of  them  of  a 
trivial  character,  which  would  be  most 
unjust  upon  the  medical  officer.  His 
humanity  would  be  unduly  and  inces¬ 
santly  taxed  by  attending  upon  pauper 
cases,  which  he  would  with  reluctance 
see  perishing  for  want  of  medical  aid, 
but  which  he  must  administer  at  his 
own  expense.”  These  objections  are 


forcible ;  although  it  may  be  said,  in 
defence  of  the  plan,  that  it  establishes 
a  proportion  between  the  amount  of 
work  done,  and  the  remuneration  re¬ 
ceived,  while  it  saves  medical  atten¬ 
dance  upon  a  large  number  of  trivial 
cases.  Nevertheless,  there  can  be  no 
doubt  that  the  general  experience  of 
the  Union  medical  officers  is  in  favour 
of  a  fixed  salary,  and  the  majority  agree 
that  it  would  be  better  to  leave  the 
amount  of  salary  to  be  fixed  by  the 
Commissioners,  than  by  the  Boards  of 
Guardians. 

We  have  on  various  occasions  en¬ 
deavoured  to  prove  that  nothing  could 
be  worse  than  the  anomalous  and  un¬ 
equal  manner  in  which  payments  for 
medical  services  are  now  made.  We 
are  by  no  means  surprised  to  find,  that 
according  to  a  careful  examination 
made  by  the  Committee,  “  a  rule  ob¬ 
tains,  wherely  the  remuneration  de¬ 
creases  in  the  ratio  that  the  duty  in¬ 
creases — a  rule  so  obviously  unjust, 
that  it  requires  only  to  be  stated  to  be 
condemned.”  Thus,  in  the  Axbridge 
Union 

“  The  Medical  Officer  of  one  district, 
attending  only  200  cases  of  sickness 
annually,  and  working  an  area  of  only 
7100  acres,  receives,  on  an  average, 
3s.  6d.  per  case  ;  whilst  his  colleague  in 
the  adjoining  district,  attending  1440 
cases  annually,  and  working  an  area  of 
17,420  acres,  receives  only  lid.  per 
case.  In  the  Northwich  Union,  in  the 
Middlewich  district  No.  1,  with  an 
acreage  of  9,446,  and  a  population  of 
3,258,  the  payment  amounts  to  6s.  2d. 
per  case  ;  whilst  in  Weaver-lane  dis¬ 
trict  of  the  same  union,  the  acreage 
being  15,610,  and  the  population  5,641, 
the  payment  is  only  lOd.  per  case.  Again, 
in  the  Grantham  Union,  the  Grantham 
district,  with  an  acreage  of  11,818,  and 
a  population  of  8,734,  the  payment  is 
only  7d.  per  case  ;  whilst  in  the  Burton 
Coggles  district  of  that  Union,  the 
acreage  is  11,864,  and  the  population 
1,288,  and  the  amount  per  case  is  as 
high  as  7s.  Id. 

“  From  the  returns  which  have  been 
made,  it  appears  that  throughout  the 


REPORT  OF  THE  COMMITTEE  OF  POOR-LAW  MEDICAL  OFFICERS.  207 


country  the  rate  per  case  varies  from 
as  low  as  3d.  to  14s.  4d.  The  average 
rate  of  payment  for  each  case  of  sick¬ 
ness,  as  ascertained  bv  Returns  received 
from  805  Medical  Officers,  is  Is.  6fd. 
for  the  Metropolitan  Districts  within 
three  miles  of  the  General  Post  Office, 
and  2s.  7d.  for  the  country  districts — 
whereas  the  average  cost  of  drugs, 
alone,  for  a  single  case  occurring  in 
the  practice  of  the  Surgeons  to  Dispen¬ 
saries,  who  relieve  the  same  class  of 
persons  as  the  Medical  Officers  of 
Unions,  amounts  to  2s.  l|d.,  and  for 
Hospital  cases  to  4s.  4£d. 

Who  can  doubt  that  under  such  a 
system  grave  injury  must  be  done  both 
to  the  medical  officer  and  the  destitute 
poor!  It  is  true  that  the  Poor-law 
Commissioners  act  as  a  Court  of  appeal 
from  the  decisions  of  the  Boards  of 
Guardians,  yet  practically  the  griev¬ 
ances  complained  of  remain  unre¬ 
dressed.  Either  the  instructions  of  the 
Commissioners  are  utterly  neglected,  or 
their  orders  are  pertinaciously  resisted 
and  evaded.  So  much  for  the  local 
control  exercised  by  Boards  of  Guar¬ 
dians,  of  w’hich  the  new  President 
appears  to  be  a  strenuous  advocate. 

We  come  now  to  the  scheme  by 
which  the  Committee  propose  to  re¬ 
move  the  more  pressing  evils  of  w7hich 
the  Union  medical  officers  now  justly 
complain.  They  are  as  follows  : — 

“  1st.  That  in  the  opinion  of  your 
memorialists,  it  is  essential  that  the 
payment  of  medical  officers  should  be 
by  a  fixed  salary,  exclusive  of  fees  for 
midwifery  and  important  surgical  cases. 

“2d.  That  the  amount  of  salary 
might  justly  be  fixed,  either  by  an  esti¬ 
mate  of  the  average  of  cases  attended 
during  a  series  of  past  years,  con¬ 
sidered  in  connection  with  the  area 
of  the  medical  district,  or  by  the 
payment  of  a  certain  sum  per  head  on 
the  population,  corrected  by  the  con¬ 
sideration  of  the  relative  density  and 
poverty  of  the  district. 

“3d.  That  making  every  allowance 
for  the  difference  which  must  exist  in 
the  remuneration  of  private  and  public 
practice,  it  would  not  be  just  that  the 
salary  should  be  based  on  a  less  amount 


than  6s.  6d.  per  case,  with  the  charge 
varying  with  the  area. 

“4th.  That  medical  officers  of  work- 
houses  should  be  paid  a  separate  salary, 
based  on  the  average  number  of  in¬ 
mates,  at  not  less  than  7s.  to  10s.  per 
head. 

“  5th.  That  it  is  just  and  proper,  and 
conducive  to  the  interests  of  the  poor, 
that  an  extra  payment  should  be  made, 
as  at  present,  for  midwifery  and  for 
important  surgical  cases;  and  that  it 
appears  to  your  memorialists  advisable 
that  the  fees  should  be  paid  for  cases 
occurring  in  wrorkhouses,  as  w7ell  as  in 
out-door  cases. 

“  6th,  That  to  the  cases  of  surgery 
requiring  payment,  enumerated  in  the 
General  Order  of  the  Poor-law  Com¬ 
missioners,  should  be  added — 

“Fractures  of  the  clavicle; 

“Fractures  of  the  skull; 

“Retention  of  urine,  when  requiring 
repeated  introduction  of  the  catheter. 

“  Severe  burns  and  scalds; 

“  And  that  £3  be  paid  for  compound 
fracture  of  the  arm. 

“7th.  That  the  payments  allowed 
for  midwifery  and  surgical  cases  under 
the  General  Order  of  the  Poor-law 
Commissioners  are  satisfactory  in 
amount. 

“8th.  That  in  order  to  remove  diffi¬ 
culties  in  the  way  of  a  more  equitable 
payment  of  medical  officers,  and  con¬ 
sidering  that  half  the  Union  medical 
expenses  are  already  paid  from  the 
Consolidated  Fund,  it  is  highly  desi¬ 
rable  that  the  whole  expenses  of  the 
medical  attendance  on  the  poor  should 
be  removed  from  Unions  to  the  Con¬ 
solidated  Fund. 

“  9th.  That  it  is  expedient  that  there 
be  a  Director-General  of  the  Poor-law 
Medical  department  appointed  by  Go¬ 
vernment,  and  exercising  supervision 
over  Poor-law  medical  practice,  in  the 
manner  of  the  other  public  services. 

“  10th.  That  it  is  expedient  that 
there  should  be  Inspectors- General  of 
Poor-law7  medical  practice  appointed 
by  Government,  and  acting  under  the 
orders  of  the  Director-General. 

“11th.  That  the  Inspectors-General 
acting  each  in  a  district  assigned  to 
them,  should  examine  the  Infirmaries 
of  workhouses,  inspect  the  reports  of 
the  medical  officers,  inquire  into  cases 
of  alleged  negligence,  &c.  &c. ;  and 
that  matters  of  disputed  payment  should 
be  referred  to  them. 


208  REPORT  OF  THE  COMMITTEE  OF  POOR-LAW  MEDICAL  OFFICERS. 


“  12th.  That  the  medical  officers  of 
Unions  should  be  appointed  by  Boards 
of  Guardians  as  at  present,  subject  to 
the  approval  of  the  Director-General ; 
that  their  qualification  should  be  as  at 
present  ordered,  but  that  all  future 
modifications  of  the  qualifications 
should  be  made  by  the  Director- 
General. 

“  13th.  That  the  appointments  of  all 
medical  officers  should  be  permanent 
— that  is,  to  endure  until  they  die,  re¬ 
sign,  or  are  dismissed  for  some  valid 
cause. 

“  14th.  That  the  Forms  of  Books  or 
Reports  should  be  approved  by  the 
Director-General,  and  should  be  as 
short  and  simple  as  is  consistent  with 
the  requirements  of  the  public  service. 

“  15th.  That  the  access  of  the  pau¬ 
pers  to  the  medical  officers  should  be 
made  as  ready  as  a  due  distinction 
between  those  who  require  paroehial 
attendance,  and  those  who  do  not,  will 
admit.  That  in  doubtful  cases  where 
illness  exists,  and  there  appears  to  be 
temporary  destitution  only,  the  Board 
may  grant  medical  relief  by  way  of 
loan  ;  that  in  such  cases  a  fee  of 
be  paid  by  the  Board  of  Guardians  to 
the  medical  officer. 

“Signed on  behalf  of  the  Committee, 

“  Thomas  Hodgkin,  M.D. 

“  Chairman” 

There  may  be  some  difference  of 
opinion  about  details,  but  the  demands 
here  made,  appear  to  us  to  be  not  only 
reasonable  and  just,  but  absolutely 
necessary  to  the  success  of  any  mea¬ 
sure  of  Poor-law  medical  reform. 

It  would  seem  that  the  subject  of 
medical  ethics  has  incidentally  fallen 
under  the  notice  of  the  Committee. 
The  following  remarks,  which  are  es¬ 
pecially  addressed  to  those  members 
of  the  profession  who  are  eager  to 
secure  appointments  which  are  proved 
to  be  both  laborious  and  unremune- 
rative,  may  be  appropriately  applied 
to  the  present  state  of  the  Upton 
Union*  :  — 

“All  matters  of  personal  grievance 
between  medical  gentlemen  must 
surely  be  beyond  the  bounds  of  the 
Committee’s  deliberations  and  inter¬ 


ference  :  yet,  within  the  past  few 
months,  several  cases  have  been  point¬ 
edly  pressed  upon  their  notice,  in  which 
their  adjudication  was  sought  in  refe¬ 
rence  to  professional  etiquette  end  the 
sins  of  competitive  antagonism.  Deeply 
deploring  the  occurrence  of  such  cases, 
the  Committee  wmuld  earnestly  impress 
on  the  Poor-law  medical  officers  the 
vital  importance  of  disinterested  co¬ 
operation,  and  the  cultivation  of  the 
Christian  spirit  of  doing  to  others  as 
we  wrould  that  they  should  do  to  us. 
Under  the  present  pressure  of  a  redun¬ 
dant  population  and  competitive 
struggle,  one  man’s  interest  must  often 
cross  his  neighbour’s  ;  but.  every  wise 
man  wiil  feel  that  he  damages  himself 
when  he  accepts  an  appointment  wThich 
he  can  only  hold  at  the  sacrifice  of  a 
rival’s  due,  and  the  compromise  of  his 
own  character  as  a  gentleman.  No 
greater  obstacle  to  a  systematic  im¬ 
provement  of  the  present  plan  of  Poor- 
law  medical  relief  exists,  than  in  the 
readiness  with  which  medical  men  are 
found  to  accept  situations  wrhich  others 
have  resigned  under  an  indignant  sense 
of  ill-usage  and  a  stingy  payment.  A 
strong,  but  erroneous  impression,  pos¬ 
sesses  the  public  mind  that  this  wdlling- 
ness  to  take  office  under  a  system  de¬ 
nounced  as  so  bad,  arises,  after  all,  from 
some  unexplained  sinister  advantage 
accruing  to  the  medical  attendants  on 
paupers.  If  professional  gentlemen  do 
not  become  true  to  one  another,  it  is  to 
be  feared  no  Convention  can  suggest, 
nor  Government  legislate,  for  the  best 
interests  of  even  the  Poor-law  medical 
staff.” 

It  is  clear  that  an  evil  of  this  kind 
can  be  remedied  only  by  the  profession 
itself.  No  Act  of  Parliament  can  pre¬ 
vent  men  who  are  so  disposed  from 
overreaching  each  other. 

Although  there  is  no  immediate  pros¬ 
pect  of  legislation  in  the  medical  de¬ 
partment  of  the  Poor-law,  yet  it  is  a 
considerable  step  towards  a  sound  mea¬ 
sure  of  reform,  that  a  series  of  prac¬ 
tical  suggestions  are  now  for  the  first 
time  laid  before  the  public.  It  merely 
requires  the  goodwill  of  the  Govern¬ 
ment  to  mould  them  into  shape,  and  to 
enact  them  into  a  law\ 


*  See  our  last  number,  pp.  117  and  127. 


mr.  Morgan’s  lectures  on  diseases  of  the  eye. 


209 


Lectures  on  Diseases  of  the  'Eye.  By 
John  Morgan,  F.L.S.  2d  edition, 
carefully  revised  and  enlarged,  with 
Notes  by  John  F.  France,  Surgeon 
to  the  Eve  Infirmary,  and  Lecturer 
on  Ophthalmic  Surgery  at  Guy’s 
Hospital.  8vo.  pp.  222;  with  eighteen 
coloured  plates.  London  :  Highley, 
1848. 

It  is  hardly  necessary  to  say  that  the 
late  Mr.  Morgan  had  acquired  a  we’l- 
deserved  reputation  for  his  practical 
acquaintance  with  diseases  of  the  eye, 
and  that  his  “Lectures”  have  for  some 
years  been  regarded  as  a  work  of  refe¬ 
rence  and  authority.  The  necessity 
having  arisen  for  a  new  edition,  the 
preparation  of  the  treatise  for  the  press, 
has  been  entrusted  to  Mr.  J.  F  France, 
the  friend  and  successor  of  the  author. 
This  gentleman,  who  has  already 
earned  a  good  reputation  as  an  oph 
thalmic  surgeon,  has  shewn  much 
judgment  as  an  editor  in  leaving  the 
author  to  speak  for  himself.  The  addi¬ 
tions  which  he  has  found  it  necessary 
to  make  are  printed  at  the  termination 
of  each  section  in  a  smaller  type,  and 
in  the  form  of  practical  comments. 

Mr.  Morgan’s  work  has  been  long 
out  of  print,  and  w?e  are  glad  to  wel¬ 
come  the  appearance  of  a  new  edition 
under  such  favourable  auspices.  The 
necessity  for  works  of  this  stamp  is  the 
more  apparent,  because  probably  there 
is  no  department  of  surgery  in  which 
quackery  is  more  predominant  than  in 
that  which  relates  to  the  treatment  of 
diseases  of  the  eye.  We  have  here  in  a 
concise  form  the  accurately  recorded  re¬ 
sults  of  experience,  as  well  as  clear  rules 
for  diagnosis  and  treatment.  Mr.  Mor¬ 
gan’s  lectures  were  always  practical : 
the  time  of  the  student  was  not  taken 
up  wfith  the  discussion  of  the  theoretical 
views  of  ophthalmic  surgeons ;  nor 
were  his  pupils  bewildered  by  the 
details  of  a  dozen  conflicting  methods 
of  treatment. 

The  Diseases  of  the  Eye  are  arranged 
by  tlie  author  in  distinct  sections,  me¬ 
thodically  divided  into  paragraphs, 
commencing  with  Symptoms  and  His¬ 
tory,  and  terminating  with  Treatment. 

In  treating  of  Catarrh  l  Ophthalmia, 
Mr.  Morgan  makes  some  strongobserva- 


tions  on  the  injudicious  methods  which 
are  often  adopted  for  the  examination 
of  an  inflamed  eye.  He  observes, 
that — 

“  The  object  is  to  separate  the  inflamed 
surfaces  of  the  conjunctiva  of  the  lids 
and  globe  at  the  time  of  opening  the 
eye,  and  to  avoid  making  any  pressure 
upon  the  part  :  this  will  be  easily  accom¬ 
plished,  unless  excessive  tumefaction  oppose 
an  obstacle,  by  gently  drawing  down  the 
integuments  of  the  lower  lid  towards  the 
cheek  with  the  fore-finger  of  one  hand ; 
and,  with  the  thumb  or  fore-finger  of  the 
other,  drawing  up  the  skin  covering  the 
upper  lid  towards  the  supra  orbitar  ridge: 
the  third  diagram  represents  this  process. 
In  opening  an  eye,  carefully  avoid  throwing 
strong  light  upon  it,  as  otherwise  the  opera¬ 
tion  is  sometimes  rendered  difficult,  from 
spasmodic  contraction  of  the  orbicularis 
palpebrarum  ;  and  in  cases  where  the  retina 
has  been  rendered  morbidly  irritable,  tem¬ 
porary  increase  of  vascularity  will  generally 
be  the  consequence  of  neglecting  this  pre¬ 
caution.”  (p.  25). 

While  on  this  subject,  we  shall  in¬ 
troduce  some  remarks  on  the  treatment 
of  this  disease  by  Mr.  France — 

“In  a  large  majority  of  cases,  catarrhal 
ophthalmia  is  a  purely  local  affection,  and 
demands  no  further  constitutional  treatment 
than  a  gentle  purgative.  It  is,  however, 
particularly  apt  to  occur  in  a  mild  form  in 
suckling  women,  especially  if  the  subjects  of 
leucorrhoea,  or  if  lactation  have  been  pro¬ 
tracted  beyond  the  natural  term,  or  if  from 
any  other  cause  the  constitution  be  unable 
to  meet  vigorously  the  call  made  upon  it. 
In  such  cases  it  is  usual  to  find  a  constipated 
condition  of  the  bowels  ;  and  this  may 
effectively  be  relieved,  at  the  same  time  that 
general  debility  is  combated,  by  a  mixture 
composed  of  ten  or  fifteen  grains  of  car¬ 
bonate  of  magnesia,  six  drachms  of  infusion 
of  calumba,  and  the  same  quantity  of  mint- 
water.  Various  other  medicines  calculated 
to  fulfil  the  same  indications  may  proba¬ 
bly  serve  equally  well ;  the  above  is  that 
which  the  editor  is  in  the  habit  of  prescri¬ 
bing  with  satisfactory  results.  A  weak  so¬ 
lution  of  nitrate  of  silver  constitutes  a  local 
application  which,  from  its  universal  efficacy 
in  this  disease,  is  almost  entitled  to  the 
character  of  a  specific.  Two  or  three  drops 
of  a  collyrium,  consisting  of  a  grain  or  a 
grain  and  a  half  of  this  substance  dissolved 
in  an  ounce  of  rose-water,  should  be  in¬ 
stilled  upon  the  inflamed  membrane  thrice 
daily,  and  generally  the  remedy  acts  with  a 
degree  of  celerity  and  certainty  in  subduing 
the  disorder  in  its  recent  stages,  quite  sur¬ 
prising  to  those  unaccustomed  to  its  use. 


210 


mr.  Morgan’s  lectures  on  diseases  of  the  eye. 


As  a  rule,  this  application  is  not  beneficial 
when  intolerance  of  light  is  present;  but  it 
must  be  borne  in  mind  that,  in  so  far  as 
intolerance  of  light  is  manifested,  does  a 
given  case  depart  from  the  normal  type  of 
catarrhal  ophthalmia,  acd  assume  the  cha¬ 
racteristic  of  the  strumous  disease  :  with 
this  proviso,  the  practitioner  may  employ 
the  above-mentioned  collyrium  in  cases  of 
catarrhal  ophthalmia  with  the  utmost  con¬ 
fidence  in  its  curative  powers.  Risk  of 
inducing  discolouration  of  the  conjunctiva  is 
only  incurred  by  long-continued  use  of  a 
solution  of  the  strength  now  directed,  or  the 
employment  of  one  containing  a  considera¬ 
bly  larger  proportion  of  the  nitrate.  But, 
for  the  disease  under  consideration,  neither 
of  these  chances  need  be  run,  as  a  few  days' 
continuance  of  the  collyiium  now  directed 
is  usually  sufficient  for  the  cure.  In  chronic 
cases  nitrate  of  silver  is  less  beneficial ; 
while  the  objection  to  its  use  gathers  weight, 
since  long  perseverance  with  local  astringents 
is  then  required.”  (pp.  25-6). 

The  subject  of  ophthalmia,  in  the 
variolous,  purulent,  and  strumous  va¬ 
rieties,  occupies  a  large  portion  of  the 
volume,  and  is  satisfactorily  treated, 
both  in  relation  to  diagnosis  and  treat¬ 
ment. 

Tile  following  extract  from  the  sec¬ 
tion  on  Chemosis  has  some  interest  in 
relation  to  the  anatomy  of  the  eye : — 

“  In  some  cases  of  chemosis  there  is  an 
appearance  interesting  both  to  the  anatomist 
and  the  pathologist,  as  it  affords  to  the 
former  a  perfect  proof  of  the  existence  of  a 
structure  he  might  not  be  able  by  dis¬ 
section  to  detect,  and  to  the  latter  a 
guide  for  the  treatment  of  his  patient — I 
mean  chemosis  of  the  corneal  conjunctiva, 
the  occasional  occurrence  of  which  demon, 
strates,  notwithstanding  the  impossibility  of 
separating  the  parts  in  the  healthy  subject, 
that  the  conjunctiva  does  form  an  anterior 
covering  to  the  cornea.  To  the  surgeon 
and  pathologist,  the  occurrence  of  corneal 
chemosis  gives  an  assurance  that  acute  dis¬ 
ease  is  not  present;  for  in  acute  inflammatory 
chemosis,  the  bagging  forward  of  the  con¬ 
junctiva  scleroticae  conceals  the  circum¬ 
ference  of  the  corneal  portion  of  the  mem¬ 
brane,  at  which  place  corneal  chemosis  almost 
invariably  commences.”  (pp.  89-90). 

A  man  may  be  acquainted  with  a 
remedy,  but  not  know  how  to  employ 
it  with  benefit  to  the  patient.  Thus, 
in  cases  of  granular  conjunctiva,  where 
it  is  desirable,  in  applying  nitrate  of 
silver,  to  avoid  staining  the  conjunc¬ 
tiva  of  the  globe,  it  is  recommended 
that  the  following  plan  should  be  re¬ 
sorted  to: — 


“  In  applying  the  Argenti  Nitras,  or  any 
other  astringent  (fluid,  solid,  or  unctuous), 
to  a  diseased  eyelid,  first  evert  the  lid,  and 
hold  it  well  away  from  the  globe  ;  dry  its 
conjunctival  surface  with  a  piece  of  linen, 
and  immediately  make  the  application. 
Directly  afterwards  dry  it  again,  and  apply 
some  mild  unirritating  ointment ;  wipe  this 
off,  and  make  the  application  of  ointment 
once  more.  You  may  then  be  almost  cer¬ 
tain  that  whatever  astringent  has  been  ap¬ 
plied  to  the  conjunctiva  of  the  lid  will  leave 
that  of  the  globe  untouched  :  an  object,  the 
desirableness  of  which  must  be  obvious, 
when  you  consider  the  effect  strong  local 
applications  would  produce  upon  the  surface 
of  a  healthy  membrane.”  (p.  94). 

In  reference  to  the  treatment  of 
opacities  of  the  cornea ,  Mr.  France 
makes  the  following  observations  : — 

“  The  prognosis  with  respect  to  opacities 
of  the  cornea  must  be  drawn  from  an  esti¬ 
mate  of  the  age  of  the  patient,  the  density 
of  the  opacity,  and  its  duration  ;  the  younger 
the  individual,  the  less  dense  the  nebula, 
and  the  shorter  the  period  of  its  duration, 
the  better  being  the  prospect  of  its  entire 
removal.  In  young  children  the  opaque 
cicatrix  following  actual  ulceration  is  sus¬ 
ceptible  of  perfect  cure.  It  is  not  often, 
however,  that  resort  to  mercury,  so  as  to 
affect  the  system,  is  called  for  in  the  treat¬ 
ment  of  these  cases.  After  the  subsidence 
of  inflammation,  local  measures  are  more  to 
be  depended  upon  ;  and  in  addition  to  the 
applications  mentioned  in  the  text,  there  are 
two  which  deserve  especial  notice.  Calo¬ 
mel,  inflated  as  powder  upon  the  cornea,  is, 
in  certain  cases  of  nebula  in  which  vascular 
excitement  has  quite  passed  away,  of  ex¬ 
cellent  service ;  and  the  same  credit  is  due 
to  iodide  of  potassium  dissolved  in  water  in 
the  proportion  of  six  or  eight  grains  to  the 
ounce.  Of  the  use  of  hydrocyanic  acid 
vapour  for  the  same  purpose,  the  editor  has 
no  satisfactory  experience,  but  can  recom¬ 
mend  the  remedies  now  named,  together 
with  those  previously  specified,  as  worthy  of 
the  fullest  reliance.”  (pp.  105-6). 

There  is  but  little  to  be  said  with 
respect  to  Amaurosis.  Glaucoma  is 
not  necessarily  a  sign  of  this  morbid 
state  :  many  persons,  whose  vision  is 
perfect,  are  glaucomatous ;  but  when 
glaucoma  accompanies  amaurosis,  the 
case  is  generally  hopeless. 

An  amaurotic  patient,  it  is  well 
known,  looks  directly  forward,  with  a 
peculiar  vacant  stare,  as  if  “staring 
into  space”  ;  and  this  appearance  is  so 
highly  characteristic,  that,  w^hen  amau¬ 
rosis  is  combined  with  partial  opacity 
of  the  humours,  it  may  be  thus  readily 


DEATH  CAUSE  D  BY  THE  INHALATION  OF  CHLOROFORM  IN  FRANCE.  211 


distinguished  from  cataract.  Of  the 
treatment  of  amaurosis,  the  author  ob¬ 
serves — 

“  Amaurosis  is  sometimes  attended  by 
congestion,  sometimes  by  want  of  active  cir¬ 
culation  in  the  part,  and  now  and  then  by 
functional  derangement  in  the  nervous 
system  unattended  by  any  obvious  indication 
of  altered  action.  In  congestive  amaurosis, 
you  may  observe,  to  greater  or  less  extent, 
a  turgid  state  of  the  veins  of  the  head  and 
vessels  of  the  conjunctiva :  it  is  usually  met 
with  in  plethoric  subjects.  In  such  cases, 
the  object  being  to  lessen  action,  antiphlo¬ 
gistic  measures  must  be  adopted.  General 
and  local  depletion,  and  a  brisk  cathartic, 
are  therefore  required  in  the  first  instance. 
If  there  is  reason  to  believe  that  the  disease 
is  kept  up  by  sympathy  with  a  morbid  con¬ 
dition  of  the  digestive  or  other  organs,  the 
remedies  best  calculated  to  remove  the  exist¬ 
ing  cause  must  be  exhibited.  The  patient 
should  of  course  avoid  stimulants,  and  be 
kept  on  low  diet. 

“  In  the  next  place,  you  should  give  mer¬ 
cury  with  a  view  of  affecting  the  system  ; 
and  if,  after  a  few  weeks,  the  exhibition  of 
this  remedy  produce  no  alleviation,  the  case 
will  probably  terminate  unfavourably. 

Mercury  is  as  much  a  specific  in  conges¬ 
tive  functional  amaurosis  as  in  syphilic 
iritis ;  and  when  it  fails  to  effect  a  cure, 
all  other  remedies  are  commonly  useless. 
How  mercury  acts  in  these  cases  has  not 
been  explained,  farther  than  that  it  produces 
a  salutary  effect  by  its  operation  upon  the 
capillary  system. 

“  In  congestive  functional  amaurosis,  then, 
deplete,  affect  the  system  with  mercury,  and 
attend  to  the  healthy  condition  of  the  con¬ 
stitution  generally.  In  the  incipient  stage 
these  remedies  will  arrest,  and  in  many  cases 
remove,  the  morbid  action  ;  but  when  the 
disease  has  been  allowed  to  gain  ground, 
and  the  sense  of  vision  is  once  lost,  or 
nearly  so,  you  will  hardly  ever  be  able  to 
save  the  organ.  Incipient  amaurosis  is 
under  our  control ;  complete  amaurosis  is 
rarely  benefited  by  medical  treatment.”  (pp. 
169-70). 

Some  space  is  devoted  to  the  subject 
of  Cataract,  and  the  operations  re¬ 
quired  for  its  treatment.  For  an  ac¬ 
count  of  these  we  must  refer  the  reader 
to  the  work  itself.  The  coloured  litho¬ 
graphic  plates  attached  to  the  volume, 
aid  considerably  the  descriptions  given 
in  the  text  of  the  diseases  of  the  eye 
and  the  operations  required  for  their 
treatment. 

A  biographical  notice  of  the  author, 
which  appeared  originally  in  this  jour¬ 
nal,  is  prefixed  to  the  volume.  The 


mode  in  which  the  second  edition  has 
been  revised  and  edited  is  higtily  cre¬ 
ditable  to  Mr.  France. 


■Dhoceetungs  of  jiboctettes. 


ACADEMY  OF  MEDICINE,  PARIS. 

July  4,  1848. 

M.  Rayer-Collard,  President. 


ON  A  CASE  OF  DEATH  CAUSED  BY  THE  IN¬ 
HALATION  OF  CHLOROFORM.  BY  M. 
GORRE',  SURGEON-IN-CHIEF  TO  THE 
HOSPITAL  OF  BOULOGNE  ;  CORRESPOND¬ 
ING  MEMBER  OF  THE  ACADEMY  OF  MEDI¬ 
CINE,  PARIS.* 

Mlle.  Stock,  a  young  person  30  years 
of  age,  well  formed  :  enjoyed  habitually 
good  health.  I  ought  to  state,  however, 
that  she  had  consulted  me  some  months  pre¬ 
viously  for  palpitation,  which  appeared  to 
me  to  depend  on  a  chlorotic  state,  and  on 
which  preparations  of  iron  had  the  happiest 
effect.  Her  health  since  then  had  experi¬ 
enced  no  change. 

Some  weeks  since  she  was  thrown  out  of 
a  carriage,  and  besides  some  contusions,  the 
result  of  the  fall,  she  was  wounded  in  the 
thigh  by  a  splinter  of  wood,  which  made  its 
way  beneath  the  skin,  without  leaving  any 
trace  besides  a  very  small  laceration,  and 
the  presence  of  which  was  not  then  recog¬ 
nized.  Her  medical  attendant  applied  some 
leeches  over  this  point.  Fluctuation  being 
soon  manifest,  he  proposed  an  incision,  but 
the  patient  refused.  Some  days  afterwards 
pus  escaped  in  some  quantity  through  a 
spontaneous  opening,  and  as  the  suppura¬ 
tion  did  not  cease,  I  was  called  to  the  case. 
I  easily  made  her  understand  that  a  free  in¬ 
cision  was  necessary  for  her  complete  re¬ 
covery.  She  now  consented,  but  on  condi¬ 
tion  that  I  should  put  her  under  the  influ¬ 
ence  of  chloroform.  I  had  no  reason  to 
refuse  her  request.  I  went  next  day  with 
some  chloroform,  the  good  quality  of 
which  cannot  be  doubted,  as  it  was  supplied 
from  the  Chemical  Laboratory  of  Quesne- 
ville. 

I  found  my  young  patient  in  her  usual 
good  spirits,  free  from  all  fear :  her  usual 
medical  attendant  was  present,  and  a  mid¬ 
wife,  to  render  assistance.  Everything  being 
ready  for  the  operation,  in  itself  very  insig¬ 
nificant,  I  placed  over  the  nostrils  of  the 
patient  a  handkerchief  moistened  with  from 
fifteen  to  twenty  drops  at  the  most  of  chlo¬ 
roform. 

*  We  here  give  in  a  more  complete  form,  a  full 
history  of  the  alleged  case  of  poisoning  by  chlo¬ 
roform  vapour  in  France. 


212  DEATH  CAUSED  BY  THE  INHALATION  OF  CHLOROFORM  IN  FRANCE. 


Scarcely  had  she  taken  several  inspira¬ 
tions,  when  she  put  her  hand  on  the  hand¬ 
kerchief  to  withdraw  it,  and  cried  with  a 
plaintive  voice,  “  I  choak  !”  Immediately 
the  face  became  pale ;  the  countenance 
changed  ;  the  breathing  embarrassed  ;  and 
she  foamed  at  the  mouth.  At  the  same  in¬ 
stant,  (and  that  certainly  less  than  a  minute 
after  the  beginning  of  the  inhalation),  the 
handkerchief  moistened  with  chloroform  was 
withdrawn.  But  persuaded  that  the  bad 
symptoms  were  only  evanescent,  and  that  it 
would  suffice  for  the  effect  to  cease  to  have 
suppressed  the  cause,  I  hastened  to  pass  a 
director  into  the  small  fistulous  wound  in 
the  thigh,  and  to  lay  open  the  abscess  in  its 
whole  extent — that  is  to  say,  between  two 
and  three  inches,  and  I  withdrew  from  the 
bottom  of  the  wound  a  small,  thin,  and 
pointed  splinter  of  wood.  During  the  in¬ 
finitely  short  time  occupied  by  this  little 
operation,  my  colleague  sought  by  every 
means  to  remedy  the  threatening  annihila¬ 
tion  of  life.  I  joined  him,  and  both  of  us  put 
into  force  with  activity  the  measures  most 
likely  to  prevent  a  fatal  issue. 

Frictions  upon  the  temples  and  the  precor¬ 
dial  region,  throwing  cold  water  on  the  face, 
tickling  the  fauces  with  a  feather,  blowing 
air  into  the  air  passages,  ammonia  to  the 
nostrils,  everything  that  it  is  possible  to  do 
in  such  a  case,  was  tried  by  my  colleague  and 
myself,  during  more  than  two  hours.  We 
were  willing  to  believe  that  there  was  only 
a  suspension,  not  an  abolition  of  the  senso¬ 
rial  functions.  It  seemed  impossible  that 
the  inhalation  of  so  minute  a  quantity  of  the 
anaesthetic  agent  during  so  short  a  time, 
(not,  indeed,  calculated  by  the  watch,  but 
certainly  not  more  than  a  minute)  had  been 
sufficient  to  extinguish  life.  Our  efforts 
were  vain  ! 

This  death,  though  we  clung  to  the  belief 
that  it  was  but  apparent,  was  real ;  and  it  had 
been  so  prompt,  that  already  it  was  without 
doubt  complete  at  the  moment  when  I  made 
the  incision.  I  can  only  give  a  just  idea  of 
the  lightning-like  rapidity  with  which  it  was 
produced,  by  saying  that  it  recalled  to  me 
most  accurately  death  from  the  accidental 
introduction  of  air  into  the  veins.  The  de¬ 
tails  of  the  very  minute  examination  give 
value  to  this  analogy,  the  idea  of  which 
struck  me  when  observing  the  symptomatic 
expression  of  the  last  moments  of  life. 

Autopsy ,  24  hours  after  death. — Exterior 
aspect.  The  right  side  of  the  face  presents 
several  large  eschars,  the  skin  being  as  it 
were  parchment-like  :  these  eschars  are  due 
to  the  ammoniacal  frictions  made  to  recal 
life.  Complete  rigidity  of  the  limbs ;  cor¬ 
nea  dull;  abdomen  distended  with  gas;  a 
blood-stained  bandage  covers  a  wound  at  the 
internal  superior  part  of  the  right  thigh. 

Head. — Scarcely  any  blood  flows  from 


the  cutaneous  incision.  The  superior  longi¬ 
tudinal  sinus  is  empty ;  the  veins  on  the 
convex  surface  of  the  brain  are  not  engorged, 
but  they  present  this  remarkable  peculiarity, 
that  the  column  of  blood  is  broken  every  here 
and  there  by  bubbles  of  gas.  These  veins 
when  punctured,  collapse,  owing  to  the  es¬ 
cape  of  the  gas.  There  is  also  air  in  the 
veins  at  the  base  of  the  skull.  Numerous 
bullae  of  air  escaped  with  the  hlood  from  the 
ophthalmic  veins,  the  cavernous  sinuses,  and 
the  inferior  cerebral  veins.  The  lateral  ven¬ 
tricles  contain  a  moderate  quantity  of  serum. 
The  substance  of  the  brain  is  firm  ;  no  drops 
of  blood  escape  on  cutting  into  it. 

The  air  escapes,  bubbling  up  in  the  midst 
of  a  remarkably  black  and  very  fluid  blood, 
from  the  internal  saphena  and  the  left  crural 
veins.  The  crural  artery  is  entirely  empty. 

The  right  thigh  presents,  on  the  inner  side 
of  it,  in  the  upper  part  and  somewhat  back¬ 
wards,  a  wound  made  in  opening  an  abscess. 
This  wound,  made  through  the  skin  and 
cellular  tissue,  is  stained  with  black  blood ; 
the  vena  saphena  is  at  a  distance  from  the 
incision,  and  could  not  have  been  touched 
by  the  bistoury.  The  universal  presence  of 
air  in  the  circulatory  system  called  for  a 
careful  examination  of  the  blood-vessels  near 
the  wound :  dissected  with  the  greatest  care, 
they  are  found  to  be  perfectly  entire. 

Chest. — The  lungs,  especially  the  left,  are 
voluminous,  and  visibly  engorged  in  the 
lower  lobes.  When  cut  into,  a  large  quan¬ 
tity  of  very  black  fluid  blood  escapes.  Re¬ 
markable  crepitation  ;  pulmonary  vesicles 
dilated  by  the  air  blown  in  during  the  last 
moments  of  life,  with  a  view  to  reanimate 
the  patient,  supposed  to  be  in  a  state  of 
asphyxia.  Neither  interlobular  nor  sub- 
pleural  emphysema ;  the  tracheal  mucous 
membrane  is  of  a  bright  red;  complete  ab¬ 
sence  of  froth  in  the  bronchi ;  some  amount 
of  serum  in  the  pleura  and  pericardium  ; 
heart  excessively  flaccid,  of  the  usual  size  ; 
right  and  left  cavities  absolutely  empty. 
Not  the  smallest  clot  either  in  the  auricle  or 
between  the  fleshy  columns  of  the  ventricles  ; 
frothy  blood  in  the  orifice  of  the  ascending 
cava.  The  pulmonary  veins,  opened  near 
the  auricle,  allow  a  little  blood  to  escape, 
mixed  with  air.  The  internal  membrane  of 
the  heart,  especially  of  the  right  cavities,  is 
red.  Its  tissue  is  pale,  and  tears  easily. 

Abdomen. — Liver  very  voluminous,  its 
colour  like  the  lees  of  wine ;  on  cutting  into 
it,  air  bubbles  out  of  the  vessels  along  with 
much  black  and  fluid  blood  ;  the  intestines 
are  distended  by  foetid  gas.  The  spleen 
is  softened,  and  is  gorged  with  blood ;  on 
pressure,  several  bubbles  of  air  escape  from 
its  substance. 

In  closing  the  account  of  this  autopsy,  I 
have  particularly  to  notice  that  the  blood 
was  blacker  than  it  is  in  simple  asphyxia.  It 


DEATH  CAUSED  BY  THE  INHALATION  OF  CHLOROFORM  IN  FRANCE.  2J3 


wws  literally  as  black  as  ink.  The  above 
post-mortem  appearances  lead  me  to  the 
following  conclusions,  which  I  submit  to  the 
consideration  ot  the  Academy  : — 

Mile.  Stock  did  not,  properly  so  to  speak, 
die  from  asphyxia.  According  to  all  proba¬ 
bility,  her  death  was  due  to  syncope,  caused 
by  the  sudden  suspension  of  the  cerebral 
functions  under  the  influence  of  chloroform. 

The  presence  of  air  in  the  venous  system 
cannot  be  explained  by  the  introduction  of 
air  into  a  vein  imprudently  opened  when  the 
incision  was  made  in  the  thigh.  The  in¬ 
cision  being  altogether  superficial  and  cuta¬ 
neous,  could  not  reach  a  vein  of  large  size. 

Nor  yet  was  it  the  artificial  respiration 
which  caused  the  air  to  find  its  way  into  the 
circulation  through  the  rupture  of  the  pul 
monary  cells  ;  for  at  the  moment  when  the 
artificial  respiration  was  resorted  to,  life  was 
extinguished,  if  it  had  not  been  already  abo¬ 
lished,  and  the  action  of  the  left  side  of  the 
heart  had  ceased. 

Thus,  by  shutting  out  other  causes,  one 
must  admit,  as  the  most  probable  view,  the 
spontaneous  formation  of  air  in  the  veins. 
Was  this  fluid  produced  during  life  or  after 
death  ? 

Morgagni  relates  cases  of  sudden  death, 
in  which  the ^autopsy  revealed  a  large  accu¬ 
mulation  of  air  in  the  heart  and  great  vessels, 
without  any  possible  external  origin.  In 
these  cases  decomposition  had  not  com¬ 
menced,  and  no  organic  change  accounted 
for  the  death.  M.  Olliviers  (d’ Angers),  has 
related  analogous  examples,  which  led  him 
to  admit  the  possibility  of  the  disengagement 
of  a  gaseous  fluid  during  life,  which  kills  after 
the  same  manner  and  with  the  same  rapidity 
as  if  air  had  penetrated  accidentally  through 
the  opening  of  a  venous  trunk  contiguous  to 
the  heart. 

I  am  consequently  induced  to  think  that 
the  above  case  must  be  added  to  those  singu¬ 
lar  cases  of  pneumatosis  related  by  Mery, 
Littre,  Morgagni,  and,  among  ourselves,  M. 
Ollivier  (d’Angers).  In  this  case,  it  appears 
to  me  that  the  rapidity  of  the  death  is  due  to 
a  complication  of  causes — namely,  first,  to 
the  special  deleterious  influence  of  the  chlo¬ 
roform  upon  the  brain,  which  led,  as  the  im¬ 
mediate  consequence,  to  the  abolition  of  the 
sensorial  functions ;  and  secondly,  to  the 
spontaneous  development  of  gaseous  fluid  in 
the  circulatory  system,  the  probable  result 
of  the  hitherto  unexplained  action  of  the 
ethers  upon  the  blood,  under  the  circum¬ 
stances  related. 

Whatever  may  be  the  value  of  this  ex¬ 
planation,  one  thing  is  certain,  resulting 
from  the  case  just  related,  and  from  that  re¬ 
ported  in  the  Lancet,  that  the  chloroform,  in 
certain  kinds  of  constitution,  which  it  is  ab¬ 
solutely  impossible  for  the  man  of  science  to 
recognize,  may  cause  death  with  a  lightning- 


like  rapidity.  Even  in  experienced  hands, 
there  is  no  certain  safe-guard  against  the  un¬ 
fortunate  consequences  of  this  agent,  which 
only  too  well  justify  the  words  applied  by 
M.  Flonrens  to  chloroform,  “  a  marvellous 
and  terrible  agent.”  Finally,  the  dangers 
indicated  by  M.  Bouisson  of  Montpellier, 
and  Sedillot  of  Strasburg,  are  but  too  real, 
and  in  face  of  the  dangers  now  so  thoroughly 
realized  it  would  be  the  highest  imprudence 
still  to  employ  chloroform,  as  has  been, 
done  hitherto,  for  insignificant  operations — • 
such  as  the  drawing  of  teeth,  opening  an 
abscess,  and  t.ie  application  of  a  moxa.  In 
future,  chloroform  should  only  be  exhibited 
for  great  operations.  In  fact,  important  ad¬ 
vantages  only  can  compensate  for  the  risk 
incurred  by  the  patient — a  risk  necessarily 
incurred  even  in  acting  with  extreme  circum¬ 
spection. 

M.  Velpeau. — There  are  two  things  to 
be  considered  in  relation  to  the  case  just  re¬ 
lated, — the  case  itself,  and  the  consequences 
to  be  derived  from  it.  The  case  is  singular, 
isolated,  and  so  much  the  more  extraordi¬ 
nary,  that  instead  of  15  or  20  drops  of 
chloroform  being  placed  over  the  nostrils  of 
patients  previously  to  operation,  there  is 
usually  as  much  as  from  2  to  3  drachms. 
And  yet  no  accident  of  importance  occurs. 
Remark,  that  such  instances  may  now  be 
related  by  thousands.  No  operation  is  per¬ 
formed  in  the  hospitals  without  the  employ¬ 
ment  of  chloroform,  and  yet  the  surgeon 
would  reject  this  agent;  although,  indeed,  he 
could  not,  for  the  patients  themselves  would 
insist  upon  its  use.  The  chloroform  is,  I 
say,  free  from  danger,  except  perhaps  where 
its  use  is  too  much  prolonged,  and  even  in 
such  cases  the  means  used  ro  recal  the  pa¬ 
tients  to  themselves  must  go  for  something. 

I  am  not,  then,  convinced  that  the  death 
of  this  case  can  be  altogether  attributed  to 
the  chloroform.  M.  Gorre  ascribes  it  to 
syncope.  He  speaks  also  of  the  introduc¬ 
tion  of  air  into  the  veins :  I  own  that  this 
appears  to  me  very  improbable  ;  on  one  ac¬ 
count,  because  no  vein  of  importance  was 
wounded,  and  on  another,  because  the  opera¬ 
tion  was  performed  on  the  thigh, — very 
far,  consequently,  from  the  centre  of  the 
.circulation.  On  the  inspection  there  was 
found,  he  says,  a  great  quantity  of  air  in  the 
vessels.  That  is  not  astonishing  :  the  in¬ 
spection  was  not  made  until  twenty-four 
hours  after  death,  and  in  the  month  of  May, 
in  warm  weather.  Perhaps  there  has  been 
a  coincidence,  unfortunate  without  doubt ; 
but  yet  all  surgeons  know  that  there  is  no 
operation,  however  trifling,  but  it  may  occa¬ 
sionally  cause  death.  I  prefer  this  expla¬ 
nation  to  that  of  M. Gorre ;  otherwise  we 
must  absolutely  renounce  the  use  of  chloro¬ 
form  in  all  surgical  operations,  great  or 
small. 


214  DEATH  CAUSED  BY  THE  INHALATION  OF  CHLOROFORM  IN  FRANCE. 


M.  Moreau. — I  am  not  so  certain  as  M. 
Velpeau  of  the  perfect  safety  of  chloroform. 
Here  is  a  case  to  place  beside  that  related 
by  M.  Gorre.  I  learn  from  M.  Robert, 
surgeon  of  the  Hospital  Beaujon,  that  after 
the  employment  of  chloroform  he  was  about 
to  take  the  knife  to  cut  off  the  thigh,  when 
his  patient  suddenly  died.  I  have  to  add 
that  the  case  shall  be  communicated  to  the 
Academy  in  all  its  details. 

M.  Honore.  —  Sudden  deaths  at  the 
moment  of  operation  have  been  spoken  of : 
here  is  an  instance,  of  which  I  was  witness. 
About  a  year  since  I  saw  a  patient  who 
suffered  from  very  severe  pain  in  the  bladder. 
This  man  was  excessively  excitable,  and  of 
a  remarkable  susceptibility.  M.  Civiale  was 
called  in  ;  he  sounded  him,  and  discovered 
a  calculus ;  but  he  shewed  such  excessive 
excitement  that  M.  Civiale  refused  to  ope¬ 
rate.  Some  time  afterwards  the  pain  re¬ 
turned  ;  M.  Civiale  was  called  on  to  operate: 
he  introduced  the  catheter,  and  the  patient 
died  suddenly. 

M.  Roux. — I  would  first  reply  to  M. 
Moreau,  that  before  we  can  reason  on  the 
case  he  has  related — before  accusing  chloro¬ 
form — we  must  wait  for  the  communication 
of  M.  Robert.  At  present  I  address  myself 
to  the  case  of  M.  Gorre,  although  M.  Velpeau 
has  in  great  part  said  what  I  meant  to  say  ; 
for  it  appears  that  we  have  both  received 
the  same  impressions  from  this  recital.  And 
first,  I  declare  that  if  it  can  be  proved  that 
chloroform  can,  either  at  the  time  or  after¬ 
wards,  directly  or  indirectly  compromise  the 
life  of  the  patient,  it  would  be  necessary  to 
renounce  its  use  without  hesitation,  not 
only  in  small,  but  also,  and  still  more,  in 
great  operations  ;  for  it  cannot  be  permitted 
to  the  surgeon  to  add  to  the  danger  of  an 
operation  the  danger  of  additional  steps. 
But  I  own  that  I  partake  with  M.  Velpeau 
the  doubts  expressed  by  him  as  to  the  cause 
of  death  assigned  by  M.  Gorre;  and  I  repeat, 
that  so  many  operations  have  been  per¬ 
formed  under  the  influence  of  chloroform, 
and  these  operations  have  been  so  happy 
in  their  results,  that  it  would  be  imprudent 
to  condemn  a  means  so  precious  for  a  mis¬ 
fortune  which  it  possibly  did  not  occasion. 
I  question  whether  the  manner  in  which  M. 
Gorre  administers  the  chloroform  is  free 
from  objection :  he  impregnates  with  it  a 
handkerchief  or  a  sponge,  which  he  applies 
under  the  nose.  In  this  manner  the  patient 
inspires  the  chloroform  vapour  without  air, 
while,  when  inhalers  are  employed,  the 
vapour  of  chloroform  is  always  diluted 
with  air.  On  the  other  hand,  I  ask  if  the 
external  air  has  not  penetrated  into  the 
veins,  not  indeed  by  the  veins  of  the  thigh — 
they  are  too  far  from  the  heart — but  by  the 
pulmonary  veins,  which  might  be  ruptured 
in  the  efforts  of  respiration.  That  the  air 


penetrates  thus  was  a  conjecture  of  Mor¬ 
gagni’s  adopted  by  Bichat.  Once,  a  very 
long  time  since,  I  opened  a  body  with 
Bichat ;  on  opening  the  cranium  we  were 
struck  with  the  quantity  of  air  spread 
through  the  sinuses  and  veins.  We  in¬ 
quired  into  the  employment  of  this  man, 
and  we  learned  that  he  was  a  shoemaker, 
and  that  he  died  suddenly  while  making  a 
strong  effort.  Bichat  supposed  that  during 
this  effort  the  air  was  introduced  into 
the  venous  system.  Why  might  it  not  be 
thus  with  the  patient  of  M.  Gorre  ? 

M.  Baillarger. — I  do  not  pretend  to 
give  an  explanation  of  the  unfortunate  case 
communicated  to  the  Academy  by  M.  Gorre, 
but  in  relation  to  the  dangers  of  chloroform 
I  think  it  right  to  remind  you  of  its  influence 
on  epileptics.  We  know,  from  the  trials 
made  at  the  Bicetre  by  M.  Moreau,  that  the 
inhalation  of  chloroform  not  only  excites 
epileptic  fits,  but  that  the  fits  have  then  an 
extreme  degree  of  gravity.  A  military  sur¬ 
geon  has  taken  advantage  of  this  special 
action  to  recognize  the  reality  of  epilepsy 
among  the  conscripts  who  have  asserted 
themselves  to  be  subject  to  that  disease.  It 
is,  then,  prudent  to  forbid  the  use  of  chloro¬ 
form  in  persons  afflicted  with  convulsive 
affections,  and  this  is  a  precaution  that  sur¬ 
geons  ought  not  to  neglect  to  take.  In  this 
case  the  patient  had  no  convulsions,  but 
foam  was  observed  on  the  mouth.  Has  the 
chloroform  excited  here  one  of  those  epilep¬ 
tic  paroxysms  that  put  on  the  form  of  syn¬ 
cope,  and  in  which  there  are  no  convulsions? 
On  this  point  we  can  only  throw  out  con¬ 
jectures,  but  these  conjectures  would  merit 
serious  consideration,  if  the  lady,  aged  thirty 
years,  who  has  died  so  suddenly,  had  pre¬ 
viously  had  any  convulsive  ailments — a 
point  which  has  not  been  mentioned  in  M. 
Gorre’s  communication  to  the  Academy. 

M.  Bussy  asked  if  the  quality  of  the 
chloroform  had  nothing  to  do  with  the  death 
of  the  case  communicated  by  M.  Gorre. 
This  is  worth  verifying ;  and  it  would  be 
well  to  write  to  M.  Gorre  to  send  a  small 
quantity,  that  it  may  be  tried  on  animals. 

M.  Velpeau  answered  that  the  chloro¬ 
form  used  by  M.  Gorre  came  from  the  labo¬ 
ratory  of  M.  Quesneville,  and  everything 
would  lead  us  to  believe  that  it  was  very  well 
prepared. 

M.Gibert. — I  wish  to  make  two  remarks, 
one  on  the  probable  cause  of  death  in  this 
case,  and  another  on  the  practical  and  usual 
employment  of  chloroform. 

The  explanation  of  the  death  by  syncope, 
adopted  by  the  author,  appears  to  me  in¬ 
admissible.  All  the  details  of  the  case  seem 
to  establish  that  the  sudden  death  has  been 
caused  by  the  introduction  of  air  into  the 
veins,  due  probably  to  a  rupture  of  the  pul¬ 
monary  vascular  tissue,  as  in  the  case  cited 


DEATH  CAUSED  BY  THE  INHALATION  OF  CHLOROFORM  IN  FRANCE.  215 


by  M.  Roux.  Syncope,  they  say,  has  only 
negative  characters  ;  I  believe,  from  some 
facts  that  I  have  observed  carefully,  that 
there  are  cases  in  which  syncope  may  be 
characterised  in  the  dead  body  by  the  ab¬ 
sence  of  blood  in  the  right  cavities  of  the 
heart  and  in  the  great  venous  trunks :  this 
is  contrary  to  what  one  generally  sees  in  the 
dead  body,  and  it  is  explained,  without 
doubt,  by  the  sudden  suspension  of  the  left 
side  of  the  heart. 

For  the  usual  employment  of  chloroform, 
I  declare  that,  while  I  defer  to  the  high  sur¬ 
gical  experience  of  M.  Roux,  I  persist  in 
believing  that  the  best  mode  of  administering 
it  is  also  the  simplest  and  easiest, — that 
which  every  one  has  at  hand,  and  which 
good  common  sense  points  out, — that  is  to 
say,  the  use  of  a  handkerchief  impregnated 
with  chloroform,  and  which  it  is  not  neces¬ 
sary,  as  M.  Roux  conceives,  to  apply 
exactly  over  the  nostrils  in  such  a  manner 
as  to  hinder  the  mixture  of  air  with  the  va¬ 
pours  of  chloroform. 

The  inhalers  employed  either  for  the  ad¬ 
ministration  of  ether  or  chloroform  are 
more  or  less  inconvenient  and  annoying, 
and  it  is  to  them,  whether  from  the  difficulty 
of  breathing  through  the  inhalers,  or  the 
moral  effect  produced  by  them  on  some 
individuals,  that  we  must  attribute  various 
disagreeable  results  in  different  individuals, 
and  the  difficulty  of  exciting  in  them  the 
ordinary  effects  of  the  anaesthetic  agents. 

M.  Piorry. — Three  things  have  been 
spoken  of — 

1st.  The  introduction  of  air  into  the 
veins.  It  results,  from  published  experi¬ 
ments  made  by  me  long  since  on  rabbits, 
that  the  inflation  of  the  lungs  of  rabbits  with 
air  sometimes  causes  sudden  death, — not 
because  of  pulmonary  emphysema,  but  from 
the  penetration  of  air  into  the  veins.  We 
find,  in  fact,  the  elastic  fluid  in  numerous 
bubbles  in  the  heart  and  great  vessels  :  it  is 
then  probable,  but  only  probable,  that  in 
the  adult  a  strong  inspiration,  followed  by  a 
forced  and  difficult  expiration,  may  result  in 
the  penetration  of  air  into  the  veins,  and 
death. 

2d.  I  have  not  studied  the  action  .of  chlo¬ 
roform  on  the  hysterical  and  epileptic,  but 
this  I  can  say,  that  the  inhalation  of  ether, 
tried  by  myself  when  it  was  first  introduced 
into  practice  in  France  with  a  view  to  meet 
and  prevent  the  paroxysms  of  hysteria, 
gave  rise  to  terrible  effects,  particularly  in 
one  female  ;  and  in  spite  of  some  partial 
success,  I  have  not  dared  to  have  recourse 
to  it  anew. 

3d.  As  to  syncope :  it  would  at  first  be 
well  to  know  what  is  meant  by  that  word. 
Many  organopathic  states  are  so  named  : 
there  are  some  in  which  there  is  no  blood  in 
the  heart,  as  in  death  from  haemorrhage ; 


there  are  cases  in  which  the  blood  is  abun¬ 
dant  in  all  the  cavities  of  the  heart,  while  it 
is  deficient  in  the  brain  ; — in  fine,  it  may  be 
that  in  certain  cases  there  is  no  blood  in  the 
right,  while  there  is  blood  in  the  left  cavities; 
but  this  is  an  observation  which  I  have  not 
verified  by  experiments  on  animals,  which 
are  here  of  great  importance. 

M.  Amussat  remarked  that  he  has  de¬ 
monstrated  that  sulphuric  ether  and  chloro¬ 
form  act  both  of  them  in  the  same  manner  : 
they  cause  the  death  of  animals  by  asphyxia. 
With  regard  to  the  modes  of  administration, 
the  most  simple  are  the  most  dangerous.  In 
every  case  he  finds  it  necessary  to  act  with 
great  caution.  When  the  operation  is  long, 
he  suspends  from  time  to  time  the  inhalation 
of  chloroform  ;  and  with  this  single  precau¬ 
tion  he  has  never  seen  a  fatal  case  ;  but  he 
is  always  alarmed  when  the-  patient  does  not 
promptly  recover  consciousness.  As  to  the 
entrance  of  air  into  the  veins  through  a 
wound  of  the  thigh,  there  is  no  example  of 
such  an  occurrence. 

M.  Castel  corrected  an  inaccuracy  in 
language.  Death  is  not  caused  by  syncope, 
but  by  the  cause  which  produces  the  syncope. 

M.  Rayer-Collard,  President,  asked 
leave  to  make  a  remark  on  the  case  the  sub¬ 
ject  of  the  discussion.  They  have  spoken, 
said  he,  of  the  patient  from  whom  Dupuy- 
tren  removed  a  large  tumor  seated  between 
the  shoulders,  and  who  died  suddenly  under 
the  knife.  This  circumstance  has  never 
been  related  as  it  occurred  ;  I  know,  for  I 
was  present  when  it  occurred.  They  say 
that  Dupuytren  heard  a  noise,  a  hissing, 
caused  by  the  penetration  of  air  into  the 
vessels  ;  and  they  have  put  into  his  mouth 
words  which  he  never  uttered.  Dupuytren 
did  not  know  to  what  to  attribute  the  sudden 
death  :  he  spoke  at  first  of  the  exhaustion  of 
sensibility  ;  it  was  not  until  the  next  day, 
after  having  observed  the  heart  and  great 
vessels,  that  he  suspected  the  introduction 
of  air. 

M.  Duval. — They  have  spoken,  he  said, 
of  syncope ;  I  have  been  several  times  wit¬ 
ness  of  this  morbid  state :  I  have  seen 
swoons  that  have  lasted  several  minutes. 
Among  all  the  means  for  bringing  the  pa¬ 
tient  out  of  this  state  there  is  one  but  little 
known,  and  which  I  have  several  times 
found  efficacious,  frictions  with  the  essence 
of  mint  upon  the  gums(!) — V Union  Med . 

It  is  evident,  from  the  above  ample  report 
by  M.  Gorre,  that  in  this  case  of  alleged 
death  from  chloroform  at  Boulogne,  the 
death  was  complete  before  the  operation  was 
performed. 

In  criticising  the  procedure  in  this  case, 
it  must  be  understood  that  the  remarks 
apply  to  our  present  extended  knowledge  of 
the  action  of  chloroform,  and  to  what  it 


216  DEATH  CAUSED  BY  THE  INHALATION  OF  CHLOROFORM  IN  FRANCE. 


would  be  right  to  do  in  a  similar  case  in 
future.  M.  Gorre  is  not  to  be  blamed  :  he 
was  ignorant  of  the  dangers  of  the  agent — 
an  agent  employed  apparently  in  every 
operation  in  Paris,  trivial  or  great ! 

The  following  errors  were  committed  in 
administering  chloroform  to  this  case 

The  operation  was  insignificant,  and 
therefore  did  not  warrant  the  use  of  chloro¬ 
form. 

The  patient  had  suffered  from  palpitation, 
and  therefore  she  was  not  a  proper  subject 
for  its  administration, — illustrating  the  re¬ 
marks  made  #in  the  paper  on  Death  from 
Chloroform,  in  the  Gazette  of  July  21. 

M.  Gorre,  the  operator,  himself  gave  the 
chloroform,  and  therefore  left  his  patient,  so 
far  as  chloroformization  was  concerned,  at 
the  critical  moment — operating,  indeed, 
when  she  was  lifeless  ! 

The  chloroform  was  given  on  a  handker¬ 
chief  :  in  the  North  this  is  thought  the  best 
plan,  not  so  in  England.  But  granting  that 
it  was  right  to  use  a  handkerchief,  the  mode 
of  using  it  was  altogether  wrong  :  it  was 
placed,  it  appears,  close  under  the  nostrils 
at  the  beginning  of  the  operation  ;  it  was 
not  given  largely  diluted  at  first,  gradually 
increa-ing  the  dose,  but  it  was  sent  sud¬ 
denly  into  the  lungs  and  heart  in  the  most 
concentrated  form.  The  heart  almost  seems 
to  have  been  dead  even  before  she  lost 
consciousness.  Immediately  after  crying, 
“  J’etouffe  !”  her  face  became  pale,  and  she 
appeared  lifeless. 

The  operation  ought  not, under  the  circum¬ 
stances,  to  have  been  performed  at  all.  At 
the  very  time  it  was  performed,  M.  Gorre’s 
colleague  was  seeking  by  all  means  to  restore 
life. 

Everything  was,  indeed,  done  to  restore 
life,  as  will  be  seen  in  M.  Gorre’s  admira¬ 
bly  honest  naive  description,  and  that,  too, 
for  two  hours  after  life  was  absolutely  ex¬ 
tinct.  “  Vain  efforts  !”  Everything  was 
done  in  consternation,  and  without  order. 
What  could  frictions  to  the  temples  and 
prsecordia  do  but  lose  time  ?  Ammonia — 
she  was  far  beyond  the  reach  of  that  sti¬ 
mulus  ;  even  electro-magnetism  would  not 
have  roused  her;  even  M.  Duval’s  sovereign 
remedy — frictions  with  the  essence  of  mint 
over  the  gums — would  have  failed.  Artificial 
respiration  was  performed,  but  how  and 
when  does  not  appear.  It  ought  to  have 
been  instantly  resorted  to,  and  ought  to 
have  been  combined  with  the  active  applica¬ 
tion  of  general  external  warmth,  stimulants, 
and  friction.  From  the  result  in  this  case, 
and  in  the  three  or  four  other  fatal  cases,  these 
means  would  probably  have  been  vain  ;  but 
if  anything  could  have  been  of  service,  they 
would. 

From  the  autopsy,  and  from  the  descrip¬ 
tion  of  the  death-scene,  it  is  certain  that  the 


instant  death  was  from  paralysis  of  the 
heart  :  the  face  suddenly  became  pale ;  the 
heart  was  flaccid. 

The  heart  was  quite  empty.  How  could 
a  heart  that  could  not  contract  empty  itself? 
The  left  ventricle  is  most  usually  rigid,  and 
it  is  empty.  It  has  wrung  the  blood  out  of 
itself  during  its  last  effort.  The  right  ven¬ 
tricle  is  usually  full  of  blood,  its  walls  being 
flaccid.  I  have  often,  when  taking  diagrams 
of  the  internal  organs,  distended  the  lungs 
to  the  full,  the  trachea  being  tied,  and  the 
chest  unopened.  In  these  instances  I 
usually  found  the  heart  quite  empty  of  its 
fluid  contents.  The  lungs,  when  distended, 
pressed  in  upon  the  flaccid  heart  in  every 
direction,  and  so  compressed  and  emptied 
its  cavities.  The  artificial  inflation  of  the 
lungs  that  will  empty  the  heart  when  it  has 
ceased  to  act,  and  its  walls  are  flaccid,  is 
very  different  from  artificial  distension  of 
the  lungs  when  the  heart  is  active,  and  the 
blood  leaves  it,  and  returns  to  it  with  sys¬ 
tematic  regularity.  I  have  seen  an  ass, 
apparently  dead  from  wourali,  but  the 
heart  beating,  return  to  life  after  seven  hours 
of  artificial  respiration. 

It  is  very  difficult  to  account  for  the  ap¬ 
pearance  of  air  in  the  veins.  M.  Velpeau’s 
suggestion,  that  it  was  from  putrefaction, 
can  scarcely  be  correct.  The  brain  even 
was  firm.  M.  Amussat  found  air  in  the 
veins  of  rabbits  who  died  suddenly  during 
the  artificial  inflation  of  their  lungs.  It  is 
easy  to  see  how  by  this  means  the  air  found 
its  way  into  the  pulmonary  veins.  But  if  it 
was  thus  injected  into  the  whole  venous 
system,  how  came  it  that  the  veins  every¬ 
where  contained  much  air,  while  the  heart 
was  absolutely  empty,  it  not  being  stated 
that  there  was  air  in  any  of  the  arteries  ? 
It  is  evident  that  if  the  air  entered  the  cir¬ 
culatory  apparatus  in  the  lungs,  it  must 
have  passed  through  the  heart,  arteries,  and 
capillaries,  before  it  could  reach  the  veins. 
Is  it  possible  that  the  heart  and  arteries 
could  have  entirely  emptied  themselves  after 
conveying  the  air  to  the  veins  ?  While  this 
mode  of  accounting  for  the  presence  of  the 
air  cannot  be  absolutely  rejected  without 
farther  .inquiry ,  we  may  at  once  reject  the 
supposition  of  MM.  Roux  and  Amussat, 
that  the  air  entered  through  ruptured  air- 
cells  during  the  final  struggling  inspiration 
and  expiration.  It  is  not  stated  that  they 
were  made  with  remarkable  effort.  The 
circulation  in  the  face  had  already  ceased. 

From  the  interesting  discussion  that  fol¬ 
lowed  the  recital  of  the  case,  it  appears  that 
another  death  from  chloroform  has  occurred 
in  France,  in  the  practice  of  M.  Robert. 
This  patient,  too,  died  suddenly  when  M. 
Robert  was  taking  the  knife  to  amputate 
at  the  thigh.  The  details  of  this  case  have 
been  promised  to  the  Academy. 


DEATH  CAUSED  BY  THE  INHALATION  OF  CHLOROFORM  IN  FRANCE.  217 


Some  of  the  opinions  offered  by  the  great 
surgeons  present  are  well  worth  weighing. 
This  must  be  acknowledged — that  the  mean¬ 
ing  of  the  term  “  syncope,”  as  a  cause  of 
death,  is  very  ill  defined,  and  is  applied,  as 
M.  Piorry  says,  to  several  distinct  condi¬ 
tions.  In  syncope  from  mental  influence, 
the  face  becomes  suddenly  pale,  respiration 
very  slow,  and  the  pulse  very  feeble  or  im¬ 
perceptible,  often  slow ;  consciousness  dis¬ 
appears,  the  pupils  being  dilated.  These 
phenomena  are  simultaneous — due  to  some 
mental  influence.  I  have  observed  a  woman 
faint  on  seeing  a  wound  on  another  person’s 
finger.  Such  cases  rarely  die,  and  the  state 
of  their  internal  organs  is  uncertain.  The 
capillary  circulation  at  the  surface  is  in¬ 
stantly  arrested,  the  influence  being  trans¬ 
mitted  by  the  nerves  direct  from  the  brain. 
I  believe  that  the  heart’s  action  is  oppressed 
by  the  sudden  suppression  of  the  capillary 
circulation,  not  by  the  direct  transmission  of 
an  influence  from  the  brain. 

In  syncope  from  loss  of  blood,  the  heart’s 
action  will  be  diminished  or  arrested,  from 
the  comparative  or  absolute  want  of  blood 
for  the  heart  to  act  upon. 

In  death  by  syncope  from  heart  disease, 
the  heart  is  absolutely  paralysed. 

In  M.  Gorre’s  case,  the  death  was  from 
true  syncope,  from  the  cessation  of  the 
heart’s  action,  due  to  the  direct  action  upon 
its  walls  of  chloroform,  a  powerful  poison, 
carried  to  them  in  its  most  concentrated  form 
by  the  coronary  arteries.  In  this  case,  and 
the  three  other  deaths  from  chloroform,  the 
heart’s  action  and  respiration  ceased  simul¬ 
taneously  :  they  were  true  cases  of  death 
from  syncope. 

The  so-called  “  death  from  syncope,” 
caused  by  tobacco  and  digitalis,  is  usually 
not  really  death  from  syncope,  but  from  a 
variety  of  asphyxia.  Sir  Benjamin  Brodie 
poisoned  an  ass  with  tobacco :  the  heart’s 
action  and  respiration  ceased  simultaneously  ; 
the  heart  was  much  distended.  On  stimu¬ 
lating  the  heart,  and  keeping  up  artificial 
respiration,  its  action  was  renewed.  The 
heart  cea-ed,  because  of  the  temporarily  im¬ 
passable  barrier  to  the  flow  of  the  blood 
through  the  pulmonic  capillaries.  When 
the  distension  was  lessened,  the  heart’s 
action  recurred.  The  heart’s  action  was 
not  destroyed,  but  overpowered. 

In  dogs,  as  M.  Amussat  correctly  states, 
chloroform  and  ether  usually  kill  by  as¬ 
phyxia  :  the  respiration  ceases  before  the 
heart’s  action,  and,  by  artificial  respiration, 
suspended  animation  is  restored.  Unfor¬ 
tunately,  in  the  cases  of  death  in  man 
hitherto  recorded,  the  death  has  been  im¬ 
mediately  in  the  heart,  from  syncope,  and 
not  from  asphyxia. 

The  remarks  of  M.  Amussat  arediscrimi- 
nating,  and  of  much  value.  He  insists  on 


the  cautious  administration  of  chloroform, 
and  on  the  renewal  of  it  from  time  to  time 
during  an  operation ;  and  he  speaks  of  the 
alarm  occasioned  in  his  mind  when  cases 
remain  long  under  its  influence.  Who  that 
has  given  chloroform  has  not  felt  anxiety 
during  the  administration  ?  MM.  Velpeau 
and  Roux  surprise  us  by  their  partizauship, 
advocating  chloroform  in  every  case,  re¬ 
fusing  belief  in  its  fatal  influence  in  this  or 
any  case,  and  rejecting  its  use  altogether  if 
they  could  believe  that  it  could  ever  destroy 
life. 

He  is  the  true  friend  of  chloroform  who 
is  alive  to  its  danger,  will  discriminate  be¬ 
tween  cases  proper  and  improper  for  its 
employment,  and  will  administer  it  with 
every  physiological  precaution. 

The  case  related  by  M.  Honore,  in  which 
the  mere  introduction  of  a  catheter  caused 
immediate  death,  is  the  exact  case  in  which 
chloroform  mav  be  of  inestimable  service. 
Had  it  been  used  in  that  case,  the  sensibility 
would  have  been  destroyed,  and  life  saved. 
It  is  exactly  in  such  a  case,  as  was  stated  in 
the  paper  On  Death  from  Chloroform,  that 
this  anaesthetic  agent  is  of  value. 

M.  Baillarger’s  remarks  with  regard  to 
the  injurious  effect  of  chloroform  in  epileptic 
cases  are  of  particular  value,  and  corrobo¬ 
rate  some  observations  made  in  a  paper  On 
the  Use  of  Chloroform  in  Neuralgia.  It 
was  found  that  while  chloroform  was  of 
service  in  periodical  neuralgia,  it  was  in¬ 
jurious  when  the  neuralgia  was  due  to,  or 
accompanied  by,  cerebral  affection. 

2 

July  11,  1848. 

President,  M.  Velpeau. 

Death  during  the  Administration  of  Chlo¬ 
roform  at  the  Hdpital  Beaujon. 

M.  Robert  related  the  following  case 
A  young  man,  24  years  of  age,  corpulent, 
of  a  lymphatic  habit,  his  tissues  being  soft, 
was  admitted  into  the  Hopital  Beaujon  on 
the  25th  of  last  June,  having  been  struck  in 
the  left  thigh  by  a  ball,  which,  traversing 
the  limb  from  before  backwards,  at  its 
middle  part,  had  broken  the  diaphysis  of 
the  thigh-bone  into  large  splinters.  The 
disarticulation  of  the  thigh,  judged  indis¬ 
pensable,  was  decided  on.  The  patient  was 
submitted  to  the  action  of  chloroform  by 
means  of  a  small  bottle,  pierced  with 
several  holes,  containing  a  peculiar  dia¬ 
phragm  saturated  with  chloroform,  and  sur¬ 
mounted,  at  its  opening,  with  a  large  cone 
adapting  itself  to  the  mouth  of  the  patient. 
The  nostrils  were  closed  by  the  finger  of  an 
assistant.  At  the  end  of  three  or  four 
minutes,  the  patient  manifested,  though  in 
a  slight  degree,  the  convulsive  movements 
which  characterise  the  stage  of  excitement, 
and  soon  afterwards  he  was  in  a  state  of 


218  ON  THE  USE  OF  TAR  AND  ARSENIC  IN  CUTANEOUS  DISEASES. 


complete  relaxation.  M.  Robert  com¬ 
menced  immediately.  The  femoral  artery 

being  compressed  in  the  groin,  he  plunged 
in  a  long  straight  knife  at  a  point  three 
fingers’  breadth  beyond  the  antero-superior 
iliac  spine,  and  made  a  large  anterior  flap. 
During  this  part  of  the  operation,  the  pa¬ 
tient  (although  the  artery  had  for  a  very  short 
time  not  been  perfectly  compressed)  lost 
but  a  very  small  quantify  of  blood.  At  this 
period  the  patient  began  to  recover  con¬ 
sciousness.  M.  Robert  wished  to  prolong 
the  state  of  insensibility,  and  directed,  with 
this  view,  a  renewal  of  the  inhalation  while 
he  continued  the  operation  ;  but  a  quarter 
of  a  minute  had  scarcely  elapsed  when  the 
respiration  became  stertorous,  and  he  im¬ 
mediately  discontinued  the  inhalation.  The 
patient’s  face  was  very  pale ;  his  lips  dis¬ 
coloured ;  his  eyes,  the  pupils  being  dilated, 
were  turned  upwards  under  the  upper  eyelid. 
The  operation  was  immediately  suspended, 
and  M.  Robert  hastened,  with  the  help  of 
assistants,  to  attempt  to  recover  the  patient, 
whose  respirations  had  become  infrequent 
and  sighing,  whose  pulse  was  no  longer  per¬ 
ceptible,  and  whose  limbs  were  in  a  state  of 
perfect  relaxation.  Frictions  to  the  skin, 
irritation  of  the  pituitary  membrane,  fre¬ 
quent  movements  of  the  arms  and  the 
thorax,  were  all  employed  with  energy  and 
perseverance.  Several  times  respiration 
seemed  to  return,  and  the  pulse  became 
appreciable ;  but  the  amelioration  was  but 
for  the  moment,  and,  after  three  quarters  of 
an  hour  of  incessant  efforts,  the  patient  had 
ceased  to  live. 

The  nature  of  the  symptoms  observed 
during  these  last  moments  left  no  doubt  as 
to  the  immediate  cause  of  death.  The 
sudden  pallor,  the  annihilation  of  the  pulse, 
demonstrated  that  the  patient  had  died  from 
syncope.  The  introduction  of  air  into  the 
veins  could  alone  perhaps  destroy  the  patient 
with  such  rapidity  ;  but  he  presented  no 
symptom  characterising  that  occurrence. 

After  endeavouring  to  establish  that  the 
patient  died  from  syncope,  M.  Robert 
tried  to  determine  what  could  have  been  its 
cause.  After  demonstrating  that  it  could 
be  attributed  neither  to  haemorrhage  nor  to 
the  length  of  the  operation,  M.  Robert 
thought  that  chloroform  had  not  been  a 
stranger  to  this  fatal  syncope  ;  and  he  added, 
that  to  that  agent,  before  anything  else,  it 
must  be  attributed. 

Nevertheless,  in  expressing  this  opinion, 
M.  Robert  thought  it  right  to  advert  to 
those  special  conditions  of  the  wound  which 
might  concur  in  producing  this  result. 
Those  conditions  are,  the  state  of  stupor 
and  depression  of  the  nervous  system  which 
usually  accompany  gun-shot  wounds,  espe¬ 
cially  those  which  involve  the  great  articula¬ 
tions  ;  in  the  second  place,  the  moral  con¬ 


dition  of  the  wounded,  who  was  plunged 
into  gloomy  despair,  which  depressed  the 
nervous  system  hnd  lessened  the  reaction 
from  the  injury. 

A  confused  discussion  followed  the  rela¬ 
tion  of  this  case,  and  finally  the  fatal  cases 
of  M.  Gorre  and  M.  Robert  were  referred  to 
a  special  commission. — V  Union  Medicate. 


CDoEre^pontjence, 


ON  THE  USE  OF  TAR  AND  ARSENIC  IN 
CUTANEOUS  DISEASES. 

Sir, — Allow  me  to  thank  Mr.  Hunt, 
through  the  medium  of  your  valuable  jour¬ 
nal,  for  his  liberal  notice  of  my  paper  on 
the  use  of  tar  in  cutaneous  diseases.  The 
subject  is  now  fairly  under  the  notice  of  the 
profession,  to  whose  candid  and  mature 
judgment  may  be  referred  the  question  of 
each  remedy — arsenic  and  tar.  But  in 
answer  to  one  (the  3rd)  objection  adduced  by 
Mr.  Hunt,  viz.  the  disagreeable  odour  at¬ 
tending  the  external  use  of  the  remedy,  I 
would  reply,  that  in  the  generality  of  cases 
no  such  application  is  necessary,  the  tar  cap¬ 
sules  being  alone  sufficient,  as  in  acne  lepr* 
and  sycosis  ;  while  in  eczema,  and  other  dis¬ 
eases  requiring  the  external  use  of  tar,  the 
remedy  is  far  less  offensive  than  the  excre¬ 
tions  which  the  complaint  itself  gives  rise  to. 

Mr.  Hunt’s  very  great  success  in  the  ad¬ 
ministration  of  arsenic,  even  in  cases  where 
all  other  remedies  had  failed,  must  entitle 
his  opinion  to  the  respect  of  the  whole  pro¬ 
fession  ;  but  perhaps  the  case  detailed  below 
may  not  be  unworthy  the  attention  of  any 
one  desiring  to  form  an  accurate  opinion  as 
to  the  respective  merits  of  the  two  remedies. 

In  April  last  I  was  requested  to  see  a 
patient  living  in  Villiers  Street,  Strand,  and 
found  the  case  to  be  one  of  well-marked 
lepra  in  the  first  stage,  attended  with  much 
heat  and  irritation  :  the  disease  was  nearly 
confined  to  the  hands  and  arms,  very  little 
appearing  on  other  parts.  Purgative  medi¬ 
cines  and  moderate  diet  were  ordered,  and 
continued  from  the  20th  April  until  the  20th 
May,  when  the  inflammatory  action  being 
subdued,  the  patient  was  ordered  5  minims 
Liq.  Potassa  Arsenitis  ter  die,  with  the  food, 
which  was  continued  till  the  15th  June. 
During  this  time  the  conjunctive  became 
inflamed,  and  dizziness  of  sight  was  present, 
proving  the  action  of  arsenic  on  the  system  ; 
the  eruptive  disease  in  a  slight  degree  dimi¬ 
nished,  but  still  the  patches  of  lepra  re¬ 
mained  very  distinct.  At  this  time  the 
health  and  strength  became  so  reduced  as  to 
render  it  absolutely  necessary  to  give  up  the 
Liq.  Potassa  Arsenitis,  and  to  employ  tonics 
and  steel  with  ammonia,  which  in  ten  days 
enabled  the  patient  to  walk  about  during 
the  day,  which  she  could  not  do  before.  In 


RESOLUTIONS  PASSED  BY  A  MEETING  OF  SURGEONS  AT  MANCHESTER.  219 


the  beginning  of  this  month,  I  gave  her  the 
capsules  of  tar,  which  she  was  afraid  to  at¬ 
tempt  to  swallow  in  the  first  instance.  The 
capsule  has  been  taken  with  ease  twice  a  day 
until  the  present  time  ;  the  eruption  has  dis¬ 
appeared  ;  the  general  health  and  strength 
greatly  improved  ;  she  assured  me  a  few  days 
ago  she  had  not  enjoyed  such  good  health  a 
long  time.  No  external  application  of  tar 
was  made  in  this  case,  and  during  the  first 
stage,  so  great  was  the  irritation  at  certain 
hours  of  the  day,  that  neither  gruel,  decoc¬ 
tion  of  poppies,  or  any  other  of  the  usual* 
soothing  remedies,  could  be  borne  ;  dusting 
the  part  over  with  flour  and  starch-powder, 
seemed  to  answer  best.  This  is  only  the 
second  case  of  lepra  treated  with  tar  by  me. 
I  think  it  clearly  proves  the  power  of  this 
remedy  over  the  disease. 

Not  wishing  to  trespass  too  much  on  the 
pages  of  the  Gazette,  I  will  only  again 
thank  you  and  Mr.  Hunt,  for  the  liberal  man¬ 
ner  in  which  you  have  brought  this  subject 
before  the  profession, — I  remain,  sir, 

Your  obedient  servant, 

Jno.  Wetherfield. 

July  1848. 


J&Utrfral  JiueUtgenfe. 

RESOLUTIONS  PASSED  AT  A  MEETING  OF 
SURGEONS  AT  MANCHESTER. 

At  a  meeting  of  the  members  of  the  Royal 
College  of  Surgeons  of  England  resident  in 
Manchester  and  its  neighbourhood,  convened 
by  public  advertisement,  and  held  at  the 
Town  Hall,  on  Tuesday,  July  11th,  1848, 
W.  W.  Beever,  Esq.  in  the  chair  : 

It  was  proposed  by  Daniel  Noble,  Esq., 
and  seconded  by  Dr.  Rayner,  of  Stockport, 
and  resolved  : — “  That  this  meeting  hereby 
records  its  decided  opposition  to  any  mea¬ 
sure  of  legislation  affecting  the  constitution 
of  the  medical  profession,  which  may  ratify 
the  retrospective  act  of  injustice  involved  in 
the  provisions  of  the  charter  recently  granted 
to  the  College  of  Surgeons,  at  the  instance  of 
the  council. ” 

It  was  proposed  by  James  Bower  Harri¬ 
son,  Esq.,  and  seconded  by  D.  Bowman, 
Esq.,  and  resolved  : — “  That  the  invidious 
proceedings  of  the  council  in  regard  to  the 
fellowship  have  deprived  it  of  the  value  and 
consideration  which,  under  other  circum- 
cumstances,  it  would  have  possessed  ;  and 
that  in  the  opinion  of  this  meeting  it  would 
be  derogatory  on  the  part  of  those  who  were 
members  of  the  College  anterior  to  the  date 
of  the  charter  of  1843,  to  procure  admission 
to  the  fellowship  by  re-examination  and  fur¬ 
ther  pecuniary  payment,  as  at  present  pro¬ 
posed.” 

Proposed  by  Thomas  Dorrington,  Esq., 


and  seconded  by  G.  Southam,  Esq.  : — 
“  That  this  meeting  conceives  the  Colleges 
of  Physicians  and  Surgeons,  once  placed  in 
just  and  harmonious  relation  with  their 
respective  members,  to  be  amply  sufficient 
for  all  the  requirements  of  medical  science, 
and  that  the  institution  of  a  third  and 
subordinate  college  of  general  practitioners 
would,  under  such  circumstances,  introduce 
needless  complication,  and  be  prejudicial  to 
the  best  interests  of  the  profession.” 

It  was  proposed  by  R.  H.  M'Keand, 
Esq.,  and  seconded  by  G.  Southam,  Esq.: 
— “  That  a  committee  be  appointed,  consist¬ 
ing  of  the  following  gentlemen,  with  power 
to  add  to  their  number,  to  carry  out  the 
above  resolutions  :  Mr.  Beever,  Dr.  Rayner, 
Messrs.  Noble,  M‘Keand,  Bower  Harrison, 
Southam,  Yorke  Wood,  Leah,  and  Bow- 
ring.” 

It  was  proposed  by  A.  Featherstonehaugh, 
Esq.,  of  Bolton,  and  seconded  by  J.  Leah, 
Esq.,  of  Gee  Cross  : — “  That  the  committee 
be  requested  to  publish  the  proceedings  of 
this  day  in  such  a  manner  as  they  shall  deem 
most  advisable.” 

Proposed  by  John  Windsor,  Esq.,  and 
seconded  by  T.  Dorrington,  Esq. : — “  That 
the  best  thanks  of  this  meeting  be  given  to 
his  Worship  the  Mayor,  for  his  kindness  in 
allowing  the  use  of  the  Town  Hall  for  the 
purpose  of  this  meeting.” 

(Signed)  W.  Beever, 

Chairman. 

John  Windsor,  Esq.,  in  the  chair. 

Proposed  by  R.  T.  Hunt,  Esq.,  seconded 
by  T.  Fawcett,  Esq.,  Oldham  : — “  That  the 
best  thanks  of  this  meeting  be  given  to 
W.  W.  Beever,  Esq.,  for  his  impartial  con¬ 
duct  in  the  chair.” 

(Signed)  John  Windsor, 

Chairman. 

apothecaries’  hall. 

Names  of  Gentlemen  who  passed  their  ex¬ 
amination  in  the  Science  and  Practice  of 
Medicine,  and  received  certificates  to  prac¬ 
tise,  on  Thursday,  27th  July,  1848. — 
Joseph  Drew,  St.  Austle,  Cornwall — Wm. 
Davis,  St.  George’s  Town,  Salop — Joseph 
George  Thompson,  St,  Mabyn,  Cornwall — 
Charles  Smith,  Weyhill,  Hants  —  Louis 
Truefitt,  Burwood  Place,  Hyde  Park. 


Selection#  from  journals. 


PATHOLOGY. 

on  the  state  of  the  urine  in  bright’s 
disease  of  the  kidney. 

BY  DR.  J.  F.  DUNCAN. 

Low  specific  gravity,  and  deficient  quantity, 
are  both  conditions  of  this  secretion,  com¬ 
patible  with  health,  when  they  exist  singly, 


220  BIRTHS  AND  DEATHS*  METEOROLOGICAL  SUMMARY,  ETC, 


because  they  depend  solely  upon  the  amount 
of  water  carried  off  at  the  kidneys.  In 
hysteria,  where  the  fluid  is  often  enormous, 
the  specific  gravity  is  very  little  higher  than 
that  of  ordinary  water ;  and,  on  the  other 
hand,  when  a  patient  drinks  but  little,  the 
specific  gravity  is  relatively  high.  It  is  only 
when  the  two  conditions  coexist — when  the 
specific  gravity  is  low  and  the  quantity 
small— that  we  have  reason  to  consider  the 
patient’s  state  unhealthy.  Now  both  of 
these  are  apt  to  occur  in  Bright’s  disease, 
because  the  deposit  mechanically  interferes 
with  the  secretion  of  the  gland.  In  diabetes, 
on  the  contrary,  the  very  opposite  takes 
place  :  there  is  enormous  secretion  and  high 
specific  gravity. 

In  stating,  however,  that  low  specific 
gravity  and  deficient  quantity  are  the  com¬ 
mon  attendants  of  Bright’s  disease,  I  must 
be  careful  to  guard  against  misconception. 
Many  persons  are  in  the  habit  of  consider¬ 
ing  them  invariably  present,  but  Christison 
has  shown  distinctly  that  both  in  the  earlier 
and  the  later  stages  of  the  complaint,  but 
especially  the  former,  the  quantity  of  urine 
passed  may  very  nearly  equal  the  average  of 
health.  The  diminution  of  density,  how¬ 
ever,  is  in  general  very  remarkable.  The 
reason  of  this  is  obvious  on  a  little  reflec¬ 
tion.  The  mechanical  impediment  arising 
from  granular  degeneration,  interferes  less 
with  the  secretion  of  fluid  than  with  that  of 
the  saline  matters  which  determine  the 
density.  This  change  in  the  specific  gravity 
is  often  sufficiently  indicated  by  the  ordinary 
urinometer  ;  but  evaporation  and  drying 
the  residuum  will  of  course  ensure  greater 
accuracy  in  the  result.  Dr.  Christison  in¬ 
forms  us  that  he  has  known  the  solid  con¬ 
tents  reduced  from  1340  grains  in  10,000, 
to  700,  500,  and  even  to  400  grains. — 
Dub.  Med.  Press. 


BIRTHS  &  DEATHS  in  the  Metropolis 
During  the  week  ending  Saturday ,  July  29. 

Deaths.  |  Av.  of  5  Sum. 


Births. 
Males ....  707 
Females. .  689 


Males. . . . 
Females. . 


650 

551 


Males. . . 
Females. . 


1396  1201 

West — Kensington;  Chelsea;  St.  George, 
Hanover  Square;  Westminster;  St.  Martin 
in  the  Fields;  St.  James  ..  (Pop.  301,326) 
North  — St.  Marylebone  ;  St.  Pancras  ; 

Islington  ;  Hackney . (Pop.  366,303) 

Central — St.  Giles  and  St.  George;  Strand; 
Holborn;  Clerkenwell ;  St.  Luke;  East 
London  ;  West  London  ;  the  City  of 

London  ...  . (Pop.  374,759) 

East — Shoreditch  ;  Bethnal  Green  ;  White¬ 
chapel  ;  St.  George  in  the  East ;  Stepney ; 

Poplar . . (Pop.  393,247) 

South  —  St.  Saviour  ;  St.  Olave  ;  Ber¬ 
mondsey  ;  St.  George,  Southwark  ; 
Newington;  Lambeth;  Wandsworth  and 
Clapham  ;  Camberwell ;  Rotherhithe  ; 
Greenwich . (Pop.  479,469) 


495 

477 

972 


163 


247 


200 


287 


304 


Total .  1201 


Causes  of  Death. 

All  Causes . • . 

Specified  Causes . 

1 .  25/mo(ic(or Epidemic, Endemic, 

Contagious)  Diseases . . 
Sporadic  Diseases,  viz. — 

2.  Dropsy,  Cancer,  &c.  of  uncer¬ 

tain  seat  . 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  . 

4.  Luuars  and  other  Organs  of 

Respiration . 

5.  Heart  and  Bloodvessels . 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion  . 

7.  Diseases  of  the  Kidneys,  &c... 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c . 

9.  Rhematism,  Diseases  of  the 

Bones,  Joints,  &c . 

.10.  Skin,  Cellular  Tissue,  Sic . 

11.  Old  Age . , 

12.  Violence,  Privation,  Cold,  and 

Intemperance . ! 


1201 

Av.  of 
5  Sum. 

972 

1199 

968 

505 

257 

25 

45 

112 

120 

79 

80 

26 

28 

81 

79 

11 

8 

5 

10 

6 

7 

4 

1 

31 

50 

43 

8 

The  following  is  a  selection  of  the  numbers  of 
Deaths  from  the  most  important  special  causes: 


Small-pox  . 

36 

Paralysis . 

24 

Measles  . 

5 

Convulsion. . .. .. 

35 

Scarlatina  . 

119 

Bronchitis . 

33 

Hooping-cough. . 

25 

Pneumonia . 

27 

Diarrhoea  . 

173 

Phthisis . 

133 

Cholera  . 

26 

Dis.  of  Lungs,  &c. 

7 

Typhus  . 

77 

Teething . 

17 

Dropsy . 

5 

Dis.  Stomach,  &c. 

5 

Sudden  deaths  . . 

2 

Dis.  of  Liver,  &c. 

12 

Hydrocephalus . . 

38 

Childbirth . 

4 

Apoplexy . 

18 

Dis.  of  Uterus,  &c. 

0 

Remarks. — The  total  number  of  deaths  was 
229  above  the  weekly  summer  average,  indicating 
the  large  increase  of  105  above  the  deaths  of  the 
preceding  week. 


METEOROLOGICAL  SUMMARY. 


Mean  Height  of  Barometer .  29*76 

“  “  Thermometer3  .  61*6 

Self-registering  do. b - max. 101 -3  min.  46'0 

“  in  the  Thames  water  —  66*4  —  64'2 


a  From  12  observations  daily.  b  Sun. 

Rain,  in  inches,  *75:  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 


NOTICES  to  CORRESPONDENTS. 

We  regret  that  we  could  not  find  room  in  our 
previous  number  for  the  notice  issued  by  the 
Upton-upon-Severn  Board  of  Guardians,  for¬ 
warded  by  Messrs.  Braddon  and  White.  The 
correspondence  and  remarks  on  the  subject 
which  we  lately  published  are  a  sufficient  warnj 
ing  to  all  respectable  practitioners  ;  with  regard 
toothers,  no  observations  which  we  could  make 
would  have  the  slightest  influence. 

We  have  only  this  wreek  received  a  copy  of  the 
resolutions  passed  at  a  meeting  of  the  Surgeons 
of  Manchester.  No  previous  communication 
has  reached  us. 

Mr.  J,  D.  McDonald’s  paper  on  the  Spinal 
Accessory  Nerve  will  be  inserted  in  the  follow¬ 
ing  number. 

The  communications  of  Mr.  Wells,  Mr.  Canton, 
Mr.  Lee,  Mr.  Kesteven,  and  the  letter  of  Dr. 
Brookes,  will  appear  next  week. 


221 


ifLottHon  ifflefltcal 


Settings. 


LECTURES 

ON  THE 

DISEASES  OF  INFANCY  AND 
CHILDHOOD, 

Delivered  at  the  Middlesex  Hospital. 

By  Charles  West,  M.D. 

Physician-Accoucheur  to  the  Middlesex  Hospital, 
and  Senior  Physician  to  the  Royal  Infirmary 
for  Children. 


Lecture  XXXVII. 

Fevers — chief y  belong  to  the  class  of  the 
Exanthemata — mistakes  with  reference  to 
simple  fever  in  childhood — its  identity 
with  fever  in  the  adult—  Simple  fever  or 
remittent  fever  occurs  in  two  degrees — 
Symptoms  of  its  milder  form — of  its 
severer  form — signs  of  convalescence — 
modes  of  death — Diagnosis — Treatment . 

We  come  now,  gentlemen,  to  the  last  part 
of  this  course  of  lectures,  namely — to  the 
study  of  the  febrile  diseases  incidental  to  in¬ 
fancy  and  childhood.  They  belong,  for  the 
most  part,  to  the  class  of  the  Exanthemata, — 
diseases  characterized,  as  you  know,  by  very 
well-marked  symptoms,  by  a  very  definite 
course,  and  by  their  usually  occurring  only 
once  in  a  person’s  life.  These  peculiarities 
have  always  obtained  for  them  the  notice  of 
practitioners  of  medicine,  and  few  of  the 
affections  of  early  life  have  been  watched  so 
closely,  or  described  with  so  much  accuracy, 
as  small-pox,  measles,  and  scarlatina.  Hence 
it  will  be  unnecessary  to  occupy  so  much  of 
your  time  with  their  investigation  as  we  have 
devoted  to  the  study  of  other  diseases  which, 
though  not  so  important,  have  yet  been  less 
carefully  or  less  completely  described. 

While  the  well-marked  and  unvarying 
features  of  the  eruptive  fevers,  however,  have 
forced  those  diseases  on  the  attention  of  all 
observers,  the  more  fluctuating  characters  of 
simple  continued  fever  have  been  so  masked 
by  the  differences  between  youth  and  age, 
that  the  affection,  as  it  occurs  in  eaxdy  life, 
was  long  almost  entirely  overlooked,  and  its 
nature  was,  iu  many  respects,  still  longer 
misapprehended.  Many  indeed,  even  of  the 
older  writers  on  medicine,  have  spoken  of 
fevers  as  occurring  among  children  at  all 
ages  ;  but  under  this  name  they  confounded 
together  several  diseases  in  which  febrile  dis¬ 
turbance  was  merely  the  effect  of  the  consti¬ 
tution  sympathizing  with  some  local  disorder. 
This  mistake  was  committed  with  especial 
frequency  in  the  case  of  various  affections  of 
the  abdominal  viscera ;  many  of  which  are 

xlii. — 1080.  Aug.  11,  1848. 


attended  by  a  considerable  degree  of  sympa¬ 
thetic  fever,  while  their  symptoms,  in  other 
respects,  are  often  so  obscure  that  the  im¬ 
perfect  diagnosis  of  former  days  easily  failed 
to  discover  their  exact  nature.  As  medical 
knowledge  increased,  many  of  these  disorders 
were  referred  to  their  proper  place ;  but, 
nevertheless,  the  descriptions  given  of  the 
so-called  remittent,  fever ,  worm  fever,  and 
hectic  fever  of  children,  present  little  of  a 
definite  character,  and  are  evidently  the  re¬ 
sult  of  a  blending  together  of  the  symptoms 
of  various  affections.  The  disease  described 
under  these  different  names  was  supposed  to 
be  a  symptomatic  fever,  excited  by  gastric  or 
intestinal  disorder,  and  limited  in  the  period 
of  its  occurrence  to  early  life  ;  while -the  ab¬ 
sence  of  the  well-marked  shivering  which 
usually  attends  the  onset  of  fever  in  the 
adult,  the  rarity  of  any  efflorescence  -on  the 
surface  of  the  body,  and  the  comparatively 
low  rate  of  mortality  which  it  occasions,  led 
persons  altogether  to  overlook  the  close  con¬ 
nection  between  it  and  the  continued  fever 
of  an  adult. 

If,  however,  we  look  closely  at  the  charac¬ 
ters  of  this  disease,  and  compare  them,  as 
has  been  done  by  MM.  Rilliet  and  Barthezj, 
with  those  presented  by  the  simple  continued 
fever  of  the  adult,  we  shall,  I  think,  see  so 
close  a  correspondence  between  the  two 
affections  as  to  remove  all  doubt  with  re¬ 
ference  to  their  identity.  Both  diseases 
occur  independently  of  any  unvarying  cause, 
often  independently  of  any  cause  which  we 
are  able  to  detect;  and  both,  though  gene¬ 
rally  affecting  isolated  individuals,  yet  have 
also  their  seasons  of  epidemic  prevalence. 
Though  varying  in  severity,  so  that  in  some 
cases  confinement  to  bed  for  a  few  days  is 
scarcely  necessary,  while  in  other  cases  the 
patient  scarcely  escapes  with  his  life,  yet 
medicine  has  not  yet  been  able  to  cut  short 
the  course  even  of  their  mildest  forms.  And, 
lastly,  though  the  local  affections  associated 
with  both  vary  much  in  different  cases,  yet 
in  every  instance  we  meet  with  that  assem¬ 
blage  of  symptoms  which  make  up  our  idea 
of  fever.  Or  if,  from  the  examination  of  the 
symptoms  during  life,  we  pass  to  the  inquiry 
into  the  traces  left  by  the  disease  on  the 
bodies  of  those  to  whom  it  proves  fatal,  we 
shall  find  still  further  evidence  of  the  close 
relation  that  subsists  between  the  fever  of 
the  child  and  that  of  the  adult.  Enlarge¬ 
ment,  tumefaction,  and  ulceration  of  Peyer’s 
glands,  constitute  one  of  the  most  frequent 
morbid  appearances  in  both  diseases,  and  in 
both,  the  changes  that  these  glands  are  found 
to  have  undergone  are  more  advanced  and 
more  extensive  in  proportion  to  their  near¬ 
ness  to  the  i'io-coecal  value.  In  both  too, 
the  mesenteric  glands  are  enlarged,  swollen., 
of  a  more  or  less  deep  red  colour,  and  mani¬ 
festly  increased  in  vascularity ;  while  the 


222 


SYMPTOMS  OF  REMITTENT  FEVER  IN  CHILDREN 


softened  state  of  the  spleen,  the  gorged  con¬ 
dition  of  the  lungs,  and  the  congestion  of 
the  membranes  of  the  brain,  are  appearances 
common  to  both  diseases.  There  is,  how¬ 
ever,  no  more  relation  between  the  severity 
of  the  intestinal  lesion  and  the  intensity  of 
the  symptoms  in  the  fever  of  the  child  than 
in  that  of  the  adult ;  and  there  is  no  ground 
for  regarding  the  disease  as  the  mere  effect 
of  the  constitution  sympathising  with  a  cer¬ 
tain  local  mischief  in  the  former  case,  which 
may  not  be  equally  alleged  with  reference  to 
the  latter.  The  symptoms  in  both  “  are  the 
expression  of  the  influence  of  the  disease  on 
the  whole  economy  of  the  disorder  which  it 
occasions  in  the  principal  functions  of  the 
body,  and  are  an  essential  part  of  the  disease 
itself,  rather  than  the  secondary  effects  of 
certain  lesions  of  the  bowels.”* 

There  are  still  many  questions  that  might 
he  proposed  with  reference  to  the  remittent 
fever  of  children,  but  on  which  I  do  not 
enter  now,  because  I  am  at  present  unable 
to  give  you  what  would  be,  even  to  my  own 
mind,  a  thoroughly  satisfactory  solution  of 
them.  We  will,  therefore,  pass  at  once  to 
a  safer  and  more  profitable  field  for  inquiry, 
and  will  examine  into  the  symptoms  that 
characterise  this  affection. 

The  different  degrees  of  severity  which  a 
disease  may  present  in  different  cases  do  not 
in  general  form  a  good  basis  on  which  to 
found  any  classification  of  its  varieties  ;  but 
in  the  case  of  remittent  fever  of  children  the 
differences  are  so  great  between  its  milder 
and  its  severer  form  as  to  warrant  our 
adopting  them  as  a  ground  for  a  subdivision 
of  the  disease  into  two  classes.  In  cases  of 
the  first  or  milder  kind, ,  the  disease  usually 
comes  on  very  gradually,  often  so  much  so 
that  the  parents  of  a  child  who  is  attacked 
by  it  are  unable  to  name  any  fixed  time  as 
that  at  which  the  illness  began.  The  child 
loses  its  cheerfulness,  the  appearance  of 
health  leaves  it,  the  appetite  fails,  and  the 
thirst  becomes  troublesome ;  by  day-time 
there  are  listlessness  and  fretfulness,  and 
drowsiness  towards  evening,  but  the  nights 
are  often  restless,  or  the  slumber  broken  and 
unrefreshing  ;  while  all  these  symptoms  come 
on  without  any  evident  cause,  and  are  not 
accompanied  by  any  definite  illness.  When 
once  the  attention  of  the  parents  has  been 
excited  to  the  condition  of  the  child,  it  is 
soon  ascertained  that  the  skin  is  often  hotter, 
and  almost  always  drier  than  natural,  though 
now  and  then  rather  profuse  sweats  break 
out  causelessly  on  the  surface,  and  continuing 
for  an  hour  or  two,  leave  the  patient  in  no 
respect  relieved  bv  their  occurrence.  The 
bowels  are  sometimes  loose  even  at  the  onset 
of  the  disease,  or  if  not,  they  are  in  general 


*  Chomel,  Lecons  de  Clinique  Medicale.  Fievre 
Typhoide.  8vo.  Paris,  1834,  p.  231. 


readily  disturbed  by  medicine  ;  a  very  mild 
aperient  being  not  unfrequently  followed  by 
three  or  four  actions  of  the  bowels  daily  for 
the  next  two  or  three  days.  In  a  few  in¬ 
stances  there  is  a  condition  of  rather  obsti¬ 
nate  constipation  at  the  onset  of  the  disease, 
requiring  active  measures  to  overcome  it ; 
but  this  is  not  often  the  case,  and  when  it 
does  occur,  it  is,  I  think,  more  frequently  in 
the  severe  than  in  the  milder  form  of  the 
disease.  The  appearance  of  the  evacuations 
is  almost  always  unhealthy,  and  they  are 
usually  relaxed  and  very  offensive.  The’ 
tongue  is  generally  rather  deficient  in 
moisture,  red  at  the  tip  and  edges,  thinly 
coated  on  the  dorsum  with  white  mucus, 
through  which  the  papillae  appear  of  a  deep 
red  colour.  The  abdomen  is  soft,  though 
there  is  some  flatus  in  the  intestines,  and 
pressure  is  usually  bornewithout  pain.  These 
characters  olten  continue  through  the  whole 
course  of  the  affection,  though  sometimes 
after  the  second  week  pressure  in  either  iliac 
region,  especially  the  right,  appears  to  cause 
some  suffering.  The  pulse  is  generally  ac¬ 
celerated  from  the  very  commencement  of 
the  illness,  sometimes  it  is  very  much  so> 
but  there  is  by  no  means  a  constant  relation 
between  the  heat  of  skin  and  the  rapidity  of 
the  pulse.  Occasionally  there  is  slight 
cough,  but  this  symptom  is  very  frequently 
absent  in  the  milder  cases  of  the  disease. 
As  the  symptoms  which  constitute  this  affec¬ 
tion  come  on  very  gradually,  so  they  often 
continue  for  several  days  with  little,  if  any, 
change  from  day  to  day,  though  the  patient 
is  far  from  seeming  equally  ill  at  all  times  of 
the  day ;  and  this  periodical  exacerbation 
and  remission  of  the  symptoms  have  obtained 
for  the  disorder  the  name  of  remittent  fever. 
In  some  instances  two  distinct  exacerbations 
and  remissions  of  the  symptoms  may  be  ob¬ 
served  in  the  course  of  every  twenty-four 
hours,  but  in  the  majority  of  instances  only 
one  is  well  marked.  The  child  who  during 
the  day  has  been  listless  and  poorly,  but  yet 
not  incapable  of  being  amused,  and  has  had 
the  appearance  of  a  patient  convalescent 
from  some  illness,  rather  than  of  one  still 
suffering  from  disease,  becomes  flushed  and 
uneasy  and  feverish  as  evening  approaches  j 
and  in  some  cases  slight  horripilation  ushers 
in  the  evening  exacerbation  of  fever.  The 
child  seems  drowsy  and  begs  to  be  put  to 
bed,  where  sometimes  he  sleeps,  though  sel¬ 
dom  tranquilly,  till  morning.  In  the  second 
week  the  nights  generally  become  worse  than 
they  were  at  an  earlier  stage  of  the  disease ; 
the  child’s  skin  is  very  dry  and  hot,  he  sleeps 
;  with  his  eyes  half  open,  talks  in  his  sleep, 
wakes  often  to  ask  for  drink,  and  occasion¬ 
ally  has  slight  delirium.  Early  in  the  morn¬ 
ing  he  wakes  pale  and  unrefreshed,  but  about 
9  or  10  o’clock  seems  to  have  recovered 
something  of  his  cheerfulness,  and  for  the 


SEVERE  FORM  OF  REMITTENT  FEVER  IN  CHILDREN. 


succeeding  three  or  four  hours  appears  tole¬ 
rably  well ;  but  as  evening  aproaches  he  seems 
again  weary  and  drowsy,  again  the  febrile 
paroxysm  occurs,  and  the  succeeding  night 
-closely  resembles  the  night  before.  Some¬ 
times,  in  addition  to  the  evening  exacerba¬ 
tion,  there  is  a  second  one,  though  less 
severe,  at  about  11  o’clock  in  the  morning  ; 
from  which  the  child  has  hardly  recovered 
before  the  severe  evening  attack  comes  on. 
As  the  case  advances  towards  recovery,  the 
morning  attack*  disappears  long  before  the 
evening  paroxysm  ceasefe  to  recur  ;  and  it 
happens  not  infrequently  that  a  slight  threat¬ 
ening  of  the  evening  exacerbation  continues 
to  return  long  after  the  child  has  seemed  in 
other  respects  well.  It  is  during  the  second 
week  of  the  disease  that  the  typhoid  eruption 
generally  makes  its  appearance,  if  it  appear 
at  all.  In  the  milder  cases  it  is,  I  believe, 
much  oftener  absent  than  present,  and  even 
in  cases  of  a  severer  kind,  it  is,  if  I  may  judge 
from  my  own  experience,  much  less  common 
in  this  country  than  in  France.  Towards 
the  end  of  the  second  or  beginning  of  the 
third  week  the  symptoms  begin  to  abate,  the 
bowels  act  more  regularly,  the  appearance 
of  the  evacuations  becomes  more  natural,  the 
tongue  grows  cleaner  and  uniformly  moist, 
the  thirst  diminishes,  and  the  evening  exa¬ 
cerbations  of  fever  grow  shorter  and  less 
severe;  while  the  child’s  cheerfulness  by  day 
returns,  and  the  face  resumes  the  aspect  of 
health.  Still,  after  even  a  mild  attack  of 
this  disease,  the  child  is  in  general  left  ex¬ 
tremely  weak,  and  greatly  emaciated  ;  the 
loss  of  flesh  and  strength  being  quite  out  of 
proportion  to  the  severity  of  the  illness,  and 
the  progress  to  complete  recovery  being 
generally  very  slow. 

It  sometimes  happens,  that,  having  set  in 
with  comparatively  mild  symptoms,  the  in¬ 
fantile  remittent  fever  assumes  a  serious 
character  in  the  course  of  the  second  week. 
In  the  majority  of  instances,  however,  the 
severer  form  of  the  disease  gives  some  earnest 
of  its  severity  at  a  very  early  period.  It 
commonly  sets  in  with  vomiting,  accom¬ 
panied,  in  many  cases,  by  head-ache,  of 
which  the  child  complains,  if  it  be  old 
enough  to  describe  its  sensations,  or  by  a 
remarkable  degree  of  drowsiness  and  heavi¬ 
ness  of  the  head.  Coupled  with  these  symp¬ 
toms,  there  are  those  indications  of  fever 
which  accompany  the  milder  forms  of  the 
disease,  though  in  this  case  with  a  propor¬ 
tionate  increase  in  their  severity  ;  and  some¬ 
times  distinct  rigors  may  be  observed  alter¬ 
nating  with  the  heat  of  the  surface,  or 
preceding  the  evening  exacerbations  of  the 
fever.  In  the  greater  number  of  instances 
the  vomiting  with  which  the  disease  sets  in 
does  not  return  after  the  second  or  third 
day  of  the  patient’s  illness  ;  but  to  this  there 
are  occasional  exceptions ;  and  as  the  sick- 


223 


ness  is  usually  most  severe  in  cases  in  which 
constipation  is  present,  there  is  some  risk  of 
mistaking  the  real  nature  of  the  affection, 
and  of  regarding  the  irritability  of  the  stomach 
as  a  sign  of  approaching  cerebral  disease. 
Now  and  then,  too,  the  drowsiness  at  the  on¬ 
set  of  the  disease  is  so  overwhelming  that  I 
have  known  a  child  fall  asleep  three  or  four 
times  during  breakfast,  while  his  dizziness, 
and  inability  to  walk  steadily,  still  further 
strengthened  the  impression  that  he  was 
suffering  from  some  affection  of  the  brain. 
Either  of  these  occurrences,  however,  is 
unusual,  and,  though  listless  and  drowsy,  the 
child  is  in  general  unwilling  to  keep  his  bed, 
while  by  night  he  is  commonly  very  rest¬ 
less,  waking  often  in  a  state  of  alarm,  or 
talking  much  in  his  sleep.  The  countenance 
before  long  begins  to  wear  the  peculiar  heavy 
appearance  of  a  fever  patient,  and  by  the 
end  of  the  first  or  the  beginning  of  the 
second  week  the  child  is  often  found  to  have 
sunk  into  a  state  of  stupor,  from  which  he 
seems  unwilling  to  be  roused.  The  skin  of 
the  trunk  is  now  almost  constantly  hot  as 
well  as  dry  ;  the  temperature  being  often 
higher  than  in  any  other  disease,  with  the 
exception  of  scarlatina,  and  ranging  as  high 
as  105°  Fahrenheit.  My  own  observations 
with  reference  to  the  date  of  the  appearance 
of  any  eruption  on  the  surface,  are  neither 
sufficiently  numerous  nor  sufficiently  accu¬ 
rate  for  me  to  rely  on  their  authority.  MM. 
Rilliet  and  Barthez  observe,  that  it  very  sel¬ 
dom  appears  so  early  as  the  fourth  day, 
from  the  sixth  to  the  tenth  being  the  most 
common  date  of  its  appearance  ;  while  both 
the  period  during  which  it  remains  visible, 
and  the  number  of  spots,  are  liable  to 
very  great  variation.  In  by  far  the  greater 
number  of  cases,  the  eruption,  according,  to 
their  experience,  is  extremely  scanty  ;  it  often 
remains  visible  for  only  two  or  three  days, 
and  in  not  a  few  instances  is  absent  altoge¬ 
ther.  In  a  few  cases  of  severe  remittent 
fever  profuse  sweats  take  place,  but  they  do 
not  seem  to  have  anything  of  a  critical  cha¬ 
racter.  The  pulse  is  very  frequent,  and  I 
have  found  it  continue  at  nearly  140  in  a 
minute,  for  several  days  together,  during  the 
increase  of  the  fever  in  a  child  eight  years 
old.  A  frequent,  short,  hacking  cough  often 
occurs  during  the  first  ■week,  and  rhonchus, 
sibilus,  and  occasional  large  crepitation,  are 
heard,  in  many  cases,  in  both  lungs.  Now 
and  then,  too,  the  respiration  continues  much 
accelerated  for  several  days,  without  any 
other  sign  of  serious  pulmonary  disease  being 
present,  and  gradually  regains  it  proper  fre¬ 
quency  as  the  febrile  symptoms  subside. 
Tenderness  of  the  abdomen  is  generally  very 
evident  before  the  first  week  is  passed,  but 
frequently  there  is  no  complaint  of  pain, 
even  in  severe  cases,  except  on  pressure. 
Diarrhoea  is  usually  present,  though  not  in 


224 


DIAGNOSIS  OF  REMITTENT  FEVER 


general  severe,  the  bov/els  not  acting  above 
four  or  five  times  in  the  twenty-four  hours. 
The  tongue  is  in  general  more  thickly  coated 
at  the  commencement  than  in  the  milder 
forms  of  the  disease ;  a  dry  streak  soon 
appears  down  the  centre,  and  by  degrees 
the  tongue  becomes  uniformly  dry,  red,  and 
glazed  ;  or  less  often  it  is  partially  covered 
with  sordes.  In  the  course  of  the  second 
week  the  patient  generally  sinks  into  a  more 
profound  stupor,  a  condition  which  alternates 
in  many  cases  with  delirium,  though  some¬ 
times  the  mind  wanders  occasionally  almost 
from  the  commencement  of  the  disease,  and 
in  other  cases  delirium  is  a  very  temporary 
symptom,  occurring  only  at  night,  or  when 
the  child,  during  the  day-time,  wakes  from 
sleep.  Now  and  then,  though  not  generally, 
the  delirium  is  of  a  noisy  kind,  but  the  child 
not  infrequently  tries  to  get  out  of  bed  ;  and 
both  the  restlessness  and  delirium,  though 
generally  present  in  bad  cases  during  the 
day-time,  are  aggravated  in  a  marked  degree 
at  night.  Once  or  twice  I  have  seen  violent 
delirium  come  cn  towards  evening,  the  child 
crying  and  shouting  aloud  during  nearly  the 
whole  night,  and  sinking  into  a  state  of 
stupor  by  day.  The  child  now  seems  nearly 
or  quite  unconscious  of  all  that  goes  on 
around  it ;  its  evacuations  are  passed  uncon¬ 
sciously,  and  it  often  seems  dead  to  the  sen¬ 
sation  of  thirst,  by  which,  in  the  early  stages 
of  the  disease,  it  was  so  much  distressed ; 
but  this  stupor  of  fever  is  so  different  from 
the  coma  which  supervenes  in  affections  of 
the  brain,  and  the  insensibility  which  cha- 
racterises  it  so  much  less  profound,  that  one 
can  hardly  be  mistaken  for  the  other.  Even 
when  the  disease  is  most  severe,  neither  sub- 
sultus  nor  floccitation  is  frequent,  though  it 
often  happens  that  during  the  tedious  and 
fluctuating  convalescence  the  child  picks  its 
nose  till  it  bleeds,  or  makes  the  tips  of  its 
fingers,  or  different  parts  of  its  body,  sore  by 
picking  them.  The  patient  is  by  the  end  of 
the  second  week,  sometimes  earlier,  reduced 
by  the  continuance  of  these  symptoms  to  the 
most  extreme  degree  of  emaciation,  and  to  a 
condition  apparently  hopeless ;  but  there  is 
no  disease  irom  which  recovery  so  often 
takes  place,  in  spite  of  even  the  most  unfa¬ 
vourable  symptoms,  as  from  remittent  fever. 
The  signs  of  recovery  are,  in  the  main,  the 
same  as  would  betoken  the  recovery  of  an 
adult  suffering  from  fever,  but  the  amend¬ 
ment  has  seemed  to  me  always  to  be  gradual, 
and  not  in  any  case  the  result  of  any  critical 
occurrence.  Moisture  begins  to  reappear 
upon  the  edges  of  the  tongue,  the  pulse  loses 
its  frequency,  the  delirium  ceases  by  degrees, 
and  more  quiet  rest  is  enjoyed  at  night. 
Such  signs  of  improvement  may  in  general 
be  looked  for  about  the  end  of  the  second 
week,  but  often  the  patient’s  progress  is  in¬ 
terrupted  by  many  fluctuations  :  the  conva¬ 


lescence  is  almost  always  slow,  and  relapses 
occur  from  very  slight  causes. 

In  the  few  cases,  and  according  to  my  ex¬ 
perience  they  are  but  few,  in  which  remit, - 
tent  fever  terminates  fatally,  death  is  hardly 
ever  the  result  of  complications  such  as  not 
infrequently  supervene  in  the  course  of  fever 
in  the  adult,  but  the  vital  powers  give  way 
under  the  severity  of  the  constitutional  affec¬ 
tion,  the  symptoms  of  which  assume  more 
and  more  of  a  typhoid  character.  It  is  to¬ 
wards  the  end  of  the  second,  or  at  the  begin¬ 
ning  of  the  third  week,  that  death  under 
these  circumstances  is  most  likely  to  occur ; 
i  have  seen  it  take  place  as  late  as  the  29th 
day  in  one  instance,  and  at  the  end  of  the 
fifth  week  in  another,  but  in  both  of  these 
instances  gangrene  of  the  mouth  came  on 
after  the  more  alarming  general  symptoms 
had  begun  to  subside ;  and  to  this  the  death 
of  the  child  was  chiefly  due.  Now  and  then 
a  fatal  termination  takes  place  after  the  lapse 
of  little  more  than  a  week  from  the  com¬ 
mencement  of  the  illness,  under  signs  of 
cerebral  disturbance  which  throw  the  general 
febrile  symptoms  into  the  shade  ;  great  rest¬ 
lessness  and  agitation,  with  loud  cries,  being 
succeeded  by  convulsions,  and  they,  in  their 
turn,  being  followed  by  a  condition  of  coma, 
in  which  the  child  dies ;  while  an  examina¬ 
tion  after  death  discovers  nothing  more 
serious  than  a  somewhat  greater  vascularity 
than  natural  of  the  brain  and  its  membranes. 

The  diagnosis  of  remittent  fever  has  been 
rendered  needlessly  difficult  by  the  loose 
manner  in  which  the  name  has  been  applied 
to  a  variety  of  affections ;  still  it  must  be 
confessed  that  there  are  several  diseases  be¬ 
tween  which,  and  remittent  fever,  there  are, 
in'  some  parts  of  their  course,  points  of  simi¬ 
larity  that  may  easily  deceive  the  unwary. 
The  resemblance  is  often  very  close  between 
the  milder  varieties  of  the  fever  and  some  of 
those  cases  of  gastro-intestinal  disorder,  by 
no  means  unusual  in  young  children,  which 
are  excited  by  errors  of  diet,  and  are  either 
associated  with  diarrhoea  or  preceded  by  it. 
Even  in  such  cases,  however,  the  loss  of 
strength,  the  dry  heat  of  the  skin,  and  its  in¬ 
tensity  at  the  time  of  the  exacerbations  of  the 
fever,  the  marked  disturbance  of  the  senso- 
rium,  and  the  delirium  at  night,  which  is  al¬ 
most  always  present  in  children  sufficiently 
old  for  this  symptom  to  be  apparent,  are  cha¬ 
racters  by  which  remittent  fever  may  gene¬ 
rally  he  known.  General  tubercular  disease, 
running  an  acute  course,  may  now  and  then 
be  taken  for  a  short  time  for  remittent  fever, 
but  the  observation  of  the  case  for  a  few 
days  will  usually  suffice  to  correct  the  error. 
In  most  instances  of  the  former  affection, 
indeed,  the  possibility  of  mistake  is  altoge¬ 
ther  prevented  by  the  skin  being  less  hot, 
the  sensorium  not  disturbed,  the  abdominal 
symptoms  either  more  or  less  severe  than 


TREATMENT  OF  REMITTENT  FEVER  IN  THE  CHILD. 


225 


they  might  be  expected  to  be  in  a  fever  of 
the  same  degree  of’  severity.  Independently 
of  this,  too,  auscultation  will  often  show  good 
reason  for  suspecting  the  real  nature  of  the 
case,  or  the  previous  history  of  the  child 
will  afford  some  clue  with  reference  to  it. 
There  are  two  other  affections  between  which 
and  remittent  fever  it  is  often  far  from  easy 
to  distinguish,  while,  unfortunately,  the  prac¬ 
tical  evils  which  follow  from  a  wrong  diag¬ 
nosis  are  of  a  very  serious  nature.  When 
speaking,  however,  of  hydrocephalus  in 
Lecture  VI.,  and  of  pneumonia  in  Lecture 
XVII.,*  I  dwelt  so  fully  upon  the  circum¬ 
stances  that  might  lead  you  to  mistake 
either  of  those  diseases  for  remittent  fever, 
and  of  the  characteristics  which  belong  to 
the  last-named  affection,  that  it  will  be  un¬ 
necessary  to  do  more  than  refer  you  to  the 
observations  made  on  those  occasions.  It 
remains  now,  therefore,  that  we  notice,  in 
conclusion,  the  rules  that  should  guide  us 
in  the  treatment  of  this  disease. 

In  the  treatment  of  remittent  fever  in  the 
child,  just  as  in  that  of  fever  in  the  adult, 
the  grand  object  to  which  our  attention 
ought  to  be  turned,  is  to  carry  the  patient 
through  an  affection  which  we  cannot  cut 
short,  with  as  small  an  amount  of  suffering 
or  danger  as  possible.  “  Medicus  curat, 
natura  sanai  vnorbum ,”  says  an  old  Latin 
adage,  and  in  no  disease  is  it  of  so  much  im¬ 
portance  as  in  fever  that  we  should  assign  to 
our  art  its  proper  position  as  the  handmaid 
of  nature.  The  gradual  approach  of  the  dis¬ 
order  in  the  great  majority  of  instances,  of 
itself  points  out  the  propriety  of  that  expec¬ 
tant  mode  of  treatment  which  is  generally 
the  most  appropriate  during  the  first  week 
of  the  child’s  illness.  The  languid  and  list¬ 
less  state  of  the  little  patient,  his  head-ache 
and  drowsiness,  often  lead  him  to  wish  to 
remain  in  bed  all  day  long,  but  there  is  no 
reason  for  confining  him  to  bed  if,  during 
the  period  of  remission  of  the  fever,  he  should 
wish  to  sit  up.  The  impaired  appetite  often 
renders  any  other  directions  about  the  diet 
unnecessary,  than  a  caution  to  the  parents 
or  nurse  not  to  coax  or  tempt  the  child  to 
take  food  which  it  is,  and  will  probably  for 
some  days  continue  to  be,  entirely  u,;»able 
to  digest.  The  heat  of  skin  and  the  craving 
thirst  are  the  two  most  urgent  symptoms  in 
the  early  stages  of  the  affection.  The  first 
of  these  is  generally  relieved  by  the  tepid 
bath  at  90°  or  92°  every  morning,  and  by 
sponging  the  surface  of  the  body  several 
times  a  day  with  lukewarm  water.  The  de¬ 
sire  for  cold  drinks  is  often  very  urgent,  and 
no  beverage  is  half  so  grateful  as  cold  water 
to  the  child.  Of  this  it  would,  if  permitted, 
take  abundant  draughts,  but  it  should  be 


*  See  the  Gazette  for  July  16,  and  for  Dec. 

17,  1847. 


explained  to  the  attendants  that  the  thirst  is 
not  more  effectually  relieved  by  them  than 
by  small  quantities  of  fluid,  while  pain  in 
the  abdomen  is  very  likely  to  be  caused  by 
the  over-distension  of  the  stomach.  The 
cup  given  to  the  child  should  therefore 
only  have  a  dessert  or  tablespoonful  of 
water  in  it,  for  it  irritates  the  little  patient 
to  remove  the  vessel  from  its  lips  un¬ 
emptied.  In  the  milder  forms  of  the 
disease,  and  during  the  first  week,  medicine 
is  little  needed  ;  but  a  simple  saline  may  be 
given,  such  as  the  citrate  of  potass  in  a  mix¬ 
ture  to  which  small  doses  of  vinum  ipecacu¬ 
anha  may  be  added,  if,  as  sometimes  happens, 
the  cough  be  troublesome.  If  the  bowels  act 
with  due  frequency,  and  the  appearance  of 
the  evacuations  be  not  extremely  unhealthy, 
it  is  well  to  abstain  from  the  employment  of 
any  remedy  which  might  act  upon  them,  for 
fear  of  occasioning  diarrhoea,  which  is  so 
apt  to  supervene  in  the  course  of  this  affec¬ 
tion.  For  the  same  reason,  if  an  aperient 
be  indicated,  drastic  purgatives  are  not  to 
be  given,  but  a  moderate  dose  of  castor  oil 
should  be  administered.  Now  and  then, 
however,  cases  are  met  with  in  which  the 
bowels  remain  confined  during  a  great  part 
of  the  affection,  and  in  which  such  purga¬ 
tives  as  senna  are  not  only  borne,  but  abso¬ 
lutely  necessary.  They,  however,  are  purely 
exceptional  cases  ;  and  it  will  generally  suffice 
to  give  a  small  dose  of  the  mercury  and  chalk 
night  and  morning,  and  during  the  day  time 
a  small  quantity  of  the  tartrate  of  soda  or 
the  sulphate  of  magnesia,  dissolved  in  some 
simple  saline  mixture,  every  six  or  eight 
hours. 

The  unhealthy  state  of  the  evacuations 
that  exists  in  a  large  number  of* cases  is  gene¬ 
rally  associated  with  a  disposition  to  diarrhoea, 
which  becomes  a  more  prominent  symptom 
in  the  second  than  it  was  in  the  first  week 
of  the  disorder.  Equal  parts  of  the  hydrar¬ 
gyrum  cum  creta  and  Dover’s  powder  are 
the  best  means  of  relieving  both  these  morbid 
conditions ;  the  remedy  being  given  either 
once  or  twice  a  day,  or  more  frequently,,  ac¬ 
cording  to  the  urgency  of  the  symptoms. 
The  amount  of  abdominal  pain  and  tender¬ 
ness  must  be  ascertained  every  day ;  and  a 
few  leeches  must  be  applied  to  either  iliac 
region  if  the  tenderness  seem  considerable, 
or  if  the  child  appear  to  suffer  much  from  pain 
in  the  abdomen,  or  if  the  diarrhoea  be  severe. 
If  depletion  be  needed,  the  application  of 
but  a  small  number  of  leeches  will  gene¬ 
rally  meet  the  requirements  of  the  case, 
while  copious  bleeding  is  neither  useful  nor 
well  borne.  Even  in  children  of  ten  years 
old  I  never  apply  above  four  or  six  leeches, 
and  it  is  very  seldom  that  any  occasion  arises 
for  a  repetition  of  the  bleeding.  The  appli¬ 
cation  of  poultices  to  the  abdomen,  either  of 
linseed  meal  or  scalded  bran,  and  their  fre- 


226 


TREATMENT  OF  REMITTENT  FEVER  IN  CHILDREN. 


quent  repetition,  is  a  very  valuable  means  of 
relieving  the  griping  pain  which  often  dis¬ 
tresses  children,  and  in  most  cases  it  is  de¬ 
sirable  to  make  trial  of  them  before  having 
recourse  to  depletion. 

There  is  but  one  other  class  of  symptoms 
likely  to  occur  during  the  first  week  of  the 
fever,  to  the  management  of  which  I  have 
not  yet  referred ;  namely,  those  signs  of 
cerebral  disturbance  which  are  sometimes  so 
serious  as  to  call  for  treatment.  The  early 
occurence  of  delirium,  though  it  generally 
implies  that  the  disease  will  assume  a  rather 
serious  character,  yet  does  not  of  itself  indi¬ 
cate  the  necessity  for  taking  blood  from  the 
head  ;  but  if  the  child  be  quiet  and  generally 
rational  during  the  day-time,  though  dull 
yet  not  in  a  state  of  stupor  ;  while  the  deli¬ 
rium  at  night  is  of  a  tranquil  kind,  it  will 
generally  suffice  to  apply  cold  to  the  head, 
and  to  keep  the  apartment  cool,  and  abso¬ 
lutely  quiet.  On  the  other  hand,  if  there  be 
great  restlessness  and  noisy  delirium  early 
in  the  disease,  with  heat  of  head  or  flushing 
of  the  face,  local  depletion  is  called  for  ;  nor 
is  it  less  useful  in  those  cases  which  set  in 
with  symptoms  that  bear  a  close  resem¬ 
blance  to  those  of  hydrocephalus,  in  which 
vomiting  occurs  frequently,  and  the  sense  of 
nausea  is  abiding,  while  the  child  either  is 
constantly  making  a  low  moan  as  if  in  pain, 
or  is  extremely  restless,  and  makes  loud 
complaints  of  head-ache. 

In  mild  cases  of  the  disease,  that  expec¬ 
tant  treatment  usually  appropriate  during  its 
early  stages  may  be  continued  throughout 
its  course  ;  great  caution  being  exercised,  as 
the  child  begins  to  improve,  to  prevent  its 
committing  any  error  in  diet.  When  severe, 
however,  the  second  week  often  brings  with 
it  a  train  of  symptoms  that  require  many 
modifications  in  the  plan  of  treatment.  The 
vital  powers  need  to  be  supported,  and  the 
nervous  system  requires  to  be  tranquillised  ; 
and  this  is  to  be  attempted  by  means  similar 
to  those  which  we  should  employ  in  the 
management  of  fever  in  the  adult.  The 
mere  diluents  which  were  given  during  the 
previous  course  of  the  fever  must  now  be 
exchanged  for  beef  or  veal  tea  or  chicken 
broth,  unless  the  existence  of  severe  diarrhoea 
contraindicate  their  administration.  In  that 
case,  which  however  does  not  very  often 
occur,  we  must  substitute  arrow  root,  milk, 
and  isinglass,  for  animal  broths.  In  a 
large  proportion  of  cases  nutritious  food 
is  all  that  will  be  required,  but  wine  is 
sometimes  as  essential  as  in  the  fevers  of 
the  adult ;  and  the  indications  for  giving 
it  are  much  the  same  in  patients  of  all  ages. 
Even  though  wine  be  not  necessary,  I  gene¬ 
rally  give  some  form  of  stimulant  during  the 
second  and  third  weeks  of  the  affection. 
The  prescription  which  I  usually  follow  is 
one  much  praised  under  such  circumstances 


by  Dr.  Stieglitz,  of  St.  Petersburgh.  For  a 
child  of  five  years  old,  it  is  four  minims  of 
dilute  hydrochloric  acid,  eight  of  the  com¬ 
pound  spirit  of  sulphuric  ether,  and  three 
drachms  of  camphor  mixture  every  six 
hours.  It  seldom  disorders  the  bowels  if 
they  be  not  much  disturbed  at  the  time  of 
commencing  its  administration ;  while  a 
small  dose  of  Dover’s  powder,  as  a  grain  or 
a  grain  and  a  half  at  bed-time,  is  doubly 
useful,  both  in  checking  tendency  to  diarrhoea 
and  in  procuring  sleep  for  the  child,  who, 
without  it,  would  probably  be  watchful  and 
delirious  all  night  long.  So  long  as  any 
severe  abdominal  symptoms  are  present,  I 
abstain  from  the  use  of  the  acid  mixture ; 
but  give  the  mercury  and  chalk,  with  Do¬ 
ver’s  powder,  every  four  or  six  hours,  to 
which  I  occassionally  add  an  opiate  enema  at 
bed- time  ;  and  support  the  strength  by  food 
and  wine  as  may  be  necessary. 

The  only  complication  that  is  apt  to  be 
troublesome  is  the  bronchitis.  Usually, 
however,  the  cough  to  which  this  gives  rise 
is  rather  an  annoying  than  a  dangerous 
symptom  ;  and  it  is  in  general  more  haras¬ 
sing  at  the  commencement  of  the  affection, 
and  again  when  convalescence  is  beginning, 
than  during  that  time  when  the  graver 
symptoms  are  present.  A  little  ipecacuanha 
wine,  nitrous  ether,  and  paregoric,  will  usu¬ 
ally  relieve  it,  to  which  it  may  occasionally 
be  expedient  to  add  the  application  of  a 
mustard  poultice  to  to  the  chest. 

The  convalescence  is  often  extremely 
tedious  ;  the  child  is  left  by  the  disease  not 
only  extremely  weak  and  emaciated,  but 
with  its  digestive  powers  greatly  impaired. 
It  is  often  many  days  before  the  stomach  is 
able  to  digest  any  solid  food ;  even  a  piece 
of  bread  will  sometimes  irritate  the  intestines 
and  bring  on  a  return  of  diarrhoea.  The 
appetite  seems  sometimes  quite  lost;  tonics 
either  do  no  good  or  are  actually  injurious 
by  rekindling  fever,  and  there  seems  reason 
to  apprehend  the  devolopment  of  tubercular 
disease,  a  consequence  which  sometimes 
follows  severe  attacks  of  remittent  fever. 
Under  such  circumstances,  change  of  air, 
and  the  removal,  if  possible,  to  the  sea-side, 
are  often  the  only  means  of  restoring  the 
child  to  health;  a  means  which  you  may 
recommend  with  the  more  confidence,  since 
it  hardly  ever  fails  to  be  successful. 

apothecaries’  hall. 

Names  of  Gentlemen  who  passed  their  ex¬ 
amination  in  the  Science  and  Practice  of 
Medicine,  and  received  certificates  to  prac¬ 
tise,  on  Thursday,  3d  August,  1848. — 
Frederic  Foreman  Ladd,  St.  Peter’s,  Isle  of 
Thauet — Charles  Underhill,  Wolverhampton 
— John  Mills  Wills,  Brixham,  Devon — 
Thomas  Scott,  Sherborn — George  Charles 
Sharman,  Moseley. 


INFLUENCE  OF  RESEARCHES'  IN  CHEMISTRY  ON  THERAPEUTICS.  227 


LECTURES  ON  THE 

INFLUENCE  OF  RESEARCHES  IN 
ORGANIC  CHEMISTRY  ON 
THERAPEUTICS, 

ESPECIALLY  IN  RELATION  TO  THE  DEPURA¬ 
TION  OF  THE  BLOOD. 

Delivered  at  the  Royal  College  of  Physicians, 

By  Dr.  Golding  Bird,  A.M.  F.R.S. 
Fellow  of  the  College. 

Lecture  YI. — May  10,  1848. 

Therapeutical  application  of  these  inquiries. 
—  observations  of  the  older  physicians — 
influence  of  water  drinking.  Kidneys 
compensating  for  deficient  liver — chola- 
gogue  action  of  some  diuretics.  Depu¬ 
rating  influence  of  the  kidneys — influence 
of  mercurials  —  renal  alterants — their 
increase  of  metamorphosis  of  tissue. 
Krahmer’s  researches.  Specific  and 
chemical  diuretics — depur  ants — experi¬ 
mental  examination  of  their  effect — 
vitality  opposed  to  chemical  change — 
influence  of  alkalies  in  struma — nitre  in 
rheumatism.  Dr.  Lethcby’s  researches. 
Concluding  propositions. 

Mr.  President, — In  my  last  lecture,  hav¬ 
ing  brought  to  a  close  all  the  chemical  evi¬ 
dence  I  could  adduce  to  illustrate  the  facility 
with  which  many  bodies  regarded  as  ex¬ 
clusively  the  products  of  life  were  convertible 
into  each  other,  I  passed  on  to  the  conside¬ 
ration  of  the  existence  of  a  positive  depu¬ 
ration  of  the  blood  by  the  kidneys  in  diseases 
in  which  there  existed  a  state  of  caco-aemia, 
whether  depending  on  zymotic  influence  or 
the  presence  of  an  effete  materies  morbi;  and 
hope  I  succeeded  in  satisfying  the  minds  of 
my  auditors  that  such  really  existed,  and 
was  evidenced,  not  so  much  by  a  critical 
alteration  in  the  appearance  of  the  urine,  as 
by  a  sudden  increase  in  the  amount  of  solids 
existing  in  it.  Further,  I  laid  considerable 
stress  on  the  fact  that  it  was  not  necessary, 
or  even  logical,  for  us  to  deny  this  depu¬ 
rating  power,  merely  on  the  grounds  of  the 
proper  or  peculiar  poison  of  the  disease  not 
being  detected  in  the  urine,  inasmuch  as  it 
could  only  be  expected  to  be  found  there 
metamorphosed  into  some  of  the  proper 
elements  of  the  excretion. 

Having,  as  1  hope,  demonstrated  the 
truth  of  these  statements  (and  I  may  here 
add,  the  observations  have  not  been  scanty, 
for  I  have  now  notes  of  369  distinct  exami¬ 
nations  of  the  urine  in  33  selected  cases 
treated  in  the  hospital), — having  shewn  that 
all  we  have  observed  in  diseases  is  in  accor¬ 
dance  with  these  views, — having  adduced 
actual  evidence  that  sudden  improvement 


has  occurred  in  patients  concomitantly  with 
the  evolution  of  a  large  quantity  of  solids  by 
the  kidneys,  I  next  proposed  to  consider  the 
great  question  arising  out  of  all  this — viz., 
can  we  at  will,  by  therapeutic  agents,  pro¬ 
duce  this  depurating  effect,  and,  by  hastening 
the  metamorphosis  of  matter,  aid  the  re¬ 
moval  of  a  materies  morbi,  whether  itself 
the  exciting  cause,  or  effect  of  antece¬ 
dent  morbid  action  ?  To  this  inquiry  I 
propose  devoting  the  present  lecture. 

We  must,  I  conceive,  then,  at  once  admit, 
from  the  facts  already  stated,  that  the  kid¬ 
neys  perform  a  function  of  the  highest  im¬ 
portance, — one  which  we  are  all  familiar 
wTith,  but  one  which,  from  that  very  fami¬ 
liarity,  we  hardly  sufficiently  appreciate. 
Although  the  merest  tyro  in  physiology  is 
aware  that  the  organs  in  question  separate 
from  the  blood  about  one  and  a  half  ounces 
of  solids  in  twenty-four  hours,  yet  every  one 
is  not  equally  cognizant  of  the  fact  that  the 
amount  of  excreta  bears  a  direct  ratio  to 
the  quantity  of  mal-assimilated  matter  in 
the  blood,  either  derived  from  the  food  di¬ 
rectly,  or  indirectly  under  the  influence 
of  the  leaven  of  the  disease,  as  shewn 
in  the  results  of  the  analyses  of  urine 
excreted  at  different  times  of  the  day,  as 
well  as  in  different  phases  of  disease.  Let 
us  now  endeavour  to  give  a  practical  turn  to 
this  question,  and  ask  whether  a  thera¬ 
peutical  indication  of  importance  may  not 
be  drawn  from  it  ?  And  here  we  touch 
upon  facts  known  and  recognised  by  our 
predecessors  centuries  ago,  but  forgotten  by 
ourselves.  Having  admitted  that  certain 
diseases  are  excited,  kept  up,  or  aggravated 
by  a  poison,  if  you  will, — or  in  other  words, 
by  a  noxious  or  lethal  effete  matter  in  the 
blood, — can  we  not  hope  to  aid  our  patient 
by  exciting  its  removal  by  stimulati  g  the 
depurating  function  of  the  kidneys?  This 
indication  was  acted  upon  by  the  old  physi¬ 
cians — witness  the  host  of  apozems,  diuretic 
decoctions,  and  diet  drinks,  in  which  renal 
stimulants  abound  ;  and  let  us  not  shut  our 
eyes  to  the  success  of  the  practice,  for  unless 
we  deny  all  credence  to  the  statements  of 
the  painstaking  practitioners  of  past  times, 
those  who  will  read  their  quaint  records  of 
cases  will  learn  how  generally  they  succeeded 
in  curing  the  effects  of  a  caco-cemia,  an 
unhealthy  blood,  as  evidenced  by  various  erup¬ 
tive  affections,  cellular  membranous  sores, 
furuncuii,  and  very  many  such  ailments.  It 
is  true  that  in  looking  at  some  of  their  pre¬ 
scriptions  we  do  not  generally  observe  reme¬ 
dies  which  have  now  much  confidence  placed 
in  them  as  trustworthy  diuretics,  but  then 
an  important  element  of  their  potions  is 
most  undoubtedly  the  water  of  the  decoc¬ 
tion  employed,  not  in  doses  of  table-spoon¬ 
fuls,  but,  as  was  common  in  former  days,  of 
pints.  A  most  important  truth  here  de- 


228  ON  THE  INFLUENCE  OF  RESEARCHES  IN  ORGANIC  CHEMISTRY  ON 


mands  our  attention.  It  may  be  said  that 
it  is  true  that  if  a  patient  takes  a  pint  or  two 
extra  of  water  he  will,  supposing  that  no 
Organic  lesion  exists,  excrete  a  large  bulk  of 
urine,  from  the  necessity  there  exists  for 
pumping  off  the  excess  of  diluent  partaken 
of.  In  this  way  a  pint  or  two  of  water  be¬ 
comes  a  diuretic  :  this  every  one's  experience 
will  enable  him  to  admit ;  but  wbat  is  this, 
it  may  be  asked,  but  the  mere  drawing  off 
of  excess  of  water, —  where  is  the  proof  of 
blood-depuration  ?  This  proof  is  found  by 
collecting  the  urine,  measuring  it,  and  by 
means  of  the  formula  and  table  before  ex¬ 
plained,  calculating  the  amount  of  its  solid 
constituents.  It  will  then  be  found  that  the 
excess  of  water  does  not  escape  alone,  but 
there  is  really  washed  away  with  it  a  certain, 
although  cot  very  large  quantity,  of  solid 
debris.  To  Edmund  Becquerei  must  be  ac¬ 
corded  the  credit  of  this  observation  ;  and 
any  one  may  satisfy  himself  of  its  accuracy 
fcv  collecting  all  the  urine  he  passes  in 
twenty-four  hours,  and  determining  the 
quantity  of  solids  it  contains  ;  and  repeating 
this  proce«s  next  day,  while  throwing  into 
his  system  three  or  four  bottles  of  aerated — 
the  so-called  soda — water.  This  observation 
affords  a  key  to  many  of  the  undoubted  cures 
effected  by  the  use  of  many  of  the  mineral 
Springs.  Some  of  them  are.  like  that  of 
Malvern,  remarkable  only  for  the  positive 
purity  of  their  water,- — setting  aside  (what 
we  must  never  forget)  the  influence  of 
change  of  scene  and  association, — the  dimi¬ 
nution  of  the  friction  of  mind  on  matter  by 
business  relaxation  :  healthy  air  and  exer¬ 
cise,  amusement  of  mind  and  excitement 
of  renewed  hopes,  we  cannot  help  recognising 
in  the  active  action  of  the  kidneys,  excreted 
by  a  course  of  so  called  mineral  water, — a 
most  important  agent.  A  man  labouring 
under  some  chronic  ailment,  which,  perhaps, 
like  old  rheumatism,  is  the  direct  result  of 
unhealthy  constituents  of  the  blood,  starts 
for  one  of  the  Brunnens  or  Spas,  and  with 
fearful  devotion  swallows  the  enormous 
quantity  of  ten  or  fourteen  beakers  of  the 
warm  and  bubbling  water.  In  a  few  minutes 
he  begins  to  secrete  abundance  of  urine,  and 
is  engaged  alternately  drinking  and  mictu¬ 
rating  for  part  of  the  morning, — active  exer¬ 
cise,  when  possib’e,  being  enjoined  the  whole 
time.  By  this  exercise  the  wear  of  tissue  is 
increased,  and  the  copious  v  ater- bibbing 
positively  aids  the  metamorphosis  of  tissue, 
and  washes  its  results  from  the  body.  An 
excellent  and  esteemed  physician,  the  late 
Dr.  J.  Johnson,  who  paid  great  attention  to 
this  subject,  informed  me  that  he  had  been 
long  accustomed  to  regard  this  active 
diuresis  an  essential  element  in  the  patient’s 
well-doing  ;  and  where  it  was  not  produced 
the  patient  was  generally  the  worse  for  his 
visit.  ■  Hence  he  was  in  the  habit  of  never 


sanctioning  any  of  his  patients  making  a  pil¬ 
grimage  to  the  Spas  if  any  organic  lesion 
existed  capable  of  interfering  with  the  func¬ 
tion  of  the  kidneys. 

The  same  explanation  may  be  given  to 
the  success  which  has  attended  some  cases 
when  submitted  to  the  hydropathic  quackery : 
the  patient  being  actually  cleaned  out, — the 
old  and  diseased  tissues  being  literally 
washed  away,  to  make  room  for  new  .struc¬ 
tures  deposited  under  the  cheering  results  of 
the  hygenic  influences  of  exercise,  good  air, 
and  change  of  scene ;  and  the  cheerfulness 
of  mind  produced  by  the  bright  promises  of 
the  future  too  often  delusively  held  out  by 
the  disciples  of  Preissnitz. 

When  we  are  consulted  by  patients 
labouring  under  severe  ailment,  attended 
with  dark  urine,  pale  alvine  dejections,  and 
a  jaundiced  face, — who  hesitates  for  a  mo¬ 
ment  making  an  appeal  to  his  liver,  and 
bringing  into  full  play  his  battery  of  chola- 
gogues, — who,  when  consulted  on  a  case  in 
which  the  skin  is  hard  and  dry,  the  surface 
im perspirable,  and  as  a  result,  perhaps,  the 
mucous  membrane  congested,  would  demur 
to  the  practice  of  directing  his  attention  to 
the  deficient  function,  and  of  doing  his  best 
towards  arousing  the  torpid  duties  of  the 
skin  ? 

Although  all  will  admit  the  importance  of 
an  appeal  to  the  functions  of  liver  and  skin, 
and  are  daily  in  the  habit  of  stimulating  these 
great  filters  when  tardy  in  their  offices,  yet 
the  depurating  offices  of  the  kidneys  are  for¬ 
gotten.  True,  if  a  dropsical  effusion  accumu¬ 
lates, — if  a  patient  is  threatened  with  falling 
a  victim  to  waters  of  his  own  forming,  the 
renal  pumps  are  always  looked  to,  and 
they  are  set  to  work,  or  rather  expected  to 
obey,  the  influence  of  stimulants,  when, 
perhaps,  in  many  cases  a  more  philosophical 
and  enlarged  view  or  the  etiology  of  the  dis¬ 
ease  would  have  suggested  the  propriety  of 
leaving  them  alone.  But  the  filtering  off  of 
Water  is,  as  I  have  said,  but  one,  and  really 
a  subordinate  function,  of  the  kidneys- — one 
whch  it  shares  in  common  with  the  cuta¬ 
neous  and  mucous  surfaces.  If  we  are  all 
ready  to  admit  that  an  appeal  to  the  liver  is 
important  in  separating  matters  rich  in  car¬ 
bon,  hydrogen,  and  sulphur,  from  the  blood, 
— are  not  the  kidneys  equally  so  in  their 
special  function  of  separating  matters  rich 
in  nitrogen  ?  But  we  must  not  forget  that 
we  are  thus  taking  a  very  narrow  view  of 
the  great  importance  of  the  depurative  func¬ 
tions  of  these  great  glands,  for  I  have  shewn 
you  that  one,  namely  the  liver,  separates  from 
the  blood  the  elements  of  glyeocoil,  a  body 
representing  the  atomic  composition  of  urea 
and  sugar,  the  former  in  health,  the  latter 
in  disease,  being  constitutents  of  the  urine. 
If  we  assume  the  computation  as  correct 
that  an  adult  man  secretes  twenty  ounces  of 


THERAPEUTICS  IN  RELATION  TO  THE  DEPURATION  OF  THE  BLOOD.  229 


bilein  the  twenty-  four  hours,  this  quantity  will 
yield  about  1000  grains  of  solids  containing 
thirty-seven  grains  of  nitrogen,  representing, 
if  half  this  quantity  can  be  obtained  as  glyco- 
coll,  forty  grains  of  urea,  or  about  one-eighth 
of  that  secreted  by  the  kidneys  in  the  same 
time.  The  kidneys  not  only,  too,  you  will  re¬ 
collect,  separate  nitrogenised,  but  a  con¬ 
siderable  quantity  of  carbonised  matter,  and 
hence  perform  a  depurative  function  anala- 
gous  to,  although  less  effective  than,  that  of 
the  liver,  so  far  as  elimination  of  carbon  and 
sulphur  are  concerned.  Hence  there  is  a 
still  more  important  view  to  take  of  the 
kidneys,  in  their  being  able  to  compensate, 
to  a  most  remarkable  extent,  for  the  deficient  j 
functions  of  other  emunctories.  This, 
indeed,  is  a  duty  these  organs  can  perform 
readily,  because  I  presume  it  is  less  in  vio¬ 
lation  of  their  normal  and  definite  functions 
than  is  the  case  with  any  other  gland.  Thus 
the  liver  excreting  normally  but  thirty- seven 
grains  of  nitrogen,  could  hardly  be  expected 
to  secern  any  considerable  proportion  of  this 
matter  from  the  blood, — not  so  the  kidneys, 
for  these  organs,  as  we  have  learned,  always 
excrete,  besides  the  nitrogenised  bodies, 
urea,  uric  acid,  creatine  and  creatinine,  a 
pigment  (the  uroxanthin),  nearly  as  rich  in 
carbon  as  the  bile  itself,  to  which  it 
bears  no  small  analogy,  and  a  peculiar 
extractive  allied  to  cystine,  although  not  yet 
isolated,  but  containing  much  sulphur,  and 
thus  in  another  important  point  approach¬ 
ing  the  hepatic  secreta.  But,  dismissing 
theory,  look  to  bed-side  observation  :  observe 
any  case  in  which  the  hepatic  functions  are 
deficient,  and  we  see  the  urine  assuming  a 
compensatory,  although,  of  course,  not  quite 
a  complementary  function,  from  the  kidneys, 
depurating  the  blocd  of  carbon  in  the  form 
of  an  increased  quantity  of  its  peculiar  pig¬ 
ment — a  body  containing.  59  per  cent,  of 
carbon,  and,  as  a  proof,  the  addition  of  a  few 
drops  of  hydrochloric  acid  to  the  warmed 
fluid,  develops  a  magnificient  crimson  or 
purple  hue,  instead  of  the  pale  lilac  of  healthy 
urine  thus  treated.  Let,  however,  the  liver 
remain  inactive,  no  matter  whether  from  dis¬ 
ordered  function  or  lesion  of  structure,  still 
the  industrious  kidneys  labour  on,  and  the 
chamber-pot  is  now  observed  by  the  patient 
to  present  a  delicate  high-water  mark  of  an 
exquisite  lake-colour.  Soon  this  matter  in¬ 
creases,  and  deposits  of  varying  shades  of 
crimson  and  purple  occur.  What  is  this 
purple  deposit  ?  what  its  function  and  ori¬ 
gin  ?  It  consists  of  the  ordinary  urate  of 
ammonia,  mixed  with  the  body  once  sus¬ 
pected  to  be  murexid  or  purpurate  of  am¬ 
monia,  but  with  which  it  has  not  the  most 
remote  analogy,  save  in  colour.  This  pur- 
purine,  as  I  ventured  to  name  it  when  I 
first  suggested  its  then  probable  and  now 
ascertained  function,  is,  as  I  hinted  to  you 


last  week,  but  a  slightly  metamorphic  form 
of  an  element  of  the  bile,  and  contains  no  less 
than  63  per  cent,  of  carbon.  Let,  however, 
the  disease  assume  another  phase,  let  the  ex¬ 
cretion  of  bile  by  the  liver  become  arrested', 
the  varying  shades  of  yellow  of  the  surface 
attesting  its  presence  in  the  blood ;  then, 
not  by  assuming  any  new  function,  but  in 
accordance  with  the  law  announced  by 
Wohler,  of  removing  all  soluble  noxious 
matters,  the  kidneys  secern  and  excrete  ihe 
matter  in  health  proper  to  the  liver,  and  the 
contents  of  the  bladder  become  nearly  as 
bilious  as  urinous.  The  picture  1  have 
sketched  is  a  familiar  one  ;  and  of  every-day 
occurrence  as  it  is,  can  we  not  deduce  from 
it  a  useful  lesson,  in  learning,  (and,  what  will 
be  better)  acting  upon  the  important  fact, 
that  the  kidneys  can  depurate  the  blood,  not 
only  of  matters  generally  regarded  as  pro¬ 
per  to  their  function,  but  of  substances 
which  it  is  the  normal  duties  of  other 
emunctories  to  separate  from  the  animal 
organism. 

Is  it  not  wise,  then,  to  take  a  more  enlarged 
view  of  the  class  of  alterative  or  resolvent  re¬ 
medies  than  we  now  do  ?  We  scarcely  use 
one  of  this  class,  without  intending  it  as  more 
or  less  to  influence  the  liver.  Hence  an 
alterative  and  mercurial  are  in  common  par¬ 
lance  nearly  convertible  terms.  These 
powerful  remedies,  however,  acting  as  they 
do  in  general  on  the  capillary  functions,  are 
capable  of  influencing  all  the  glands,  and 
hence,  however  intended,  and  with  whatever 
view  prescribed,  they  often  effect  good  by 
exerting  a  less  special  influence  than  was  in- 
tendedby  thephysician :  andas  I  confessmyself 
to  be  an  utter  sceptic  to  the  generally  re¬ 
ceived  and  popular  notion  of  the  specific 
action  of  mercury  on  the  liver,  this  im¬ 
portant  and  most  ancipital  remedy  exerts  a 
marvellous  influence  over  that  great  labora¬ 
tory  of  the  system,  the  capillary  circulation, 
and  wherever  the  capillary  structure  most 
abounds,  there  its  effects  are  most  promi¬ 
nently  developed.  Mercury  is  then  a  stimulant 
to  the  function  of  the  liver  only  in  as  much 
as  this  great  organ  contains  an  enormous 
mesh-work  of  capillaries :  it  influences 
equally  in  proportion  to  their  bulk  all  the 
other  organs  in  which  this  curious  vascular 
structure  exists.  A  dose  of  mercury,  then, 
when  administered,  acts  on  all  the  organs  in 
which  capillaries  abound,  and  the  liver  being- 
one  of  these  is  influenced  by  it,  but  not  more 
in  proportion  to  their  development  than  the 
kidneys  or  sa-lvary  glands.  After  what  has 
been  said,  I  think  I  need  hardly  point  out 
the  therapeutic  indication  I  am  anxious  to 
advocate.  I  would  press  upon  the  practi¬ 
tioner  the  importance  of  directing  his  atten¬ 
tion  to  diuretics,  not  as  merely  helping 
the  pumping  off  of  water,  but  as  renal  altera¬ 
tives — as  remedies  aiding  the  removal  from 


230  ON  THE  INFLUENCE  OF  RESEARCHES  IN  ORGANIC  CHEMISTRY  ON 


the  body  of  injurious  matters.  I  am  aware 
that  this  indication  is  often  unintentionally  ful¬ 
filled,  whenever  alkalies  or  salts  of  vegetable 
acids  are  given,  but  still  at  the  present  time 
these  and  other  analogous  remedies  are  not 
administered  with  the  confidence  they  de¬ 
serve. 

I  am  now  anxious  to  announce  to  you  a 
new  fact,  one  which  bids  fair  to  be  of  great 
importance  in  the  treatment  of  disease,  and 
one  which  I  believe  has  never  yet  been  an¬ 
nounced,  and  which  the  examination  of  the 
urine  secreted  under  the  influence  of  remedies 
has  led  me  to  discover.  It  is,  that  we  possess 
remedies  ivhich  when  administered  remark¬ 
ably  increase  the  metamorphosis  of  tissue, 
and  enable  us  to  produce  at  will  the  very 
depur ative  effects ,  which  I  have  pointed  out 
to  you  as  resulting  normally  in  the  course 
of  certain  zymotic  diseases.  In  taking  a 
practical  view  of  the  so-called  diuretic  agents, 
it  will  now  become  necessary  to  divide  these 
into  two  classes  :  the  one  including  those 
which  simply  increase  the  bulk  of  the  urine  ; 
the  other,  those  which  act  as  renal  altera¬ 
tives,  and  aid  the  depuration  of  the  blood. 

To  the  former  class  belong  all  those  agents 
which  out  of  the  body  exert  no  chemical 
effect  on  animal  matter,  as  all  the  vegetable 
diuretics — squill,  copaiba,  broom,  juniper, 
guaiac,  digitalis,  &c.  All  these,  in  the 
absence  of  any  opposing  cause  connected 
with  mechanical  obstructions  to  the  free 
course  of  the  circulation,  will,  it  is  well 
known,  increase  the  discharge  of  fluid  by 
the  kidneys,  and  become  often  valuable 
agents  in  enabling  us  to  successfully  treat 
dropsical  accumulations.  Hitherto  no  dis¬ 
tinction  has  been  drawn  between  these  agents 
and  those  which  exert  a  chemical  influence 
on  organic  matter  :  and  hence  two  sets  of 


Remedies,  then,  vjhich  exert  no  chemical 
action  on  organic  matter  out  of  the  body, 
appear  to  be  incapable  of  augmenting  the 
quantity  of  solids  in  the  urine,  and  hence 
are  only  of  use  in  increasing  the  elimina¬ 
tion  of  water, — they  may,  and  do  act  as 
renal  hydragogues,  but  not  as  renal  depu- 
rants. 

We  have  next  to  notice  those  remedies 
among  the  reputed  diuretics  which  exert  the 


agents  exerting  most  different  physiological 
effects  were  confounded.  If  the  urine 
secreted  under  the  influence  of  the  diuretics 
I  have  enumerated,  be  examined,  the  quan¬ 
tity  of  solids  present  will  never  be  found  to 
much  exceed  the  normal  quantity  :  nay, 
sometimes  they  will  even  be  in  smaller 
quantity  than  in  health,  in  consequence  of 
their  in  some  instances  acting  as  irritants  to 
the  kidneys,  and  by  producing  congestion, 
interfere  with  active  secretion  :  the  non¬ 
arrest  of  the  elimination  of  water,  admitting 
an  explanation  on  the  fact  pointed  out  by 
that  most  zealous  and  successful  cultivator 
of  physiological  science,  Mr.  Bowman,  and 
to  which  I  alluded  at  our  last  meeting.  After 
I  had  fully  satisfied  myself  of  the  general 
truth  of  the  facts  now  mentioned,  I  was 
much  gratified  by  meeting,  in  Heller’s 
Archiv  fur  Physiologische  und  Pathologische 
Chemie  (December-Heft  1847),  with  a  paper 
by  Professor  Krahmer,  on  this  subject.  He 
administered  to  persons  in  health  different 
diuretic  agents,  and  having  collected  and 
analysed  the  urine  secreted,  he  found  the 
proportion  of  solids  seldom  exceeded,  and 
was  often  rather  less  than,  the  normal 
average ;  and  hence  concluded  that  these 
agents  had  no  physiological  action  on  the 
system  ;  at  least,  so  far  as  the  excretion  of 
solids  was  concerned  :  “  dass  die  gewolmlich 
sogenannten  Diuretica  ohne  alle  physiolo¬ 
gische  Wirkung  sind.”  I  adduce  Krah- 
mer’s  observations  in  preference  to  my  own, 
as  they  were  evidently  not  made  ’  under 
the  influence  of  any  preconceived  view,  as 
it  is  evident  from  his  paper  that  he  had  no 
knowledge  whatever  of  the  new  fact  I  have 
hinted  at.  I  have  calculated  the  following 
table  from  his  experiments  :  — 


influence  I  have  alluded  to,  and  according  to 
my  own  observation,  increase  the  rnetarflbr- 
phosesof  tissue,  and  act  as  depurating  agents  : 
this  classineludes  the  alkalies,  theircarbonates 
and  their  salts  with  such  acids  as  in  the 
animal  economy  are  capable  of  being  con¬ 
verted  into  carbonic  acid,  including  the  ace¬ 
tates,  tartrates,  citrates  of  soda  and  potass. 
These  remedies  all  act  alike,  they  all  actively 
stimulate  the  excreting  function  of  the'  lad- 


Medicine  given. 

' 

Solids  in  the  urine  of 
twenty-four  hours. 

Combustible  (animal) 
matter  in. 

# 

Saline  matters  in. 

None  .... 
Juniper  . 

Venice  turpentine 
Squill  .... 
Digitalis  . 

Guaiac 

Colchicum 

2*4  ounces. 

2*12  „ 

1  94  „ 

2-25  „ 

2*45  „ 

2-43  „ 

2-32  „ 

1  *28  ounces. 

0-94  „ 

Ml  „ 

1-04  „ 

1-28  „ 

1-38  „ 

1*36  „ 

1*13  ounces. 

1-18  „ 

0-83 

1-21  „ 

M7  ,, 

1-05 

0*96 

THERAPEUTICS  IN'  RELATION  TO  THE  DEPURATION  OF  THE  BLOOD.  231 


nevs,  and  increase  the  bulk  of  the  urine  ; 
but  they  do  more,  they  actually  increase  the 
metamorphoses  of  tissueby,  in  all  probability, 
a  direct  chemical  action  on  the  elements  of 
worn-out  and  exhausted  tissues,  or  other 
matter  in  the  capillary  laboratory  of  the 
the  body.  It  is  well  known  that  alkalies  and 
their  carbonates  powerfully  dissolve  albumen 
out  of  the  body,  and  even  break  it  up  into 
various  secondary  bodies  :  thus,  digested  with 
an  alkali,  albumen  yields  leucine,  protid, 
and  erythro-protid,  bodies,  allied  to  gelatine, 
formic  acid,  and  other  compounds.  In  like 
manner  casein  is  broken  up  into  tyrosin, 
leucine,  valerianic  acid,  and  other  elements. 
From  some  such  changes  occurring  in  the 
body,  and  in  the  living  organism  itself,  we 
find  the  chemical  diuretics  easily  effecting 


important  changes.  This  I  have  repeatedly 
confirmed  by  absolute  experiment.  I  will 
adduce  but  one,  as  it  may  be  taken  as  an 
example  of  the  rest.  A  young  lady  is  now, 
and  has  been  for  some  time,  under  my 
care,  labouring,  among  other  things, 
und  r  a  condition  of  the  orifice  of  the 
urethra  which  prevents  her  passing  water 
without  the  aid  of  a  catheter,  so  as 
to  admit  of  a  very  accurate  examination 
quantity  secreted  in  twenty-four  hours. 
This,  when  no  medicine  was  administered, 
was  thus  collected  and  examined  ;  and  then 
three  drachms  of  acetate  of  potass  being 
administered  in  the  course  of  twenty-four 
hours,  the  urine  secreted  in  that  time  was 
collected  and  analysed.  The  results  are 
shewn  in  this  table  : — 


Without  medicine. 

After  ^iij.  pot. 

acet. 

Quantity  of  urine  in  twenty-four  hours 

•  •  fsxvj.  .  . 

.  .  fgxlvj. 

Specific  gravity  of . 

.  .  1-017 

Solids  in . 

.  .  416  grs.  .  . 

.  .  782  grs. 

Uric  acid  .... 

•  •  •  •  • 

3-45 

Urea . 

•  •  •  •  • 

202-40 

Soluble  salts  .  .  . 

•  •  •  •  • 

248  40 

Insoluble  salts  .  .  . 

.  .  .  21*6 

•  •  •  •  • 

32-20 

Organic  matters  not  in¬ 
cluded  in  the  above  . 

1 

) 

.  .  .  189*3 

295-50 

416 

782 

The  results  of  these  analyses  shew  that, 
after  deducting  the  excess  in  the  amount  of 
soluble  salts  arising  from  the  conversion  of 
acetate  of  potass  into  carbonate,  the  solids 
of  the  urine  excreted  under  the  influence  of 
the  chemical  diuretic  exceed  those  recovered 
without  its  aid  by  190  grains;  and  we  fur¬ 
ther  learn,  that  although  a  large  proportion 
of  matter  was  metamorphosed  into  both 
uric  acid  and  urea  when  the  remedy  was 
given,  still  that  the  greatest  increase  was  in 
that  mixture  of  organic  products  set  down 
as  extractive,  and  consisting  chiefly  of  crea¬ 
tine,  creatinine,  uroxanthin,  and  matter  rich 
in  sulphur.  In  the  example  adduced,  not 
only  did  the  patient  losean excess  of  30  ounces 
of  water  in  24  hours,  but  she  ivasted  to  the 
extent  of  190  grains  more  than  if  no  remedy 
had  been  given,  and  to  this  extent  had  the 
blood  been  depurated  of  those  elements 
which  yielded  easiest  to  the  influence  of  the 
alkaline  salt.  In  these  lectures  I  have  ad¬ 
vanced  much  which  tends  to  limit  the  in¬ 
fluence  of  the  vital  force,  and  have  endea¬ 
voured  to  shew  that  it  is  not  the  active 
agent  in  controlling  metamorphic  changes ; 
but  let  me  not  be  supposed  for  a  moment 
to  deny  its  influence.  I  regard  life  as  an 
active  agent  in  controlling  organisation,  and 
in  exerting  an  influence  opposed  to  chemical 
or  destructive  changes — in  a  word,  as  a 
conservative  agent.  Now,  admitting  that 
the  elements  of  our  frames  resist  chemical 
influences  in  the  ratio  of  their  vitality,  it 


would  follow  that  such  constituents  of  our 
fibres  as  present  the  greatest  departure  from 
health  are  less  highly  vitalised,  and  thus 
yield  the  easiest  to  the  chemical  force 
exerted  by  the  alkaline  diuretics.  On  this 
account  it  is  fair  to  presume  that,  when  we 
cause  an  alkaline  carbonate  to  circulate 
through  the  blood,  it  exerts  an  influence 
on  the  nascent  elements  of  those  matters 
less  highly  influenced  by  life,  allied  to  that 
which  they  exert  on  dead  matter,  aids  their 
resolution  into  substances  allied  to  those 
produced  out  of  the  body,  and  actually  causes 
the  matter  to  assume  so  soluble  a  form  as  to 
allow  of  its  ready  excretion.  This  remark¬ 
able  effect  of  the  alkaline  diuretics,  although 
now  for  the  first  time  demonstrated  by 
actual  experiment,  and  the  results  of  their 
chemical  influence  detected  in  the  stream 
by  which  they  are  washed  from  the  body, 
was  not  overlooked  by  the  observing  physi¬ 
cians  of  other  days. 

Before  the  introduction  of  iodine  into 
medicine,  such  remedies  were  more  fre¬ 
quently  given,  and  we  must  either  admit 
their  value,  or  declare  the  recorded  expe¬ 
rience  on  the  subject  as  a  tissue  of  falsehood 
or  error.  As  one  among  many  illustrations, 
I  would  refer  to  the  results  of  Mr.  Bran- 
dish’s  experience  with  his  solution  of  potass. 
In  chronic  visceral  ailments,  in  cases  where 
albuminous  deposits  have  occurred  iu 
glands,  as  in  some  forms  of  struma,  and  par¬ 
ticularly  in  old  rheumatic  cases  (carefully 


£32  ON  THE  INFLUENCE  OF  RESEARCHES  IN  ORGANIC  CHEMISTRY  ON 


distinguishing  them  from  mere  neuralgic 
affections)  where  much  of  the  suffering  is 
kept  up  by  the  formation  of  an  undue  pro¬ 
portion  of  acid  urates  in  the  system,  much 
good  promises  to  be  effected  by  the  reme¬ 
dies  in  question.  The  acetate  of  potass  at 
one  time  enjoyed  a  high  reputation  as  a 
remedy  in  the  treatment  of  strumous  glan¬ 
dular  deposit. 

In  connection  with  this  subject  I  would 
especially  draw  attention  to  the  undoubted 
benefit  resulting  from  the  treatment  even  of 
acute  rheumatism  by  large  doses  of  one  of 
our  most  certain  diuretics,  nitrate  of  potass, 
in  doses  of  Jss.  or  ^j.  dissolved  in  two  or 
three  pints  of  any  diluent  in  the  twenty- 
four  hours.  An  enormous  amount  of  mine 
replaces  the  scanty  excretion  generally  no¬ 
ticed,  and  the  cure  of  the  patient  is  conside¬ 
rably  expedited.  This  practice,  which  has 
been  popular  in  the  Parisian  hospitals  for 
the  last  two  or  three  years,  has  already 
attracted  notice  here.  The  quantity  of 
solids  removed  from  the  system  by  the 
nitrate  of  potass  is,  however,  far  less  than 
that  which  is  carried  off  under  the  solvent 
influence  of  those  agents  which  act  more 
energetically  on  animal  matters.  It  must 
not,  however,  be  supposed  that  nitre,  or, 
indeed,  any  other  of  the  neutral  salts,  are 
destitute  of  influence.  It  has  been  long 
shewn  that  the  salt  in  question  will  readily 
dissolve  coagulated  albumen  and  fibrin  ;  and 
it  thus,  when  circulating  in  the  capillaries, 
may  probably  exercise  no  mean  influence  in 
aiding  the  metamorphosis  of  tissue.  It 
requires  some  courage  to  leave  what  expe¬ 
rience  has  taught  us  to  be  a  safe  and  beaten 
path,  to  venture  on  a  new  and  less  trodden 
track  in  the  treatment  of  a  disease  so  serious 
as  rheumatic  fever.  I  have  scarcely  given, 
in  consequence,  the  nitre  a  fair  trial,  but 
have  largely  employed  its,  with  us,  more 
familiar  ally,  the  acetate  of  potass,  and 
with,  to  my  mind,  certainly  great  advan¬ 
tage. 

I  would  earnestly  beg  those  who  are  now 
doing  rae  the  honour  of  listening  to  my 
remarks,  to  give  a  careful  and  steady  trial  to 
the  depurating  or  chemical  diuretics ,  espe¬ 
cially  the  salts  of  potass  with  vegetable 
acids,  when  they  are  called  upon  to  treat  a 
chronic  affection  in  which  the  exciting  cause, 
or  existing  disease,  depends  upon  the  pre¬ 
sence  of  some  product  of  less  vitality  or 
imperfect  organisation.  I  fully  believe  that 
in  many  instances  such  matters  will  be  often 
found  to  yield,  whether  they  present  them¬ 
selves  as  albuminous  deposits  in  glands, 
furuncular  disease  of  cellular  tissue,  or  in¬ 
crustations  on  the  skin,  as  in  some  of  the 
squamous  and  tubercular  cutaneous  diseases. 
That  they  will  succeed  in  increasing  the 
waste  of  matter,  is,  from  my  observation, 
beyond  all  doubt ;  that  the  lowest  vitalised 


matters  will  yield  to  the  solvent  the  readiest 
is  most  probable,  and  that  an  important 
and  powerful  addition  to  our  supply  of 
therapeutic  weapons  is  certain. 

I  am  not  anxious,  so  soon  after  the  ob¬ 
servation  of  the  fact  I  have  announced,  to 
appeal  too  soon  to  the  results  of  my  own 
practice  in  support  of  it,  as  I  know  full 
well  how  deceptive  often  are  the  results  of 
experience  unless  largely  extended  ;  and  the 
whole  history  of  medicine  is  one  great  com¬ 
mentary  on  the  errors  arising  from  observa¬ 
tion  on  results  which  the  mind  of  the  ob¬ 
server  has  anticipated  —  an  obedience  to 
those  idola  speeds  against  the  influence  of 
which  Lord  Bacon  long  ago  warned  us.  I 
will  not  dare  to  do  more  than  state  that  it 
has  occurred  to  me  to  see  the  periodicity  of 
ague  broken  through,  the  paroxysms  les¬ 
sened  and  made  more  distant,  and  the  sallow 
dirty  aspect  of  malaria  exchanged  for  the 
cleaner  and  brighter  complexion  of  return¬ 
ing  health,  under  the  influence  of  the  agents 
I  am  advocating.  The  disease  has  thus  been 
rendered  readily  amenable  to  the  subsequent 
administration  of  the  anti-periodic  whose 
previous  influence  it  had  resisted,  or,  at 
least,  not  satisfactorily  obeyed.  Jaundice, 
connected  with  a  large  sluggish  congested 
liver,  has  certainly  better  yielded  to  setting 
up  a  complementary  function  on  the  parts  of 
the  kidneys  by  a  diuretic  alterant,  than  by 
goading  the  liver  with  remedies  whose  in¬ 
fluence  it  refused  to  obey ;  and  in  more 
than  a  single  instance  a  strumously  en¬ 
larged  cervical  gland  has  yielded  to  the  per¬ 
sisted  use  of  an  analogous  retnedy  even  after 
resisting  the  iodide  of  potassium. 

In  corroboration,  to  some  extent,  of  the 
views  I  have  announced,  I  would  particu¬ 
larly  draw  attention  to  the  extraordinary 
discovery  made  by  Dr.  Letheby,  and  an¬ 
nounced  by  him  last  year  at  the  Royal 
Medico-Chirurgical  Society.  Tiiis  gentle¬ 
man  discovered  that  arsenious  acid,  when 
administered  to  an  animal,  ceased,  under 
the  influence  of  an  active  diuretic  to  de¬ 
velop  its  poisonous  effects,  being  rapidly 
carried  off  by  the  kidneys.  The  high  and 
deserved  reputation  of  Dr.  Letheby  ha¬ 
ve  ts  this  most  unexpected  and  remarka¬ 
ble  observation  with  authority,  and,  if 
corroborated  by  the  experience  of  others,  it 
must  be  regarded  as  one  of  the  most  mar¬ 
vellous  facts  connected  with  therapeutical 
inquiries. 

I  would  impress  upon  those  who  will  now 
act  on  mv  suggestion  of  employing  alkaline 
acetates,  tartrates,  or  citrates,  as  remedies 
for  the  depuration  of  the  blood,  or  for  aid¬ 
ing  the  solution  of  lowly  organised  or  caco- 
plastic  deposits,  the  necessity  of  testing  the 
work  done  by  the  kidneys,  by  collecting  the 
urine  of  twenty-four  hours  several  times 
during  the  treatment;  and  then,  by  aid  of 


THERAPEUTICS  IN  RELATION  TO  THE  DEPURATION  OF  THE  BLOOD.  233 


the  specific  gravity,  and  the  table  I  have 
given,  the  amount  of  excreted  solids  indi¬ 
cating  so  much  metamorphosis  of  matter 
may  be  observed. 

I  have  not  alluded  to  the  influence  of 
benzoic  and  cinnamic  acids  as  depurating 
remedies,  because  I  have  in  an  early  lecture 
alluded  to  their  mode  of  action.  I  may  re¬ 
mark,  however,  that  their  efficacy  is  by  no 
means  limited  to  the  quantity  of  carbon, 
hydrogen,  nitrogen,  and  oxygen,  they  sepa¬ 
rate  in  the  form  of  hippuric  acid,  as  first 
pointed  out  by  Mr.  Ure,  but  I  find  that 
they  induce  an  increased  metamorphosis  of 
ttssue,  and  the  quantity  of  matters  included 
under  the  vague  term  of  extractive,  remark¬ 
ably  increases  during  the  administration  of 
benzoic  acid. 

I  may  now  be  permitted  to  express  the 
statements  I  have  advanced  in  this  lecture 
in  the  form  of  five  propositions  : — 

A.  That  a  knowledge  of  the  amount  of 
solids  escaping  from  the  body  in  the  urine 
will,  independently  even  of  their  chemical 
composition,  often  enables  us  to  detect  a 
deficient  function  of  the  kidneys,  although 
the  bulk  of  the  secretion  may  not  be  mate¬ 
rially  affected.  This  can  only  be  ascertained 
by  the  plan  now  proposed. 

B.  That  whilst  specific  diuretics,  as  a 
rule,  only  increase  the  exhalation  of  water 
from  the  renal  capillaries,  the  alkaline  salts 
( chemical  or  alterative  diuretics),  on  the 
other  hand,  when  coming  in  contact,  in  the 
capillary  circulation,  with  the  nascent  ele¬ 
ments  of  tissues  or  parts  of  low  vitality, 
remarkably  accelerate  their  metamorphosis 
and  subsequent  solution  in  the  blood. 

C.  That  in  certain  diseases  attended  by 
caco-plastic  or  even  saline  deposits,  before 
despairing  of  all  aid  from  medicines,  it 
would  be  well  to  try  to  effect  their  removal 
by  the  agents  in  question. 

D.  That  in  the  treatment  of  disease,  the 
question  ought  often  to  be  entertained  whe- 
the  ailment  is  not  excited,  kept  up,  or  ag¬ 
gravated,  by  an  unhealty  condition  of  the 
blood,  either  by  the  actual  existence  of  a 
materius  morbi,  or  the  presence  of  the  re¬ 
sults  of  mal-assimilation. 

E.  That  when  one  or  other  indications  be 
made  out,  great  benefit  may  be  often  de¬ 
rived  by  aiding  the  metamorphosis  and  solu¬ 
tion  of  the  morbid  elements  by  the  chemical 
diuretics  (B),  not  administered  w'ith  the 
view  of  separating  mere  water,  but  of  aiding 
the  excretion  of  solid  elements  of  the  urine. 


our  remedial  agents  may  be  more  scientifi¬ 
cally  and  effectively  wielded  by  this  know¬ 
ledge.  If  I  have  been  tedious,  I  can  only 
offer  the  apology  arising  from  the  difficulties 
with  which  my  subject  is  beset,  and  offer, 
in  return,  my  sincere  thanks  for  the  atten¬ 
tion  and  consideration  which  has  been  so 
kindly  and  encouragingly  extended  to  me. 


©nrtna!  <£cmmtmtcflttong. 


SUBSTANCE  of  a  REPORT 
TO  THE  DIRECTOR  GENERAL 

OF  THE 

MEDICAL  DEPARTMENT  OF  THE 
NAVY, 

UPON  THE  WOUNDED  IN  THE  HOSPITALS  OF 
PARIS  AFTER  THE  INSURRECTION  OF 
JUNE. 

By  T.  Spencer  Wells,  F.R.C.S. 
Surgeon,  R.N. 


From  the  23rd  to  the  26th  of  June,  the 
streets  of  Paris  were  the  scenes  of  con¬ 
flict  between  the  workmen  and  lowest 
order  of  the  population  on  the  one 
hand,  and  on  the  other,  the  soldiery 
and  different  classes  of  national  guards. 
The  insurgents  firing  from  behind 
barricades,  or  from  the  windows  of 
houses,  were  able  to  take  good  aim  at 
their  assailants,  who,  in  their  attacks 
upon  barricades  and  narrow  streets, 
were  almost  at  the  mercy  of  their  op¬ 
ponents.  Thus  the  number  of  wounded 
insurgents  in  the  hospitals  has  been 
very  few,  when  compared  with  that 
of  the  troops  and  guards.  I  have  net 
been  able  to  obtain  an  exact  account 
of  the  number  of  wounded  insurgents, 
but  the  following  is  the  official  report, 
including  among  the  civilians  thene  of 
this  class  who  fought  on  either  side  : — 
Return  of  wounded  brought  to  the 
Civil  Hospitals  of  Paris,  between  the 
23rd  and  28th  of  J une 


Wounded  received  | 
during  this  period  j 
Brought  in  dead  . 


Mily.  &  Wo- 


Civil.  Guards 

.  men 

i.  Total. 

773 

813 

33 

1,019 

127 

33 

2 

162 

And  now,  sir,  I  have  brought  to  a  close 
my  allotted  task,  and  hope  I  have  succeeded 
in  shewing  how  close  is  the  relation  between 
the  chemistry  of  living  and  dead  matter, — 
how  much  this  relation  may  elucidate  even 
among  the  penetralia  of  therapeutical  in¬ 
quiry, — and  how  probable  it  is  that  ere  long 


900 

846 

35 

1,781 

Discharged  during  "j> 
this  period  .  .  ) 

51 

104 

2 

157 

Died  .... 

115 

77 

3 

195 

Remaining  J uly  29 

607 

632 

28 

1,267 

,,  in  ambulances 

77 

77 

77 

364 

234  mr.  wells’s  report  upon  the  wounded  tn  the 


This  does  not  include  upwards  of  500 
soldiers  in  the  Military  Hospital. 
Thus  the  killed,  and  those  who  died 
during  the  five  days  amounted  to 
357,  or  a  proportion  of  deaths  of 
about  1  in  8  of  those  taken  to  the  hos¬ 
pitals  alive.  No  autopsies  having  been 
made  during  this  time,  no  accurate  re¬ 
port  can  be  given  as  to  the  various 
causes  of  death.  The  daily  discharges 
by  death  or  recovery,  have  now  re¬ 
duced  the  general  total  to  1,100.  As 
some  months  must  elapse  before  a  cor¬ 
rect  statistical  return  can  be  drawn  up 
of  the  nature  of  these  wounds,  and  the 
results  of  operations  or  other  treat 
ment,  my  present  observations  must 
consist  of  a  few  general  remarks  upon 
what  1  observed  in  the  wards. 

Almost  all  the  wounds  were  made  by 
musket  balls;  a  very  few  sabre  cuts, 
some  few  bayonet  thrusts,  and  con¬ 
tused  wounds  from  splinters,  portions 
of  shells,  broken  stones  of  the  barri¬ 
cades,  forming  together  a  very  incon¬ 
siderable  proportion  of  the  wounded. 
The  combatants  being  very  near  to  each 
other,  the  balls  struck  with  a  force  un¬ 
diminished  by  distance,  and  thus  the 
wounds  were  generally  of  a  more  severe 
nature  than  would  be  met  with  in  a 
field  of  battle  when  the  parties  were 
at  a  considerable  distance  from  each 
other  ;  consequently,  in  a  large  pro¬ 
portion,  the  wound  is  complicated  by 
fracture  of  the  bones,  and  very  often  the 
ball  has  not  lodged,  but  has  traversed 
the  limbs  or  chest,  leaving  two  open¬ 
ings.  In  many  cases  balls  have  been 
apparently  split  into  two  or  more 
pieces,  by  striking  against  bones,  in 
others  they  have  been  found  very  irre¬ 
gular  in  form,  probably  from  the  same 
cause;  while  in  some  cases,  balls  cast, 
upon  pieces  of  old  iron  or  copper,  pro¬ 
jecting  from  the  sides,  have  caused  con¬ 
siderable  laceration  of  tissues,  and  diffi¬ 
culty  of  extraction.  In  some  cases  the 
balls  were%pierced,  and  found  filled  with 
a  white  powder,  the  composition  of 
which  has  been  investigated  but  not 
published.  No  marked  symptoms  of 
poisoning  by  such  balls,  however,  have 
been  observed.  The  direction  cf  the 
wounds  is  generally  from  above  down¬ 
wards,  and  from  before  backwards,  in 
the  troops  and  national  guards.  Among 
the  insurgents  a  large  proportion  are 
wounded  about  the  head  and  chest, 
these  being  the  only  parts  they  exposed 
when  firing  at  their  assailants. 


With  regard  to  the  treatment,  the  first 
objects  were,  of  course,  to  check  he¬ 
morrhage  (which  appears  by  the  by  to 
have  been  more  abundant,  as  a  general 
rule,  than  is  commonly  observed),  and  to 
allow  the  patient  to  recover  from  the 
state  of  stupor,  collapse,  or  nervous 
tremulousness  into  which  he  had  fallen. 
Then,  in  cases  of  simple  wounds  of  soft 
parts,  either  ice  was  employed,  irriga¬ 
tion  by  cold  water,  warm  fomentations, 
or  poultices,  either  directly  applied,  or 
between  two  cloths.  As  far  as  I  ob¬ 
served,  if  the  wound  was  slight  it  pro¬ 
gressed  as  favourably  under  any  one 
of  these  applications  as  any  other;  and 
1  saw  nothing  to  shake  my  conviction 
that  lint  wetted  with  water  at  the 
temperature  most  agreeable  to  the 
patient,  is  the  best  and  cleanest  appli¬ 
cation  that  can  be  used.  A  great 
diversity  of  practice  prevails  as  to 
the  extraction  of  foreign  bodies.  In 
the  Military  Hospital,  the  surgeons  are 
exceedingly  particular  in  removing 
every''  portion  of  ball,  clothing,  or 
splinter  of  bone  that  can  be  detected, 
thus  reducing  the  case,  as  they  say,  to 
the  condition  of  a  simple  wound:  ice 
or  cold  water  is  then  applied  as  long  as 
the  patient  can  bear  it,  and  when  he 
desires  it  warm  applicatitions  are  sub¬ 
stituted.  At  the  Hopital  St.-Lonis,  on 
the  other  hand,  the  surgeons,  especially' 
M.  Jobert  insists  upon  non-interference 
with  the  wound,  on  the  ground  that 
searching  for  balls  is  dangerous, — that 
they  either  become  encysted  and  re¬ 
main  harmless  in  the  part, or  excite  sup¬ 
puration,  and  are  discharged.  In  the 
same  way  they  say  splinters  of  bone  are 
either  removed  by  suppuration,  or  re¬ 
main  and  assist  in  consolidating  the 
broken  bone.  From  what  I  saw'  in  the 
wards  of  this  hospital,  I  should  be  very 
unwilling  to  follow'  the  example  of  M. 
Jobert;  and  I  am  convinced  that  the 
proportion  of  cases  of  gangrene  and 
secondary  hsemorrhage,  of  erysipelatous 
inflammation,  unhealthy  suppuration, 
and  purulent  absorption,  was  far 
greater  in  his  than  in  other  hospitals. 
In  one  of  his  shew  cases  of  the  wounded 
of  February,  what  he  calls  a  cure  of  a 
compound  comminuted  fracture  of  the 
head  of  the  humerus,  the  patient  is  evi¬ 
dently  suffering  from  the  effects  of  por¬ 
tions  of  necrosed  bone  being  surrounded 
by  a  large  deposit  ofcallus.  AttheHotel- 
Dieu  and  La  Chari  te,  Roux,  Velpeau,  and 
Blandin,  take  a  middle  course,  making 


HOSPITALS  OF  PARIS  AFTER  THE  INSURRECTION  OF  JUNE.  235 


just  sufficient  dilatation  of  the  wound 
to  admit  of  the  extraction  of  foreign 
bodies  or  splinters,  which  can  be  readily 
reached,  and  then  applying  ointment 
spread  upon  charpie,  with  or  without 
poultices.  Gangrene  was  generally 
limited  to  the  parts  immediately 
surrounding  the  course  of  the  ball, 
but  in  some  cases  it  extended,  and 
considerable  haemorrhage  came  on 
after  the  separation  of  the  slough. 
I  only  saw  one  ca^e  resembling  hos¬ 
pital  gangrene.  This  was  a  large 
superficial  wound,  and  it  improved 
rapidly  under  the  application  of  slices 
of  lemon  by  Roux,  with  whom  this  is 
a  favourite  remedy  in  such  cases.  In 
some  cases,  gangrene  of  a  whole  limb 
led  to  the  question  whether  amputa¬ 
tion  should  be  performed  immediately, 
or  not  until  a  line  of  demarcation  had 
formed.  Velpeau,  and  most  other  sur¬ 
geons,  did  not  wait  for  the  line  of  de¬ 
marcation  when  the  gangrene  was  near 
the  centre  of  the  body,  and  removed 
the  limb  as  the  only  chance  of  saving 
the  patient’s  life. 

When  a  wound  was  complicated  by 
fractured  bone,  and  amputation  was 
not  required,  in  some  cases  irrigation 
was  employed,  in  others  poultices,  but 
more  often  the  limb  was  covered  with 
greased  charpie,  enveloped  in  broad 
folds  of  linen,  surrounded  by  a  many¬ 
tailed  bandage,  over  which  three  straw 
pillows  or  pads  would  be  fastened  by 
tapes  surrounding  them  and  a  long 
narrow  splint  which  wras  laid  upon 
each.  All  this  was  generally  removed 
and  reapplied  daily,  on  account  of  the 
quantity  of  purulent  discharge  from 
the  wound.  No  care  appeared  to  be 
taken  to  keep  the  limbs  extended  or 
immoveable,  and,  on  the  whole,  the 
treatment  of  fractures  in  the  Parisian 
hospitals  struck  me  as  being  far  less 
simple  and  efficacious  than  in  our  own. 
Wounds  of  joints  were  numerous.  1 
saw  three  cases  in  which  balls  un¬ 
doubtedly  traversed  the  knee-joint,  in 
one  from  before  backwards  through 
the  patella;  in  the  others  from  side  to 
side,  injuring  the  condyles  of  the  femur 
All  are  as  yet  going  on  well,  under  the 
influence  of  rest  and  an  antiphlogistic 
regimen. 

A  great  many  amputations  have 
been  performed,  both  primary  and 
secondary.  Of  course  as  yet  no  accu¬ 
rate  return  can  be  made  of  their  rela¬ 
tive  success  ;  but  common  observation 


would  shew  that  the  former  have  been 
very  successful;  the  latter  quite  the 
reverse.  The  deaths,  as  far  I  could 
learn,  have  not  exceeded  one  in  ten  of 
the  primary  operations ;  while  the  se¬ 
condary  have  been  almost  uniformly 
unfortunate  in  their  result.  By  pri¬ 
mary  I  do  not  mean  immediate  ampu¬ 
tation,  or  amputation  during  the  state 
of  stupor  or  tremor  which  first  succeeds 
the  injury,  but  when  the  patient  has 
rallied  from  this  state,  and  reaction  is 
coming  on  before  local  inflammation  is 
set  up.  From  what  I  saw  of  the 
practice  in  Paris,  1  should  say  that  if 
this  period  were  not  taken  advantage 
of,  it  would  be  far  better  to  wait  until 
healthy  suppuration  was  established 
in  the  part,  and  a  sort  of  hectic  had 
replaced  the  irritative  fever  which  ac¬ 
companies  the  inflammatory  condition 
of  the  wound  before  pus  is  freely 
formed,  than  to  amputate  under  the 
influence  of  this  irritative  fever,  as 
some  surgeons  did,  with  the  belief  that 
they  were  giving  the  patient  his  only 
chance  of  life. 

The  circular  operation  appears  to  be 
commonly  preferred  to  the  flap,  as  an 
opinion  is  becoming  general  that,  after 
three  or  four  years,  the  stump  is  a 
better  one  than  when  flaps  have  been 
formed.  At  most  of  the  hospitals, 
the  old-fashioned  method  of  dressing 
stumps  is  persevered  in  :  whether  pins, 
sutures,  or  strapping,  are  used  to 
bring  the  edges  of  the  wound  together, 
quantities  of  greased  charpie  are  laid 
on,  and  carried  by  numerous  folds  of 
linen,  and  a  bandage.  I  saw  the 
method  M.  Baudens  lately  proposed,  of 
surrounding  the  limb  by  a  bandage,  and 
then  drawing  this  forward  by  cotton 
threads,  so  as  to  approximate  the  lips 
of  the  wound.  It  is  betterand  simpler 
than  the  other  plan  :  the  limb  is  cool, 
and  easily  kept  clean  ;  but  I  thought 
three  or  four  sutures  or  strips  of  adhe¬ 
sive  plaster  would  have  kept  up  more 
accurate  adaptation  of  the  flaps  to  each 
other. 

Chloroform  is  almost  universally 
used,  but  in  two  cases  appears  to  have 
contributed  to  the  fatal  result  of  am¬ 
putations.  One,  a  patient  of  M.  Robert, 
died  before  the  operation  was  com¬ 
pleted  ;  the  other  I  saw  die  in  the  bed 
just  as  M.  Malgaigne  had  completed 
disarticulation  at  the  slioulder-joint, 
and  feel  convinced  that  chloroform 
was  the  immediate  cause  of  death,  al- 


236  MR.  canton’s  remarks  on  interstitial  absorption  of 


though  M.  Mnlgaigne  did  not  appear 
to  think  so.  Velpeau,  though  he  uses 
it  in  other  cases,  objects  to  its  employ¬ 
ment  in  cases  of  gun-shot  wounds,  as 
he  says  it  invariably  increases  existing 
prostration. 

Having  freely  expressed  my  opinion 
of  the  practice  of  the  Parisian  surgeons, 
it  would  be  unfair  to  conclude  without 
paying  a  tribute  of  admiration  to  the 
zeal  and  intrepidity  they  displayed 
during  the  conflict.  Not  content  with 
merely  remaining  day  and  night  at 
their  posts  in  the  hospitals,  they  sought 
the  wounded  among  the  combatants, 
established  ambulances  (or  temporary 
hospitals  in  large  shops)  in  every  dis¬ 
trict,  and  obtained  supplies  of  every¬ 
thing  required  until  the  sufferers  could 
he  removed  to  the  hospitals.  Praise  is 
equally  due  to  the  surgeons  of  the 
Army  and  National  Guard,  to  civil 
practitioners,  and  to  the  students,  both 
French  and  foreigners,  residing  in 
Paris.  All  were  actuated  by  the  same 
generous  feelings,  and  many  were 
wounded  themselves  while  endeavour¬ 
ing  to  assist  others.  Insurgents, 
troops,  or  guards,  were  all  treated  with 
equal  care;  and,  amidst  the  storm  of 
anarchy,  Medicine  alone  shone  forth 
as  an  example  of  their  boasted  egalitd 
and  fraternite  to  the  republicans  who 
found  themselves  equals  in  the  eyes  of 
abrotherhood  of  charity. 

Paris,  July  23,  1848. 


REMARKS  ON 

INTERSTITIAL  ABSORPTION 

OF  THE  NECK  OF  THE  FEMUR  FROM 
BRUISE  of  the  HIP, 

With  Cases. 

SIMILARITY  OF  THE  POST-MORTEM  AP¬ 
PEARANCES  TO  THOSE  SEEN  IN 
CHRONIC  RHEUMATIC  ARTHRITIS 
OF  THIS  JOINT. 

By  Edwin  Canton,  F.R.C.S. 

Demonstrator  of  Anatomy  at  the  Charing-Cross 
Hospital  School  of  Medicine. 

The  injury  in  ear:y  age. — We  possess 
no  data  on  which  to  found  an  opinion 
as  to  the  probability,  in  any  given  case, 
of  the.  limb  becoming  shortened  from 
interstitial  absorption  of  the  cervix 
femoris,  after  injury  to  the  hip  of  a 
comparatively  young  subject.  Either 


sex  may  suffer  the  change ;  no  pecu¬ 
liarity  of  constitution  is  to  be  detected, 
as  constantly  present,  in  these  cases; 
blows  on  other  bones  or  joints  are  not 
followed  by  such  a  phenomenon ;  early 
or  late  in  life  atrophy  may  succeed  the 
violence  ;  the  shortening  may  advance 
with  greater  or  less  speed  ;  and  the 
gradual,  insidious,  and,  in  some  in¬ 
stances,  almost  complete  removal  of 
the  neck  of  the  femur,  is  accomplished 
without  any  appreciable  signs  of  in¬ 
flammation, — without  any  general  af¬ 
fection  of  the  system,  and  in  the  ab¬ 
sence,  it  may  be,  of  much  local  incon¬ 
venience.  The  commencement  of 
shortening  may  date  from  the  time  of 
the  accident,  or  occur  some  weeks  or 
months  subsequently.  Mr.  B.  Bell 
attended  a  lady  in  1825,  who  could 
walk  with  assistance  a  few  days  after 
the  accident.  In  this  case  the  limb 
was  shortened  to  the  extent  of  an  inch 
in  the  course  of  ten  months  after  the 
injury. 

It  is  important  that  we  should 
always  bear  in  mind  that  interstitial 
absorption  may  supervene  upon  bruise 
of  the  hip,  for  blame  by  patient  and 
friends  is  readily  cast  upon  the  medical 
man  who  has,  originally,  pronounced 
the  violence  inflicted  to  be  a  matter  of 
no  further  moment  than  to  require,  but 
for  a  short  time,  rest  and  local  appli¬ 
cations  to  relieve  its  consequences;  and 
who  has  been  unaware,  or  neglected 
to  state,  that  such  an  apparently  trivial 
injury  entails,  in  some  instances,  in¬ 
curable  lameness. 

Beyond  this,  a  great  error  in  diag¬ 
nosis  is  believed  to  have  been  commit  ted  ; 
for  a  fracture  of,  or  ciose  to,  the  neck 
of  the  thigh-bone,  or  a  dislocation,  is 
presumed  to  have  been  overlooked,  and 
those  measures  necessary  for  maintain¬ 
ing  coaptation  or  effecting  reduction, 
consequently',  neglected,  and  which 
otherwise  might,  by  their  employment, 
have  secured  the  former  length  and 
utility  of  the  limb.  That  such  an 
error  should  be  made,  however,  is  by 
no  means  probable,  for  the  accident  is 
unaccompanied  by  a  single  symptom 
characteristic  of  the  fracture  or  luxa¬ 
tion  :  the  result  of  the  case,  neverthe¬ 
less,  might  expose  the  character  of  the 
unguarded  practitioner  in  attendance, 
to  an  imputation  of  ignorance,  raised 
by  uninformed  or  interested  persons; 
whilst  the  evidence  of  apparent  mis¬ 
take  presented  by  the  sequelae  of  the 


THE  NECK  OF  THE  FEMUR  FROM  DISEASE  OF  THE  HrP 


237 


case,  gives  a  strong,  though  false, 
colouring  to  the  justice  of  the  charge. 

An  acquaintance  with  cases  of  this 
description  is  valuable  also,  I  believe, 
as  the  disease  during  its  progress  might, 
otherwise,  be  confounded  with  that  more 
serious  and  often  intractable  affection, 
morbus  coxarius, — this  latter  complaint 
leading,  not  unfrequently,  to  total  dis¬ 
organization  of  the  joint  and  anchy¬ 
losis,  or  terminating  in  death ;  the 
former  being  an  affection  unconnected, 
except  incidentally,  with  the  strumous 
diathesis,  and  ending  in  loss  of  the 
cervix  femoris  without  producing  any 
constitutional  disturbance,  without  the 
establishment  of  ulcerative  absorption 
and  the  formation  of  matter, — involv¬ 
ing,  to  a  variable  extent,  the  head  of  the 
bone  and  acetalnlum,  but  not  affecting, 
eventually,  to  any  great  degree,  the 
range  of  motion. 

I  have  been  unable  to  find  the  details 
of  any  cases  in  which  the  neck  of  the 
thigh-bone  has  suffered  this  peculiar 
affection  in  young  subjects,  as  a  conse¬ 
quence  of  injury  inflicted  over  the  part, 
with  the  exception  of  those  so  well 
described  by  Mr.  Gulliver.*  The  com¬ 
plaint  at  this  period  of  life  is  acknow¬ 
ledged  to  occur  occasionally,  from  vio¬ 
lence;  but  an  idea  that  it  is  not  so 
generally  known  as  it  should  be,  has 
induced  me  to  communicate  these  par¬ 
ticulars,  and  with  a  view,  also,  of 
eliciting  further  information  from 
others  on  this  very  interesting  subject. 

Occasional  allusion  is  made  by 
authors  to  the  effect  of  this  accident  in 
comparatively  young  persons,  as  in  the 
following  extract  from  Mr.  B.  Bell’s 
wrorkf:—  “I  have  met  with  cases  in 
which  interstitial  absorption  had  af¬ 
fected  the  neck  of  the  thigh-bone  of 
one  side  in  persons  of  thirteen,  thirty, 
and  forty  years  of  age.  In  cases  which 
occur  in  middle  age  it  does  not,  in 
general,  appear  to  be  an  idiopathic 
affection,  but  is  the  direct  result  of  cold, 
or  a  fall,  blow,  or  injury  of  the  tro¬ 
chanter  major.”  The  subjects  of  the 
complaint  who  fell  under  the  notice  of 
Mr.  Gulliver  were  all  males,  of  the 
respective  ages  of  fifteen,  nineteen, 
thirty,  thirty-two,  and  forty-five  years. 

Case  I. —  Marv  Betton,  set.  it), 
an  inmate  of  St.  Martin’s  workhouse. 


*  Edin.  Med.  and  Snrg.  Journal,  vol.  xlvi. 
t  On  tlie  Diseases  of  the  Bones. 


The  patient  is  of  strumous  diathesis, 
hysterical,  menstruating  with  irregu¬ 
larity,  and  is  subject  to  a  confined  state 
of  the  bowels. 

In  March,  1847,  whilst  carrying  a 
can  up  stairs,  she  missed  her  footing 
and  caught  her  ankle  between  two 
rails.  She  fell  down  three  steps,  strik¬ 
ing  at  the  same  time  the  left  trochanter 
major  and  left  leg;  the  latter  continued, 
in  consequence,  to  be  swollen  and  ten¬ 
der  for  two  or  three  weeks.  There  was 
slight,  diffused  ecchymosis  over  the 
outer  part  of  the  injured  hip,  accom¬ 
panied  by  some  swelling;  and  general 
soreness  of  the  part  was  felt  for  several 
weeks,  obliging  her  to  keep  her  bed. 
The  least  movement  of  the  joint  gave 
her  great  pain,  which  she  describes  to 
have  been  of  a  sharp,  shooting  charac¬ 
ter,  extending  down  the  inner  side  of 
the  thigh  to  the  knee.  She  has  always 
enjoyed  good  health  until  three  years 
ago,  when  she  was  knocked  down  by  a 
cab :  the  ribs  were  broken  and  the 
abdomen  bruised,  but  neither  hip  was 
hurt.  Since  this  period  she  has  had 
frequent  attacks  of  erysipelas  in  various 
parts  of  the  body, — has  suffered  from, 
strumous  ophthalmia,  eruptions  on  the 
face,  and  has  been,  as  she  says,  “  al¬ 
together  out  of  health  ever  since.” 

For  the  injury  to  the  hip  described 
she  was  confined  to  her  bed  three 
months,  during  which  time  there  was 
felt  a  constant  pain  in  the  joint,  aggra¬ 
vated  almost  invariably  at  night,  and 
always  by  moving  the  limb.  Lini¬ 
ments  and  fomentations  were  fre¬ 
quently,  and  without  benefit,  employed. 
At  the  expiration  of  the  time  named, 
on  quitting  the  bed  and  endeavouring 
to  move  about,  she  found  that  the  left 
leg  was  shorter  than  its  fellow,  and 
occasioned  her,  consequently,  to  limp 
in  walking.  The  amount  of  shortening 
was  not  then  ascertained,  but  it  has, 
from  that  period  to  the  present,  been 
on  the  increase.  The  pain  is  worst  at 
night,  and  increased  in  damp  weather; 
it  is  aggravated  on  motion,  and  slightly 
so,  by  pressing  the  heel  upward,  or  the 
trochanter  inwards. 

Throbbing  pain  is  also  complained 
of  at  the  inner  side  of  the  knee,  but 
only  when  the  hip  is  moved.  The 
former  joint  is  free  from  swelling,  red¬ 
ness,  or  tenderness  on  pressure,  and. 
its  movements  are  perfect.  She  is 
unable  closely  to  approximate  the  left 
to  the  right  leg,  or  to  abduct  and  ex- 


238  MR.  canton’s  remarks  on  interstitial  absorption  of 


tend  the  left  thigh  without  augmenting 
the  pain,  which  does  not,  however, 
under  any  of  these  circumstances,  ap¬ 
pear  to  be  of  a  severe  character. 
Flexion  of  the  hip  is  unattended  by  in¬ 
convenience.  In  progression,  the  left 
foot  is  thrown  somewhat  forward,  the 
heel  is  elevated,  and  in  standing  or 
walking,  the  toes  of  the  left  foot  sup¬ 
port  in  part  the  weight  of  the  body. 
The  sole  cannot  be  brought  to  the 
ground  without  a  slight  inclination 
of  the  body  to  the  left  side. 

On  examining  the  patient,  placed  in 
the  horizontal  position,  the  body  and 
limbs  are  seen  to  be  well  formed,  and 
there  is  but  little  muscular  wasting  of 
the  left  side  of  the  nates  perceptible. 
There  is  no  redness  over  or  in  the 
neighbourhood  of  the  hip,  and  there 
is  absence  of  undue  heat.  The  left 
heel  is  found  to  be,  at  least,  an  inch 
and  a  half  above  the  level  of  the  right 
one.  The  distance  between  the  ante¬ 
rior  superior  spine  of  the  ilium  and  the 
upper  edge  of  the  great  trochanter  is 
less  by  three-quarters  of  an  inch  than 
on  the  sound  side.  The  trochanter  is 
shewn  to  be  much  nearer  than  natural 
to  the  head  of  the  bone,  by  compara¬ 
tive  measurement,  on  passing  a  tape 
from  the  centre  of  the  pubes  to  the 
fissure  of  the  nates,  so  as  to  include  this 
part  of  the  femur. 

The  patient  states  thatshe  has  never 
suffered  from  rheumatism. 

The  injury  in  old  age. — It  the  neck 
of  the  thigh-bone  of  an  elderly  person 
be  examined,  a  particular  change  is 
often  to  be  noticed  in  its  direction,  and 
in  lieu  of  finding  it  set  on  to  the  shaft 
at  an  angle  of  45°,  it  will  be  seen  to 
have  assumed  a  position  more  or  less 
inclining  to  a  horizontal  one.  This 
alteration,  however,  l  believe,  is  not  to 
be  looked  upon  as  of  such  invariable 
occurrence,  or,  as  happening  to  such 
an  extent  in  the  aged  as  is  usually 
supposed  ;  and  I  have  been  at  some 
trouble  to  satisfy  myself  on  this  head, 
by  inspection  of  the  part  in  numerous 
subjects,  whose  ages  ranged  between 
sixty  and  ninety  years.  “  I  would 
venture  to  suggest,  that  those  who  have 
the  opportunity,  should  examine  the 
state  of  this  part  in  relation  to  the 
later  periods  of  life,  so  as  to  enable  us 
to  distinguish  between  what  has  been 
considered  as  connatural  with  old  aye , 
and  that  which  may  be  regarded  as  the 


effect  of  disease.”*  Since  my  atten¬ 
tion  has  been  drawn  to  this  subject, 
I  have  had  frequent  occasion  to  profit 
by  this  valuable  advice  in  post-mortem 
inquiry,  and  to  be  satisfied  that  many 
specimens  which  might  be  regarded  as 
strikingly  illustrative  of  senile  atrophy, 
with  change  in  position  of  the  cervix 
femoris,  are,  virtually,  examples  only  of 
an  alteration  occurring  in  connection 
with  the  disease, — chronic  rheumatic 
arthritis,  which  presents,  in  addition, 
even  in  an  early  stage  of  its  progress, 
certain  morbid  appearances,  which 
will,  I  believe,  when  duly  attended  to, 
clearly  point  to  the  peculiar  character  of 
the  affection.  There  is,  nevertheless, 
a  certain  condition  of  the  neck  of  the 
femur  present  after  the  age  of  fifty, 
which  predisposes,  not  unfrequently, 
to  great  change  in  it  upon  the  applica¬ 
tion  of  violence,  and  this  is  particu¬ 
larly  well  shewn  by  what  ensues  wdien 
the  part  is  fractured  wholly  within  the 
capsular  ligament ;  the  absorbents  then 
become  busy  agents  in  the  removal  of 
the  cervix,  and  in  the  course  of  a  few 
wmeks  only  may  have  accomplished 
completely  their  work.  This  may  oc¬ 
cur  even,  where,  prior  to  the  fracture, 
no  change  in  the  direction  of  the  neck 
had  been  present.  I  examined  lately 
an  intra-capsular  fracture,  which  befel 
a  female,  aged  sixty,  two  months  after 
the  injury,  and  found  the  cervix  had 
wholly  disappeared,  whereas,  on  the 
opposite  side  of  the  body,  this  part  pre¬ 
sented  the  obliquity  natural  to  an  adult 
bone.  This  case  would,  1  doubt  not, 
frequently  find  its  parallel,  if,  after 
death,  both  joints  are  examined,  in 
place  of  it  being  taken  for  granted, 
that  from  the  age  of  the  patient  ail 
almost  horizontal  direction  of  the  neck 
existed,  as  a  predisposing  cause  of  the 
original  mischief.  Mr.  Howship  has 
described  a  case  in  which  the  neck  had 
lost  half  an  inch  of  its  length,  by  ab¬ 
sorption  on  the  third  week  after  the 
accident.  Illustrations  of  the  fact  are 
in  most  museums. 

Where  the  head  and  neck  of  the  fe¬ 
mur,  however,  suffer  concussion  only,  in 
consequence  of  a  smart  blow  upon  the 
trochanter  major, — where,  indeed,  these 
parts  are  submitted  to  a  momentary 
compressing  force,  passing  between  the 
trochanter  and  the  opposite  point  of 
resistance,  the  acetabulum, — the  same 

*  Gulliver,  op.  cit. 


THE  NECK  OF  THE  FEMUR  FROM  BRUISE  OF  THE  HIP. 


289 


change  is  liable  to  take  place  as  that  i 
just  described,  and  is  one  which  is  very 
generally  taken  into  account,  as  being 
possible, and  not  improbable,  in  forming 
a  prognosis  of  the  accident.  If  the 
cervix  be  already  inclining  to  the  hori¬ 
zontal  direction  ;  if  the  patient  be  bed¬ 
ridden  ;  if  a  female  be  the  sufferer,  or 
if  a  rheumatic  diathesis  be  present,  the 
probability  is  in  each  case,  I  imagine, 
increased  of  the  supervention  of  inter¬ 
stitial  absorption  upon  violence  applied 
to  the  great  trochanter  of  a  person  who 
has  passed  the  age  of  fifty. 

“The  numerous  pathological  in¬ 
quiries  which  have  been  instituted  in 
reference  to  the  condition  of  the  neck, 
of  the  femur,  seem  clearly  to  indicate 
two  facts — 1st,  that  this  portion  of  the 
bone  is  less  capable  of  maintaining 
its  vascularity  than  the  other  parts  of 
the  osseous  system;  and  2dly,  that  the 
universal  decay  of  bone  natural  to  ad¬ 
vanced  age,  first  commences  in  it.”* 
These  interesting  facts  seem  to  me  to 
bear  upon  the  subject  under  considera¬ 
tion  :  thus,  if  violence  be  applied  in  a 
particular  direction,  producing,  pro¬ 
bably,  rupture  or  contusion  of  some  of 
the  nutrient  vessels  passing  along  the 
ligamentum  teres  for  the  head  and  cer¬ 
vix  femoris,  the  quantity  of  blood  sup¬ 
plied  to  these  parts  being  thereby  less¬ 
ened,  becomes  still  more  inadequate  to 
compete  in  the  work  of  deposition 
against  theopposing  absorption  which  is 
already  assuming  the  mastery,  and  the 
neck  of  the  femur,  naturally  less  capable 
of  maintaining  its  vascularity  than  the 
other  parts  of  the  osseous  system,  falls 
a  prey  (so  to  speak)  in  the  unequal 
struggle,  and  is  slowly  but  surely  de¬ 
stroyed  ;  whilst  the  universal  decay  of 
bone  coincident  with  life’s  decline, 
here  first  committing  its  ravages,  adds 
a  potent  influence  in  determining  the 
issue. 

The  idea  that  at  the  time  of  the  acci¬ 
dent  some  vessels  of  the  round  ligament, 
probably,  suffer,  is  strengthened  by  the 
post  mortem  appearances  described  by 
Mr.  Gulliver,  in  the  case  of  M‘Gruth  ; 
the  capsule  of  the  joint  appeared  un¬ 
injured,  but  the  round  ligament  had 
apparently  been  detached  from  the 
head  of  the  bone  to  which  it  had  ac¬ 
quired  a  new  connection  near  its  origi¬ 
nal  site. 

The  following  I  have  copied  verba- 

*  B.  Curling,  Med.-Cliir.  Trans,  vol.  xx. 


tim  from  the  case  book  of  the  late  Mr. 
Howship  :  — 

Case  II. -July  23d,  1828.  Mary 
Hyde,  eet.  72.  In  the  hard  winter, 
fifteen  years  ago,  she  fell  with  the 
upper  part  of  the  right  thigh  on  the 
pavement,  raised  herself  by  the  railings, 
but  fell  a  second  time  on  the  same 
thigh,  which  felt  benumbed,  and  for 
some  time  she  lay  lame  and  helpless. 
It  took  her  two  hours  to  go  on  foot 
from  Sackville  Street  to  Bond  Street. 
The  leg,  she  observed,  was  first  turned 
outwards,  and  is  so  still.  About  a 
month  after  the  accident,  she  was  able 
to  crawl  with  a  stick,  and  came  into 
the  Oxford  ward,  St.  George’s  Infir- 
maly,  under  Mr.  Heaviside.  For  many 
weeks  the  hip  was  fomented,  With  par¬ 
tial  relief.  She  went  out  carried  in  a 
coach.  She  was  very  weak,  and  the 
right  limb  was  getting  shorter,  but  she 
is  quite  sure  that  since  the  accident 
there  has  been  gradual  shortening, 
and  especially  within  the  last  twelve 
months.  In  walking,  it  appeared  to 
me  that  the  limb  was  shortened  full 
two  inches,  and  this  accorded  with  her 
own  idea.  There  is  pain  in  the  articu¬ 
lation  of  the  hip-bone  in  standing  on 
it,  as  if  she  had  been  struck  a  blow  : 
aching  and  throbbing  wdien  fatigued, 
but  alw'ays  feels  it :  if  she  walks  across 
the  room  it  is  slightly  benumbed,  or  as 
if  there  wTas  no  strength  in  the  bone. 
If  exposed  to  fatigue,  ail  the  distress  is 
in  the  neck  of  the  femur. 

On  examination,  by  measuring  with 
a  tape  from  the  bottom  of  the  heel  to 
the  anterior  superior  spine  of  the  ilium, 
the  right  thigh  is  shorter  than  the  left 
very  nearly  two  inches;  the  trochanter 
seems  enlarged,  but  is  much  higher  up 
than  on  the  opposite  side;  but  the  mo¬ 
tions  of  the  head  of  the  bone  prove 
this  part  in  its  place;  but  the  neck 
appears  exceedingly  shortened,  and  I 
think  its  direction  changed. 

June  1831. — Examined  her  again: 
able  to  walk  very  comfortably  ;  no 
pain  in  bearing  her  weight,  only  an 
inconvenience  from  shortening. 

January  30,  1832. — After  an  insen¬ 
sible  decline,  sunk  and  died. 

On  removal  of  the  right  hip  I  found 
the  neck  of  the  bone  so  shortened  that 
the  margin  of  the  head  (directly  behind 
which  the  capsule  was  attached  all 
round)  was  brought  nearly  into  contact 
with  the  two  trochanters.  A  narrow, 
very  small  cord  (the  remains  of  the 


240  MR  canton’s  remarks  on  interstitial  absorption  of 


ligamentum  teres),  of  its  proper  sub¬ 
stance  and  appearance,  yet  existed  ; 
and  in  the  space  usually  filled  at  the 
bottom  of  the  acetabulum  by  synovial 
glands,  I  found  two  very  red  and 
vascular  masses  of  bone,  partially 
covered  with  cartilage,  apparently  an 
ossification  of  the  fatty  substance. 

I  shall  venture  to  describe,  some¬ 
what  more  in  detail,  the  bony  parts  of 
the  hip,  which  are  preserved  in  the 
Museum  attached  to  the  Charing-Cross 
Hospital.  Less  than  half  an  inch  of 


the  neck  of  the  femur  remains  below, 
whilst  the  upper  part  has  suffered  still 
more  in  the  destruction,  and  is  en¬ 
croached  upon,  and  overhung  by,  a 
buttress  of  bone  springing  from  the 
anterior  inter-trochanteric  line,  and 
gradually  becoming  thinner  as  it  sweeps 
around,  and  marks  the  limit  of  the 
head  at  its  upper,  posterior,  and  lateral 
margins.  This  projection  is  on  a  level 
with  the  summit  of,  and  separated 
from,  the  trochanter  major,  by  a  dis¬ 
tance  of  a  quarter  of  an  inch  only. 
The  head  itself  is  depressed,  spread 
out  so  as  to  be  2|  inches  in  breadth, 
and  in  height  3  inches,  preserving 
still  a  certain  degree  of  convexity,  and 
overhangs,  to  concealment,  the  neck  of 
the  bone,  so  that  the  resemblance  of 
the  two  to  a  mushroom,  with  a  thick 
and  stunted  stem,  is  far  from  fanciful. 


a r. 

The  encrusting  cartilage  is  absent  in 
certain  places,  leaving  porous  bone  ex¬ 
posed.  The  whole  bone,  like  the  cor¬ 
responding  os  innominatum,  is  light 
and  spongy,  but  firm  withal.  The  ace¬ 
tabulum  is  widened,  and  corresponds  in 
breadth  and  height  with  the  measure¬ 
ments  given.  The  cartilage  is  wanting 
in  places  opposite  to  the  deficiencies 
on  the  head  of  the  femur.  The  width 
of  the  notch  is  If  inches.. 

I  have  already  shewTn  that  the 
changes  occurring  in  the  neck  of  the 
femur,  incidental  to  advanced  age,  are 
not  to  be  confounded  with  the  alte¬ 
rations  which  ensue  from  violence  or 
disease  ;  and  the  statements  of  authors 
I  find,  not  unfrequently,  are  such  as  to 
warrant  the  idea  that  there  is  little  if  any 
difference  in  these  affections;  —  e.  g. 
Prof.  Miller*  says:  “In  consequence 
of  external  violence,  as  a  smart  blow 
or  fall  on  the  trochanter  major,  it  is 
not  uncommon  to  find  the  neck  of  the 
femur  undergo  much  change  by  inter¬ 
stitial  absorption;  and  similar  alteration 
may  occur  spontaneously  —  that  is, 
without  any  assignable  cause, — seem¬ 
ing  to  be  one  of  the  signs  of  the  frame's 
decay,  not  only  in  mass  but  in  its  details , 
which  usually  accompany  old  ayef 

Analogous  alterations  from  disease. 
—  It  is  interesting  to  remark  how 
similar  are  the  morbid  alterations  in 
the  hip,  consequent  upon  this  injury,  to 
those  seen  in  cases  of  chronic  rheumatic 
arthritis  :  the  same  absorption  of  the 
neck,  giving  rise,  in  part,  to  shorten¬ 
ing  of  the  limb ;  removal  of  cartilage; 
eburnation  of  the  exposed  surface 
where  pressure  is  greatest ;  flattening, 
expansion,  and  depression  of  the  head, 
with  an  irregular  projecting  osseous 
girdle,  generally,  where  it  joins  the 
cervix;  enlargement  of  the  acetabu¬ 
lum,  disappearance  of  the  ligamentum 
teres,  with  thickening  of  the  capsule, 
and  irregular  deposits  of  new  bone 
around,  are  to  be  noticed  ;  loose  carti¬ 
lages  also  may  be  found  in  the  joint, 
and  the  transverse  ligament  be  con¬ 
verted  into  a  bridge  of  bone,  &c. 
Such  changes,  I  believe,  have  not  un¬ 
frequently  been  regarded  (in  the  ab¬ 
sence  of  a  history  of  the  case)  as  ag¬ 
gravated  examples  merely  of  that 
atrophy  of  the  part  natural  to  declining 
years.  In  the  examinations  I  have 
myself  made  of  the  hip  in  a  large  num- 


*  Principles  of  Surgery. 


THE  NECK  OF  THE  FEMUR  FROM  BRUISE  OF  THE  HIP. 


241 


her  of  subjects  (male  and  female),  who 
had  lived  upwards  of  sixty,  seventy,  or 
eighty  years,  I  have  never  been  able  to 
find  any  other  alteration  than  a  de¬ 
scent  of  the  cervix,  and  that  to  a  less 
degree  than  I  imagined  would  be  found 
at  this  period  of  life,  from  the  descrip¬ 
tion  usually  given  bv  authors  of  the 
horizontal  position  of  the  neck  of  the 
femur,  which  is  to  be  considered  as 
characterising  the  bone  in  an  elderly 
person. 

T  should  mention,  in  addition,  that  a 
thinness  of  the  cortex  of  this  part,  and 
a  more  open  condition  of  the  cancelli, 
was  usually  to  be  noticed.  In  three 
femalestibjects,each  more  than  90  years 
of  age,  the  cervix  I  found  was  but  little 
altered  from  its  natural  obliquity.  I 
have  occasionally,  however,  met  with 
a  hip-joint  (and  in  general  both  sides 
had  suffered)  where  the  morbid  changes 
previously  alluded  to  were  present; 
whilst  the  existence,  ordinarily,  of  ana¬ 
logous  alterations  in  some  other  articu¬ 
lations  would  more  definitely  indicate — 
though  such  corroboration  is  needless 
— the  real  nature  of  the  affection. 

Mr.  Adams,  in  his  account  of  the 
rheumatic  disease  of  the  hip,  has,  in 
the  subjoined  remark,  hinted  at  the 
similarity  of  the  morbid  appearances 
found  after  this  accident  to  those  con¬ 
sequent  upon  the  above  complaint. 
He  says,  “  We  have  also  reason  to 
think  that  falls  upon  the  great  tro¬ 
chanter  have  given  rite  to  the  first 
symptoms  of  this  disease.”  In  al¬ 
luding  to  these  observation,  Dr.  Todd* 
observes,  “  This  is  by  no  means  impro¬ 
bable,  nor  is  the  fact  opposed  to  that 
view  of  the  disease  which  assigns  it  a 
rheumatic  origin ;  for,  doubtless  the 
perversion  of  nutrition  excited  by  the 
violence  of  the  fall,  would,  as  often 
happens  in  gout,  occasion  a  greater 
attraction  of  the  rheumatic  matter  to 
the  injured  joint  than  would  otherwise 
have  taken  place.”  I  have  already 
quoted  from  Mr.  B.  Bell’s  work  a 
passage,  part  of  which  bears  upon  the 
present  question — “  In  the  cases  which 
occur  in  middle  age,  it  (interstitial  ab¬ 
sorption  of  the  neck  of  the  thigh-bone) 
does  not  in  general  appear  to  be  an 
idiopathic  affection,  hut  is  the  direct 
result  of  cold,  or  a  full,  Mow,  or  injury 
of  the  trochanter  major”  The  latest 
authority  on  this  subject,  Mr.  Smith, 


of  Dublin,  remarks,  “The  limb  be¬ 
comes  shortened,  the  foot  everted,  and 
not  unfrequently  we  will  find  in  such 
cases  all  the  symptoms  of  chronic 
rheumatic  arthritis  established.”* 

Not  only  are  the  appearances  found 
after  death  analogous  to  those  seen 
when  the  hip  is  affected  with  the  rheu¬ 
matic  disease,  but  the  symptoms  during 
life  are  the  same.  In  both  there  is 
stiffness:  limitation  of  motion  in  certain 
directions  ;  dull,  wearying  pain  in  the 
joint,  and  extending  down  the  thigh  ; 
aggravated  at  night  and  after  exercise: 
increased  in  damp  and  frosty  weather, 
and  augmented  by  inclining  the  limb 
in  particular  ways.  There  is  shorten¬ 
ing  of  the  latter;  some  wasting  of  the 
muscles  around  the  hip  ;  an  inability 
of  supporting  the  weight  of  the  body 
long  on  the  affected  side  without  in¬ 
ducing  dull  pain  in  the  articulation  ; 
absence  of  redness,  and  undue  heat  of 
the  part,  &c. 

104,  St.  Martin’s  Lane. 


OBSERVATIONS  ON  THE 

TREATMENT  OF  HEMORRHOIDAL 
TUMORS, 

CONNECTED  WITH  RELAXATION  OF  THE 
MUCOIDS  MEMBRANE  OF  THE  RECTUM. 

By  Henry  Lee,  Esq.,  F.R.C.S. 
Assistant-Surgeon  to  King’s  College  Hospital. 


Pathologists  have  described  internal 
hemorrhoidal  tumors  as  presenting 
themselves  under  three  principal  va¬ 
rieties  :  first,  as  consisting  simply  of 
elongated  and  convoluted  vessels  ; 
secondly,  as  being  formed  by  the  dila¬ 
tation  of  one  or  more  veins  in  which  the 
blood  has  become  coagulated ;  and 
thirdly,  as  resulting  from  the  effusion 
and  coagulation  of  the  blood  in  the 
cellular  tissue  immediately  surround¬ 
ing  the  mucous  membrane  of  the  rec- 

O 

tum.f 

*  A  Treatise  on  Fractures  in  the  Vicinity  of 
Joints. 

t  There  is  frequently  difficulty  in  determining 
whether  the  coagulated  blood  found  in  hemor¬ 
rhoidal  tumors  is  contained  in  dilated  vessels, 
or  in  the  cellular  tissue.  In  examining  the  parts, 
the  small  coagula  of  blood  will  almost  always  be 
found  contained  in  cavities  of  a  corresponding 
size,  lined  with  a  delicate  smooth  and  shining- 
membrane  :  the  surface  of  this  membrane  at 
first  sight  so  much  resembles  that  of  the  inner 
coat  of  the  veins  as  to  lead  to  the  conclusion  that 
the  blood  is  still  within  the  hemorrhoidal  ves¬ 
sels.  The  evidence  upon  which  this  opinion  is 


*  Practical  Remarks  on  Gout,  Rheumatic 
Fever,  and  Chronic  Rheumatism  of  the  Joints. 


Each  of  these  forms  of  disease  may 
occasionally,  although  rarely,  be  found 
by  dissection  to  exist  independently  of 
the  other  varieties,  and  uncomplicated 
by  other  changes  of  structure.  But  in 
the  great  majority  of  cases,  whatever 
may  be  the  primary  form  in  which  the 
affection  presents  itself,  subsequent 
alterations  are  produced  which  exercise 
a  marked  influence  upon  the  progress 
of  the  disease,  and  have  an  especial  re¬ 
ference  to  the  structure  and  dependent 
position  of  the  parts.  The  first  edict 
of  an  internal  hemorrhoidal  tumor  is 
to  raise  the  mucous  membrane,  to 
separate  it  from  the  muscular  coat,  and 
to  cause  it  to  protrude  into  and  en¬ 
croach  upon  the  cavity  of  the  rectum  : 
the  lower  aperture  of  the  bowel  is  thus 
narrowed,  and  increased  efforts  are  re¬ 
quired  in  order  to  evacuate  its  con¬ 
tents.  Thestraining  which  accompanies 
these  efforts  forces  the  tumor  and  the 
mucous  membrane  which  covers  it  be¬ 
low  their  usual  situation,  but  as  they 
soon  recover  their  position,  no  further 
inconvenience  is  perhaps  at  the  time 
experienced.  At  length,  however, some 
slight  attack  of  inflammation  occurs  in 
the  part ;  the  hemorrhoidal  tumor  is  in¬ 
creased  in  size  by  the  deposition  of 
lymph  and  serum,  and  renewed  efforts 
are  made  which  force  it  farther  down, 
and  at  length  expel  it  from  the  extre¬ 
mity  of  the  bowel. 

The  peculiar  disposition  of  the  mus¬ 
cles  situated  at  the  lower  aperture  of 
the  rectum,  now  exercises  a  marked 
and  very  important  influence  upon  the 
progress  of  the  disease.  The  extremity 
of  the  bowTel  is  surrounded  not  only  by 
the  muscular  fibres  wdiich  constitute 
its  proper  sphincter,  but  also  by  the 
posterior  and  superior  portion  of  the 
levator  ani  :  this  portion  of  the  muscle 
consisis  of  a  broad  band  of  fibres, 
which  embrace  the  sides  and  the  back 
part  of  the  rectum,  and  sling  it  forward 


based  does  not,  however,  appear  to  be  very  con¬ 
clusive  :  first,  because  it  frequently  happens 
that  no  communication  can  be  traced  between 
the  cavity  in  which  the  blood  is  contained  and 
the  neighbouring  vessels;  and,  secondly,  be¬ 
cause  it  has  been  proved  that  blood  coagulated 
in  other  parts  may  have  a  membrane  formed 
upon  it,  derived  from  the  blood  itself,  and  as¬ 
suming  all  the  appearances  of  a  serous  covering. 
Cases  where  this  membrane  has  been  formed 
upon  the  surface  of  coagulated  blood  are  recorded 
by  Mr.  Hewett  in  the  28th  volume  of  the  Medico- 
Chirurgical  Transactions:  and  preparations  illus¬ 
trative  of  the  same  subject  may  be  seen  in  the 
museum  of  Guy’sHospital :  see  Nos.  152325  and 
15256  4.  . 


towards  the  pubis.*  The  last  inch 
and  a  half  or  twro  inches  of  the  bowel 
are  thus  surrounded  by  muscular  fibres 
capable  of  exerting  very  considerable 
pressure  upon  any  body  placed  within 
their  grasp.  When,  therefore,  any 
tumor  in  the  bowel  is  forced  below  its 
natural  level,  and  becomes  encircled  by 
the  fibres  above  mentioned,  it  is  placed 
in  circumstances  very  similar  to  those 
of  a  knuckle  of  intestine  in  a  hernial 
sac.  The  degree  of  compression  may 
vary  from  that  which  is  attended  with 
only  a  slight,  dull,  heavy  aching  pain 
of  short  duration,  to  that  which  pro¬ 
duces  real  strangulation,  preceded  by 
the  most  acute  suffering. 

Case  I. — A  gentleman  of  plethoric 
habits,  had  been  subject  to  piles  for 
fifteen  or  twenty  years,  and  occasionally 
experienced  great  uneasiness  and  irri¬ 
tation  about  the  rectum.  During  an 
attack,  he  was  observed  frequently 
to  change  his  posture,  and  to  seek  some 
hard  projecting  corner  of  a  chair  to  sit 
upon.  The  pain  upon  one  occasion 
being  much  more  severe  than  usual, 
he  was  confined  to  his  bed,  and  I  had 
an  opportunity  of  examining  the 
parts.  Upon  separating  the  nates,  a 
small  portion  of  a  highly  congested 
livid  warty- looking  excrescence  could 
be  seen  forced  down  within  the  grasp 
of  the  sphincter.  This  tumor  was  of  a 
dark  purple  colour,  and  so  exquisitely 
tender,  that  he  would  not  allow  the 
requisite  attempt  to  be  made  in  order  to 
return  it  to  its  original  situation  within 
the  bowel.  During  the  night  following 
my  examination,  the  pain  entirely  and 
somewhat  suddenly  ceased.  From  that 
time  to  the  present,  a  period  of  upwards 
of  six  years,  he  has  had  no  return  of 
his  former  symptoms. 

There  can  be  no  doubt  that,  in  this 
case,  the  action  of  the  sphincter  muscle 
produced,  the  same  effect  as  if  a  ligature 
had  been  applied  to  the  base  of  the 
tumor,  and  that  the  patient  was  cured 
of  his  disease  in  the  same  way  as  if  this 
operation  had  been  performed.  In  the 
great  majority  of  cases,  the  circular 
fibres,  above  mentioned,  exert  a  com¬ 
paratively  slight  degree  of  compression, 
but  still  sufficient  to  produce  an  im¬ 
portant  effect  upon  a  tumor  placed 


*  This  portion  of  the  levator  ani,  which  is 
seldom  properly  described  in  anatomical  works, 
is  well  represented  by  a  plate  in  the  fifth  volume 
of  the  Dublin  Hospital  Reports. 


MR.  LEE  ON  THE  TREATMENT 


within  their  grasp.  A  very  slight  de¬ 
gree  of  pressure  is  sufficient  to  retard 
:he  free  return  of  blood  from  the  part. 
This  is  necessarily  followed  by  conges¬ 
tion  and  swelling  of  the  tumor,  and 
places  it  under  those  conditions  which 
of  all  others  render  it  most  liable  to 
repeated  attacks  of  inflammation.  The 
tumor,  which  was  originally  of  a  red 
colour,  now  assumes  a  dark  purple  ap 
pearance,  and  the  mucous  membrane 
in  the  neighbourhood  being  drawn 
upon  whenever  the  pile  is  forced  below 
its  natural  level,  at  length  assumes  a 
permanent  disposition  to  “  bag,”  and 
portions  of  it  are  continually  being 
forced  through  the  lower  aperture  of 
the  bowel.  These  changes  are  gene¬ 
rally  accompanied  by  an  occasional 
dull,  heavy  aching  pain,  either  in  the 
perineum  or  in  the  rectum  ;  but  usually 
it  is  not  till  repeated  attacks  have  been 
experienced,  that  the  pain  and  incon¬ 
venience  are  sufficient  to  induce  the  pa¬ 
tient  to  seek  for  surgical  relief. 

The  removal  of  hemorrhoidal  tumors 
either  by  ligature  or  excision,  affords, 
when  it  can  be  had  recourse  to  with¬ 
out  danger,  an  easy  and  effectual  re¬ 
medy  for  the  disease.  But  there  are 
cases  in  which  the  common  mode  of 
operating  is  not  unattended  with 
danger;  and  it  will  not  unfrequently 
happen  that  a  patient  wishes  “  some¬ 
thing  to  be  done,”  although  he  is  un¬ 
willing  to  submit  to  the  pain  and  in¬ 
convenience  attending  the  ordinary 
operation. 

It  will  occasionally  happen,  from 
some  peculiarity  of  the  constitution, 
either  natural  or  acquired,  that  the 
healthy  adhesive  inflammation  will 
not  take  place  after  a  wound,  however 
trifling,  of  the  rectum.  “  I  have  had 
he  misfortune,”  says  Sir  B.  Brodie, 
“of  losing  three  patients  out  of  the 
jreat  number  on  whom  I  have,  in  the 
(ourse  of  the  last  thirty  years,  per- 
firmed  the  operation  of  applying 
lgatures  to  piles.  In  each  of  these 
cises,  on  examination  after  death, 
I  found  diffuse  cellular  inflammation, 
aid  a  sloughy  condition  of  the  cel- 
ldar  membrane  between  the  mucous 
membrane  of  the  intestine  and  the 
muscular  tunic.”*  In  such  cases,  the 
inflammatory  action  not  being  circum¬ 
scribed  by  the  healthy  effusion  of 
lymph,  is  not  confined  to  its  intended 


OF  HEMORRHOIDAL  TUMORS.  243 


limits,  and,  instead  of  repairing  the 
injury  that  has  been  done,  becomes 
itself  a  new  and  formidable  disease. 
This  termination  to  the  operation  for 
the  removal  of  piles  is  unfortunately 
too  well  known  to  require  farther  no¬ 
tice  ;  but  another  result  occasionally 
presents  itself  which  has  not  received 
the  same  attention  from  the  profession, 
nor  been  so  satisfactorily  accounted 
for. 

Case  II.— Thomas  Duffy,  set.  42, 
was  admitted  into  St.  George’s  Hos¬ 
pital  on  the  15th  of  October,  1845. 
On  the  30ih  of  the  same  month  he  was 
operated  upon  for  piles.  The  external 
tumors  were  removed  by  excision,  and 
the  internal  were  tied  in  the  usual 
way.  On  the  5th  of  November  the 
ligatures  had  all  separated,  and  no 
peculiar  feature  presented  itself  in  the 
case.  On  the  9th  he  had  a  rigor,  but 
experienced  no  pain  in  any  part. 

10th,  11th,  and  12th. — On  each  of 
these  days  the  rigor  was  repeated,  fol¬ 
lowed  by  fever. 

13th  and  14th.  —  He  experienced 
great  pain  in  the  right  hypochondriac 
region,  and  vomited  a  large  quantity 
of  green  fluid. 

15th. — The  left  knee-joint  had  be¬ 
come  swollen. 

He  died  on  the  17th. 

On  examining  the  body,  recent  ef¬ 
fusion  of  lymph  was  found  upon  the 
right  pleura.  Both  lungs  presented, 
through  their  whole  extent,  numerous 
large  spots  of  venous  congestion  and 
condensation.  In  one  of  these  spots 
upon  the  right  side  was  found  the  com¬ 
mencement  of  a  secondary  abscess. 
The  coagula  in  the  right  auricle  of 
the  heart  were  of  a  dirty  yellow  colour. 
The  liver  was  found  thickly  studded 
with  abscesses,  some  of  which  were  as 
large  as  a  turkey’s  egg.  The  mucous 
membrane  of  the  rectum  was  of  a 
darkish  green  colour,  and  thrown  in 
many  places  into  ridges  by  the  promi¬ 
nence  of  the  hemorrhoidal  veins  :  se¬ 
veral  of  these  were  hard,  thickened, 
and  filled  with  lymph  and  pus.  The 
inferior  mesenteric  vein  was  in  a 
similar  condition,  and  at  its  junction 
wTith  the  splenic  vein  there  was  a  thick 
coagulum  containing  pus.  The  vena 
porta  and  splenic  veins  were  appa¬ 
rently  healthy.  The  cavity  of  the 
left  knee-joint  was  filled  with  pus. 

Case  III.— John  Munday,  set.  36, 


*  See  Med.  Gazette,  Lecture  II.  1843. 


244  MR.  LEE  ON  THE  TREATMENT  OF  H HEMORRHOIDAL  TUMORS 


was  admitted  into  St.  George’s  Hos¬ 
pital  on  the  3d  of  September,  1845. 
He  had  suffered  from  the  usual  symp¬ 
toms  of  piles  for  eight  years,  and  his 
general  health  had  evidently  become 
impaired.  On  the  16th  of  September, 
the  piles  were  tied  in  the  usual  man¬ 
ner,  and  the  ligatures  had  all  separated 
on  the  23d.  The  next  day  he  had  a 
rigor,  followed  by  heat  of  skin  and 
rapid  pulse. 

On  the  23d  the  countenance  was 
very  anxious,  and  slightly  jaundiced ; 
pulse  150,  weak  and  irritable;  skin 
extremely  hot  and  dry.  He  expe¬ 
rienced  no  pain  in  any  part,  but  still 
the  symptoms  continued  unrelieved, 
and  he  died  upon  the  28th  of  the  same 
month. 

On  examining  the  body,  recent  effu¬ 
sion  of  lymph  was  discovered  on  the 
right  pleura,  and  secondary  abscesses 
were  found  in  both  lungs. 

About  the  same  time  that  these  cases 
occurred,  I  had  the  opportunity  of 
examining  the  rectum  which  had  been 
removed  from  the  body  of  a  gentleman 
who  had  died  with  effusion  of  bloody 
serum  into  one  of  the  pleural  cavities. 
The  usual  operation  of  applying  liga¬ 
tures  to  some  hemorrhoidal  tumors  had 
been  performed,  and  the  patient  sank 
with  extreme  prostration  a  few  days 
afterwards.  The  only  peculiarity  that 
could  be  detected  in  the  appearance  of 
the  rectum  was,  that  the  blood  was 
still  fluid  in  one  of  the  largest  veins, 
which  led  directly  to  an  ulcer,  pro¬ 
duced  by  the  operation  ;  even  at  the 
extremity  of  the  vein  near  the  wound 
there  was  no  appearance  of  coagulum. 

It  was  shewn  by  Mr.  Hunter  that  if 
a  vein  were  inflamed,  and  its  cavity 
not  completely  obliterated,  the  product 
of  the  inflammation  might  find  its  way 
up  the  vein,  and  be  carried  in  the 
course  of  the  circulation  ;*  and  in  other 
parts  of  the  body  the  danger  of  tying 
veins  has  been  generallyacknowledged. 
The  cases  above  related  shew  that  the 
veins  of  the  rectum  do  not  always 
afford  an  exception  to  the  general  rule; 
nor  is  it  difficult  to  conceive  the  way- 
in  which  foreign  matter  may  enter  the 
system  through  the  hemorrhoidal 
veins,  after  the  common  mode  of  ope¬ 

*  See  Mr.  Hunter’s  paper  on  “  Inflammation 
of  the  Veins,”  in  the  Transactions  of  a  Society 
for  the  Improvement  of  Medical  and  Surgical 
Knowledge,”  vol.  i.  1893.  See,  also,  preparation 
in  pathological  museum  of  the  College  of  Sur¬ 
geons,  No.  1728. 


rating  for  piles.  In  passing  a  needle 
armed  with  a  ligature  through  the 
base  of  a  haemorrhoidal  tumor,  it  must 
occasionally  happen  that  one  of  tie 
larger  veins  of  the  rectum  is  transfixed; 
and  although  a  vein  is  seldom  found  ii 
this  situation  sufficiently  large  to  allov 
the  needle  to  pass  through  it  withou; 
completely  dividing  it,  yet  when  the  li¬ 
gatures  are  tied  upon  the  opposite  sides 
of  the  tumor,  the  parts  included  in  their 
(being  connected  more  or  less  closely 
with  the  vein)  will  have  the  effect  oi 
separating  the  sides  of  the  vein  from 
each  other.  The  wounded  vein  is 
thus  held  open,  and  maintained  in  a 
condition  most  favourable  for  the  di¬ 
rect  absorption  of  pus,  or  of  any  se¬ 
cretion  that  may  present  itself.*  The 
first  means  provided  by  nature  against 
the  entrance  of  any  foreign  matter 
into  an  open  vein  is  the  coagulation 
of  the  blood  ;  and  in  the  vast  majority 
of  instances  this  effectually  seals  the 
vessel.  But  in  cases  where  the  ex¬ 
tremity  of  a  divided  vein  remains 
open,  and  the  coagulum  is  not  suffi¬ 
ciently  firmly  formed,  morbid  secretions 
may  become  mixed  with  the  blood 
and  the  whole  system  suddenly  af¬ 
fected,  as  in  the  preceding  cases. 

When,  from  any  of  the  causes  men¬ 
tioned,  or  from  timidity  on  the  part  of 
the  patient,  it  is  desirable  to  avoid 
the  common  operations  of  tying  or 
removing  the  hemorrhoidal  tumors, 
are  there  any  other  means,  not  liable 
to  the  same  objections,  by  which  the 
disease  may  be  effectually  cured  ? 

Case  IV. — S.  S.  W.,  Esq.,  about  7{) 
years  of  age,  had  been  troubled  will 
the  usual  symptoms  of  piles  for  many 
years.  In  the  summer  of  the  yen’ 
1844  the  inconvenience  had  greatly 
increased,  and  it  became,  to  use  lis 
own  words,  “absolutely  necessary  that 
something  should  be  done.”  Eis 
general  health  at  the  time  was  eviderdy 
upon  the  decline,  and  his  legs  wire 
swollen  and  cedematous.  On  exami¬ 
nation  I  found  the  margin  of  the  aius 
surrounded  by  soft  livid  tumors,  to¬ 
gether  with  a  considerable  portior  of 
prolapsed  mucous  membrane,  which  he 
was  unable  to  return  into  the  bovel. 
The  projection  altogether  was  the  dze 
of  half  a  large  orange.  Consideiing 


*  See  a  table  of  Secondary  Inflammations, 
published  by  the  author  in  the  Med.  Gaz.  of  the 
year  1845. 


MR.  kesteven  on  the  action  of  chloroform. 


245 


the  state  of  health  of  this  patient,  I 
■was  unwilling  to  perform  the  common 
operation,  and  I  ultimately  determined 
to  destroy  a  portion  of  the  relaxed 
mucous  membrane  upon  each  side  of 
the  bowel,  with  the  strong  nitric  acid*. 
This  was  easily  accomplished,  with  the 
precautions  hereafter  mentioned;  and 
J  had  the  satisfaction  to  find  that  the 
operation  was  attended  with  scarcely 
any  pain. 

For  some  time  after  this  operation 
the  heemorrhoids  descended  every  time 
that  the  patient  had  a  motion  ;  and  at 
first  little  good  appeared  to  have  re¬ 
sulted  from  the  application.  The  small 
sores  left  after  the  separation  of  the 
sloughs  soon,  however,  began  to  heal; 
and  as  their  edges  were  drawn  together 
by  the  process  of  cicatrization,  the 
parts  descended  less  frequently,  and  in 
three  weeks  from  the  time  of  the  ope¬ 
ration  L  had  the  satisfaction  to  find 
that  the  whole  of  the  parts  were  habi¬ 
tually  retained  within  the  sphincter. 
The  distressing  symptoms  from  which 
this  gentleman  had  so  long  suffered 
were  now  entirely  relieved ;  and  al 
though  I  saw  him  occasionally  for 
many  months  afterwards,  I  never 
heard  that  he  experienced  any  return 
of  his  former  complaint. 

It  is  important  to  remark  that  the 
benefit  to  be  derived  from  such  an 
operation  must  not  be  expected  till 
the  small  ulcers  made  by  the  caustic 
begin  to  heal.  The  loose  folds  of  mu¬ 
cous  membrane  are  then  drawn  upon, 
and  the  whole  of  the  mucous  lining  is 
rendered  more  tense.  Each  small  cica¬ 
trix,  moreover,  serves  as  a  permanent 
point  of  attachment  for  the  relaxed 
membrane,  and  consequently  the  inner 
coat  (which  alone  descends  in  such 
cases)  is  retained  permanently  in  con¬ 
tact  with  the  other  coats  of  the  bowel. 

The  degree  of  pain  experienced  in 
this  operation  depends  in  great  measure 
upon  the  way  in  which  the  nitric  acid 
isappiied:  the  sensibilhyof  the  thin  skin 
around  the  anus  is  very  great,  and  if 
the  acid  is  allowed  to  come  in  contact 
with  it,  the  degree  of  tingling  pain 
experienced  is  very  considerable ;  if 
care  be  taken,  on  the  other  hand,  to 
confine  the  application  of  the  acid  to 
the  comparatively  insensible  mucous 
membrane,  a  slight  uneasy  sensation 


in  the  lower  part  of  the  abdomen  is 
generally  all  that  is  complained  of. 

13,  Dover  Street,  July  1S48. 

[To  be  continued.] 


ACTION  OF  CHLOROFORM. 

By  W.  B.  Kesteven,  M.R.C.S.  &c. 

It  has  been  assumed  that  the  loss  of 
pain  consequent  on  the  administration 
of  chloroform  is  dependent  on  the  loss 
of  consciousness  which  is  produced, 
and  that  therefore  this  and  similar 
agents  cannot  strictly  be  called  anaes¬ 
thetic. 

In  reference  to  this  question,  I  beg 
to  offer  the  following  case,  if  you  should 
find  space  for  its  insertion  in  your 
journal : — A  woman,  aged  30,  in  her 
first  labour,  on  account  of  the  severity 
and  duration  of  the  pains  desired  the 
exhibition  of  chloroform.  It  was 
breathed  for  about  three-quarters  of 
an  hour,  from  a  pocket-handkerchief 
held  at  a  short  distance,  about  a  quarter 
of  an  inch  from  the  nose  and  month; 
the  quantity  used  might  have  been 
three  drachms. 

She  immediately  discontinued  her 
cries,  expressed  herself  free  from  pain, 
and  retained  her  consciousness,  so  as  to 
maintain  connected  conversation  dur¬ 
ing  the  whole  time,  and  on  the  expul¬ 
sion  of  the  child’s  head,  she  observed 
that  instead  of  pain,  “  it  was  an  agree¬ 
able  sensation  of  relief.” 

The  purity  of  the  chloroform  used, 
had  been  ascertained  by  the  tests  re¬ 
commended  by  Dr.  Letheby.* 

From  this  case,  as  wTell  as  others 
which  have  been  published,  it  is  evi¬ 
dent  that  loss  of  mental  consciousness 
is  not  inevitably  a  condition  of  loss 
of  pain  under  the  use  of  anaesthetic 
agents :  it  is  clear  that  its  powder  was 
here  exerted  only  on  that  portion  of 
the  nerves  whence  pain  is  made  evi¬ 
dent,  or  in  altering  that  condition  of  the 
nerves,  whatever  it  may  be,  which  we 
recognize  as  pain. 

I  fully  concur  in  your  observations 
on  the  hesitation  and  caution  to  be 
observed  in  the  administration  of  chlo¬ 
roform  vapour  ;  the  occurrence  of  even 
only  one  death  in  a  million  of  cases, 
should  induce  us  to  pause  ere  we 
employ  such  a  potent  agency.  The 


*  See  Dr.  Houston’s  paper  in  the  Dublin  Medi¬ 
cal  Journal,  vol.  xxiii. 


*  Med.  Gaz,,  June  16. 


246  ON  THE  CONNECTION  OF  THE  SPINAL  ACCESSORY  NERVE  WITH  THE 


cases  you  published  in  your  last  num¬ 
ber  will  have  the  effect  on  myself,  and 
doubtless  on  others,  of  making  us 
more  careful  than  hitherto  in  its  admi¬ 
nistration  ;  but  it  appears  from  a  con¬ 
sideration  of  other  cases  which  have 
been  published,  that  ill  effects  have 
seldom  followed  its  exhibition  when 
it  has  been  administered  during  severe 
pain,  as  in  the  last  stages  of  labour, 
capital  operations,  tic  douloureux,  &c. 
and  that  where  it  has  been  known  to 
produce  any  injurious  consequences, 
it  has  been  most  frequently  when  ad¬ 
ministered  in  the  absence  of  pain  — as 
before  tooth-drawing,  and  other  minor 
operations. 

Is  it  probable  that  the  presence  of 
pain  forms  the  condition  of  safety  ? 
that  the  greater  part  of  its  power  is 
expended  on  altering  that  state  of  the 
nervous  system  under  which  pain  is 
felt?  If  such  be  in  any  degree  the 
truth,  the  objections  to  its  cautious  use 
in  midwifery  and  some  other  cases  are 
much  shorn  of  their  force. 

I  would  with  great  deference  submit 
that  the  fact  of  the  pain  of  childbirth 
being  “one  of  the  general  conditions  of 
man,”  constitutes  no  valid  reason 
against  the  diminution  or  removal 
thereof,?/  it  can  be  done  safely;  the 
risk  of  life,  or  of  damage  to  the  consti¬ 
tution,  constitutes  the  only  valid  objec¬ 
tion,  and  this,  as  you  have  justly  re¬ 
marked,  occurring  in  only  one  in  ten 
thousand,  should  be  a  solemn  caution. 

The  use  of  opium  and  other  medicines 
in  midwifery — in  fact,  the  healing  art 
altogether— may  with  some  show  of 
reason  be  objected  to,  on  the  ground 
that  disease  and  pain  form  part  “  of 
the  general  condition  of  man.” 

Again,  there  are  few  among  the  most 
valuable  remedial  agents,  but  have  pro¬ 
duced  ill  effects  in  their  early,  or  by 
their  injudicious,  use;  and  while  it  is 
beyond  a  doubt  that  powerful  anaes¬ 
thetic  agents  have  been  in  too  many 
instances  rashly  and  unwisely  exhi¬ 
bited  for  a  trifling  pain,  or  no  pain  at 
all,  yet  I  think  it  will  be  admitted  that 
here,  as  elsewhere,  the  abuse  of  a  thing 
is  no  argument  against  its  use.  Fur¬ 
ther  experience  is  required  to  enable  us 
to  draw  distinctly  the  line  of  separation 
for  every  case. 

Holloway,  July  1848. 


REMARKS  ON  THE 

PHYSIOLOGICAL  CONNECTION 

OF  THE 

SPINAL  ACCESSORY  NERVE 

WITH  THE 

POSTERIOR.  ROOTS  and  GANGLIA. 
OF  THE  SPINAL  NERVES. 

By  John  Denis  Macdonald, 
Student  of  King’s  College,  London. 


Preparatory  to  the  following  obser¬ 
vations,  it  will  be  necessary  to  give  a, 
brief  outline  of  the  anatomy  of  the 
parts  to  which  they  refer,  but  more 
especially  as  relates  to  the  postericr 
roots  and  ganglia  of  the  spinal  nerves, 
one  or  two  points  merit  notice,  which 
have  hitherto  been  either  very  lightly 
considered  in  anatomical  works,  or  not 
mentioned  at  all.  The  posterior  roots 
consist  of  much  largerfasciculi  than  the 
anterior,  and,  having  a  more  extended 
origin  from  the  side  of  the  cord,  they 
leave  very  small  spaces  between  them 
as  compared  with  the  anterior  :  indeed, 
in  some  instances,  they  scarcely  exceed 
the  intervals  between  the  fasciculi  of 
the  roots  themselves.  Upon  each  pos¬ 
terior  root  is  developed  a  ganglion, 
upon  which  the  anterior  seems  to  lie 
only  in  contact  :  for  the  present  pur¬ 
pose  they  will  be  considered  as  ner¬ 
vous  centres,  simply  consisting,  in 
this  case,  of  grey  nervous  matter 
entangled  in  a  nodular  interlacement 
of  nerve-tubes.  Not  only  is  there 
this  apparent  approach  to  a  conti¬ 
nuity  of  the  posterior  roots  in  a  linear 
series,  but  there  also  exists  a  num¬ 
ber  of  well-defined  nervous  filaments, 
which  occupy  the  angular  spaces  be¬ 
tween  the  roots  and  ganglia:  they  may 
be  traced  as  commissural,  first  between 
the  ganglia  and  cord,  and  secondly 
between  the  ganglia  themselves  :  the 
usual  arrangement  is,  that  a  con¬ 
siderable  trunk,  which  generally  lies 
at  the  under  edge  of  each  root,  springs 
from  the  cord,  and  sooner  or  later 
divides  into  two  branches,  which  may 
be  traced  into  the  ganglia,  above  and 
below,  enveloped  at  this  point  by  a 
distinct  fibrous  sheath ;  while,  con¬ 
necting  these  branches  with  one 
another,  is  a  bundle  which  acts  as  a 
commissure  to  the  pair  of  ganglia  be- 


POSTERIOR  ROOTS  AND  GANGLIA  OF  THE  SPINAL  NERVES.  247 


tween  which  it  is  placed,  and  into 
which  both  its  extremities  can  be 
traced.  The  spinal  accessory  nerve 
may  be  seen  to  arise  by  a  very  delicate 
filament  from  the  side  of  the  cord 
between  the  fifth  and  sixth  cervical 
nerves,  and  in  the  space  bounded  in 
front  by  the  ligamentum  dentatum, 
and  behind  by  the  posterior  roots  of 
those  nerves,  but  much  nearer  the 
latter* 

This  small  filament  lies  at  first 
parallel  with  the  cord,  and  embedded 
in  its  substance;  it  next,  at  the  point 
of  origin  of  the  fifth  nerve,  emerges 
from  the  cord  lying  between  it  and 
the  pia  mater,  which  last  begins  to  en¬ 
velope  it  about  this  point;  it  soon 
afterwards  receives  a  number  of  minute 
radicles  from  the  neighbouring  parts 
of  the  cord,  and  others  from  the  poste¬ 
rior  roots  of  the  spinal  nerves  :  it  gra¬ 
dually  augments  in  bulk  as  it  proceeds 
upwards,  outwards,  and  forwards  ;  the 
filaments  of  origin  increasing,  both  in 
number  and  size,  from  below  upwards. 
It  is  by  no  means  true  that  the  spinal 
accessory  is  limited  in  its  origin  to  the 
middle  line  of  the  latteral  region  of 
the  cord,  for  many  radicles  may  be 
traced  backwards  from  this  line  to  the 
emerging  point  of  the  posterior  roots 
of  the  nerve,  and  forwards  beneath  the 
ligamentum  dentatum;  towards  the 
anterior  these  two  orders  of  filaments 
generally  unite  in  pairs,  forming  larger 
bundles  which  join  the  common  trunk 
on  its  inner  side.  The  anatomical 
connections  of  this  nerve,  especially 
with  the  posterior  roots  of  the  cervical 
nerves,  are  very  remarkable.  There  is 
a  ligamentous  structure  which  borrows 
a  tubular  envelope  from  the  invest¬ 
ments  of  the  nerve  within  the  theca, 
which  seems  not  only  to  tie  it  down  to 
the  dura  mater,  just  above  the  poste¬ 
rior  root  of  the  second  spinal  nerve 
between  it  and  the  dentiform  process 
immediately  above,  but  to  perforate  the 
dura  mater  at  this  point,  and  become 
connected  with  the  cellular  tissue  about 
the  arteria  vertebralis ;  it  is  probable 
that  some  nervous  filaments  pass  out 
th  rough  this  tube  to  be  distributed  ex¬ 
ternally. 

The  spinal  accessary  nerve,  from 
this  extensive  origin  in  the  neck, 
enters  the  cranium  by  the  foramen 
magnum,  and  passing  beneath  the 
vertebral  artery,  it  joins  the  other  divi¬ 
sions  of  the  eighth  pair  of  cerebral 


nerves,  of  which  it  forms  part,  and 
emerges  with  them  from  the  skull  by 
the  foramen  lacerum  posterius ;  it  be- 
becomes  intimately  united  with  the 
par  vagum,  and,  indeed,  gives  off  a 
very  distinct  bundle  of  filaments, 
which  may  be  traced  descending  with 
that  nerve,  and  is  no  doubt  distributed 
with  it.  on  the  mucous  membrane  of 
the  air  passages;  while  the  trunk  of  the 
accessary  nerve  itself,  after  piercing 
the  sterno-mastoid  muscle,  is  supplied 
to  the  trapezius  over  the  acromion  pro¬ 
cess.  This  brief  sketch  will  be  quite 
sufficient  for  the  purpose  of  pointing 
out  a  very  ingenious  explanation  of 
the  functions  of  this  nerve  put  forward 
by  Dr.  Todd  and  Mr.  Bowman,  with 
the  view7  also  of  accounting  for  its 
singular  and  extended  mode  of  origin 
from  the  cord. 

They  suppose,  with  Bell,  that  this 
nerve  plays  an  important  part  in  the 
respiratory  process,  but  consider  that 
the  two  portions  above  described  fulfil 
each  a  distinct  office  from  the  other — 
viz.,  that  that  portion  which  seems  to 
be  distributed  on  the  pulmonary  mu¬ 
cous  membrane  with  the  pneumo  gas¬ 
tric  nerve,  is  afferent  or  excitory  in 
its  function  ;  while  the  other  divi¬ 
sion,  which  is  supplied  to  the  sterno- 
mastoid  and  trapezius  muscles,  is 
efferent  or  motor,  so  that  any  stimu¬ 
lus  applied  to  the  surface  of  the  air- 
passages  is  propagated  along  the  ex- 
citor  portion,  which,  by  its  large  con¬ 
nection  with  the  respiratory  tract  of 
the  cord,  induces  a  reflex  action  in  the 
motor  portion  of  the  same  nerve,  and 
also  in  the  other  nerves  which  have  an 
immediate  connection  with  this  part. 
The  influence  of  the  motor  portion  of 
the  spinal  accessary  nerve  in  the  func¬ 
tion  of  respiration  is  manifest  when 
the  action  of  the  muscles  which  it  sup¬ 
plies  is  taken  into  account:  their  chief 
operation  is  to  elevate  and  fix  the 
whole  shoulder;  and  consequently  all 
the  inspiratory  muscles  connected  with 
the  bones  comprising  it — viz.,  the  sub- 
clavius,  greater  and  lesser  pectoral, 
serratus  magnus,  and  latissimus  dorsi — 
can  act  more  effectively  in  an  extra¬ 
ordinary  effort.  Now,  embracing  the 
very  beautiful  idea  above  mentioned, 
may  not  impressions  be  received  by 
the  excitor  portion  of  the  spinal  acces¬ 
sary,  and  propagated  not  only  to  the 
respiratory  tract  of  the  cord,  but  also, 
by  means  of  the  commissural  filaments 


248  the  registrar-general’s  quarterly  return  of  mortality. 


previously  described,  from  ganglion  to 
ganglion  of  the  spinal  nerves,  and 
thereby  from  one  segment  of  the  cord 
to  another:  so  that  an  extensive  reflex 
action  may  be  induced  in  all  the  motor 
nerves  of  the  cord, — manifesting  such 
phenomena  as  occur  during  suffo¬ 
cation,  or  the  inhalation  of  noxious 
and  stimulating  vapours  ?  In  this  way 
a  very  satisfactory  explanation  of  the 
use  of  the  ganglia  is  afforded,  different 
from  any  hitherto  advanced.  They 
seem,  according  to  this  view,  to  act  as 
centres,  each  of  which  receive  impres¬ 
sions  (eitherdirectly conveyedtoit  byits 
own  proper  sentient  nerve,  or  indirectly 
from  other  nerves  by  means  of  the 
neighbouring  ganglia),  and  propagate 
them  to  the  cord  from  which  reflex 
actions  originate.  And  further,  the 
roots  of  the  nerves  being,  as  it  were, 
commissural  between  the  ganglia  and 
cord,  serve  to  carry  impressions  to  the 
latter  from  distant  parts  in  the  manner 
above  explained,  independent  of  any 
influence  derived  from  the  nervous 
trunks  to  which  they  give  rise. 


PRECAUTIONS  IN  THE  TREATMENT  OF 
FEVER. 

Knowing  what  organic  lesions  may  exist, 
we  should  hesitate  and  feel  our  way  before 
adopting  any  plan  of  treatment  which  might 
call  up  symptoms  at  present  latent.  But 
we  must  go  further :  a  patient  presenting 
inflammation  of  some  organ,  as  of  the  lungs, 
with  obscurely  marked  constitutional  symp¬ 
toms,  must  be  treated  very  cautiously  ;  for 
behind  this  inflammation,  fever  may  be  going 
on,  which  it  might  cost  the  patient  his  life 
to  unmask  by  ordinary  treatment  directed  to 
subdue  the  inflammation.  And  further  yet : 
we  must  not  always  expect  definite  dis¬ 
ease  of  some  important  organ  to  tell  us 
that  the  patient  is  really  very  ill,  and  to 
put  us  on  our  guard.  It  is  only  a  part  of 
the  treatment  of  fever,  which  regards  it  as 
characterized  by  its  own  unmistakeable 
signs  :  we  must  be  prepared  to  recognise  it, 
and  its  organic  results,  though  the  latter 
can  only  be  surmised  to  exist,  and  itself 
appear  to  have  passed  away  and  left  only 
simple  weakness  :  to  fear  it  again  where 
simple  weakness  seems  to  mask  the  symp¬ 
toms  of  ordinary  disease,  and  to  look  beyond 
this  weakness  itself,  if  it  be  the  only  obvious 
symptom,  so  as  to  catch  the  earliest  indica¬ 
tions  of  latent  fever ;  for  fever  and  weakness 
become  truly  commensurate  terms  only  when 
all  treatment  has  to  give  way  to  the  simple 
indication  of  obviating  the  present  tendency 
to  death. —  Ormercd’s  Clinical  Observations 
on  Fever, 


MEDICAL  GAZETTE 


FRIDAY,  AUGUST  11,  1848. 

The  Quarterly  Return  of  the  Registrar- 
General  is  of  especial  interest  at  the 
present  time,  when  there  is  great  reason, 
to  apprehend  that  the  inhabitants  of 
this  country  may  be  again  exposed  to 
the  attacks  of  the  Asiatic  cholera. 
About  three  weeks  since  we  ventured  to 
hint  that  the  health  of  the  metropolis 
was  in  a  favourable  state,  and  that  there 
was  no  indication  of  the  fatal  preva¬ 
lence  of  those  disorders  which  are 
usually  regarded  as  the  forerunners  of 
this  formidable  disease.  The  return  of 
the  mortality  for  the  quarter  ending 
June  30th,  is  on  the  whole  reassuring. 
The  Registrar  remarks — 

“  It  is  gratifying  to  observe  a  very 
remarkable  improvement  in  the  state 
of  the  public  health.  The  number  of 
deaths  registered  in  the  three  months 
ending  June  30,  was  46552;  which  is 
less  by  11 158  than  were  registered  in 
the  winter  quarter  of  the  present  year, 
and  less  by  5033  than  were  registered 
in  the  corresponding  quarter  ending 
the  last  day  of  June,  1847.  The  mor¬ 
tality  of  the  country,  after  having  been 
excessively  high  during  the  latter  half 
of  the  year  1846,  the  whole  of  1847, 
and  the  first  quarter  of  1848,  is  now 
little  above  the  average  of  the  nine 
years  1839  47-  The  mortality,  how¬ 
ever,  is  still  much  higher  than  it  was 
in  the  spring  quarter  (April,  May,  and 
June),  of  1844,  when  the  number  of 
deaths  was  only  38977  ;  which,  taking 
the  increase  of  population  into  account, 
implies  a  lower  rate  of  mortality  than 
has  been  experienced  in  the  spring 
season  of  any  other  year. 

In  London  the  deaths  in  the  quarter 
were  12945 ;  the  deaths  in  the  preced¬ 
ing  quarter  were  16455  ;  in  the  quarter 
ending  December,  1847,  when  influenza 
prevailed,  19605.  Influenza  has  almost 
disappeared  :  it  was  the  cause  of  death 
in  only  50  cases  during  the  13  weeks 
ending  in  June.  Small-pox  was  fatal 
to  38 i  persons  in  London  ;  measles  to 
306 ;  scarlatina  to  816 ;  hooping-cough 


.YTTJATHOM  “40  MflUTaH  yjiJ3TffAl  <)HH  a HT  fUj 

THE  REGISTRAR-GENERAL  S  QUARTERLY  RETURN  OF  MORTALITY.  249 


to  441;  purpura  and  scurvy  to  12; 
typhus  to  882;  erysipelas  to  129. 
Small-pox ,  scarlatina ,  and  typhus,  were 
prevailing  epidemics  in  London.  Scar¬ 
latina  in  one  week  destroyed  107  lives. 
Typhus  was  at  a  maximum  (1279)  in 
the  last  quarter  of  the  year  1847:  it  is 
now  declining;  but  it  prevails  in¬ 
variably  longer  in  the  epidemic  form 
than  other  diseases  of  the  class.  The 
diseases  of  the  tubercular  class — namely, 
scrofula,  tabes,  consumption,  and  hy¬ 
drocephalus,  fluctuate  very  little ;  to 
them  2640  deaths  were  ascribed  in  the 
J*une  quarter  of  1841,  and  2403  in  the 
June  quarter  of  1848;  which  were  the 
highest  and  lowest  numbers  returned 
in  the  8  years  1841-8.  Diseases  of  the 
lungs  declined  rapidly ;  they  were  the 
cause  of  176  deaths  in  the  first  wreck, 
and  of  76  deaths  in  the  last  w  eek  of  the 
quarter. 

“The  deaths  in  London  from  diar¬ 
rhoea,  dysentery,  and  cholera,  were 
11,  23,  13,  and  14,  in  the  first  four 
weeks;  27,  31,  37,  and  51  in  the  last 
four  weeks  of  the  quarter.  The  mor¬ 
tality  from  these  diseases  is  somewhat 
higher  than  it  was  in  the  correspond¬ 
ing  weeks  of  1847.  The  deaths  ascribed 
to  cholera  in  the  June  quarters  of  the 
eight  years  1841-8,  were,  1.  7,  8,  9,  2, 
9,  4,  17;  in  the  last  year,  therefore, 
though  the  deaths  are  not  numerous, 
there  is  a  slight  excess.  These  three 
diseases  are  always  most  common  in 
the  three  months  of  July,  August,  and 
September,  when  the  temperature  is 
highest.” 

We  find  in  this  report  some  remarks 
on  the  Asiatic  cholera,  which,  as  they 
are  of  immediate  interest,  we  here 
transcribe : — 

“  There  is  as  yet  in  England  no 
trace  of  the  epidemic  of  cholera  whicli 
is  ravaging  Russia,  from  Moscow  to 
St.  Petersburgh,  and  ascending  the 
Danube.  It  raged  in  the  summer  of 
1831,  seventeen  years  ago,  at  St. 
Petersburgh,  reached  Sunderland  in 
October,  London  in  February  1832, 
Paris  in  March  of  the  same  year. 
Whether  it  will  pursue  the  same  course 
now,  travel  at  the  same  rate,  and  be 
less  or  more  fatal,  must  depend  on  a 
variety  of  circumstances.  If  the  visi¬ 
tation  cannot  be  arrested,  it  is  greatly 
to  be  wished  that  it  should  be  deferred  ; 
lor  though  enlightened  communities 


have  before  been  too  much  in  the 
habit  of  postponing  sanatory  arrange¬ 
ments,  and  only  commencing  them 
when  .the  plague  is  actually  destroy¬ 
ing -them, — which  is  very  like  admitting 
the  enemy  within  the  city  walls  and 
then  putting  the  fortifications  in  re¬ 
pair,  —  it  is  certain  that  the  great 
capitals  of  the  continent  were  never  in 
a  worse  condition  to  withstand  an 
epidemic  than  they  are  at  the  present 
time.” 

*  *  *  * 

“  It  is  not  easy  to  determine  from 
the  vague  terms  employed  in  the  let¬ 
ters  and  papers  from  St.  Petersburgh, 
whether  cholera  is  now  more  or  less 
fatal  than  it  was  in  the  former  epi¬ 
demic,  which  began  on  June  14,  1831, 
and  ended  in  April  1832;  attacked 
13905  persons,  and  was  fatal  to  9696  in 
that  city.*  It  is  usual  in  this  country, 
in  speaking  of  the  population  of  St.  Pe¬ 
ters  burgh,  to  refer  to  the  province, 
which,  according  to  an  official  return 
made  by  the  Russian  Government,  had 
in  1842  a  population  of  465791,  or 
229427  males,  236364  females,  on  an 
area  of  15087  English  square  miles — an 
area  equal  to  more  than  one-fourth  part 
of  the  area  of  England  and  Wales 
(57,812  square  miles).  The  mortality 
of  this  province  was  4*417  per  cent, 
among  males,  3*770  per  cent,  among 
females  in  1842.  The  province  of  Pe- 
tc-rsburgh  contains  nine  large  districts, 
the  district  of  Petersburgh  proper  con¬ 
tained  only  28,911  inhabitants:  15519 
males,  13392  females,  among  whom  the 
deaths  in  1842  were  833  males,  628 
females. 

“  The  government  or  province  of 
Moscow — on  an  area  of  11688  English 


*  The  deaths  in  Petersburgh  up  to  July  12th 
of  the  present  year  were  7623.  This  would  imply 
a  much  higher  mortality  than  that  experienced 
in  the  first  epidemic.  Little  dependence,  how¬ 
ever,  can  be  placed  upon  returns,  or  upon  any¬ 
thing  else  commenced  in  the  midst  of  the  conster¬ 
nation  which  an  epidemic  occasions.  It  is  highly 
desirable  that  all  the  great  cities  in  Europe 
should  publish,  at  all  times,  such  weekly  state¬ 
ments  of  the  mortality  and  cause  of  death  as 
now  appear  in  London.  They  should  be  com¬ 
menced  before  any  epidemic  breaks  out.  Such 
tables  have  been  published,  however  imperfectly, 
in  London  ever  since  the  reign  of  Queen  Eliza¬ 
beth  ;  and  were  begun  at  the  suggestion  of  the 
able  statesmen  by  whom  she  was  surrounded. 
When  simultaneous  observations  are  recorded  on 
an  extended  scale,  it  will  be  possible,  with  the 
assistance  of  a  body  of  trained  Health  Officers, 
to  determine  the  singular  laws  which  regulate 
the  diffusion  of  zymotic  diseases.— Reg. 


250  THE  REGISTRAR-GENERALS  QUARTERLY  RETURN  OF  MORTALITY. 


square  miles — bad  in  1842,  1398977 
inhabitants  —  740517  males,  658460 
males  :  the  deaths  among  males  were 
26648,  females  26407,  in  1842;  the 
mortality  of  males  was  3.599  per  cent., 
of  females  4.010  per  cent.  The  district 
of  Moscow  had  455644  inhabitants 
(with  which  it  is  usual  to  compare 
very  erroneously  the  population  of  the 
province  of  St.  Petersburgh)  :  the  males 
were  275328,  females  180316 ;  the 
deaths  of  males  6950,  females  6678,  in 
1842.  The  mortality,  in  1842,  of  fe¬ 
males  in  the  province  of  Moscow  was 
4.010  per  cent.;  of  females  in  the  dis¬ 
trict  of  Petersburgh  4.689  ;  the  mor¬ 
tality  of  females  in  London  within  the 
Tables  of  Mortality  in  the  same  year 
was  2.220.  Petersburgh  and  Moscow 
are  in  nearly  the  same  sanatory  condi¬ 
tion  as  London  was  in  the  17th  and 
18ih  centuries;  and  under  any  circum¬ 
stances  the  mortality  from  cholera  in 
London,  or  in  the  other  cities  of  the 
United  Kingdom,  will  probably  not 
approach  the  mortality  in  Petersburgh, 
where  the  mortality  was  raised  84  per 
cent,  in  1831-2,  when  the  church 
burials  in  London  were  raised  from 
38794  in  1831  to  43082,  or  11  per  cent. 
The  deaths  in  Paris  were  raised  by 
cholera  from  31115,  in  1831  to  53382,  in 
1832,  nearly  72  per  cent.  18602  deaths 
were  ascribed  to  cholera  in  the  official 
returns.  The  scanty  supply  of  water, 
the  bad  drainage,  the  filthy  state  of  the 
privies  (which  can  scarcely  be  con¬ 
ceived),  the  wretchedness  of  the  poor, 
who  have  no  poor  law  to  fall  back 
on,  sufficiently  account  for  the  devas¬ 
tation  of  cholera  in  Paris  sixteen  years 
since ;  and  sanatory  improvement  is, 
unfortunately,  one  of  those  practical 
questions  which,  not  appealing  to  the 
imagination,  has  hitherto  attracted 
little  public  attention  in  France. 

The  table  of  metropolitan  mortality 
shows  a  great  increase  in  the  deaths 
from  zymotic  diseases  during  the  last 
quarter.  This  increase  is  especially 
observable  under  scarlatina  and  typhus. 
If  we  take  the  June  quarters  of  the 
two  preceding  years,  we  have  the  fol- 


lowing  results ; — 
Deaths  from 

1846. 

1847. 

1848. 

Small  Pox  .  . 

87 

181 

381 

Measles  .  .  . 

163 

277 

306 

Scarlatina .  .  . 

177 

174 

816 

Typhus  .  .  . 

364 

568 

882 

With  respect  to  diarrhoea  and  cho¬ 
lera,  we  have  the  following  compara¬ 
tive  amount  of  mortality  :  — 

Deaths  from.  1846.  1847-  1848. 

Diarrhoea  .  .  .  153  202  239 
Cholera  ...  9  4  17 

The  return  of  the  week  ending  July 
29th,  indicates  a  sudden  increase  of 
deaths  from  these  diseases,  which  may 
be  merely  a  result  of  some  temporary 
changes  in  the  temperature  and  hygro- 
metric  condition  of  the  atmosphere. 
There  is  nothing  in  this  report  to  con¬ 
firm  the  rumour  that  cases  of  Asiatic 
cholera  have  already  appeared  in  va¬ 
rious  parts  of  the  metropolis. 


In  the  Parliamentary  debates  we  have 
seldom  met  with  an  official  statement, 
regarding  the  Asiatic  cholera,  more 
calculated  to  excite  alarm  than  that 
made  by  Lord  Morpeth  on  Monday 
night  in  the  House  of  Commons.  His 
•Lordship  was  desirous  of  neutralizing 
the  effect  of  a  most  injudicious  altera¬ 
tion  which  had  been  made  in  the 
Public  Health  Bill.  There  was  reason 
enough  to  support  his  views  without 
bringing  in  the  Consular  correspon¬ 
dence  on  the  cholera  ;  but  this  appears 
to  have  been  employed  as  a  heavy 
battery  to  demolish  at  once  the  argu¬ 
ments  of  all  objectors.  It  is  not  our 
desire  that  there  should  be  any  conceal¬ 
ment  of  the  truth  :  but  then  we  should 
have  the  whole  truth  ;  and  we  very 
much  question  whether  letters  written 
by  foreign  Consuls,  under  the  excite¬ 
ment  and  fear  occasioned  by  the  sud¬ 
den  irruption  of  a  formidable  disease, 
can  be  trusted  as  true  exponents  of  the 
facts.  Fear  is  one  of  the  great  predis¬ 
posing  causes  to  an  attack  of  cholera  : 
and  the  statement  of  Lord  Morpeth 
appears  to  us  to  be  well  calculated  to 
excite  a  general  panic.  Let  our  medi¬ 
cal  readers  consider  what  is  likely  to 
be  the  effect  of  the  following  letter, 
read  publicly  on  Monday  last  by  his 
Lordship  laoonoo  oJ  off 


OFFICIAL  STATEME  NT  ON  THE  PROGRESS  AND  MORTALITY  OF  CHOLERA.  251 


The  latest  communication  received 
on  the  subject  was  a  second  despatch 
from  Mr  Fonblanque,  dated  July  9:  — 

“  Belgrade,  July  9. 

“  Sir,  —  A  letter  from  the  small 
town  of  Graditza,  on  the  Danube, 
about  twenty  leagues  hence,  states — 

‘“The  cholera  has  appeared  in  a 
dreadful  form  ;  we  have  heard  of  no 
recoveries,  and  most  of  the  cases  ter¬ 
minated  fatally  within  twelve  hours. 

“  ‘  A  healthy  woman  while  occupied 
in  cooking,  was  attacked  by  agoniz¬ 
ing  cramps  in  the  limbs,  which  brought 
her  to  the  ground  in  an  instant;  her 
skin  became  blue  and  cold,  and  in  less 
than  five  minutes  she  expired.  Two 
men  in  the  next  village  died  almost  in¬ 
stantaneously  ;  their  bodies  all  blue, 
and  their  knees  drawn  up  to  their  sto¬ 
machs.  Every  hour  we  see  corpses 
carried  out  for  interment,  it  being  im¬ 
possible  to  keep  them  .until  the  next 
day.’  I  am,  sir, 

“  T.  de  G.  de  Fonblanque. 

“  John  Bidwell,  Esq.” 

This  is  bringing  up  the  heavy  artil¬ 
lery  with  a  vengeance  to  batter  down 
the  trivial  objections  of  the  few  un¬ 
reasonable  opponents  of  the  Public 
Health  Bill.  In  the  whole  statement 
there  is  not  a  spark  of  consolation — 
not  even  a  ray  of  hope  to  the  timid. 
Here  is  a  woman  attacked  while  cook¬ 
ing,  brought  to  the  ground  in  an  in¬ 
stant.  Her  skin  became  blue  and  cold, 
and  she  was  dead  in  five  minutes  !  Our 
medical  readers  will,  we  think,  agree 
with  us  in  rejecting  this  case  as  a  gross 
exaggeration;  but  admitting  it  to  be 
true,  it  is  preposterous  to  suppose 
that  a  Public  Health  Bill,  aided  by 
all  the  appliances  of  medical  art  and 
skill,  can  by  any  possibility  prevent 
the  occurrence  of  such  cases.  The 
probability  is  that  the  story  rests 
upon  hearsay  testimony,  and  is  un¬ 
worthy  of  belief :  it  is,  however,  likely 
to  have  a  most  injurious  effect  upon 
the  public  mind.  His  lordship  shall 
now  speak  for  himself. 

“  It  was  far  from  his  wish  to  excite 
undue  alarm  on  the  subject  of  the  cho¬ 
lera  ;  but  he  would  not  be  acting  a  fair 
and  friendly  part  to  the  public,  were 
he  to  conceal  the  fact  that  it  had  been 


ascertained  that  the  cholera  was  ad¬ 
vancing  in  precisely  the  same  direction 
as  that  which  it  pursued  in  1832— that 
it  had  been  heralded  in  this  country  by 
the  same  precursor  as  on  the  foimeV 
occasion— namely,  a  great  amount  of 
influenza,  which  prevaileda  few  months 
ago,  and  by  a  great  increase  of  diar¬ 
rhoea,  ending  fatally  in  many  cases*, 
now  prevalent — and  that  by  recent  ac¬ 
counts  it  has  spread  as  far  west  as 
Riga,  Narva,  and  Revel.  It  would  be 
most  gratifying  to  his  feelings  to  be 
able  to  state  that  this  frightful  visita¬ 
tion  was  approaching  us  in  a  more  mild 
form  than  that  under  which  we  had  al¬ 
ready  had  dreadful  experienceof  its  mor¬ 
tal  effects  ;  but  unfortunately  lhat  was 
not  the  case,  as  would  appear  from  the 
communications  received  from  our 
Ministers  and  Consuls  abroad,  some 
of  which  he  would  take  the  liberty 
of  reading  to  the  house.  A  return 
of  the  casualties  from  cholera  at 
St.  Petersburgh  to  the  latest  date, 
July  24,  gave  the  following  results  :  — 
cases,  1 7,74i  ;  deaths,  10,138;  cures, 
4,618;  under  treatment,  1,986.  Pro¬ 
portions  per  100 -deaths,  57;  cures, 
26;  under  treatment,  17.  At  Moscow 
the  cases  were  9,754;  deaths,  4,309.” 

Now  what  we  complain  of  here  is, 
that  we  have  not  the  whole  truth. 
Lord  Morpeth  appears  to  forget  entirely 
that  London  is  not  St.  Petersburgh, 
and  that  the  mortality  from  cholera  in 
one  city  cannot  be  taken  to  represent 
the  mortality  from  the  disease  which 
is  likely  to  occur  in  the  other.  His 
lordship  appears  to  us,  however,  to  be 
strangely  inaccurate  in  his  statements. 
On  his  own  showing,  the  deaths  from 
cholera  in  St.  Petersburgh,  according 
to  the  latest  return  (July  24),  have 
been  only  5 7  per  cent.  If  our  readers 
will  refer  to  the  preceding  article  they 
will  find,  from  the  calculations  of  the 
Registrar  General,  that  the  deaths  in 
St.  Petersburgh  when  cholera  is  not 
present,  are  more  than  double  of  those 
which  occur  in  this  country.  Thus, 
in  1842,  the  deaths  were  from  37  to  44 
in  1,000;  while  Lord  Morpeth  stated 

*  The  fatal  cases  are  chiefly  among-  infants, 
which  are  comparatively  exempt  from  attacks  of 
cholera.  Out  of  141  fatal  cases  of  diarrhoea  last 
week,  117  were  under  five  years  of  ag'e ! 


252 


INDICES  TO  PERIODICALS. 


n  Monday  night,  just  before  making 
his  startling  exposition,  that  for  all 
England  and  Wales  they  were  not 
more  than  21  to  1,000  of  the  popula¬ 
tion!  In  183*1-2,  i  e.  during  the  pre¬ 
valence  of  cholera,  the  mortality  in 
St.  Petersburgh  was  raised  to  84  per 
cent.;  while  in  London  it  was  raised 
not  more  than  11  per  cent.,  or  about 
one  eighth  of  the  St.  Petersburgh  mor¬ 
tality  !  If  we  add  the  present  mor¬ 
tality  from-  cholera  (5 7  per  cent.) 
to  the  average  deaths  in  St.  Peters- 
burgh,  it  will  fall  far  short  of 
the  rate  of  increase  (84  per  cent.) 
assigned  by  the  Registrar  General 
to  the  Russian  cholera  of  1831-2. 
In  fact,  it  will  not  make  more  than 
61  per  cent.  On  what  pretence,  there¬ 
fore,  could  his  Lordship  assert  that  the 
cholera  was  approaching  us  in  a  more 
alarming  and  more  frightful  form  ? 
Figures,  upon  which  we  think  full  re¬ 
liance  may  be  placed,  prove  that  it  has 
not  even  increased  the  St.  Petersburgh 
mortality  to  the  amount  of  1831-2.  In 
giving  this  awful  account  of  the  pro¬ 
portionate  deaths  from  cholera  in  the 
Russian  capital,  his  Lordship  should 
have  told  his  panic-stricken  hearers 
that  these  figures  did  not  fairly  repre¬ 
sent  the  probable  mortality  from  the 
disease  in  this  country;  that  at  all 
times  the  deaths  were  twice  as  nume¬ 
rous  in  St.  Petersburgh  as  in  England 
and  Wales;  and  that  in  the  former 
visitation  of  cholera  nearly  eight  per¬ 
sons  died  in  that  capital  when  one  only 
died  from  cholera  in  London.  We  have 
a  great  desire  that  the  Public  Health 
Bill  should  be  enacted  into  a  law  ;  but 
we  deprecate  any  attempt  to  procure 
this  object  by  an  appeal,  founded  on 
an  insufficient  acquaintance  with  facts, 
to  the  fears  of  the  public. 


We  elsewhere*  insert  a  good-humoured 
letter  from  a  correspondent,  imputing 


to  us  a  charge  of  inconsistency,  because 
we  have  strongly  advocated  the  neces¬ 
sity  of  publishing  at  certain  intervals 
general  indices  to  periodicals.  We 
have  praised  in  a  contemporary,  the 
execution  of  a  task  which  we  have 
omitted  to  perform  with  respect  to 
our  own  journal,  although  our  argu¬ 
ment  goes  to  shew  that  a  general 
index  is  even  more  urgently  required 
for  the  Medical  Gazette  than  for  the 
British  and  Foreign  Medical  Re¬ 
view.  Now  we  are  quite  willing  to 
concede  that  our  friendly  monitor,  Mr. 
Jones,  is  justified  in  drawing  the  in¬ 
ference  that  the  old  series  of  our 
journal  urgently  requires  a  General 
Index;  and  we  are  equally  ready  to 
adopt  his  advice — i.  e.  “  of  taking  a 
lesson  from  our  own  words  in  future,” 
and  be  careful  how  we  praise  others 
for  that  which  may  appear  a  crime 
of  omission  on  our  own  part.  There 
is,  however,  one  little  proviso  which 
must  not  be  lost  sight  of.  Every 
question  has  two  sides  ;  and  some 
questions,  according  to  the  views  of 
ingenious  barristers,  may  have  three  or 
even  four.  Mr.  Jones  tells  us  totidem 
verbis , — “  I  am  sure  your  subscribers 
would  most  cheerfully  pay  amply  for 
it  as  a  distinct  publication  from  the 
journal.”  We  fully  recognize  the  ne¬ 
cessity  and  value  of  such  an  index, 
to  render  the  valuable  information 
contained  in  about  forty  volumes  of 
this  journal  easily  accessible  to  practi¬ 
tioners;  but  its  compilation  would  in¬ 
volve  a  large  amount  of  labour,  and  en¬ 
tail  upon  the  proprietors  of  the  journal, 
considerable  expense.  Such  a  work 
can  only  be  fairly  undertaken  by  sub¬ 
scription  ;  and  we  have  to  announce 
to  Mr,  Jones  and  others  who  have  ad¬ 
dressed  us  on  the  subject  that  a  list  is 
now  opened  with  the-  printers,  Messrs. 
Wilson  and  Ogilvy,  who  will  receive 
the  names  of  those  gentlemen  who 
may  be  desirous  of  becoming  subscribers 
to  a  General  Index  to  the  old  series  of 
the  London  Medical  Gazette.  This 
will  put  to  the  test  Mr.  Jones’s  predic¬ 
tion.  We  only  require  to  be  assured 
that  a  sufficient  number  of  our  sub¬ 
scribers  take  the  same  view  of  the 
subject  as  that  advanced  by  our  corre¬ 
spondent,  in  order  to  commence  the 
preparation  of  a  General  Index. 


*  Page  256. 


MATERNAL  MANAGEMENT  OF  CHILDREN  IN  HEALTH  AND  DISEASE.  253 


&ebtefo£» 


The  Maternal  Management  of  Children 
in  Health  and  Disease.  By  Thomas 
Bull,  M.D.,  Member  Roy.  Coll,  of 
Physicians,  &c.  3d  edition,  care¬ 
fully  revised,  and  considerably  en¬ 
larged  ;  pp.  400.  Longman  and  Co. 
1848. 

The  maternal  management  of  children 
concerns  those  early  hours  in  the 
starting  point  of  one’s  existence  which 
stamp  our  future  character  in  mind 
and  body,  in  health  and  disease.  It 
takes  the  precedence  of  all  other 
sciences,  for  it  is  impossible  to  con¬ 
ceive  an  office  more  important  in  the 
social  system,  a  duty  more  onerous  in 
its  undertaking,  or  a  sense  of  gratifica¬ 
tion  more  permanent  in  its  results, 
than  the  proper,  or  rather  the  scientific, 
management  of  children  and  infants. 
We  could  show  upon  very  substantial 
grounds  the  evils  that  follow  from  mis¬ 
management,  which  do  not  terminate 
where  they  have  begun,  in  the  nursery, 
nor  fail  to  bear  fruit  in  the  noon-day  of 
age  according  to  the  seed  that  has  been 
sown  in  the  twilight  of  our  years.  The 
end  of  our  lives  responds  to  their  be¬ 
ginning — the  effect  is  proportioned  to 
its  cause,  neither  can  the  effect  surpass 
its  cause.  For  the  moving  throng  of 
mankind  are  only  so  many  animated 
effects,  resulting  from  the  care  or  care¬ 
lessness  with  which  they  were  nur¬ 
tured  or  left  to  chance,  when  life  was 
young,  and  the  morning  of  their  days 
had  scarcely  dawned  upon  their  senses. 
Were  it  possible  to  impress  this  grand 
truism  powerfully  on  the  minds  of 
mothers,  how  much  good  might  be 
achieved  that  is  now  lost  for  ever 
through  inadvertence,  and  how  much 
evil  might  be  warded  off  that  is  now 
fostered  by  ignorance,  or  actually  en¬ 
grafted  by  a  prejudicial  perseverance 
in  erroneous  habits,  and  mistaken 
view's  of  right  and  wrong. 

Dr.  Bull  has  struck  out  a  path  for 
himself,  by  undertaking  to  give  in¬ 
struction  upon  the  very  subject  we  have 
just  alluded  to,  and  by  stepping  for¬ 
ward  to  teach  in  those  quarters  where 
the  teacher  is  most  required.  Trite  as 
the  title  of  his  book  may  sound,  ad¬ 
dressed  as  it  is  to  the  young  mother 
and  the  nurse,  there  is,  nevertheless,  a 
praiseworthy  intention  at  the  bottom 


|  of  it,  as  well  as  a  solid  reason,  which 
if  it  is  not  precisely  a  scientific  one,  is, 
at  least,  such  as  could  not  be  expressed 
except  by  a  scientific  person.  We  are 
accustomed  to  regard  nothing  but  lofty 
works  of  art  as  the  proper  effort  of 
genius,  which  appeals  to  the  select  few 
whose  talents  exalt  them  above  (he 
ordinary  race  of  mortals.  These  pro¬ 
ductions  are  the  splendid  lamps  of 
intelligence,  that  burn  only  in  the  halls 
of  the  initiated.  But  we  forget  the 
crowd  that  stands  without — the  young, 
the  feeble,  and  the  untutored.  It  is 
these  that  demand  the  master  and  the 
guide,  to  point  out  to  them  the  way 
they  should  go,  and  to  show  them  in 
what  manner  they  should  proceed. 
This  is  by  no  means  an  easy  task,  and 
requires  nothing  short  of  the  best 
talents.  Let  any  one  try  for  himself, 
and  he  will  discover  the  difficulty  of 
teaching  the  alphabet  of  his  own  lan¬ 
guage,  and  the  labour  of  instructing, 
we  will  not  say  an  obstinate,  but  a 
willing  child,  how  to  read.  Hie  labor , 
hoc  opus  est , — and  thankful,  indeed, 
ought  wTe  to  be  to  any  one  who  will 
bestow  the  time  and  patience  necessary 
for  the  accomplishment  of  it.  To  do 
common  things  well  is  no  mean  merit. 

It  is  the  third  edition  that  we  are 
now  noticing,  and  a  great  deal  of  new 
matter  has  been  added  to  it,  so  much 
so,  in  fact,  that  it  is  almost  anew  work. 
The  introductory  remarks  on  the  ex¬ 
tensive  mortality  of  children, — the  ge¬ 
neral  remarks  on  illness  (Chap.  IX.), 
and  on  the  prevention  of  scrofula  and 
consumption  (Chap.  XV.),  are  entirely 
new.  The  introductory  part  on  venti¬ 
lation  (Chap.  V.)  is  new.  Chapter  XII. 
is  wholly  re-written,  and  much  added 
to  it.  Twelve  new  sections  are  sub¬ 
joined  to  Chapter  XIV. ;  and  to  seve¬ 
ral  other  chapters,  as  well  as  through¬ 
out  the  book,  copious  additions  have 
been  made.  Dr.  Bull  evinces  an  ear¬ 
nest  desire  to  render  his  work  a  useful 
one.  To  give  information  of  the  gene¬ 
ral  management  of  children,  such  as 
every  mother  ought  to  possess,  together 
with  the  directions  for  the  domestic 
management  of  illness,  such  as  every 
right-minded  medical  man  would  be 
pleased  that  she  should  have  a  ready 
knowledge  of,  constitutes  the  leading 
idea  of  Dr.  Bull’s  book,  and  expresses 
the  character  which  it  professes  to  hold 
forth.  If  in  any  part  he  has  advanced 
beyond  this  cautious  line  (which,  how- 


254  M.  FLEURY  ON  THE  TREATMENT  OF  INCOMPLETE  AMAUROSIS. 

-  — - .  ..  _  .. _ _ _ _  . 


ever,  we  do  not  perceive  that  he  has 
done),  it  is  for  the  sake  of  those  mo¬ 
thers  without  a  medical  adviser  at 
hand,  as  he  states  in  his  preface ;  al¬ 
though  such  a  trespass  would,  in  our 
estimation,  only  tend  to  give  greater 
weight,  and  impart  a  still  higher  feel¬ 
ing  of  benevolence  to  his  efforts.  Me¬ 
dical  men  are  very  fastidious  on  these 
points ;  they  like  to  have  every  thing 
all  their  own  way.  The  young  practi¬ 
tioner  is  obviously  better  pleased  with 
an  ignorant  patient  than  with  an  expe¬ 
rienced  one;  while  the  old  physician 
betrays  a  sort  of  instinctive  horror 
against  the  growing  intelligence  of  the 
rising  generation,  lest  it  should  take 
him  by  surprise  and  push  him  from 
his  stool.  But  such  sentiments  are 
vain.  The  more  widely  real  know¬ 
ledge  is  diffused,  the  better  for  all  par¬ 
ties.  As  for  ourselves,  we  would  ra¬ 
ther  prescribe  for  a  highly  educated 
invalid  with  a  well-regulated  mind, 
than  for  a  sickly  patient  full  of  whims 
and  fancies;  and  to  prefer  the  con¬ 
trary,  is  to  append  a  libel  to  our  own 
understanding  and  acquirements.  Ex¬ 
perience  must  always  surpass  know- 
ledge  by  as  much  as  knowledge  sur¬ 
passes  ignorance. 

The  best  part  of  Dr.  Bull’s  work  is 
that  which  relates  to  prophylactics. 
At  the  present  moment,  when  so  much 
is  written  and  said  about  sanitary  re¬ 
form,  both  in  Parliament  and  out  of  it, 
little  mention  is  ever  made  of  the 
cordon  sanitaire,  so  highly  requisite  in 
every  well-ordered  household.  We 
have  reason  to  believe  that  neglect  and 
uncleanliness  in  the  preparation  of 
children’s  food  are  a  frequent  source  of 
disease.  A  practitioner  often  finds 
himself  bewildered  by  a  series  of  symp¬ 
toms,  the  source  of  which  may,  how¬ 
ever,  in  many  cases  be  traced  to  the 
employment  of  dirty  utensils,  or  to  the 
admixture  of  unwholesome  food  with 
the  daily  meal.  In  a  doubtful  case, 
therefore,  we  would  advise  him  not  to 
remain  content  with  the  statements  of 
attendants,  who  can  never  be  expected 
to  inculpate  themselves,  but  to  inspect 
the  vessels  in  which  the  food  is  pre¬ 
pared. 

The  inculcation  of  good  principles  is 
a  noble  achievement;  for  a  principle, 
when  it  is  once  firmly  established,  be¬ 
comes  a  dogma  with  the  weight  and 
resistance  of  a  fact ;  for  what  is  a  fact, 
but  a  substantial  dogma  ?  no  science 


can  proceed  against  it,  nor  can  any 
truth,  human  or  divine,  subsist  without 
it.  Now,  it  is  among  the  uninformed 
that  this  mode  of  teaching  is  the  most 
serviceable,  precisely  such  as  we  appre¬ 
hend  the  greater  number  of  Dr.  Bull’s 
readers  will  be;  and  we  are  certain, 
that  many  of  those  who  read  his  work 
attentively,  will  rise  from  its  perusal 
possessed  of  rules  of  which  they  had 
been  hitherto  ignorant,  and  imbued 
with  principles  which  they  will  feel  it 
impossible  ever  to  lay  aside  or  forget. 


iproccctitngs  of  ^Societies. 


ACADEMIE  DES  SCIENCES. 

10th  July,  1848. 

President — M.  Pouillet. 


M.  Louis  Fleury  read  a  memoir  on  the 
separate  and  combined  action  of  the  cold 
douche  and  of  passive  motion  in  the  treat¬ 
ment  of  incomplete  anchylosis. 

M.  Fleury  has  submitted  several  patients 
affected  with  incomplete  anchylosis  to  the 
cold  douche,  in  the  hope  of  fulfilling  two  im¬ 
portant  indications. 

In  employing  cold  water  as  an  excitor  of 
the  capillary  circulation,  he  trusted  to  restore 
the  secretion  of  synovia,  to  act  on  interstitial 
absorption  a’ d  nutrition  so  as  to  restore  to 
the  fibrous  tissue  its  flexibility  and  elasticity, 
and  to  the  atrophied  and  more  or  less  para¬ 
lysed  muscles  their  volume  and  contractility  ; 
to  place,  in  short,  the  hard  and  soft  parts  in 
their  normal  condition. 

In  employing  cold  water  as  a  sedative 
agent,  he  hoped  to  make  forcible  movements 
possible  or  less  painful,  and  to  reduce  to 
their  minimum  the  irritation  in  the  joint, 
and  the  general  reaction  that  such  move¬ 
ments  so  often  excite. 

Four  patients  affected  with  anchylosis  of 
longer  or  shorter  standing,  more  or  less 
complete,  were  treated  with  the  cold  douche, 
alone  or  combined  with  passive  motion  and 
the  results  lead  to  the  following  conclu¬ 
sions  : — 

1st.  In  certain  cases  of  incomplete  anchy¬ 
losis,  for  which  forcible  movements  would 
be  useless  or  injurious,  the  repeated  cold 
douche  is  preferable  to  any  other  means  ;  it 
exercises  a  favourable  action  in  rendering 
the  capillary  circulation  and  absorption 
more  active,  in  modifying,  the  vitality  of  the 
tissues,  and  in  so  restoring  the  parts  within 
and  without  the  joint  to  their  healthy  state. 

2d.  In  those  cases  of  incomplete  anchy¬ 
losis  which  demand  the  use  of  forcible  move- 


0%  THE?PLEA.  IHS 


ments,  but  in  which  they  are  impossible, 
owing  to  the  pain,  the  irritation  in  the  joint, 
a  d  the  general  reaction  which  they  excite, 
the  cold  douche  acts  better  and  more  rapidly 
than  any  other  agent  in  removing  those  bad 
effects,  and  permits  the  surgeon  again  to 
employ  graduated  forcible  movements. 

3d.  In  those  cases  of  incomplete  anchy¬ 
losis  which  require  and  permit  the  use  of 
forcible  movements,  a  more  speedy  and 
sometimes  a  more  complete  recovery  is 
gained  by  associating  with  them  the  cold 
douche. 

Perhaps  no  cases  give  the  surgeon  more 
annoyance  than  those  where  incomplete 
anchylosis  follows  inflammation  or  injury  in 
the  neighbourhood  of  a  joint,  especially  the 
elbow  and  the  finger  joints.  This  may  usu¬ 
ally  be  averted  by  bending  the  joint  every 
day  to  an  increasing  extent,  as  soon  as  the 
progress  of  the  case  will  permit.  This  does 
not,  of  course,  apply  to  those  cases  of  arti¬ 
cular  disease  in  which  the  limb  is  saved  by 
the  long  enjoinment  of  absolute  rest,  and  the 
production  of  anchylosis. 

The  bone-setters  have  a  way,  with  cases  of 
incomplete  anchylosis,  which  very  often  an¬ 
swers.  They  drag,  straighten,  and  bend  the 
stiffened  limb  with  great  violence.  They 
thus  lacerate  the  new  ligaments  and  short¬ 
ened  tendons  that  prevent  articular  motion  ; 
their  patient  can  often  immediately  after¬ 
wards  move  the  limb,  and  they  then  invari¬ 
ably  tell  him  that  the  surgeon  has  miserably 
mistaken  the  case,  that  the  joint  was  out,  and 
that  he  has  put  it  in  again.  I  know  of 
several  such  cases  which  affected  somewhat 
the  reputation  of  very  excellent  surgeons. 
The  surgeon  dare  not,  dreading  the  results, 
employ  the  violence  resorted  to  by  these 
men.  But  there  is  no  doubt  about  the  value 
of  the  treatment.  It  is  a  certain  rough 
tenotomy. 

M.  Fleury  is  evidently  alive  to  the  value 
of  graduated  forcible  movements  as  a  means 
of  treating  incomplete  anchylosis,  and  he 
would  in  some  cases  conjoin,  and  in  others 
substitute,  the  cold  douche.  His  three 
“  conclusions/’  important  if  true,  are  based 
upon  no  more  than  four  cases  !  How  the 
cold  douche  is  to  restore  to  unused  muscles 
their  volume  and  contractility,  to  fibrous 
tissue  its  flexibility  and  elasticity,  he  does 
not  tell  us. 

Pumping  cold  water  on  a  sprained  and 
stiffened  joint  is  an  excellent  domestic  mode 
of  treatment.  The  combination  of  the  cold 
douche  with  graduated  movements  may  often 
be  of  unquestionable  value.  The  cold  douche 
should  not,  however,  be  long  continued. 
We  all  know  the  remarkable  effect  of  the 
cold  douche  to  the  head  in  allaying  the  most 
violent  delirium,  and  the  alarming  prostra¬ 
tion  that  its  employment  may  occasion. 


M.  Foville  employs  the  affusion  of  tepid 
instead  of  cold  water  to  maniacs  ;  in  such 
cases  the  delirium  is  completely  subdued 
without  prostration.  The  same  plan  answers 
in  the  delirium  of  fever,  and  in  the  violent 
paroxysms  of  chorea.  The  tepid  douche 
may  often  be  exchanged  for  the  cold  in  the 
treatment  of  cases  of  incomplete  anchylosis. 

It  is  one  of  the  important  uses  of  chloro¬ 
form,  to  administer  it  when  any  imperfectly 
anchylosed  joint  is  suddenly  and  forcibly 
bent  or  straightened. 

M.  Fleury  seems  to  lose  sight  of  the  value 
of  tenotomy  in  the  cases  of  which  his  memoir 
is  the  subject. 

2 


i$lctucal  trials  anti  inquests. 


NORFOLK  CIRCUIT. 

Huntingdon,  Thursday,  July  20. 

Crown  Court. — ( Before  Mr.  Baron 
Parke.) 

CASE  OF  ALLEGED  HOMICIDAL  INSANITY. 

REJECTION  OF  THE  PLEA. 

Charles  Burton  was  indicted  for  the 
wilful  murder  of  Harriet  Burton,  his  wife, 
on  the  22d  of  June  last. 

It  appeared  that  on  the  27th  of  May, 
about  9  o’clock,  the  prisoner  and  his  wife 
were  standing  at  their  own  door,  conversing 
about  the  health  of  their  child  with  their 
next-door  neighbour.  About  4  o’clock  the 
next  morning  a  loud  scream  was  heard  by 
the  next-door  neighbours,  who  started  up, 
went  to  the  window,  and  saw  the  prisoner’s 
wife  looking  out  of  her  own  window'.  After 
some  time  an  entrance  was  made  into  the 
prisoner’s  house,  when  he  was  found  below, 
standing  in  his  shirt,  bleeding  from  the  throat. 
On  going  upstairs  the  prisoner’s  wife  was 
seen  lying  on  the  floor,  quite  dead,  with  her 
throat  cut.  The  wounds  on  her  throat  were 
three  in  number  and  large,  one  dividing  the 
vessels  and  nerves  down  to  the  spine.  The 
prisoner  had  always  been  fond  of  his  wife 
and  child.  To  questions  put  to  him  by  the 
surgeon  he  said  that  trouble  had  made  him 
do  it ;  that  he  was  afraid  his  wife  and  child 
would  want  when  he  was  gone  ;  that  he  had 
been  thinking  of  committing  suicide  for  a 
week  past ;  that  he  had  not  had  a  quarrel  with 
his  wife  ;  that  he  had  first  thought  of  killing 
his  wife  and  child  when  he  got  oat  of  bed  to 
destroy  himself ;  that  he  made  the  first 
attack  on  his  wife  whilst  she  was  asleep  ; 
that  she  rushed  to  the  window ;  that  he  then 
killed  the  child,  which  was  asleep,  and,  tak¬ 
ing  his  wife  from  the  window,  held  her  in 
his  arms,  and  with  her  back  turned  to  him 
cut  her  throat ;  that  he  then  tried  to  commit 


256  ALLEGED  HOMICIDAL  INSANITY - REJECTION  OF  THE  PLEA. 


suicide,  but  had  not  the  power;  that  he  had 
been  unwell  of  late,  and  had  passed  sleepless 
nights,  but  not  sufficiently  to  apply  to  the 
surgeon.  The  prisoner  exhibited  no  sorrow 
or  remorse  while  making  this  statement. 

In  the  opinion  of  the  surgeon  who  had 
been  called  in,  and  who  had  known  the 
prisoner  long,  the  whole  conduct  of  the 
prisoner  shewed  that  when  he  committed 
the  act  he  had  not,  owing  to  an  uncontrol¬ 
lable  impulse  to  which  a  human  being  may 
be  subject,  had  control  over  himself.  The 
perversion  of  the  affections,  in  doing  injury 
to  those  previously  dear  to  the  person,  was 
one  indication  of  insanity.  The  impossibility 
of  resisting  a  sudden  homicidal  impulse  was 
another.  There  was  no  necessary  connection 
between  suicidal  monomania  and  homicidal 
monomania,  but  it  would  be  more  natural 
for  a  monomaniac  who  bad  been  contem¬ 
plating  suicide  to  kill  a  person,  than  for  one 
who  had  not.  By  monomania  was  under¬ 
stood  an  affection  that  far  the  moment  de¬ 
prives  a  person  of  all  control  over  himself  in 
respect  of  the  particular  matter.  The  pri¬ 
soner’s  reason,  however,  did  not  appear  af¬ 
fected,  and  he  never  had  appeared  to  the 
surgeon  to  be  under  delusions.  The  mono¬ 
mania  in  the  prisoner’s  case  was  attributable 
to  the  impression  that  he  was  coming  to 
destitution.  He  had,  in  fact,  been  distressed 
about  some  property  that  ought  to  have 
come  to  him.  The  prisoner  had  said  that 
bis  wife  had  reproached  him  before  he  made 
the  second  attempt ;  but  that  the  feeling  was 
too  strong  upon  him.  He  did  not  appear 
sorry  at  first,  but  he  did  the  second  day. — 
In  answer  to  a  question  from  the  learned' 
judge,  the  surgeon  said,  “  It  is  my  opinion 
that  he  was  in  an  unsound  state  of  mind  at 
the  moment  he  did  the  act ;  that  is  my 
opinion  of  all  cases  of  murder.”  (?) 

It  was  further  shewn  that  the  prisoner  had 
left  his  razor  to  be  sharpened  the  day  before, 
and  had  insisted  on  having  it  hack  on  the 
same  day,  giving  out  that  it  was  for  some 
one  else. — Mr.  Crouch  then  addressed  the 
jury  for  the  defence,  and  contended  that  they 
must,  in  conformity  with  the  evidence  of  the 
medical  man,  acquit  the  prisoner  on  the 
ground  of  insanity.  The  insanity  was,  as 
the  surgeon  had  said,  attributable  to  dis¬ 
appointment  about  property,  as  he  would 
shew  by  witnesses. 

Witnesses  were  then  called,  who  shewed 
that  the  prisoner  was  entitled  to  a  fourth 
share  of  i£70Q,  which  the  trustee,  a  shoe¬ 
maker  of  Mount-street,  Grosvenor-square, 
had  invested  in  his  own  trade ;  that  fcbe 
trustee  had  become  insolvent ;  and  that  the 
dividend  would  be  a  small  one.  This  was 
made  known  to  the  prisoner  rather  more 
than  a  week  before  this  occurrence,  and 
seemed  to  affect  him  very  much. 

Mr.  Baron  Parke  told  the  jury  that  the 


evidence  left  but  one  question  for  their  de¬ 
termination — Was  the  prisoner  a  responsible 
man  when  he  did  this  dreadful  act  ?  That 
depended  upon  whether  he  knew  at  the  time 
the  nature  and  character  of  the  act  he  was 
doing ;  and  if  he  did,  that  in  doing  so  he 
was  doing  wrong.  Though  medical  men 
had  found  fault  with  this  mode  of  leaving 
the  question,  he  must  express  his  concur¬ 
rence  in  the  opinion  of  Mr.  Baron  Rolfe, 
that  the  excuse  of  an  irresistible  impulse 
coexisting  with  the  full  possession  of  reason, 
would  justify  any  crime  whatever.  It  was 
for  them  to  say,  not  leaving  out  of  conside¬ 
ration  the  evidence  of  the  surgeon,  which 
had  been  given  with  great  good  sense, 
whether  the  impulse  which  had  urged  the 
prisoner  to  this  crime  was  one  that  deprived 
him  of  the  power  to  know  that  he  was  doing 
wrong.  An  attempt  to  commit  suicide  was 
not  necessarily  a  sign  of  insanity;  and  the 
desire  to  commit  suicide  appeared  in  this 
case  to  have  been  suggested  by  a  fact,  and 
not  by  a  delusion.  That  circumstance,  how¬ 
ever,  must  be  taken  into  consideration  ;  so 
also  the  absence  of  an  attempt  to  escape,  and 
the  want  of  sense  on  the  first  day  while  it 
supervened  afterwards.  Still  it  must  be 
borne  in  mind  that  no  delusion  had  been 
shewn,  nor  any  symptoms  of  weak  intellect 
at  another  time. 

The  jury  then  retired  to  consider  their 
verdict.  After  a  short  time  they  returned 
into  court  with  a  verdict  of  guilty. 

Mr.  Baron  Parke  then,  in  a  most  impres¬ 
sive  manner,  passed  sentence  of  death  on 
the  prisoner. 


(£oES£SsponDence. 


THE  IMPORTANCE  AND  UTILITY  OF  INDICES 
TO  PERIODICALS. 

Sir, — In  your  number  for  the  21st  ult. 
in  a  notice  of  the  index  to  the  British  and 
Foreign  Medical  Review,  we  read — “  A  work 
consisting  of  twenty-four  volumes, — extend¬ 
ing  over  a  period  of  twelve  years, — was  ob¬ 
viously  in  need  of  a  general  index ;  for  it 
could  not  be  expected  that  any  reader  would 
afford  time  or  patience  to  wade  through  the 
indices  of  twenty- four  volumes  for  the  sake 
of  a  single  reference.”  Quite  true  ;  but  if 
it  be  difficult  to  afford  “  time  and  patience” 
sufficient  to  consult  the  indices  of  twenty- 
four  volumes  of  the  Review,  how  much  more 
difficult  must  it  be  to  have  “  time  and  pa¬ 
tience”  enough  to  examine  the  indices  of 
forty-one  volumes  of  the  Gazette  !  You 
must  have  forgotten  yourself  when*  you 
penned  this  sentence :  for  a  more  suicidal 
admission  I  really  never  read.  It  in  fact 
amounts  to  this  :  either  the  former  volumes 

,  Ilijili.  TMJ..  i  .All  J /I  .  » 1  i  a*  all* 


THE  IMPORTANCE  AND  UTXLITyFoF  INDICES  TO  PERIODICALS. 


of  your  journal  are  not  worth  referring  to, 
or  are  quite  worthless  except  as  so  much 
waste  paper  ;  or  they  require  a  general  index 
nearly  twice  as  much  as  the  Review  required 
it,  for  your  volumes  are  nearly  twice  the 
number.  The  want  of  general  indices — 
which  should  appear  at  regular  intervals  of 
some  years, — to  all  voluminous  periodicals 
extending  over  a  long  period,  render  them 
almost  valueless  for  reference, — and  pray 
take  yourself  a  lesson  from  your  own  words, 
for  the  future.  Was  not  the  notice  alluded 
to  written  by  a  contributor,  who  thought¬ 
lessly  let  out  a  truth  so  condemnatory  of  the 
very  journal  for  which  he  wrote,  and  which 
slipped  into  print  unknown  to  you,  Mr. 
Editor  ?  Were  you  to  publish  a  general 
index  every  three  or  four  years,  what  a  boon 
it  would  be,  and  I  am  sure  your  subscribers 
would  most  cheerfully  pay  amply  for  it  as  a 
distinct  .publication  from  the  journal.  In 
its  facility  of  immediate  reference  on  occa¬ 
sions  of  emergency  consists  the  chief  utility 
of  oraeof  the  “  retrospects  ”  and  “  abstracts” 
you  so  unjustly  condemned  in  December 
last — I  mean  “  Braithwaite’s  Retrospect.” 
Here  we  have  a  most  comprehensive  general 
index  to  every  four  volumes  ;  and  if  the 
more  presuming  Ranking,  who  now  takes 
by  far  the  lead  in  circulation,  do  not  adopt 
a  similar  plan,  they  are  sure  yet  to  exchange 
places  among  those  who  chiefly  want  such 
publications, — the  busy  general  practitioners. 
If  the  conductors  of  the  weekly  periodicals 
were  to  condescend  to  imitate  their  humble 
follower  in  this  respect,  his  vocation  would 
be,  in  a  great  measure,  gone ;  but  until  they 
do  so,  such  “  parasites,”  as  you  are  pleased 
to  call  them,  will  command  extensive  pa¬ 
tronage,  and  deservedly  too,  for  every  man 
in  active  practice  must  acknowledge  their 
paramount  utility. — Excuse  this  extempore 
scrawl,  and  allow  me  to  subscribe  myself,  sir, 
With  unfeigned  respect, 

Your  obedient  servant, 

J.  Jones,  Surgeon. 

Llanfair,  Montgomery, 

5th  August,  1848. 

la  reference  to  your  article  of  December, 
there  is  an  observation  relative  to  the  “  ab¬ 
stracts,”  the  truth  of  which  forcibly  struck 
me.  You  say,  “  The  purchasers  of  these 
half-yearly  summaries  are  led  to  believe  that 
they  contain,  either  in  the  shape  of  lengthened 
reports  or  of  copious  extracts,  all  original 
contributions  to  medical  literature  which  are 
of  any  practical  utility.”  But  this  is  entirely 
a  delusion.  Braithwaite,  in  the  preface  to 
his  12th  volume,  when  he  abandoned  the 
**  retrospective  summary,”  truly  says,  “  such 
retrospective  addresses,  to  say  the  least  of 
them.,  however  general  and  comprehensive 
they  may  be,  seldom  satisfy  the  reader  on 
any  one  subject  to  which  they  refer.  Gene¬ 
rally  speaking,  they  are  little  better  than 


267 


copious  indices ;  they  give  ns  a  slight  taste 
of  the  original  article,  leaving  us  after  all  to 
refer  to  the  book  or  journal  from  which  it  is 
obtained  for  further  information.  The  wine 
may  be  good,  but  we  are  only  allowed  to  wet 
our  lips!”  This  is  characteristically  appli¬ 
cable  to  Ranking’s  “  Reports,”  so  highly 
lauded,  and  which  undoubtedly  evince  very 
great  industry^  still  they  give  one  only  a 
smattering  of  almost  everything,  without 
our  really  understanding  and  mastering  any 
one  subject.  For  instance,  chemistry  may 
be  said  to  be  almost  a  new  science  since 
Ranking’s  first  volume  appeared.  Let  any 
one  (conversant  only  with  the  science  as  it 
was  a  few  years  ago)  read,  mark,  learn, 
every  line  which  has  appeared  in  that  work 
from  that  day  to  this,  and  nothing  else,  on. 
the  subject,  and  how  much  wiser  will  he  be  ? 
He  will  have  amassed  a  vast  number  of 
facts,  which  he  can  neither  comprehend  nor 
account  for,  because  he  will  have  no  general 
enlarged  views  of  the  principles  which  have 
recently  been  developed.  He  will  not  know 
that  the  Daltonian  theory,  the  groundwork 
of  the  old  chemistry,  is  proved  to  be  erro¬ 
neous  in  several  fundamental  points.  I  un¬ 
hesitatingly  assert  that  a  few  hours’  careful 
study  of  the  admirable  article  on  Chemical 
Philosophy,  in  No.  II.  of  the  British  and 
Foreign  Medico -Chirurg.  Review,  will  teach 
one  more  of  the  science  of  chemistry  than 
days  poring  over  Ranking’s  laborious  re¬ 
ports.  The  fact  is,  he  attempts  too  much, 
and  thus  defeats  his  object ;  and  if  we  trust  to 
him  only  (as,  to  my  knowledge,  many  do 
who  used  to  take  the  Gazette,  Lancet,  or 
British  and  Foreign  Review,  now  take  only 
Ranking)  to  keep  our  pace  with  the  progress 
of  science,  we  shall  find  ourselves  miserable 
sciolists  at  last. 


LOCAL  APPLICATION  OF  CHLOROFORM  FOR 
THE  RELIEF  OF  PAIN. 

An  aged  person,  who  had  been  suffering  for 
ten  or  twelve  days  under  very  acute  pain 
from  internal  suppuration  and  disorganiza¬ 
tion  of  the  eye,  with  pus  in  the  anterior 
chamber,  (her  age  and  circumstances  pro¬ 
hibiting  the  employment  of  very  active 
measures  for  subduing  inflammatory  action) 
was  mast  effectually  relieved  of  pain  by  the 
vapour  of  chloroform  applied  directly  to  the 
eye  by  means  of  the  common  chimney  glass 
of  an  Argand  lamp.  A  small  piece  of  rag 
being  moistened  with  the  fluid,  it  was 
placed  in  a  saucer  over  a  cup  of  warm 
water,  and  the  vapour  thus  directed  solely 
to  the  eye  ;  relief  was  almost  immediately 
experienced,  and  after  a  very  few  applica¬ 
tions  she  had  no  return  of  pain,  comfortable 
sleep  being  also  procured  by  the  remedy. 

Might  not  a  small  glass  vessel  in  shape 
resembling  a  retort  with  an  oval  mouth, 


.woavioj  to  YTienavmu  am-  to  SHawAH  hoitawii 

258  DR.  BROOKES’  CASES  OF  SCIRRHUS  OF  THE  LIP. 


be  a  convenient  apparatus  for  similar 
applications  ? 

A  Retired  Practitioner. 


ON  SCIRRHUS  OF  THE  LIP. 

Sir, — May  1  request  a  small  space  in 
your  valuable  periodical,  to  report  some 
short  notes  of  a  few  cases  that  have  come 
under  my  notice  of  scirrhus  of  the  lips  : 
deeming  this  a  fitting  occasion  for  making 
these  observations,  as  I  perceive  in  the 
Medical  Gazette  of  June  the  23rd,  in  a 
lecture  delivered  by  Mr.  Bransby  Cooper, 
■whilst  speaking  of  cancer  of  the  lips,  the 
following  words  : — “  It  is  remarkable  the  dis¬ 
ease  attacks  almost  exclusively  the  lower  lip. 
Sir  Astley  Cooper  states  he  had  seen  up¬ 
wards  of  two  hundred  cases,  in  only  one  of 
which  the  upper  lip  was  the  seat  of  the  dis¬ 
ease.  ” 

I  have  myself  within  the  last  four  years 
had  two  cases  under  my  treatment,  in 
which  the  upper  lip  was  the  primary  seat  of 
the  disease,  and  three  in  the  lower  lip  :  short 
notes  of  each  case  I  now  append. 

I  am,  sir, 

Your  obedient  servant, 

Wm.  Philpot  Brookes, 

M.D.  M.R.C.S.,  &c. 

Albion  House,  Cheltenham, 

July  21,  1848. 

F.  S.,  aged  54,  residing  in  Cheltenham, 
had  suffered  for  some  time  from  a  scirrhous 
sore,  with  everted  edges,  and  discharging  a 
most  offensive  odour  in  the  upper  lip  :  this 
had  been  once  extirpated,  but  it  reappeared 
in  a  few  months  afterwards.  In  February 
last  he  consulted  me  :  I  then  found  him  with 
the  whole  of  the  upper  lip  involved  in  a  large 
cancerous  sore,  giving  out  so  disagreeable  an 
odour,  that  the  room  in  which  he  resided 
was  barely  to  be  tolerated :  this  sore  also 
extended  into  the  cheek  on  the  left  side,  and 
up  to  the  border  of  the  eyelid,  by  its  pres¬ 
sure  closing  the  lower  eyelid,  so  that  he 
could  not  see  with  the  left  eye  :  it  had  also 
opened  into  the  ductus  stenonis  :  there 
was  no  enlargement  of  any  of  the  glands. 
He  would  not  hear  of  any  operative  pro¬ 
cedure,  and  the  sore  was  dressed  with 
chloride  of  zinc  and  gypsum,  but  with  no  other 
effect  than  in  a  great  degree  removing  the  dis¬ 
agreeable  odour.  In  a  short  time  the  gene¬ 
ral  health  gave  way,  and  he  removed  into 
the  country  for  change  of  air,  so  that  I  lost 
sight  of  him  ;  but  I  doubt  not  the  case  has 
terminated  in  death  long  ere  this. 

Mrs.  Fitzgerald,  aged  60,  washerwoman, 
residing  in  Taylor's  Court,  has  had  a  can¬ 
cerous  growth  of  the  right  side  of  the  upper 
lip  for  two  years.  In  March,  1848,  she 
came  under  my  notice  :  I  found  her  with  more 
than  half  of  the  upper  lip  in  an  ulcerated 
state,  extending  down  the  cheek  to  the  chin 


on  the  right  side,  saliva  constantly  dribbling 
away,  the  parotid  and  submaxillary  glands 
enlarged  and  diseased  ;  the  ulcerated  surface 
unhealthy  ;  edges  everted,  and  giving  out  an 
offensive  cancerous  odour  ;  general  health  in 
a  very  bad  state,  and  this  gradually  becom¬ 
ing  worse,  she  died  in  a  few  weeks  after  my 
first  seeing  her. 

Jesse  Castle,  aged  42,  a  strong  healthy- 
looking  man,  came  under  my  care  with  a 
scirrhous  sore  of  the  lower  lip  and  centre  of 
the  chin,  the  size  of  a  five-shilling  piece  :  no 
enlargement  of  glands,  and  general  health 
very  good.  He  attributed  the  first  origin  of 
the  disease  to  an  impoverished  diet.  After 
three  applications  of  chloride  of  zinc  and 
gypsum,  healthy  action  was  set  up  in  the 
sore,  and  it  quickly  healed.  I  have  been  in 
the  habit  of  seeing  this  man  almost  daily 
since  he  recovered,  now  more  than  four  years 
back,  and  he  continues  free  from  any  return 
of  the  disease. 

W.  B.,  aged  48,  residing  at  Cheltenham, 
was  admitted  a  patient  of  mine  on  the  1st 
of  July,  1848.  Has  now  a  sore  the  size 
of  half  a  crown  in  the  centre  of  the 
lower  lip,  with  everted  edges  of  a  scirrhous 
nature.  At  the  lower  part  of  the  sore  was 
a  hard,  red,  tumor,  the  size  of  a  nut,  and 
very  painful  to  the  touch.  Two  months 
back  this  portion  of  the  lip  was  removed  by 
a  surgeon  for  a  cancerous  growth  :  the  edges 
of  the  wound  united  well,  but  the  disease 
again  appeared  very  rapidly  after  the  opera¬ 
tion  :  there  is  no  glandular  disease ;  the  pa¬ 
tient  positively  refuses  to  have  the  knife 
again  used.  This  is  a  very  favourable  case 
for  the  use  of  the  chloride  of  zinc,  which  is 
now  being  applied,  and  I  doubt  not  will  give 
him  some  benefit. 

I  have  seen  the  chloride  of  zinc  exert  a 
most  beneficial  effect  in  cancerous  sores,  and 
those  in  which  the  malady  has  taken  too 
great  a  hold  on  the  constitution,  assisting  in 
a  great  measure  to  overcome  the  offensive 
odour  of  the  disease.  It  also  exerts  a  good 
effect  in  stubborn  ulcers,  especially  with 
callous,  hard,  even  edges  ;  and  will  rapidly  set 
up  a  healthier  action  when  other  remedial 
means  have  failed  ;  the  surface  will  speedily 
granulate  and  heal. 

The  mode  in  which  I  use  the  remedy  is  by 
taking  two  parts  of  chloride  of  zinc  and  three 
parts  of  gypsum,  spreading  the  powder  over 
the  surface  of  the  sore,  protecting  the  edges 
of  the  healthy  skin  with  vinegar,  and  apply¬ 
ing,  in  about  a  quarter  of  an  hour,  a  soft 
poultice. 


efficacy  of  the  chloride  of  zinc  in 
the  process  of  embalming. 

Sir, — Permit  me  to  direct  the  attention 
of  your  readers  to  a  very  simple  method  or 
embalming  bodies,  or  preserving  them  for 
dissection.  In  March  last,  Dr.  Galland 


EXAMINATION  PAPERS  OF  THE  UNIVERSITY  OF  LONDON.  259 


injected  through  the  aorta  of  an  adult  sub¬ 
ject  as  much  of  Sir  Win.  Burnett’s  solution 
of  chloride  of  zinc  as  he  could  without 
using  much  force.  About  a  pint  w'as  thrown 
up  the  rectum,  and  some  poured  into  the 
mouth.  The  body  remained  exposed  to  the 
air,  with  the  thermometer  averaging  above 
70  in  the  shade,  and  not  the  least  disco¬ 
louration  or  putrefaction  had  then  taken 
place,  the  limbs  remaining  perfectly  flexible. 
Dr.  Galland  has  sent  home  two  subjects 
thus  prepared,  which  may  be  seen  in  the 
museums  of  King’s  College  and  University 
College.  I  need  not  take  up  more  of  your 
valuable  columns  by  pointing  out  how 
useful  the  knowledge  of  this  fact  may  be 
to  teachers,  students,  and  the  profession 
generally. 

A  Surgeon,  R.N. 

July  1848. 


i&Utucal  lintelUgenre. 


UNIVERSITY  OF  LONDON.  * 

FIRST  EXAMINATION  FOR  THE  DEGREE  OF 
BACHELOR  OF  MEDICINE. 

Monday,  August  7.— Morning,  10  to  1. 
Anatomy  and  Physiology. 

Examiners, — Mr.  Kiernan  and  Prof. 

Sharpey. 

1 .  Give  an  account  of  the  dorsal  region  of 
the  vertebral  column,  mentioning  the  cha¬ 
racters  by  which  the  vertebrae  of  that  region 
differ  from  those  of  the  neck  and  loins,  as 
well  as  the  marks  by  which  certain  dorsal 
vertebrae  may  be  distinguished  from  the  rest. 
Describe  also  the  several  articulations  and 
ligaments  by  which  the  dorsal  vertebrae  are 
connected  with  each  other  and  with  the  ribs. 

2.  State  the  dissection  required  to  expose 
the  Peroneus  Longus  in  its  whole  course 
from  its  origin  to  its  insertion,  mentioning 
its  relations  to  other  parts.  In  the  dissection 
of  the  sole  of  the  foot  commence  at  the  skin, 
and  mention  in  the  order  in  which  they  are 
seen,  all  the  parts  which  intervene  between 
it  and  the  tendon  of  the  muscle,  and  their 
relations  to  each  other ;  but  the  attachments 
of  fasciae,  muscles  and  ligaments,  and  the 
course  of  vessels  and  nerves,  are  not  to  be 
given. 

3.  Commencing  at  the  integuments,  de¬ 
scribe  the  parts  brought  into  view  in  ex¬ 
posing  the  spinal  accessory  nerve  from  the 
point  where  it  escapes  from  beneath  the 
digastric  muscle  to  its  termination. 

4.  Describe  the  construction  and  explain 
the  mechanism  of  the  different  valves  placed 
between  the  autricles  and  ventricles  of  the 
heart,  at  the  orifices  of  the  aorta  and  pulmo¬ 


nary  artery,  and  in  the  veins.  What  veins 
are  known  to  be  destitute  of  valves  ? 

5.  Give  a  description  of  the  Caecum  and 
of  the  Uio-colic  valve,  and  state  the  differ¬ 
ences  in  point  of  structure  between  the  great 
and  small  intestines. 

Afternoon,  3  to  6. 

Anatomy  and  Physiology. 

Examiners ,  Mr.  Kiernan  and  Professor 
Sharpey. 

1.  The  malar,  superior  maxillary,  nasal 
and  inferior  turbinated  bones  being  removed 
on  one  side,  describe  the  remaining  walls  of 
the  orbit,  and  those  parts  of  the  skull 
brought  into  view  by  the  removal  of  the 
bones,  as  far  back  as  the  posterior  margin  of 
the  external  pterygoid  plate.  Commence  at 
the  superciliary  ridge,  and  describe  the  sur¬ 
faces,  sutures,  fissures  and  foramina,  in  the 
order  in  which  they  are  met. 

2.  Give  the  dissection  required  to  display 
the  supinator  and  extensor  muscles  on  the 
fore-arm  and  back  of  the  hand,  describing, 
in  the  order  in  which  they  would  be  exposed, 
the  muscles,  fasciae,  and  ligaments,  as  well 
as  the  vessels  and  nerves  met  with  in  the  dis¬ 
section. 

3.  Commencing  at  the  integuments  on 
the  forepart  of  the  thigh,  and  carrying  the 
dissection  as  far  back  as  the  anterior  surface 
of  the  adductor  magnus, — describe  the  parts 
brought  into  view  in  dissecting  the  crural 
artery  and  its  branches  in  its  course  from 
Foupart’s  ligament  to  the  point  where  it 
passes  into  the  ham. 

4.  The  walls  of  the  abdomen  being  re¬ 
moved,  describe  the  lesser  omentum  and 
Glisson’s  capsule,  their  attachments  and 
contents  ;  the  position  and  boundaries  of 
the  foramen  of  Winslow,  and  the  position  of 
the  duodenum  and  pancreas,  and  their  rela¬ 
tions  to  other  parts. 

5.  Describe  the  structure  of  a  middle- 
sized  artery,  and  state  what  are  its  physical 
and  vital  properties. 

Tuesday,  August  8.— Morning,  10  to  1. 
Chemistry. 

Examiner,  Professor  Brande. 

1.  What  are  the  substances  usually  pre¬ 
sent  in  spring  and  river  water  ;  how  are 
they  qualitatively  and  quantitatively  deter¬ 
mined  ;  and  under  what  circumstances  is 
sulphuretted  hydrogen  generated  in  such 
waters  ? 

2.  What  is  the  meaning  of  the  term 
dew-point  ?  What  is  the  usual  composition 
of  the  atmosphere,  and  how  are  the  pro¬ 
portions  of  its  several  components  ascer¬ 
tained  ? 

3.  Define  and  illustrate  the  meaning  of 
the  terms  sensible  and  latent  heat.  De¬ 
scribe  the  principles  upon  which  thermo¬ 
meters  are  graduated,  and  the  mutual  rela- 


260  DEATHS  IN  LONDON  IN  THE  QUARTERS  ENDING  JUNE  1847-8. 

i : - : ; — ‘ - L - i - — : l — ------ — u-L.—  L.  ''K: 


tions  of  the  Centigrade  and  Fahrenheit's 
scale. 

4.  Deserrbe  the  phenomena  of  vegeta¬ 
tion  in  reference  to  the  substances  which 
form  the  food  of  plants,  the  sources  whence 
those  substances  are  derived,  and  the  in¬ 
fluence  of  the  soil  and  of  manures. 

5.  What  are  the  leading  differences  in 
the  composition  of  the  urine  of  graminivo¬ 
rous  and  of  carnivorous  animals  ?  Of  what 
are  urinary  calculi  composed  ;  how  are  they 
analysed  ;  and  what  are  the  chemical  prin¬ 
ciples  upon  which  their  medical  treatment  is 
founded  ? 

6.  You  are  requested  to  name  the  salt 
held  in  aqueous  solution  in  the  bottle 
marked  A,  and  in  that  marked  B,  and  to 
give  the  symbols  of  the  two  salts  in  their 
crystallized  state.  They  are  inorganic  salts, 
and  the  tests  adequate  for  their  recognition 
are  on  the  table. 

Afternoon,  3  to  6. 

Materia  Medica  and  Pharmacy . 

Examiner,  Dr.  Pereira. 

1.  Give  a  sketch  of  the  pharmacological 
history  of  nitric  acid,  to  include  the  follow¬ 
ing  subjects  : — 

a.  The  mode  of  preparing  it,  and  the 
changes  which  attend  the  process. 

/8.  The  sp.  gr.  of  the  acidum  nitricum, 
Ph.  Lond.,  and  of  commercial 
nitric  acid. 

y.  The  composition  and  characteristics 
of  the  liquid  acid ;  and  the  diffe¬ 
rence  between  colourless  and  fum¬ 
ing  nitric  acid. 

8.  The  ordinary  impurities  of  commer¬ 
cial  nitric  acid,  and  the  methods 
of  recognizing  them. 

e.  The  effects  (including  the  chemical 

action  of  the  acid  on  the  tissues) 
and  medicinal  uses  of  the  acid. 

f.  The  doses  both  of  the  pharmacopoeial 

and  of  commercial  nitric  acid,  and 
the  precautions  to  be  adopted  in 
using  this  acid. 

7).  The  appropriate  treatment  in 
poisoning  by  nitric  acid. 

2.  State  the  evidence  in  support  of  the 
opinion  that — 

a.  Medicines  and  poisons  properly  so 
called  operate  by  absorption. 

/S.  Some  irritant  and  corrosive  agents 
operate  physically  on  the  body  and 
affect  remote  parts  through  the 
agency  of  the  nervous  system  or 
on  the  principle  of  shock. 

3.  Give  a  sketch  of  the  pharmacological 
history  of  cathartics,  to  include 

a.  A  natural-history  arrangement  of 
officinal  cathartics. 

J8.  The  general  effects  of  cathartics. 

y.  A  physiological  arrangement  of  of¬ 
ficinal  cathartics. 


8.  The  general  uses  to  which  the  diffe¬ 
rent  orders  of  cathartics  are  re¬ 
spectively  applicable. 

4.  Give  a  sketch  of  the  pharmacological 
history  of  Juniperus  Sabina,  to  include 
a.  Its  botanical  description. 

£.  Its  chemical  history. 

y.  Its  effects  and  medicinal  uses. 

8.  The  treatment  of  poisoning  by  it. 

Wednesday,  August  9. — Morning,  10  to  is. 

Botany. 

Examiner — Rev.  Prof.  Henslow. 

1.  Define  the  terms  Circinnatus,  Legu- 
men,  Polyadelphus,  Septicidalis,  Endogenus, 
Pedatus. 

2.  Give  such  diagnoses  of  the  following 
orders  as  may  be  sufficient  to  include  our 
British  genera : — Papaveracese,  Rosaceae, 
Orobanchese,  Amaryllideae. 

3.  Give  such  diagnoses  of  the  following 
genera  as  will  include  our  British  species — 
describing,  so  far  as  may  seem  to  you  im¬ 
portant,  the  peculiarities  of  their  several 
floral  whorls,  fruit,  and  seed  : — Delphinium, 
Cichorium,  Quercus,  Cypripedium. 


DEATHS  IN  LONDON  DURING  THE  QUARTERS 
ENDING  JUNE,  1847-8. 


Causes  of  Death. 

Quarters  ending  June 

1847. 

1848. 

All  Causes  . 

12361 

12945 

Specified  Causes  . 

12331 

12877 

Violence,  Privation,  Cold, ") 

395 

425 

and  Intemperance  . 

-J 

Small  Pox 

181 

381 

Measles  . 

277 

306 

Scarlatina 

174 

816 

Hooping  Cough 

392 

449 

Croup 

50 

80 

Thrush  . 

35 

49 

Diarrhoea 

202 

239 

Dysentery 

39 

41 

Cholera  . 

4 

17 

Typhus  . 

5  m 

882 

Phthisis  or  Consumption  . 

1733 

1699 

Hydrocephalus 

407 

405 

Apoplexy 

317 

256 

Convulsions 

526 

499 

Pericarditis 

34 

21 

Aneurism 

15 

20 

Disease  of  Heart 

466 

324 

Bronchitis 

710 

565 

Pleurisy 

67 

56 

Pneumonia 

748 

732 

Asthma 

201 

136 

Teething 

120 

120 

Childbirth 

102 

63 

THE  PROGRESS  OF  CHOLERA  IN  EUROPE. 

The  Kolner  Zeitung  states,  in  their  “  latest 
intelligence/ ’  that  the  cholera  has  broken 
out  at  Czernowitz  (in  the  south-east  of 
Gallicia)  and  in  Sweden.  It  is  asserted 
that  the  plague  is  not  only  raging  at 


ON  THE  REACTION  OF  THE  FLUIDS  OF  THE  HUMAN  BODY.  261 


Stockholm,  but  that  it  has  penetrated 
into  the  interior  of  the  country,  into  Finland 
and  Lapland,  and  that  it  is  of  a  most  malig¬ 
nant  character. 

The  Berliner  Zeitungshalle  (a  paper  whose 
statements  are  not  much  to  be  relied  on) 
mentions  a  case  of  Asiatic  Cholera  which 
occurred  at  the  Charite  at  Berlin.  The 
patient,  it  is  asserted,  died  after  the  illness 
had  with  fearful  rapidity  passed  through  all 
its  stages. 

It  is  stated  in  letters  from  Stettin,  that 
cholera,  notwithstanding  the  strict  regulations 
enforced,  had  broken  out  in  Central  Sweden, 
and  that  its  effects  in  Finland  had  proved 
extremely  disastrous.  Business,  which  had 
already  suffered  severely,  would,  it  was  an¬ 
ticipated,  be  further  affected  by  the  quaran¬ 
tine  laws.  Money  continued  scarce,  and  the 
prices  of  produce  were  falling.  Only  one 
cheering  feature  is  mentioned  in  these  ac¬ 
counts,  viz.,  the  prospects  of  an  abundant 
harvest. 

THE  CHOLERA  IN  EGYPT. 

Letters  from  Alexandria,  of  the  22d  July, 
announce  that  the  cholera  had  manifested 
itself  with  considerable  intensity  at  Cairo, 
and  that  the  epidemic  had  also  reached 
Tantah,  a  town  on  the  Bamietta  branch  of 
the  Nile. 

THE  WOUNDED  IN  PARIS. 

The  number  of  wounded  of  June  remaining 
in  the  civil  hospitals  of  Paris  on  the  4th  was 
543.  Ten  had  died  since  the  publication  of 
the  last  returns. 

king’s  COLLEGE  HOSPITAL.  MEDICAL  AP¬ 
POINTMENT. 

The  vacancy  occasioned  in  the  surgical  staff 
of  this  institution  by  the  resignation  of  Mr. 
John  Simon,  consequent  on  his  acceptance 
of  the  Chair  of  Pathology  at  St.  Thomas’s 
Hospital  has  been  filled  up  by  the  appoint¬ 
ment  of  Mr.  Henry  Lee  (the  former  house 
surgeon)  as  assistant- surgeon  ;  and  Dr. 
Brinton  has  been  appointed  Demonstrator 
in  the  anatomical  theatre  of  the  College. 

SURREY  DISPENSARY. 

Mr.  John  Cooper  Forster  has  been  ap¬ 
pointed  Surgeon  to  this  Institution. 

BRISTOL  GENERAL  HOSPITAL. 

Dr.  G.  D.  Fripp  was  unanimously  elected, 
on  Thursday  last,  a  physician  of  this  insti¬ 
tution,  intheroomof  Dr.  Nicholson,  resigned. 

ELECTION  OF  FELLOWS  AT  THE  COLLEGE 
OF  SURGEONS. 

The  following  members  of  the  College 
were  admitted  “ Fellows ”  on  the  10th 
instant: — W.  J.  Anderson,  Grove  Place, 
Brompton  —  W.  Cadge,  Hoveton,  Nor¬ 
folk  —  W.  W.  James,  Exeter  —  C.  H. 
Moore,  Mortimer  Street  — J.  Robertson, 


Hitchin,  Herts — and  H.  H.  Waltin,  Bernard 
Street. 

ROYAL  COLLEGE  OF  SURGEONS. 

Gentlemen  admitted  members  on  the  4th 
inst.  :  —  C.  Underhile — E.  Horner  —  J. 
Hendley — E.  Andrews — R.  O.  Clark — J. 
King — and  H.  Bowe. 

Admitted  on  the  7th  inst. : — C.  H.  Hol¬ 
man — C.  B.  Mitchell — H.  T.  Whittell — S. 
W.  Devenish— J.  Phillips— W.  H.  Slade— 
and  G.  R.  Cubiit. 

OBITUARY. 

On  the  28th  of  June,  at  Camberwell,  John 
Hopkins  Radford,  District  Surgeon,  H.  P. 
Medical  Staff,  aged  84. 

On  the  25th  July,  at  Speenhamland,  near 
Newbury,  John  Mort  Bunny,  Esq.,  M.D., 
formerly  of  the  76th  Regiment,  aged  64. 

On  the  26th  July,  at  Fiddington  House, 
near  Devizes,  John  Willett,  Esq.,  M.D., 
aged  29. 

On  the  3d  of  August,  at  Woodford,  Essex, 
after  a  short  illness,  Thomas  Morgan,  Esq., 
Surgeon,  in  the  71st  year  of  his  age. 

On  the  4th  of  August,  at  Great  Malvern, 
Alexander  Nasmyth,  Esq.,  F.R.C.S.,  late  of 
London. 


jeekcltottg  from  journals. 

ON  THE  ACID  AND  ALKALINE  REACTION  OF 
THE  FLUIDS  OF  THE  HUMAN  BODY  IN 
HEALTH  AND  DISEASE.  BY  M.  ANDRAL. 

All  the  animal  fluids,  in  their  natural  con¬ 
dition,  present  a  certain  degree  of  acidity  or 
alkalinity  ;  although,  from  acidental  circum¬ 
stances,  they  are  occasionally  rendered  neu¬ 
tral.  Thus,  the  introduction  of  a  large 
quantity  of  water  into  the  stomach  may  at 
once  remove  the  natural  acidity  of  the  urine  ; 
also,  when  the  skin  is  covered  with  a  pro¬ 
fuse  perspiration,  the  naturally  acid  reaction 
of  the  perspiratory  fluid  may,  for  the  time, 
cease  to  manifest  itself.  But  it  is  evident 
that,  in  these  cases,  the  acidity  of  the  fluids 
disappears  only  because  of  the  extreme  dilu¬ 
tion  of  the  acid  principle  by  the  abundance 
of  its  watery  vehicle.  In  the  healthy  con¬ 
dition,  no  spontaneous  change  occurs  in  the 
system  by  which  a  fluid,  naturally  acid,  is 
rendered  alkaline,  or  vice  versa.  If  such 
change  in  reaction  is  occasionally  observed, 
it  depends,  like  the  above-mentioned  con¬ 
version  into  the  neutral  state,  upon  influences 
external  to  the  system,  and  is  produced, 
either  by  the  food  or  drink ;  or  upon  the 
decomposition  of  the  liquids  exposed  to  the 
air,  or  while  contained  within  their  reser¬ 
voirs.  It  may,  therefore,  be  established  as 
a  general  principle,  that,  in  the  healthy 
human  subject,  each  of  the  several  fluids  of 


262 


ON  THE  ACID  AND  ALKALINE  REACTION  OF  THE 


the  body,  whatever  be  the  varieties  of  its 
physiological  properties,  invariably  main¬ 
tains  the  same  reaction,  whether  this  be 
cid  or  alkaline.  At  the  same  time,  how¬ 
ever,  any  of  these  fluids  may  become  acciden¬ 
tally  neutral  if  a  large  quantity  of  water  is 
taken  into  the  system,  or  if  it  is  secreted  in 
very  unusual  abundance.  This  is  especially 
the  case  in  regard  to  the  cutaneous  secretion  ; 
a  fact  which  would  seem  to  show  that  where 
this  fluid  is  poured  forth  in  large  quantities 
it  contains  proportionally  more  watery  than 
solid  principles,  otherwise  the  mere  abun¬ 
dance  of  the  secretion  would  not  cause  the 
natural  acidity  of  the  fluid  to  disappear. 

This  constant  maintenance  of  the  natural 
reaction  of  animal  fluids  being  observed  in 
health,  it  becomes  very  desirable  to  deter¬ 
mine  whether  a  similar  condition  exists  also 
in  disease.  It  is  generally  supposed  that 
certain  diseases  have  the  effect  of  so  modify¬ 
ing  the  animal  fluids  as  to  render  the  acid 
ones  alkaline,  and  the  naturally  alkaline  ones 
acid  ;  and  this  supposition  has  led  to  many 
theories  as  to  the  cause,  nature,  and  mode 
of  {attack  of  such  diseases.  To  the  inves¬ 
tigation  of  this  subject,  the  attention  of  M. 
Andra!  has  been  especially  directed.  Of  all 
the  fluids  of  the  body,  the  serum  of  the 
blood  always  appears  to  present  the  alkaline 
reaction  in  the  most  marked  degree ;  and 
M.  Andral  finds  that  the  intensity  of  this 
reaction  does  not  seem  to  present  any  sen¬ 
sible  difference,  whatever  may  be  the  nature 
and  duration  of  a  disease.  It  has  been  said, 
that  in  cases  in  which  the  blood  becomes 
very  deficient  in  fibrine,  the  proportion  of 
its  alkaline  principles  increases,  but  this 
statement  is  not  sufficiently  supported  by 
facts.  Equally  unsupported,  also,  is  the 
statement  that  the  alkalinity  of  the  blood  is 
diminished  in  diabetes,  it  has  been  said, 
also,  that  the  blood  sometimes  becomes 
neutral,  or  even  acid,  in  disease;  but  M. 
Andral  doubts  the  existence  of  such  changes, 
believing  that  the  blood,  under  all  circum¬ 
stances,  is  invariably  alkaline. 

In  health,  the  fluids  formed  from  the 
blood  are  rarely  found  neutral ;  most  com¬ 
monly  they  are  alkaline,  like  the  blood  itself, 
or  more  or  less  strongly  acid.  In  examining 
the  reaction  of  the  different  secretions,  it 
must,  however,  be  remembered,  that  upon 
most  of  the  surfaces  of  the  body,  both  ex¬ 
ternal  and  internal,  secretions  of  different 
reaction  are  poured  forth  ;  hence  care  must 
be  taken  not  to  ascribe  the  effect  of  an  acci¬ 
dental  excess  of  one  secretion  to  a  change  in 
the  reaction  of  another.  Thus,  the  skin 
secretes  two  principles  of  different  reaction  : 
the  fluid  of  perspiration,  which  is  acid  ;  and 
the  matter  discharged  by  the  sebaceous 
glands,  which  is  alkaline.  Under  all  condi¬ 
tions,  both  of  health  and  disease,  the  fluid 
of  perspiration  is  acid  ;  sometimes,  from  the 


cause  already  mentioned,  it  is  neutral,  but 
never  alkaline.  In  typhoid  fevers,  however 
severe,  its  acidity  invariably  persists ;  and 
in  diabetes  it  does  not  disappear,  as  has  been 
supposed.  In  the  latter  disease  the  perspira¬ 
tion,  though  usually  small  in  amount,  is 
sometimes,  especially  in  advanced  stages, 
very  profuse,  even  when  no  pulmonary  tu¬ 
bercles  have  manifested  themselves.  Although 
the  true  perspiratory  secretion  is  itself  inva¬ 
riably  acid,  yet  the  skin  does  not  everywhere 
present  an  acid  reaction  ;  in  some  parts,  in¬ 
deed,  even  when  covered  by  perspiration,  it 
is  manifestly  alkaline.  The  parts  in  which 
this  occurs  are  those  provided  with  numerous 
sebaceous  glands,  as  in  the  neighbourhood  of 
the  nose  in  some  persons,  and  most  com¬ 
monly  the  hollow  of  the  axilla,  the  eyebrows, 
and  many  other  parts  covered  with  hair. 
The  alkaline  reaction  in  such  cases  is  evi¬ 
dently  due,  not  to  any  alteration  of  the  per¬ 
spiratory  fluid  itself,  but  to  the  fatty  matter 
secreted  by  the  sebaceous  follicles.  It  is  not 
a  constant  condition,  being  much  more 
manifest  in  some  persons  than  in  others  ; 
and  its  existence  or  absence  appears  to  be 
quite  independent  of  all  circumstances  of 
health  and  disease. 

The  acidity  of  the  perspiratory  fluid 
proves  that  it  is  not  simply  the  liquid  part 
of  the  blood  which  exudes  from  the  blood¬ 
vessels  charged  with  more  or  less  of  the  ele¬ 
ments  of  serum  :  for  if  such  were  its  nature 
it  ought  to  be  alkaline  like  the  serum,  and 
like  those  fluids  which  appear  to  be  directly 
derived  from  the  serum.  Thus  the  fluid 
poured  forth  from  the  skin  at  a  part  irritated 
by  a  burn,  or  by  the  application  of  a  blister, 
is  always  strongly  alkaline.  So  also  are  the 
liquid  contents  of  the  vesicles  of  herpes  and 
eczema,  and  of  the  bullae  of  pemphigus.  In 
all  such  cases  in  which  the  exhalation  of  the 
fluid  has  been  preceded  by  a  greater  or  less 
degree  of  congestion  of  the  part,  it  may  be 
assumed  that  the  fluid  poured  forth  consists 
of  the  serum  of  the  blood,  modified  only  in 
regard  to  the  relative  proportions  of  its  ele¬ 
ments.  In  that  singular  form  of  vesicular 
eruption  which  is  not  preceded  by  con¬ 
gestion  of  the  skin — viz.  sudamina — the  con¬ 
tents  of  the  vesicles,  unlike  those  of  all 
other  vesicles,  are  acid,  and,  moreover, 
contain  no  albumen — a  substance  invariably 
found  in  the  fluid  of  other  vesicles  and 
bullae.  In  these  two  points  the  fluid  of 
sudamina  resembles  the  perspiratory 
fluid  :  and  the  analogy  between  them  is 
rendered  more  complete  by  the  frequent 
occurrence  of  this  form  of  eruption  in 
diseases  attended  by  profuse  perspiration. 
Sudamina  are  not,  however,  confined  to  cases 
in  which  the  perspiration  is  abundant,  for 
they  frequently  occur  largely  over  the  trunk, 
neck,  and  extremities,  in  cases  of  fever  un¬ 
attended  by  any  manifest  perspiration. 


FLUIDS  OF  THE  HUMAN  BODY  IN  HEALTH  AND  DISEASE. 


On  mucous  membranes,  still  more  than 
on  the  skin,  fluids  of  various  kinds,  and 
possessed  of  different  reactions,  are  poured 
forth  :  hence  the  difficulty  of  determining 
with  certainty  the  reaction  peculiar  to  each, 
and  hence  the  errors  which  have  so  fre¬ 
quently  arisen  on  the  subject.  Over  their 
whole  extent,  mucous  membranes,  in  the 
condition  of  health,  furnish,  like  the  skin, 
an  acid  principle.  This  principle  is  con¬ 
tained  in  the  transparent  fluid,  destitute  of 
corpuscles,  which  these  membranes,  in 
health,  separate  from  the  blood.  But  when, 
as  continually  occurs,  this  homogeneous 
fluid  is  replaced  by  another  fluid,  opaque, 
and  provided  with  corpuscles,  the  acid  reac¬ 
tion  disappears,  and  is  replaced  by  well- 
marked  alkalinity.  Thus  the  opaque  mucus 
secreted  by  mucous  membranes  which  are 
the  seat  of  acute  or  chronic  inflammatory 
affections  is  invariably  alkaline.  Few  liquids, 
indeed,  are  so  strongly  alkaline  as  the  puri- 
form  mucus  discharged  from  the  nasal 
fossae  in  cases  of  coryza.  The  matter  ex¬ 
pectorated  in  bronchitis  often  presents  both 
an  acid  and  alkaline  reaction ;  the  clear 
transparent  parts  being  acid,  while  the 
opaque  portions  are  alkaline.  The  mucous 
membrane  of  the  cavity  of  the  mouth,  com¬ 
prising  that  which  covers  both  surfaces  of 
the  tongue,  does  not  always  present  the 
same  reaction.  Examined  in  the  morning, 
before  any  food  has  been  taken,  it  presents, 
in  the  great  majority  of  cases,  an  acid  reac¬ 
tion  ;  but  in  the  course  of  the  day  this 
reaction  changes,  and  becomes  alkaline. 
The  acidity  belongs  to  the  matter  furnished 
by  the  mucous  membrane  itself,  the  alka¬ 
linity  to  the  saliva.  It  is  therefore  wrong 
to  attribute  the  acidity  of  the  mouth  to  a 
morbid  state  of  the  stomach ;  for  it  is 
not  a  pathological  state,  but  occurs  in  the 
healthiest  persons,  and  depends  upon  the 
proper  secretion  of  the  mucous  membrane 
which  happens,  at  the  time  of  examination, 
not  to  be  neutralised  by  saliva.  The  acidity 
natural  to  the  healthy  secretion  of  the 
mouth  is  retained  under  all  circumstances  of 
disease.  In  those  cases  in  which  the  cavity 
of  the  mouth  is  found  neutral  or  alkaline, 
the  change  is  due  either  to  a  cessation  of 
the  secretion,  or  to  its  neutralisation  by 
saliva,  or  some  other  fluid  not  derived  from 
the  buccal  mucous  membrane. 

When  a  piece  of  litmus  paper  is  applied  to 
the  mucous  membrane  of  the  stomach  after 
death,  it  usually  becomes  manifestly  red¬ 
dened  ;  occasionally  it  is  unchanged,  but 
under  no  circumstances  does  the  membrane 
exhibit  an  alkaline  reaction.  Its  acidity  is 
manifest,  whether  there  be  present  any  re¬ 
mains  of  food  or  not ;  whether  the  organ 
has  been  empty  for  a  considerable  time,  or 
has  only  just  peased  digesting,  and  from 
whatever  disease  the  individual  has  died.  It 


263 


is  difficult  to  reconcile  this  fact  with  the 
statements  of  recent  physiologists,  who  say 
that  the  mucous  membrane  of  the  stomach 
only  becomes  acid  when  it  is  stimulated,  as 
by  the  presence  of  food,  while  at  other  times 
it  is  neutral,  or  even  alkaline.  The  mucous 
surface  of  the  duodenum,  and  of  the  upper 
portion  of  the  small  intestine,  is  usually 
found  acid  after  death  ;  but  since  from  the 
pancreas  and  liver  secretions  of  an  alkaline 
character  are  poured  into  this  part  of  the 
intestinal  canal,  both  the  duodenum  and  the 
parts  of  the  small  intestine  below  it  are  often 
found  alkaline.  The  large  intestine  always 
presents  a  very  decided  alkaline  reaction  [the 
caecum  ?] 

With  regard  to  the  reaction  of  the  secre¬ 
tions  of  the  various  glands,  the  tears  are 
invariably  alkaline.  The  saliva  also  is 
always  alkaline.  It  has  been  said  to  be¬ 
come  acid  in  some  diseases,  e.  y.  in  diabetes, 
but  this  is  probably  never  the  case.  The 
cause  of  the  occasional  acidity  of  the  mouth 
has  been  already  explained.  That  such 
acidity  is  not  in  any  case  due  to  an  acid  se¬ 
cretion  of  saliva  may  be  at  once  proved  by 
exciting  a  flow  of  saliva, — as  may  be  done 
by  chewing  some  stimulating  substance — and 
testing  its  reaction,  which  will  be  invariably 
found  alkaline.  In  health,  urine  which  has 
not  remained  too  long  in  the  bladder,  and  is 
examined  shortly  after  it  is  voided,  is  in¬ 
variably  acid.  The  reason  of  its  being  oc¬ 
casionally  found  neutral  has  been  already 
explained.  Accidental  circumstances  occa¬ 
sionally  render  this  secretion  for  a  time 
alkaline — as  the  use  of  alkaline  salts,  and 
the  long-continued  employment  of  an 
exclusively  vegetable  diet ;  but  on  the  re¬ 
moval  of  these  causes  the  acidity  is  speedily 
restored.  Also  in  the  various  diseases  in 
which  the  composition  of  the  urine  is  sub¬ 
ject  to  be  changed,  the  acidity  of  this  fluid 
at  its  secretion  is  never  lost.  It  has  been 
said  to  be  alkaline  in  typhus,  but  such  is 
not  the  case.  It  has  also  been  said,  very 
commonly,  that  affections  of  the  spinal  cord 
have  the  power  of  so  modifying  the  secretion 
of  the  kidneys  as  to  cause  the  urine  to 
become  alkaline.  On  this  point,  however, 
considerable  confusion  seems  to  exist.  So 
long  as  the  bladder  is  not  diseased,  the  urine 
of  a  person  affected  with  spinal  mischief 
possesses  its  natural  acidity  when  it  reaches 
this  viscus,  and  retains  it  while  it  remains  in  it; 
but  if  the  mucous  membrane  of  the  bladder 
is  the  seat  of  a  purulent  secretion,  then  the 
urine  in  contact  with  it  becomes  alkaline. 
And  this  latter  condition  often  occurs,  be¬ 
cause  of  the  frequency  with  which  the  bladder 
is  affected  in  the  more  or  less  advanced 
stages  of  disease  of  the  spinal  cord.  A 
morbid  state  of  the  bladder  seems  to  be  the 
only  condition  by  which  the  urine  is  made 
alkaline.  But  even  in  such  cases,  this  fluid, 


264  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY,  ETC. 


as  it  is  secreted  by  the  kidneys,  possesses  its 
natural  acid  i*eaction,  losing  it  only  when  it 
arrives  at  the  bladder.  The  change  in  re¬ 
action  is  indeed  purely  a  chemical  act :  the 
urine  placed  in  contact  with  morbid  products 
poured  from  the  mucous  surface  of  the 
bladder,  is  decomposed,  and  becomes  arnmo- 
niacal.  If  the  morbid  product  is  purulent, 
an  additional  reason  for  the  alkalinity  of  the 
urine  is  furnished, — for  pus,  from  whatever 
source  it  is  derived,  is  invariably  alkaline. 

It  follows,  therefore,  from  the  above  ob¬ 
servations,  that  the  different  fluids  of  the 
economy  present,  in  regard  to  their  reaction, 
whether  it  be  acid  or  alkaline,  a  very  con¬ 
stant  condition,  which  is  not  altered  even  by 
disease.  So  that  it  may  be  held  as  a  law, 
applicable  both  in  health  and  disease,  that 
an  animal  fluid,  when  secreted,  invariably 
possesses  the  same  chemical  reaction. — 
Comptes  Rendws,  19  Juin,  1848. 

A 


BIRTHS  &  DEATHS  in  the  Metropolis 


During  the  week  ending  Saturday ,  Aug.  5. 


Births. 
Males ....  638 
Females..  642 

1300 


Deaths. 
Males....  518 
Females..  520 

1038 


Av.  of  5  Sum. 
Males....  495 
Females. .  477 


972 


Causes  of  Death. 

All  Causes . 

Specified  Causes . 

1.  j^m0fr‘c(orEpidemic, Endemic, 

Contagious)  Diseases . . 
Sporadic  Diseases,  viz. — 

2.  Dropsy,  Cancer,  &c.  of  uncer¬ 

tain  seat  . 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  . 

4.  Lungs  and  other  Organs  of 

Respiration . 

5.  Heart  and  Bloodvessels . 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion  . 

7.  Diseases  of  the  Kidneys,  &c.. . 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c . 

9.  Rhematism,  Diseases  of  the 
Bones,  Joints,  &c . 

10.  Skin,  Cellular  Tissue,  &c . 

11.  Old  Age . 

12.  Violence,  Privation,  Cold,  and 

Intemperance . I 


I  Av.  of 

5  Sum. 

1038 

972 

1038 

968 

434 

257 

35 

45 

101 

120 

60 

80 

25 

28 

70 

79 

17 

8 

10 

10 

7 

7 

1 

1 

24 

50 

17 

8 

The  following  is  a  selection  of  the  numbers  of 
Deaths  from  the  most  important  special  causes : 


Small-pox  .  32 

Measles  .  9 

Scarlatina  ......  97 

H  oopi  n  g-cough . .  24 

Diarrhoea  . 141 

Cholera . * . .  21 

Typhus  .  55 

Dropsy .  15 

Sudden  deaths  . .  3 

Hydrocephalus..  28 
Apoplexy .  21 


Paralysis .  14 

Convulsion .  36 

Bronchitis .  19 

Pneumonia .  23 

Phthisis . 114 

Dig .  of  Lungs,  Sic.  8 

Teething .  10 

Dis.  Stomach,  &c.  5 
Dis.  of  Liver,  &c.  11 

Childbirth .  6 


Dis.ofUterus,&c.  4 


Remarks.— The  total  number  of  deaths  was 
only  66  above  the  weekly  summer  average.  Zy¬ 


motic  diseases  are  far  more  fatal  than  the  ave¬ 
rage,  but  other  diseases  have  assumed  a  less 
fatal  character.  The  Zymotic  deaths  were  434, 
to  a  weekly  average  of  257 ;  but  it  ought  to  be 
stated,  that  out  of  the  434  deaths,  no  less  than 
342  were  among  infants. 


METEOROLOGICAL  SUMMARY. 

Mean  Height  of  Barometer .  29*54 

“  w  Thermometer*  .  60* 

Self-r egisterrng  do.b  ....  max.  91 ‘8  min.  42* 

“  in  the  Thames  water  —  66*2  —  63*5 

a  From  12  observations  daily.  •>  Sun. 

Rain,  in  inches,  1*34:  sumofthe  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological. — The  mean  temperature  of  the 
week  was  1  '6°  below  the  mean  of  the  month. 


BOOKS  &  PERIODICALS  RECEIVED 

DURING  THE  WEEK. 

Eighth  Annual  Report  of  the  Registrar-General. 

Scriptural  Authority  for  the  Mitigation  of  the 
Pains  of  Labour  by  Chloroform.  By  Protheroe 
Smith,  M.D. 

Dublin  Quarterly  Journal  of  Medical  Science, 
August  1848. 

Pharmaceutical  Journal,  August. 

Arguments  against  the  indiscriminate  Use  of 
Chloroform  in  Midwifery,  by  S.  W.  J.  Merri- 
man,  M.D. 

***  This  and  Mr.  Gream’s  pamphlet  on  the 
same  subject  will  be  shortly  noticed. 

Should  the  Cholera  come, — What  ought  to  be 
done?  By  John  Challice,  Surgeon. 

Oratio  Anniversaria  Harveiana,  mdcccxlviii. 

Edinburgh  Monthly  Journal  of  the  Medical 
Sciences,  August. 

London  and  Edinburgh  Philosophical  Magazine, 
August. 

Journal  de  Pharmacie  et  de  Chimie.  Juillet. 

Casper’s  Wochenschrift,  Nos.  28,  29,  8  and  15 
July. 

Comptes  Rendus,  Nos.  3  and  4.  17  and  24  July. 

British  Record  of  Obstetric  Medicine,  No.  15, 
August. 

Journal  of  Public  Health,  August. 

British  American  Journal  of  Medical  and  Physi¬ 
cal  Science,  July  1848. 

The  Water-Cure  Journal,  August. 


NOTICES  to  CORRESPONDENTS. 

Dr.  Andrew  Clark.— We  shall  have  great  plea¬ 
sure  in  inserting  the  series  of  papers.  That 
which  has  been  already  forwarded,  will  appear 
in  the  following  number.  Will  our  correspon¬ 
dent  be  so  good  as  to  send  the  drawings  as 
early  as  may  be  convenient  ? 

If  Mr.  J.  Jakins  will  transmit  to  us  a  description 
of  the  Duplex  Monster  it  shall  be  inserted. 

A  Subscriber  of  Five  Years.  —  We  know  of  no 
other  appointments  than  those  attached  to  our 
embassies  at  foreign  courts ;  and  the  selection 
is  generally  made  b  v  the  Ambassador.  So  far 
as  we  know  there  is  no  book  published  in 
reference  to  such  matters. 

Mr.  White’s  paper  will  be  inserted  next  week. 
A  proof  shall  be  sent  to  Mr.  Kelly. 

Dr.  W.  Reid. — At  present  there  is  no  vacancy. 
We  will,  however,  retain  our  correspondent’s 
address. 

Mr.  W.  Bowman. — We  shall  he  glad  to  publish 
the  Lectures.  Proofs  .shall  be  forwarded. 

Mr.  A.  J.  Simkins. — The  authentic  report  of  the 
case  has  come  to  hand,  and  will  be  inserted 
next  week  if  possible.  We  have  not  received 
a  copy  of  the  Staffordshire  Advertiser. 

Received.— Mr.  Girdwood.— Mr.  Swan. 


moufflon  iMetitcal  (gazette. _ 205 


tUrtuvt*. 


COURSE  OF  SURGERY, 
Delivered  in  the  years  1846  and  1847, 

By  Bransby  B.  Cooper,  F.R.S. 

Surgeon,  ancl  Lecturer  on  Surgery  at  Guy’s 
Hospital. 


Lecture  XXXV. 

SURGERY  OF  REGIONS. - CONTINUED. 

Wounds  of  the  viscera ,  and  of  the  ivalls  of 
the  abdomen  —  Symptoms — Penetrating 
wounds  in,  the  epigastrium  —  their 
dangerous  character — Wounds  of  um¬ 
bilical  and  lumbar  regions — Wounds  in 
hypogastric  regions  —  iliac  regions  — 
Danger  of  wounds  of  the  intestines  in 
proportion  to  their  proximity  to  the 
pylorus — Symptoms  of  wounds  of  intes¬ 
tines —  Treatment — Mode  of  reparation 
—  Complete  division  of  intestine — Treat¬ 
ment — by  suture — by  formation  of  arti¬ 
ficial  anus — Penetrating  wounds  of  ab¬ 
dominal  viscera  by  musket  ball — not 
always  fatal. 

Laceration  of  viscera  without  wound  of 
parietes — Symptoms —  Treatment — Col¬ 
lapse  equally  a  symptom  of  lesion  of  solid 
and  hollow  viscera — Cases — Distinctive 
symptoms  in  rupture  of  large  and  small 
intestine  —  Rupture  of  gall-bladder  — 
Symptoms  —  Rupture  of  the  stomach — 
treatment  unavailing — Rupture  of  blad¬ 
der — Danger  depending  on  liability  to 
peritonitis. 

injuries  to  abdomen  ( continued ). 

When  the  viscera,  as  well  as  the  walls  of 
the  abdomen,  are  wounded,  the  nature  of 
the  injury  is  generally  indicated  by  the  pe¬ 
culiar  character  of  the  effusion  which 
follows ;  but  sometimes  it  may  happen, 
either  from  the  oblique  direction  of  the 
wound,  from  its  small  size,  or  from  the 
emptiness  of  the  viscus  itself,  that  no  effu¬ 
sion  occurs.  In  that  case  the  diagnosis 
must  be  formed  upon  the  general  symptoms 
that  present  themselves  ;  and  these  are  in¬ 
deed  usually  sufficiently  marked  to  enable 
the  surgeon  to  form  at  once  a  tolerably 
correct  judgment. 

There  are  no  circumstances  in  which  the 
advantage  of  the  topographical  division  of  a 
region  is  more  evident  than  in  the  case  of 
penetrating  wounds  of  the  abdomen  and  its 
contents  ;  in  such  accidents  the  diagnosis 
is  greatly  facilitated  by  the  mapping  out  of 
the  surface ;  and  it  is  easy  to  determine 
upon  the  organ  which  has  been  injured,  not 

xlii. — 1081.  Aug.  18,  1848. 


only  from  the  effusion  which  makes  its 
escape,  but  also  from  the  anatomical  know¬ 
ledge  of  the  situation  of  each  particular 
organ,  which  would  afford  the  requisite 
ground  for  the  judgment,  even  should  effu¬ 
sion  be  completely  absent. 

Penetrating  wounds  into  the  epigastrium 
are  particularly  dangerous,  owing  to  the 
circumstance  of  the  liver,  gall-bladder,  sto¬ 
mach,  duodenum,  and,  indeed,  all  the  most 
important  of  the  chylo-poietic  viscera,  being 
situate  in  this  region  ;  and  wounds  here,  if 
they  do  not  lead  to  the  extravasation  of 
blood,  bile,  or  chyle,  would  at  any  rate  pro¬ 
duce  extreme  collapse,  which  would  be  in¬ 
dicative  of  injury  to  some  of  the  organs 
above  named,  and  the  prognosis  would  be 
extremely  unfavourable,  from  the  importance 
of  the  function  they  are  destined  to  perform. 
In  the  umbilical  and  lumbar  regions,  both 
the  large  and  small  intestines,  as  well  as  the 
kidneys,  are  liable  to  be  wounded  ;  injury 
to  the  latter  is  not,  however,  indicated  im¬ 
mediately  unless  the  cause  be  a  penetrating 
wound  from  behind ;  in  that  case  a  urinous 
discharge  might  take  place.  Wounds  in 
the  centre  of  the  hypogastrium  may  injure 
the  bladder  ;  and  if  this  organ  happened  to 
be  in  a  state  of  distension  at  the  time,  the 
nature  of  the  injury  would  be  indicated  by 
a  discharge  of  urine.  I11  wounds  in  the 
iliac  region,  the  iliac  vessels  are  endangered  ; 
if  the  wound  occur  on  the  right  side,  the  ca¬ 
put  coli,  if  on  the  left,  the  sigmoid  flexure  of 
the  colon,  may  be  the  seat  of  injury.  In  a 
general  sense,  wounds  of  the  intestines  must 
be  considered  as  dangerous  in  proportion  to 
their  proximity  to  the  pylorus ;  for  even  if 
the  patient  should  escape  effusion  of  the 
contents  of  the  wounded  intestine,  and  fatal 
peritonitis,  still,  with  the  formation  of  an 
artificial  anus,  as  the  contents  of  the  small 
intestines,  especially  those  of  the  duodenum 
and  jejunum,  are  evacuated  through  the  arti¬ 
ficial  opening,  inanition  would  be  a  certain 
result ;  while,  if  the  discharge  takes  place 
from  the  large  intestine,  the  contents  of 
which  are  almost  entirely  excrementitious, 
there  would  be  but  little  loss  of  nutrition. 

When  an  intestine  is  wounded  without 
protrusion,  the  character  of  the  injury  is 
indicated  by  blood  passing  with  the  stools ; 
or,  if  it  be  a  small  intestine  injured,  a 
further  symptom  will  be  the  vomiting  of 
blood,  and  the  escape  of  gas,  and  some¬ 
times  chylous  matter.  Under  such  cir¬ 
cumstances,  the  patient  should  be  kept  in 
a  state  of  perfect  quietude,  and  as  col¬ 
lapse  is  almost  inseparable  from  such  an 
accident,  stimuli  may  be  required  to  restore 
reaction ;  but  total  abstinence  from  food 
must  be  strictly  observed,  to  maintain  that 
quiescent  state  of  the  intestine  neces¬ 
sary  to  its  reparation.  Constipation  may, 
indeed,  be  permitted  to  continue  for  several 


266  SYMPTOMS  OF  WOUNDS  OF  INTESTINES — TREATMENT. 


days,  and  appears  to  form  part  of  the  means 
adopted  by  nature  in  the  restoration  of  the 
part  to  its  normal  condition. 

When  the  wounded  intestine  protrudes,  its 
contents  may  be  perceived  issuing  from  the 
wound,  although  the  opening  itself  appears 
to  be  closed  by  the  protrusion  of  the  internal 
mucous  membrane.  The  size  of  this  open¬ 
ing,  and  its  direction,  as  to  whether  it  be 
longitudinal  or  transverse,  must  now  regulate 
the  treatment  to  be  adopted.  If  the  wound 
be  very  small,  its  edges  may  be  pinched  up 
by  a  pair  of  forceps,  and  a  thin  silk  tied 
round  so  as  to  include  the  whole  of  the 
wound  ;  the  intestine  is  then  to  be  returned 
into  the  cavity  of  the  abdomen,  but  must  be 
kept  as  close  as  possible  to  the  external 
wound.  The  ligature  produces  a  sloughing 
of  all  the  included  tissues,  and  adhesive  in¬ 
flammation  of  the  peritoneum  being  set  up, 
an  external  wall  of  plastic  matter  is  formed 
around  the  dead  part,  which  ulcerates  off 
into  the  intestine,  and  is  carried  away  with 
the  iseces.  Sir  Astley  Cooper  successfully 
employed  this  method  of  treatment  in  one 
or  two  cases  in  which  the  intestine  had  been 
inadvertently  wounded  in  the  operation  for 
strangulated  hernia. 

When  the  opening  in  the  bowel  is  large, 
different  kinds  of  stitches  are  used  to  keep 
the  edges  of  the  wound  in  apposition.  The 
■uninterrupted  suture,  however,  or  glover’s 
stitch,  is,  I  believe,  the  best,  but  the  finest 
procurable  needle  and  silk  must  be  em¬ 
ployed  ;  and,  after  the  bowel  has  been  re¬ 
turned  into  its  natural  cavity,  the  same  pre¬ 
caution  as  I  have  already  mentioned  to  keep 
it  in  proximity  to  the  external  wound, 
should  be  adopted.  When  the  intestine  has 
been  completely  divided  by  a  transverse 
wound,  various  plans  have  been  recom¬ 
mended  for  re-establishing  its  continuity. 
For  this  purpose,  some  animal  substance  of 
a  cylindrical  form,  such  as  the  trachea  of  a 
sheep,  has  been  introduced.  This  serves  as 
a  sort  of  mould,  and  enables  the  surgeon  to 
keep  the  edges  of  the  severed  bowel  in 
juxtaposition  during  the  application  of  the 
suture,  the  foreign  substance  easily  passing 
away  afterwards  with  the  stools.  Some 
have  recommended  that  the  upper  extremity 
of  the  intestine  should  be  passed  into  the 
lower,  and  that  a  ligature  be  then  applied 
around  the  whole.  This  produces  contact 
of  the  peritoneal  coat  of  the  intestine  above 
and  below  the  ligature,  and,  as  adhesive  in¬ 
flammation  is  set  up,  an  effusion  of  plastic 
matter  soon  covers  the  ligature,  and  re¬ 
establishes  the  continuity  of  the  external 
part  of  the  canal ;  the  ligature  itself,  and 
the  constricted  portion,  ultimately  sloughing 
off  internally,  and  being  conveyed  away  with 
the  excretions.  It  has  been  objected  to 
this  operation,  that,  in  bringing  the  severed 
ends  of  the  intestine  together,  a  serous  is 


presented  to  a  mucous  surface,  and  that 
these  two  structures  are  ill  fitted  for  union  'r 
but  it  is  not  intended  in  this  operation  that 
they  shall  unite :  the  union  is  caused  by  the 
effusion  of  the  plastic  matter  from  the  ex¬ 
ternal  surfaces  above  and  below  the  ligature, 
and  from  serous  to  serous  membrane,  the 
whole  of  the  intestine  included  in  the  liga¬ 
ture  being  destroyed  and  sloughing  away. 
M.  Jobert  has  proposed,  as  an  improvement 
in  the  above  operation,  to  invert  the  inferior 
extremity  before  the  superior  is  introduced. 
In  that  case,  two  serous  membranes  are 
brought  in  contact,  and  the  union  may  take 
piace  at  once  between  them ;  but,  under 
these  circumstances,  the  invaginated  portion, 
would  not  be  included  in  a  ligature,  but 
returned  in  position  by  suture. 

After  all,  however,  from  the  result  of  the 
experiments,  it  remains  questionable  whether, 
in  complete  division  of  an  intestine  by  a 
transverse  wound,  it  is  not  better  to  establish 
an  artificial  anus  and  leave  nature  to  her  own 
efforts  for  the  ultimate  restoration  of  the 
patient ;  and  this  does  not  indeed  appear  to  be 
so  difficult  a  process  as  may  be  supposed, 
particularly  if  nature  be  judiciously  assisted 
by  the  art  of  the  surgeon. 

Almost  immediately  after  the  divided  in¬ 
testine  has  been  replaced  in  the  cavity  of  the 
abdomen,  an  adhesive  inflammation  shuts 
out  the  open  extremities  of  the  intestine 
from  the  peritoneal  cavity,  so  that  after  a 
few  hours  have  elapsed  the  stitch  employed  to 
secure  the  wounded  intestine  near  the  ex¬ 
ternal  wound  in  the  abdomen  may  be  re¬ 
moved,  and  as  soon  as  the  feculent  matter 
passes  partly  through  the  latter  the  patient 
may  be  considered  safe,  as  far  as  refers  to 
the  danger  of  extravasation  of  the  fseces  into 
the  abdomen.  But  as  the  formation  of  an 
artificial  anus  renders  the  patient  loathsome 
to  himself,  and  unfitted  for  a  social  state,, 
subsequent  means  must  be  adopted  to  re¬ 
establish  the  integrity  of  the  intestinal  canal. 

With  this  view,  one  of  the  first  steps  is  to 
diminish  as  much  as  possible  a  tendency 
which  the  upper  portion  of  the  bowel  has  to 
prolapsus  or  eversion  of  its  mucous  mem¬ 
brane  ;  and  this  object  may  be  attained  by 
keeping  the  faeces  in  a  semi-fluid  state,  and 
by  maintaining  slight  pressure  upon  the  ex¬ 
tremity  of  the  protruded  part.  The  lower 
portion  of  the  intestine  is  liable  to  con¬ 
tract  at  its  extremity,  so  that  the  ready  pas¬ 
sage  of  the  contents  of  the  upper  portion  is 
prevented  from  passing  into  the  lower  ;  this 
may  be  in  some  measure  obviated  by  the  use 
of  enemata,  which  stimulate  the  natural 
action  of  the  bowel  and  prevent  it  from  fall¬ 
ing  into  the  abnormal  condition  always 
produced  by  disuse.  The  strictest  attention 
to  cleanliness  of  the  external  wound  should 
constantly  be  observed,  otherwise  the  pre¬ 
sence  of  the  feculent  matter  will  interfere 


PENETRATING  WOUNDS  OF  ABDOMINAL  VISCERA  BY  MUSKET  BALL.  267 


very  materially  with  the  progress  of  the  heal¬ 
ing  process.  As  the  wound  goes  on  uniting 
it  gradually  contracts  into  a  narrow  fistula  : 
this  contraction  is  still  further  promoted  by 
gentle  pressure ;  and  after  a  while,  as  the 
faeces  meet  with  some  resistance  in  the  di¬ 
rection  of  the  wound ,  they  acquire  a  tendency 
to  pass  on  through  the  natural  passage, — a 
change  which  is  first  indicated  by  the  escape 
of  flatus  and  mucous  per  anum  ;  upon  which 
enemata  should  be  freely  employed  to  re¬ 
establish  the  natural  function  of  the  rectum 
and  anus. 

By  such  treatment  a  recent  artificial  anus 
may  very  generally  be  cured,  but  if  neglected 
the  lower  part  becomes  so  much  retracted, 
and  at  the  same  time  contracted,  as  to  ren¬ 
der  the  cure  almost  impossible.  Dupuytren 
has,  however,  proposed  the  removal  of  the 
obstruction  termed  the  •  *  eperon  ”  by  means 
of  a  pair  of  forceps  made  to  include  it, — 
one  blade  of  the  forceps  being  inserted  into 
the  upper,  the  other  into  the  lower  opening 
of  the  intestine  ;  and  being  closed  with  suf¬ 
ficient  force  to  produce  sloughing  of  the 
included  valvular  portion,  after  which  a  free 
communication  between  the  two  parts  of  the 
intestine  will  be  re-established.  The  same 
attention  must  be  paid  to  the  external 
wound  as  under  the  circumstances  I  have 
before  described. 

In  gun-shot  wounds,  where  the  ball  has 
penetrated  the  parietes  of  the  abdomen  and 
wounded  a  viscus,  nature  has  sometimes 
effected  the  reparation  of  the  part — the  ball 
tpassing  away  with  the  faeces.  A  musket- 
ball  has  also  been  known  to  penetrate  and 
lodge  in  the  urinary  bladder,  from  which  it 
has  afterwards  been  removed  encrusted  with 
calcareous  matter,  the  patient  ultimately  re¬ 
covering. 

Mr.  Travers  has  written  an  excellent 
work,  detailing  the  results  of  different  modes 
of  treatment  of  wounds  of  the  intestines  in 
the  lower  animals ;  and  I  cannot  do  better, 
gentlemen,  than  to  strongly  recommend  it  to 
your  perusal. 

Fifthly. — Laceration  or  rupture  of  the 
viscera  of  the  abdomen  mav  occur  without 

a' 

lesion  of  the  external  walls,  and,  indeed,  with¬ 
out  the  abdomen  itself  receiving  any  blow  : 
in  a  fall  from  a  height,  for  instance,  the  con¬ 
cussion  alone  may  be  sufficient  to  cause  rup¬ 
ture  of  a  viscus,  particularly  of  the  liver, 
which,  from  its  great  weight  and  peculiar 
consistence,  is  especially  liable  to  be  rent 
from  such  a  cause.  The  spleen  and  kidneys 
are  liable  to  similar  lesions,  and  when  dis¬ 
tended,  theintestines  and  urinary  bladder  may 
also  give  way  without  any  external  wound. 
In  all  these  cases  collapse  forms  the  prin¬ 
cipal  symptom;  and  the  danger  may  be  con¬ 
sidered  as  proportionate  to  the  extent  and 
duration  of  the  prostration  of  the  patient. 
In  the  treatment  of  these  accidents  the  first 


object  is  to  place  the  patient  in  a  warm  bed, 
to  assist  in  producing  reaction ;  and  if  that 
should  not  be  sufficient,  bottles  of  hot  water 
must  be  applied  to  the  soles  of  the  feet ; 
and  if  necessary,  internal  stimuli  admi¬ 
nistered.  Hot  fomentations,  or  a  thinly- 
spread  poultice,  should  be  applied  over  the 
whole  extent  of  the  abdomen  ;  and  if,  when 
reaction  is  produced,  pain,  accelerated  pulse, 
and  elevation  of  the  temperature  of  the  body, 
indicate  inflammation,  blood  must  be  taken, 
either  from  the  arm,  or  by  means  of  leeches 
from  the  abdomen.  Small  doses  of  calomel 
and  opium  may  be  ordered,  taking  care  that 
the  opium  is  sufficient  in  quantity  to  pre¬ 
vent  the  purgative  effect  of  the  calomel :  I 
usually  prescribe  a  grain  of  each  every  six 
hours.  You  should  remark,  gentlemen, 
that  in  peritonitis  the  pulse  is  always  small ; 
and  it  is  its  hardness  and  incompressibility 
which  constitute  its  specific  character :  it 
being  only  after  bleeding  that  it  becomes 
softer  and  fuller. 

Collapse  is  equally  attendant  upon  the 
rupture  of  the  solid  and  hollow  viscera,  and 
it  is  therefore  difficult  in  such  cases  to  form, 
from  this  symptom,  your  diagnosis  as  to  the 
particular  organ  that  has  sustained  injury  : 
the  judgment  may,  however,  be  guided  in 
some  measure  by  noticing  the  precise  point 
at  which  the  pain  is  chiefly  felt,  and  by  the 
locality  in  which  the  injury  has  been  inflicted. 
When  it  is  supposed  that  the  liver  or  spleen 
are  the  seat  of  the  mischief,  we  must  not  be 
too  eager  to  i*estore  the  patient  from  the 
state  of  collapse,  as  that  is  the  most  favour¬ 
able  condition  for  checking  the  haemorrhage 
inseparable  from  the  lesion  of  these  organs  ; 
and  as  the  intestines  might  have  been  rup¬ 
tured  at  the  same  time,  the  patient  should 
as  far  as  possible  abstain  from  food  for  a 
few  days,  in  order  to  preserve  the  alimentary 
canal  in  a  quiescent  state, — for  in  all  these 
cases  the  greatest  danger  arises  from  extra¬ 
vasation  of  blood,  or  the  effusion  of  the 
contents  of  the  bowels  into  the  abdominal 
cavity,  and  producing  peritonitis. 

The  following  cases  will  serve  to  illustrate 
the  principles  which  should  regulate  the 
treatment  in  such  accidents  as  I  have  already 
described : — • 

T -  II - ,  set.  21,  was  admitted 

into  the  accident  ward  in  October,  in  con¬ 
sequence  of  an  injury  he  sustained  from  a 
loaded  waggon  passing  over  his  loins.  The 
person  who  accompanied  him  stated  that  he 
spat  blood  on  his  way  to  the  hospital. 
When  admitted  he  was  in  a  state  of  extreme 
collapse ;  his  pulse  was  small,  weak  and 
labouring  ;  breathing  frequent  and  difficult; 
countenance  pallid  and  expressive  of  great 
anxiety  ;  and  the  surface  of  the  body  quite 
cold.  He  still  spat  at  intervals  mucus 
tinged  with  blood  ;  and  complained  of  con¬ 
stant  pain  throughout  the  whole  epigastric 


268  CASE  OF  SEVERE  INJURY  FROM  A  BLOW  ON  THE  ABDOMEN. 


region.  No  fracture  of  bone  could  be  de¬ 
tected. 

He  was  put  to  bed,  and  bottles  of  hot 
water  were  applied  to  the  feet,  and  fomenta¬ 
tions  to  the  abdomen.  At  8  P.  m.  his  pulse 
was  100,  small,  feeble,  and  fluttering  :  as 
he  had  not  passed  his  urine  since  his  admis¬ 
sion  into  the  hospital,  the  catheter  was  used, 
and  six  ounces  of  water  tinged  with  blood 
drawn  off :  his  bowels  were  also  evacuated 
during  the  evening,  and  he  passed  a  grumous 
stool,  but  no  clear  blood  ;  he  was  extremely 
restless,  and  unable  to  remain  for  a  minute 
together  in  the  same  position,  although  at 
the  same  time  motion  greatly  increased  the 
pain.  At  11  p.m. — pulse  still  100,  but 
altered  in  character,  being  now  contracted 
and  wiry,  indicating  loss  of  blood.  He  also 
complained  of  a  sensation  of  fulness  and 
heat  on  the  left  side  of  the  abdomen.  The 
next  morning  all  the  symptoms  were  aggra¬ 
vated  ;  but  he  lingered  until  evening,  when 
he  died. 

Upon  examination  of  the  body,  a  pound 
of  blood  was  found  in  the  abdomen.  This 
at  first  appeared  to  be  the  result  of  lace¬ 
ration  of  the  left  spermatic  vein  ;  but 
upon  further  examination  it  was  found  to 
have  proceeded  from  the  spleen,  which  was 
ruptured,  and,  indeed,  a  portion  was  torn 
from  its  upper  and  posterior  surface.  The 
diaphragm  was  ruptured  a  little  above  the 
cesophegeal  opening  ;  and  there  was  an  effu¬ 
sion  of  blood  between  the  liver  and  perito¬ 
neum,  the  former  being  lacerated;  the 
kidneys  were  also  separated  from  their 
peritoneal  covering  by  an  effusion  of  blood, 
but  as  there  was  no  lesion  of  these  organs 
the  blood  had  probably  reached  its  situation 
by  gravitation  ;  the  stomach,  intestines,  and 
bladder,  were  in  a  natural  condition ;  but 
the  inferior  part  of  the  left  lung  was  much 
altered  in  appearance,  and  gorged  with 
blood. 

Case. — A  boy,  aged  eight  years  and  a 
half,  was  admitted  into  Guy’s  Hospital  in 
consequence  of  a  severe  injury  he  had  sus¬ 
tained  from  a  blow  on  the  abdomen.  His 
father  stated  that  the  boy  was  “  minding  his 
truck,”  when  a  waggon  heavily  laden  drove 
against  the  ■wheel  of  the  truck,  and  swung  it 
round  with  considerable  violence,  the  handle 
striking  the  boy  just  at  the  junction  of  the 
cartilages  of  the  eighth  and  ninth  ribs,  forc¬ 
ing  him  against  the  post  of  the  gate-way, 
into  which  he  had  drawn  his  truck  to  get 
out  of  the  way  of  the  waggon.  Immediately 
after  the  boy  had  received  the  blow  he  fell, 
but  was  able  to  rise  and  walk  a  few  steps  ;  he 
again,  however,  fell,  upon  which  he  was  con¬ 
veyed  to  a  surgeon’s,  who  finding  him  in  a 
state  of  collapse,  gave  him  some  stimulant, 
and  sent  him  to  the  hospital. 

At  the  period  of  his  admission,  nearly  an 
hour  after  he  had  received  the  injury,  he 


pourtrayed  great  anxiety  and  pallor  of 
countenance ;  coldness  over  the  whole  sur¬ 
face  of  the  body  ;  and  some  pain  in  the 
abdomen,  which  was  not  increased  by  pres¬ 
sure  ;  his  pulse  could  not  be  felt,  but  the 
heart’s  action  was  perceptible,  although  it  was 
beating  very  feebly.  He  was  immediately 
put  to  bed,  wrapped  up  in  blankets,  bottles 
of  warm  water  applied  to  his  feet,  and  fric¬ 
tion  used  to  restore  if  possible  the  warmth 
of  the  body.  A  small  quantity  of  julep 
ammonise  was  also  administered.  Under 
this  treatment  he  seemed  somewhat  to  rally, 
but  only  for  a  few  minutes,  when  he  relapsed 
into  his  former  state  of  collapse.  Upon 
now  being  asked  if  he  suffered,  he  said  the 
“  pain  in  his  belly  increased.”  He  died 
half  an  hour  after  his  admission. 

Twenty-four  hours  after  death,  his  body 
was  examined. — Externally  there  was  evi¬ 
dently  some  slight  ecchymosis  near  the  ex¬ 
ternal  extremities  of  the  seventh  and  eighth 
ribs  on  the  right  side,  and  opposite  to  the 
last  two  ribs  on  the  left.  On  opening  the 
chest  nothing  particular  was  observed  ;  but 
upon  inspecting  the  abdomen,  it  was  found 
to  contain  a  very  large  quantity  both  of  coa¬ 
gulated  and  fluid  blood,  which  proceeded 
from  the  left  kidney,  the  upper  portion  of 
which,  above  the  renal  vessels,  was  tom 
from  the  lower  part,  which  remained  in  its 
natural  position.  The  fluidity  of  the  blood 
probably  depended  upon  its  admixture  with 
urine.  There  was  some  ecchymosis  on 
the  liver,  opposite  to  that  on  the  chest, 
so  that  it  appeared  as  if  the  kidney  had 
been  lacerated  by  the  “  contre  coup,”  owing 
to  the  boy’s  back  being  driven  against  the 
gate-post :  the  liver  was  merely  bruised, 
and  the  rest  of  the  viscera  were  uninjured. 

In  consequence  of  the  great  depth  at 
which  the  kidneys  are  placed,  their  rupture 
is  an  accident  of  comparatively  rare  occur¬ 
rence  ;  and  the  diagnostic  marks  are  rather 
difficult,  particularly  at  first,  until  indeed 
bloody  urine,  and  the  situation  of  the  pain, 
indicate  the  nature  of  the  injury.  The  treat¬ 
ment  in  these  cases,  as  in  the  injuries  of  the 
abdomen,  is  to  prevent  or  subdue  peritoneal 
inflammation,  and  this  can  only  be  effected 
by  the  strictest  antiphlogistic  means.  In  the 
foregoing  case,  however,  collapse  prevented 
the  possibility  of  such  treatment  being 
adopted.  It  is  evident  that  the  cause  of 
death  was  the  extravasation  of  blood  into 
the  cavity  of  the  abdomen,  producing  that 
degree  of  irrecoverable  prostration,  which  is 
so  strong  a  mark  of  injury  to  the  abdominal 
viscera. 

About  five  years  ago  I  was  sent  for  to  see 
a  gentleman,  who,  in  stepping  on  board  a 
steam-boat,  fell  partly  down  a  trap  hatch  on 
the  deck.  In  falling,  he  struck  his  loins 
violently  against  the  edge  of  the  opening  :  he 
immediately  felt  very  sick,  was  attacked  with 


SYMPTOMS  IN  RUPTURE  OF  LARGE  AND  SMALL  INTESTINES.  269 


severe  pain,  and  was  obliged  to  be  carried 
home.  I  saw  him  about  six  hours  after  the 
accident ;  there  were  no  signs  of  collapse, 
but  he  was  still  in  very  great  pain,  and  in 
two  attempts  to  make  water  had  voided  little 
else  than  blood.  I  immediately  took  12 
ounces  of  blood  from  the  arm,  and  had  8 
ounces  removed  from  the  loins  by  cupping. 
I  ordered  a  grain  of  calomel,  and  half  a 
grain  of  opium,  every  six  hours ;  and  as 
there  was  sufficient  evidence  that  the  intes¬ 
tinal  canal  was  uninjured,  I  also  prescribed 
acidulated  saline  draughts.  The  patient 
continued  to  pass  bloody  urine  for  several 
days  :  he  suffered  also  from  pain  along  the 
course  of  the  ureters ;  and  when  this  symp¬ 
tom  had  ceased,  he  continued  to  experience 
considerable  pain  in  the  region  of  the  kid- 
nies,  particularly  of  the  right  kidney  :  the 
pain  was  much  increased  by  motion.  A 
blister  was  applied  on  the  right  loin,  and 
the  cupping  repeated :  under  this  treat¬ 
ment  he  was  soon  considerably  relieved. 
The  urine  improved  in  colour,  and  a  greater 
quantity  was  also  passed ;  the  pain  in  the 
loins  was  diminished,  and  in  six  weeks  he 
became  quite  convalescent.  There  can  be 
no  doubt  that  in  this  case  the  right  kidney 
received  great  injury,  probably  lesion,  but 
not  to  a  sufficient  extent  to  admit  of  ex¬ 
travasation  of  urine,  and  by  perfect  rest 
the  mischief  became  ultimately  repaired. 

The  solid  viscera  are,  as  we  should  natu¬ 
rally  suppose,  more  liable  than  the  hollow,  to 
rupture  from  a  blow  on  the  abdomen,  with¬ 
out  the  lesion  of  its  parietes.  Rupture  of 
the  hollow  viscera  sometimes  occurs,  how¬ 
ever  ;  and  I  have  seen  many  instances  in 
which  the  intestines,  and  some  few  in  which 
the  urinary  bladder,  have  been  thus  injured. 
The  symptoms  arising  from  rupture  of  an 
intestine  without  lesion  of  the  abdominal 
parietes,  might  lead  you  to  suppose,  gentle¬ 
men,  that  the  diagnosis  in  such  a  case  would 
be  somewhat  difficult  to  determine.  Such  is 
not,  however,  the  fact,  as  there  are  always 
sufficiently  marked  characteristic  points  to 
enable  the  surgeon  to  judge  accurately  of  the 
nature  of  the  injury,  and  to  decide  with 
confidence  on  the  proper  mode  of  treatment. 
In  this  kind  of  injury,  as  well  as  in  penetrat¬ 
ing  wounds  of  the  intestine,  collapse  is  the 
immediate  effect ;  and  in  this  stage  it  may 
be  necessary  to  administer  stimuli  to  pro¬ 
duce  reaction.  Antiphlogistic  means  should 
next  be  employed,  to  subdue  the  slightest 
tendency  to  peritoneal  inflammation ;  but 
purgatives  must  be  strictly  withheld,  as  the 
constipation  which  invariably  follows  these 
injuries  must  be  regarded  as  the  cura¬ 
tive  means  adopted  by  nature  for  the  pur¬ 
pose  of  ensuring  a  perfect  state  of  quie¬ 
tude  of  the  intestine  during  the  progress  of 
the  reparative  action.  A  patient  has  often 
been  destroyed,  gentlemen,  by  the  too  hasty 


administration  of  purgatives,  the  surgeon 
having  mistaken  constipation  for  the  disease, 
when  in  fact  it  is  the  condition  most  essen¬ 
tial  to  the  curative  process.  Physicians  are 
constantly  meeting  in  practice  with  cases  of 
chronic  ulceration  of  the  intestines,  particu¬ 
larly  of  the  csecum,  in  which  constipation, 
attended  by  more  or  less  fixed  pain,  forms  a 
very  prominent  feature.  In  these  cases  no 
practitioner  ever  thinks  of  giving  purgative 
medicines,  but  hails  the  quiescent  state  of 
the  bowels  as  the  surest  indication  of  the  re¬ 
storative  action  which  nature  has  established. 
After  the  operation  for  strangulated  hernia 
also,  no  surgeon  who  is  well  acquainted  with 
the  principles  of  his  art  would  dream  of 
prescribing  purgatives,  but  would  leave 
nature  to  her  own  resources,  in  the  certainty 
that  the  bowel  would  be  evacuated  when  the 
injured  portion  became  again  competent  to 
the  performance  of  its  natural  functions.  It 
has, indeed,  in  my  opinion, seldom,  if  ever  oc¬ 
curred,  that  a  patient  died  of  mere  constipa¬ 
tion,  without  some  irrecoverable  disorganiza¬ 
tion  had  gone  on  in  the  course  of  the  intes¬ 
tinal  canal. 

Whether  it  be  a  small  or  large  intestine 
that  is  ruptured  may  be  partly  judged  of  by 
the  situation  in  which  the  greatest  pain  is 
experienced,  and  partly  by  the  urgency  of 
the  sickness  produced, — for  when  the 
small  intestines  are  the  seat  of  the  in¬ 
jury,  vomiting,  as  well  as  constipation,  con¬ 
stitutes  an  early  and  important  symptom  ; 
while  in  case  of  lesion  of  the  large  intestine, 
constipation  and  swelling  of  the  abdomen 
form  the  most  marked  feature  of  the  acci¬ 
dent,  and  the  vomiting  does  not  come  on 
until  a  more  advanced  period  in  the  progress 
of  the  symptoms. 

The  gall-bladder  may  be  ruptured  by  a 
blow  upon  the  abdomen,  and  is  immediately 
followed  by  collapse,  sensation  of  coldness 
on  the  surface  of  the  body,  and  a  sense 
of  deep-seated  heat  through  the  whole  in¬ 
terior  of  the  abdomen.  Sickness  soon  comes 
on,  ushered  in  by  rigor,  and  the  patient 
generally  sinks  a  few  hours  alter  the  acci¬ 
dent,  death  resulting  from  effusion  of  bile 
into  the  peritoneal  cavity.  Rupture  of  the 
stomach  leads  to  very  similar  results  ;  but 
vomiting  of  its  contents,  mixed  with  blood, 
forms  a  distinctive  diagnostic  mark.  When 
the  urinary  bladder  is  ruptured,  if  the  lesion 
involves  any  portion  covered  by  peritoneum, 
death  rapidly  follows  the  infliction  of  the  in¬ 
jury,  and  medical  treatment  is  completely  un¬ 
availing,  as  the  patient  dies  without  rallying 
from  the  state  of  collapse,  and  consequently 
antiphlogistic  means  cannot  be  had  recourse 
to.  But  if  the  bladder  be  ruptured  so 
that  the  extravasation  of  urine  take  place 
exterior  to  the  peritoneal  cavity,  the  vital 
powers  are  not  to  the  same  degree  affected, 
and  active  means  may  prevent  inflamma- 


270  SMALL-POX - CHECKED  BUT  NOT  EXTIRPATED  BY  VACCINATION. 


tion  from  following.  The  urine  should  be 
drawn  off  from  the  bladder,  to  pre¬ 
vent  any  accumulation  which  may  possibly 
occur  notwithstanding  the  rupture  of  the 
organ,  and  an  opening  should  be  made 
in  the  perineum,  even  through  the  deep 
fascia,  if  there  be  any  indication  of  urine 
being  extravasated  between  the  bladder  and 
rectum.  Several  cases  are  recorded  in  which 
individuals  have  completely  recovered  after 
such  an  accident,  where  the  rupture  has 
been  external  to  the  peritoneum;  and,  in¬ 
deed,  even  where  that  membrane  has  un¬ 
dergone  lesion,  there  may  be  reasonable  hope 
of  recovery,  if  the  quantity  of  urine  extra¬ 
vasated  be  not  large,  and  judicious  means 
be  employed  to  prevent  or  subdue  peri¬ 
tonitis. 


LECTURES 

ON  THE 

DISEASES  OF  INFANCY  AND 
CHILDHOOD, 

Delivered  at  the  Middlesex  Hospital. 

By  Chahx.es  West,  M.D. 

Physician-Accoucheur  to  the  Middlesex  Hospital, 
and  Senior  Physician  to  the  Royal  Infirmary 
for  Children. 


Lecture  XXXVIII. 

Small-pox — checked  hut  not  extirpated  by 
vaccination — Us  chief  mortality  among 
children.  Rate  of  mortality  in  cases  of 
the  disease  undiminished  during  the  last 
fifty  years.  Its  symptoms — their  early 
differences  from  those  of  the  other  exan¬ 
themata — characteis  and  progress  of  the 
eruption  —  peculiarities  of  confluent 
small-pox — dangers  attending  the  matu¬ 
ration  of  the  pustules,  and  the  secondary 
fever.  Treatment . 

Modified  small-pox — its  low  rate  of  morta¬ 
lity — its  peculiarities.  Chicken  pox — its 
symptoms,  and  differences  from  small¬ 
pox. 

Until  the  commencement  of  this  century, 
the  disease  to  which  I  wish  to-day  briefly  to 
call  your  attention,  possessed  a  degree  of  im¬ 
portance  far  greater  than  that  which  attaches 
to  it  at  present.  Before  the  introduction  of 
vaccination,  the  small-pox  was  a  disease  of 
almost  universal  prevalence,  causing  at  the 
least  eight  per  cent,  of  the  total  mortality  of 
this  metropolis,  and  disfiguring  for  life 
thousands  whom  it  did  not  destroy.  Its 
loathsome  character,  and  its  formidable 
symptoms  when  it  attacked  the  constitution 
at  unawares,  led  to  the  adoption  of  variolous 
inoculation,  by  which  the  disease  was  com¬ 
municated  in  a  mild  form,  and  under  favour¬ 
able  conditions  ;  and  persons  having  under¬ 
gone  comparatively  little  suffering,  and 


having  been  exposed  to  still  less  danger, 
enjoyed  by  this  means  almost  complete  im¬ 
munity  from  subsequent  attacks  of  small¬ 
pox.  But  great  as  its  benefits  were,  variolous 
inoculation  perpetuated  at  all  times,  and  in 
all  places,  a  disease  which  would  otherwise 
have  obeyed  the  general  law  of  epidemics, 
and  would  have  had  its  periods  of  rare  oc¬ 
currence  as  well  as  those  of  wide-spread 
prevalence.  Thus,  as  has  been  well  ob¬ 
served.  while  the  advantages  of  the  practice 
were  great  and  obvious  to  the  individual,  to 
the  community  at  large  they  were  very 
doubtful. 

No  such  drawback  exists  to  detract  from 
the  benefits  of  vaccination,  though  unfortu¬ 
nately  our  present  experience  does  not 
altogether  justify  the  sanguine  expectations 
entertained  by  its  first  promoters.  Pecu¬ 
liarities  of  climate  oppose  a  serious  barrier 
to  its  successful  introduction  into  some 
countries,*  and  even  in  our  own  land  indi¬ 
viduals  are  occasionally  met  with  in  whom 
vaccination  altogether  fails,  or  over  whom  it 
seems  to  extend  but  a  partial  ora  temporary 
protective  power. 

But  I  will  not  enter  on  the  question  of 
the  merits  of  vaccination,  nor  of  the  circum¬ 
stances  that  impair  its  preservative  power, 
or  call  for  its  repetition :  for  though  the 
subject  is  one  important  alike  to  the  physi¬ 
cian  and  the  philanthropist,  I  have  had  no 
opportunities  of  forming  a  judgment  con¬ 
cerning  it  which  are  not  alike  open  to  you 
all.  In  the  writings  of  Dr.  Gregory,  physi¬ 
cian  to  the  Small-Pox  Hospital,  and  in  the 
treatise  on  vaccination  by  Dr.  Steinbrenr.er, 
to  which  the  Institute  of  France  adjudged  a 
prize  in  1835,  yon  will  find  everything  that 
either  large  experience  or  unwearied  research 
could  bring  to  its  elucidation. 

One  fact,  which  it  behoves  us  always  to 
bear  in  mind,  is,  that  albeit  the  prevalence 
of  the  disease  has  been  greatly  checked  by 
vaccination,  small-pox  is  still  one  of  the 
most  fatal  maladies  of  this  country ;  and 
further,  that  it  selects  its  victims,  as  here¬ 
tofore,  chiefly  from  among  children  and 
young  persons  :  nearly  three-fourths  of  the 
fatal  cases  of  this  affection  occurring  before 
the  age  of  five,  and  more  than  nine- tenths 
before  the  age  of  fifteen  years.  In  spite,  too, 
of  the  increase  of  medical  knowledge  during 
the  past  fifty  years,  the  proportion  of  small¬ 
pox  cases  that  terminate  fatally,  has  been 
estimated  by  the  best  authorities  to  be  as 
great  now  as  it  was  half  a  century  ago.  To 
some  extent,  perhaps,  the  very  diminution 

*  Dr.  Duncan  Stewart’s  valuable  Report  on 
Small-Pox  in  Calcutta,  andVaccination  in  Bengal 
(8vo.  Calcutta,  1844),  shews  conclusively  that  the 
peculiarities  of  the  Indian  climate  present  ob¬ 
stacles  to  vaccination  such  as  greatly  detract 
from  its  value;  while  it  is  to  be  feared  that  they 
are  of  a  nature  which  the  greatest  care  will  never 
wholly  overcome. 


SYMPTOMS  OF  SMALL-POX 


271 


in  the  frequency  of  the  disease  may  have  had 
an  unfavourable  influence  on  its  issue  in  in¬ 
dividual  cases  :  for  practitioners,  meeting 
with  it  less  often  than  medical  men  in  for¬ 
mer  days  were  wont  to  do,  are  not  so  familiar 
with  the  meaning  of  those  minuter  variations 
in  its  symptoms,  from  which  important  prac¬ 
tical  conclusions  might  be  drawn,  by  those 
who  knew  how  to  interpret  them  aright. 

Let  me  therefore  urge  you  to  watch  every 
case  of  this  formidable  disease  that  may  come 
under  your  observation  with  most  minute 
care,  lest  you  misinterpret  the  symptoms, 
or  mistake  the  treatment  of  some  patient 
affected  with  it,  whose  well  being  may  be 
dependent  on  your  skill.  For  my  own  part, 
I  cannot  pretend  to  give  you  more  than  an 
outline  sketch  of  its  characters,  and  must 
refer  you  to  the  writings  of  others  who  have 
had  greater  opportunities  of  watching  it 
than  have  fallen  to  my  share,  to  fill  up  the 
portrait. 

The  early  symptoms  of  small-pox  are  those 
of  approaching  fever,  and  if  any  other  fe¬ 
brile  disorder  be  prevalent  at  the  time  of 
their  occurrence  they  may  possibly  be  taken 
for  the  indications  of  an  approaching  attack 
of  the  prevailing  epidemic.  There  are,  how¬ 
ever,  some  peculiarities  in  the  mode  of  onset 
of  small-pox  which  are  sufficiently  charac¬ 
teristic  of  it,  even  in  the  child,  and  which 
will  generally  distinguish  it  from  either  of 
the  other  eruptive  fevers.  The  sickness 
with  which  it  sets  in  is  in  general  severe, 
and  the  disorder  of  the  stomach  often  con¬ 
tinues  for  forty-eight  hours,  during  which 
time  vomiting  recurs  frequently.  In  measles 
there  is  comparatively  little  gastric  disorder; 
and  the  vomiting  that  often  ushers  in  scarla¬ 
tina,  though  frequently  severe,  is  not  of  such 
long  continuance.  In  young  children  we 
lose  those  complaints  of  intense  pain  in  the 
back  which  in  the  case  of  older  patients 
often  awaken  our  suspicion  ;  but  on  the 
other  hand,  the  severity  of  the  cerebral  dis¬ 
turbance  is  an  important  feature  in  the  early 
stage  of  the  disease.  At  the  commencement 
of  measles,  the  brain  is  in  general  but  little 
disturbed  ;  in  scarlatina,  delirium  often  oc¬ 
curs  very  early;  but  in  small-pox  the  con¬ 
dition  is  one  rather  of  stupor  than  of  deli¬ 
rium,  while  convulsions  sometimes  take 
place,  and  continue  alternating  with  coma 
for  as  long  a  period  as  twenty-four  or  thirty- 
six  hours.  Lastly,  though  the  skin  in  small¬ 
pox  is  hot,  it  is  neither  so  hot  nor  so  dry  as 
in  scarlet  fever  :  the  tongue  does  not  pre¬ 
sent  the  peculiar  redness,  nor  the  prominence 
of  its  papillae,  which  are  observable  in  scar¬ 
latina  ;  neither  is  there  any  of  the  sore- 
throat  which  forms  so  characteristic  a  symp¬ 
tom  of  that  disease.  The  early  stages  of 
small-pox  are  not  attended  with  those  catar¬ 
rhal  symptoms  which  accompany  measles  : 
the  eruption  of  measles  usually  appears 


later,  that  of  scarlet  fever  always  sooner, 
than  the  eruption  of  small-pox  ;  while  its 
papular  character  is  in  general  sufficiently 
well  marked  to  distinguish  it  from  the  rash 
of  either  of  these  diseases.  It  never  appears 
in  less  than  forty-eight  hours,  often  after  a 
somewhat  longer  time  from  the  first  sign  of 
indisposition  :  and  shews  itself  in  the  form 
of  small  papulae,  which  are  first  discernible 
on  the  face,  forehead,  and  wrists,  whence 
they  extend  to  the  trunk  and  arms,  and 
lastly  to  the  lower  extremities.  These 
papulae  are  at  first  slightly  red,  somewhat 
acuminated,  elevations,  so  minute  that  they 
may  easily  be  overlooked  on  a  hasty  exami¬ 
nation,  but  yet  conveying  a  distinct  sense  of 
irregularity  to  the  finger  when  passed  over 
the  surface.  They  increase  in  size,  and  in 
the  course  of  forty-eight  hours  assume  a 
vesicular  character,  and  contain  a  whey-like 
fluid  ;  while,  instead  of  a  conical  form,  they 
now  present  a  central  depression.  During 
another  period  of  forty-eight  hours  or 
thereabouts,  these  vesicles  go  on  enlarging, 
their  central  depression  grows  more  and 
more  apparent,  and  their  contents  become 
white  and  opaque  ;  they  are  no  longer  vesi¬ 
cles,  but  have  become  converted  into  pus¬ 
tules,  each  of  which,  if  they  be  distinct,  has 
an  areola  of  a  red  hue  around  its  base.  As 
the  pustules  enlarge,  the  face,  hands,  and 
feet,  become  swollen,  and  a  general  redness- 
of  their  surface  succeeds  to  the  more  cir¬ 
cumscribed  areola,  which  had  previously  sur¬ 
rounded  each  separate  pustule.  As  the  size 
of  the  pustules  increases,  they  lose  that  cen¬ 
tral  depression  which  they  had  presented 
while  vesicles :  they  assume  a  spheroidal 
form,  or  even  become  slightly  conical.  The 
next  change  observable  in  them  is  an  altera¬ 
tion  of  their  colour  from  a  white  to  a  dirty 
yellow  tint,  which  last  they  continue  to  re¬ 
tain  until  the  desiccation  of  the  eruption 
commences.  This  token  of  the  decline  of 
the  disease  is  first  apparent  on  the  face, 
where,  as  you  will  remember,  the  eruption 
is  earliest  observable  ;  while  on  the  hands 
and  feet,  probably  owing  to  the  thickness  of 
the  epidermis  in  those  situations,  this  change 
is  longest  delayed,  and  the  pustules  there 
attain  a  greater  size  than  in  any  other  situa¬ 
tion.  The  maturation  of  the  pustules 
usually  occupies  from  the  commencement  of 
the  fifth  to  the  commencement  of  the  eighth 
day  of  the  eruption,  or  from  the  eighth  to  the 
eleventh  day  of  the  disease,  when  the  process 
of  desiccation  begins.  A  few  of  the  smaller 
pustules  dry  up  and  become  converted  into 
crusts,  which  afterwards  dropoff;  but  the 
greater  number  of  them  burst,  and  the  pus 
which  they  discharge,  together  with  a  very 
adhesive  matter  which  they  continue  to 
secrete  for  two  or  three  days,  contribute  to 
form  the  scab  which  incrusts,  more  or  less 
extensively,  the  surface  of  a  small- pox  pa- 


272 


CHARACTERS  AND  PROGRESS  OF  THE  ERUPTION. 


tient  during  the  decline  of  the  disease. 
When  this  scab  falls  off,  which  it  does  in 
from  three  to  five  or  six  days,  the  skin 
appears  stained  of  a  reddish  brown  colour, 
which  often  does  not  disappear  for  several 
weeks ;  but  it  is  only  in  cases  where  the 
pustule  has  gone  so  deep  as  to  destroy  a 
portion  of  the  true  skin,  that  the  permanent 
disfigurement,  the  so-called  pitting  of  the 
small  pox,  is  produced. 

It  is  only  in  cases  of  discrete  small  pox, 
in  which  the  eruption  is  but  moderately 
abundant,  and  the  pustules  consequently 
run  their  course  without  coalescing  with  each 
other,  that  the  above-mentioned  changes  can 
be  distinctly  traced.  In  the  confluent 
variety  of  the  disease,  in  which  the  pustules 
are  so  numerous  that  they  run  together  as 
they  increase  in  size,  the  characteristic 
alterations  in  the  individual  pustules  cannot 
be  followed.  In  those  situations  where  the 
eruption  is  confluent,  the  pustules  never 
attain  the  size  which  separate  pustules  often 
reach  ;  they  do  not  become  so  prominent, 
nor  do  their  contents  in  general  assume  the 
same  yellowish  colour,  but  several  of  them 
coalesce  to  form  a  slighty  irregular  surface 
of  a  whitish  hue  ;  while,  when  the  stage  of 
desiccation  comes  on,  each  of  these  patches 
becomes  converted  into  a  moist  brown  scab, 
which  is  many  days  before  it  is  detached. 
Nor  is  it  merely  at  those  parts,  such  as  the 
face,  where  the  eruption  is  actually  confluent, 
that  its  character  is  modified,  but,  even 
where  the  pustules  are  distinct,  their  advance 
goes  on  more  slowly,  and  the  maturative 
stage  is  longer  in  being  completed,  than  in 
less  severe  cases  of  thedisease.  It  is,  more¬ 
over,  in  cases  of  confluent  small-pox  that 
the  ulceration  of  the  pustules  most  com¬ 
monly  invades  the  true  skin,  and  that  serious 
disfigurement  is  most  likely  to  take  place ; 
while  further,  the  degree  of  danger  to  life  is 
in  almost  direct  proportion,  in  every  case  of 
small-pox,  to  the  amount  of  confluence  of 
the  eruption. 

The  appearance  of  the  eruption  of  small¬ 
pox  is  attended  with  a  great  abatement, 
sometimes  with  the  almost  complete  disap¬ 
pearance,  of  those  signs  of  constitutional 
disturbance  with  which  the  disease  set  in  ; 
and  in  mild  cases  the  child  shows  few  other 
signs  of  illness  than  are  furnished  by  the 
eruption  on  the  skin.  But,  with  the  matu¬ 
ration  of  the  pustules,  the  secondary  fever , 
as  it  is  called,  is  excited,  and  the  period  of 
the  greatest  danger  to  the  patient  now  comes 
on.  The  skin  once  more  grows  hot ;  the 
pulse  rises  in  frequency  ;  restlessness,  thirst, 
and  all  the  phenomena  of  inflammatory  fever, 
develop  themselves,  and  continue  with  more 
or  less  intensity  for  about  three  days.  These 
symptoms  afterwards  diminish,  and  finally 
disappear  as  the  pustules  burst,  and  the  stage 
of  desiccation  is  accomplished.  It  is,  how¬ 


ever,  only  in  cases  of  a  favourable  kind  that 
the  secondary  fever  runs  so  mild  a  course. 
In  confluent  small-pox,  the  secondary  fever 
is  always  more  severe  than  in  the  discrete 
form  of  the  disease,  though  it  comes  on 
later,  in  consequence  of  the  more  tardy 
maturation  of  the  pustules.  Often,  indeed, 
it  assumes  a  typhoid  character;  the  pulse 
becomes  extremely  frequent  and  feeble ;  the 
tongue  dry  and  brown  ;  and  the  patient  dies 
delirious.  In  other  instances  the  matura¬ 
tion  of  the  pustules  goes  on  for  a  day  or  two 
with  very  slight  reaction ;  and  were  it  not 
that  this  extreme  mildness  of  the  secondary 
fever,  in  cases  where  the  eruption  has  been 
abundant,  is  itself  a  suspicious  circumstance, 
we  should  be  disposed  to  express,  without 
hesitation,  a  most  favourable  opinion  as  to 
the  patient’s  condition.  Suddenly,  however, 
the  pulse  begins  to  falter ;  the  pustules, 
which  before  seemed  full,  collapse  ;  the  ex¬ 
tremities  grow  cold  ;  and  in  a  few  hours  the 
patient  dies.  This  fatal  change  is  sometimes 
ushered  in  by  a  fit  of  convulsions  ;  at  other 
times  by  a  condition  of  extreme  restlessness, 
which  contrasts  remarkably  with  the  extreme 
quietude  of  the  child’s  manner  for  the  two 
or  three  previous  days  :  and  it  is  well  to 
bear  in  mind  that  the  supervention  of  either 
of  these  two  symptoms  during  the  matura¬ 
tive  stage  of  small-pox,  is  the  almost  certain 
herald  of  speedily  approaching  death.  One 
other  not  infrequent  source  of  danger  during 
this  period,  arises  from  the  pustules  which 
have  formed  on  the  mucous  membrane  of  the 
mouth,  fauces,  and  air-passages.  In  almost 
every  case  of  small-pox,  a  few  spots  of  the 
eruption  may  be  seen  upon  the  tongue  and 
on  the  interior  of  the  mouth  ;  while  an  in¬ 
spection  of  the  bodies  of  patients  to  whom 
it  has  proved  fatal,  has  shown  that  the  pus¬ 
tules  form  likewise  on  the  interior  of  the 
larynx  and  trachea  :  sometimes  in  consider¬ 
able  numbers.  It  is  to  the  presence  of  pus¬ 
tules  in  these  situations  that  the  hoarse  or 
altered  voice,  and  the  difficulty  of  degluti¬ 
tion,  which  are  observed  in  most  cases  of 
severe  small-pox,  are  due ;  as  well  as  that 
short  hacking  cough  which  sometimes 
proves  a  very  troublesome  symptom.  The 
ptyalism,  too,  which  occurs  in  many  instances, 
is  apparently  owing  to  the  salivary  glands 
sympathising  with  the  irritated  and  inflamed 
state  of  the  mucous  membrane  of  the  mouth. 
In  cases  which  run  a  fortunate  course,  these 
symptoms,  having  come  on  about  the  third 
or  fourth  day  of  the  eruption,  and  having 
increased  in  severity  until  the  eighth  or 
ninth,  then  progressively  decline.  Under 
less  favourable  circumstances,  however,  they 
continue  to  grow  worse  :  the  voice  becomes 
perfectly  extinct,  and  deglutition  almost 
impossible ;  and  the  patient  dies  from  the 
obstacle  which  the  inflammation  and  swelling 
of  the  lining  membrane  of  the  larynx  pre- 


TREATMENT  OF  SMALL-POX, 


278 


sent  to  the  free  access  of  air  to  the  lungs ; 
though  the  symptoms  are  seldom  or  never 
those  of  active  inflammatory  croup. 

You  will  find  in  the  writings  of  those 
whose  opportunities  of  observing  small-pox 
have  been  considerable,  the  description  of 
many  other  modes  in  which  it  occasionally 
proves  fatal.  Thus,  it  is  sometimes  asso¬ 
ciated  with  a  great  tendency  to  haemorrhage  ; 
petechiae  appearing  on  the  surface  of  the 
body ;  and  the  pustules  assuming  a  black 
colour,  from  the  extravasation  of  blood  into 
them.  In  other  instances,  gangrene  attacks 
the  feet  or  some  other  part  of'  the  body. 
But  these  are  occurrences  which  it  has  not 
been  my  lot  to  witness,  and  I  will  not  there¬ 
fore  take  up  your  time  by  detailing  them 
at  second-hand. 

Let  us  now  glance  for  a  few  minutes  at 
the  treatment  to  be  pursued  in  this  disease. 
You  know  that  before  the  time  of  Sydenham, 
physicians  adopted  a  heating  regimen  in 
cases  of  small-pox  :  excluding  fresh  air  from 
the  chamber,  covering  the  patient  with 
blankets,  and  administering  stimulating 
medicines  and  cordial  drinks.  To  this 
practice  the  prevalent  theory  of  fermenta¬ 
tion,  and  of  nature’s  efforts  in  disease  being 
directed  to  eliminate  the  pecccant  matter 
from  the  blood,  had  given  occasion.  In 
accordance  with  these  notions  it  was  assumed 
that,  the  more  abundant  the  eruption, 
the  more  complete  would  be  the  separa¬ 
tion  of  these  noxious  matters,  and  conse¬ 
quently  the  better  the  chance  of  the 
patient’s  well  doing.  The  observation  of 
nature,  however,  taught  Sydenham  that  the 
very  reverse  was  the  case  ; — that  the  more 
abundant  the  eruption,  the  greater  the 
danger, — the  fewer  the  pustules,  the  more 
favourable  the  prospect  of  the  patient’s  re¬ 
covery.  A  cooling  regimen,  therefore,  is 
now  universally  adopted  in  the  early  stage  of 
the  disease,  and  fresh  air  is  freely  admitted 
into  the  chamber,  in  order  to  prevent,  if 
possible,  a  copious  eruption,  while  the  same 
end  is  sought  to  be  still  further  promoted  by 
keeping  the  bowels  gently  open,  by  a  spare 
diet,  and  by  mild  antiphlogistic  medicines. 
Depletion,  which  even  in  the  adult  is  not  to 
be  practised  merely  with  the  hope  of  thereby 
diminishing  the  quantity  of  the  eruption,  is 
still  less  to  be  resorted  to  in  the  child,  unless 
evidently  called  for  by  symptoms  of  severe 
cerebral  disturbance — such  as  convulsions 
frequently  recurring,  or  ending  in  coma. 
Such  occurrences  as  those,  however,  demand 
not  merely  the  abstraction  of  blood,  but  its 
removal  with  an  unsparing  hand, — for,  as  I 
told  you  at  the  commencement  of  these  lec¬ 
tures,  the  cerebral  congestion  which  attends 
the  onset  of  the  eruptive  fevers,  if  not  speedily 
relieved,  may  prove  very  quickly  fatal. 
Cases  of  an  opposite  kind  are  sometimes  met 
with  in  which  the  patient  before  the  ap¬ 


pearance  of  the  eruption  is  in  a  state  of  de¬ 
pression  so  great  as  to  call  for  warmth  to  the 
surface,  or  for  the  hot  bath,  for  diaphoretic 
medicines,  and  sometimes  even  for  stimu¬ 
lants.  In  this,  however,  there  is  nothing 
more  than  we  may  occasionally  witness  in  a 
patient  completely  prostrated  during  the 
first  stage  of  typhus  fever,  and  needing  per¬ 
haps  the  free  administration  of  wine  and 
ammonia  to  preserve  him  from  death. 

With  the  outbreak  of  the  eruption  there 
ensues  lull  in  the  symptoms,  and  a  period 
now  succeeds  during  which  we  have  nothing 
else  to  do  than  to  leave  nature  to  her  work¬ 
ings  undisturbed.  Even  in  cases  of  con¬ 
fluent  small-pox,  there  is  in  many  instances 
not  a  single  symptom  just  at  this  time  which 
could  either  excite  solicitude  or  call  for 
treatment,  and  you  must  therefore  take  care 
not  to  allow  yourself  at  this  moment  to  be 
betrayed  into  the  hasty  expression  of  a  very 
favourable  prognosis,  which  the  superven¬ 
tion  of  the  secondary  fever  may  perhaps  in  a 
day  or  two  most  grievously  belie.  If,  how¬ 
ever,  the  number  of  pustules  should  be  but 
small,  the  secondary  fever  will  be  slight, 
our  favourable  opinion  may  be  expressed 
with  some  confidence,  and  no  deviation  from 
our  previous  expectant  plan  of  treatment 
will  in  all  probability  be  required  during  the 
subsequent  progress  of  the  disease.  If  the 
eruption  be  more  abundant,  and  the  accom¬ 
panying  secondary  fever  consequently  severe, 
an  antiphlogistic  plan  of  treatment  must  be 
carried  out  more  strictly,  while  in  all  cases 
the  restlessness  which  is  so  common  a  symp¬ 
tom  during  the  maturative  stages  of  small¬ 
pox,  must  be  controlled  by  the  administra¬ 
tion  of  Dover’s  powder,  or  some  other  form 
of  opiate  once  or  twice  a  day.  In  cases  of 
confluent  small-pox,  the  patient  needs  to  be 
very  closely  watched  during  the  maturation 
of  the  pustules, — for  on  the  second  or  third 
day  of  this  process,  the  vital  powers  some¬ 
times  suddenly  fail.  The  first  indications  of 
any  suchoccurrence,  which  would  be  furnished 
by  a  great  aggravation  of  the  previous  rest¬ 
lessness,  by  the  subsidence  of  the  swelling 
of  the  face  and  hands,  the  paleness  of  the 
skin  in  the  interval  between  the  pustules, 
and  the  collapse  of  the  pustules  themselves, 
attended  with  a  sinking  in  the  temperature 
of  the  surface,  and  a  great  diminution  in  the 
powers  of  the  pulse,  call  at  once  for  the 
energetic  employment  of  stimulants,  for  the 
administration  of  wine,  and  the  substitution 
of  nutritious  food  for  the  previous  meagre 
diet.  A  similar  course  must  also  be  pur¬ 
sued  whenever  the  secondary  fever  shows 
any  disposition  to  assume  a  typhoid  cha¬ 
racter,  while  irrespective  of  any  unfavourable 
symptoms  it  is  not  infrequently  expedient, 
if  the  eruption  be  abundant,  to  give  beef-tea, 
and  to  adopt  other  means  for  supporting  the 
strength  from  the  fifth  or  sixth  day  of  the 


274 


TREATMENT  OF  SMALL-POX 


eruption — a  period  corresponding,  as  I 
hardly  need  remind  you,  with  the  eighth  or 
ninth  day  of  the  disease. 

Various  local  means  have  been  recom¬ 
mended  to  be  adopted  at  an  early  stage  of 
the  disease,  with  the  view  of  preventing  the 
full  development  of  the  pustules,  and  con¬ 
sequently  of  preserving  the  patient  from  the 
disfigurement  produced  by  the  pitting  of  the 
eruption.  The  eautei’ization  of  each  indivi¬ 
dual  pock  with  the  nitrate  of  silver,  is  a  pro¬ 
cess  impi’acticable  from  its  tediousness, 
while  there  is  some  discrepancy  in  the  re¬ 
sults  which  different  persons  allege  that 
they  have  obtained  by  applying  mercurial 
ointment  or  plaster,  or  by  washing 
the  surface  which  it  is  wished  to  defend  with 
a  solution  of  corrosive  sublimate.  The 
weight  of  evidence  appears  to  me,  however, 
to  be  in  favour  of  some  proceeding  of  this 
kind,  and  that  which  seems  to  have  been  the 
most  successful,  is  the  application  of  the 
mercurial  plaster  at  a  period  not  later  than  the 
third  day  from  the  outbreak  of  the  eruption. 

Attention  must  be  paid  to  the  state  of 
the  eyes,  which  often  suffer  much  during 
attacks  of  the  small-pox,  though  Dr.  Gregory 
states  that  the  conjunctiva  never  becomes 
the  seat  of  the  pustules.  From  the  time 
when  the  swelling  of  the  face  begins,  during 
the  maturation  of  the  eruption,  the  eyelids 
are  often  so  much  swollen  as  completely  to 
close  the  eyes,  while  iheir  edges  are  glued 
together  by  a  tenacious  secretion  from  the 
Meibomian  glands.  The  patient  will  be  much 
relieved  by  bathing  the  eyes  frequently  with 
warm  water,  and  any  pustules  that  occupy 
the  margin  of  the  palpebree  should  be  care¬ 
fully  cauterized  with  the  nitrate  of  silver. 

The  condition  of  the  mouth  and  throat 
must  not  be  neglected.  If  old  enough,  the 
child  may  be  made  to  gargle  with  a  little  in¬ 
fusion  of  roses,  while,  should  it  be  too  young 
to  do  this,  the  endeavour  must  be  made  to 
keep  the  mouth  and  throat  free  from  the  se¬ 
cretions  which  collect  there,  by  washing  them 
fi’equently  with  warm  water,  and  applying 
a  weak  solution  of  chloride  of  lime  to  the 
fauces.  If  difficult  respiration  should  come 
on  in  consequence  of  the  affection  seriously 
involving  the  larynx  and  trachea,  the  pa¬ 
tient’s  condition,  according  to  the  testimony 
of  almost  all  writers,  is  rendered  neai'ly 
hopeless. 

The  intense  itching  of  the  eruption  during 
the  latter  part  of  the  period  of  maturation, 
and  the  stage  of  desiccation,  not  only  dis¬ 
tresses  the  patient  exceedingly,  but  is  often 
the  occasion  of  subsequent  disfigurement, 
in  consequence  of  the  desire  to  scratch 
being  irresistible,  and  the  pustules  being 
converted  by  abrasion  of  their  heads  into 
troublesome  ulcerations.  The  application  of 
sweet  oil,  cold  ci-eam,  or  spermaceti  oint¬ 
ment,  will  do  something  towards  allaying 


the  irritation  ;  but  you  will  often  find  it 
necessary  to  muffle  the  hands  of  children,  in 
order  to  prevent  their  producing  ti-ouble- 
some  soi'es  by  scratching  themselves. 

The  convalescence  from  small-pox  is  often 
very  tedious  ;  the  patient’s  recovery  is  fre¬ 
quently  interrupted  by  various  intercuri’ent 
affections,  and  the  latent  seeds  of  scrofulous 
disorder  are  in  many  instances  called  into 
activity  by  its  attack.  These,  however,  are 
occuri'ences  which  present  nothing  of  a 
special  character,  and  it  is  thei’efore  unneces¬ 
sary  to  make  any  observations  with  reference 
to  their  treatment. 

Although  previous  vaccination  usually 
confers  upon  the  system  a  complete  im¬ 
munity  from  subsequent  attacks  of  small¬ 
pox,  yet  to  this  rule  there  are  occasional 
exceptions.  In  many  instances,  mdeed,  the 
occurrence  of  small- pox  after  alleged  suc¬ 
cessful  vaccination  may  be  accounted  for  by 
the  careless  performance  of  that  operation, 
the  use  of  Ivmph  taken  from  the  arm  at  too 
late  a  period,  or  the  production  in  some 
way  of  a  spurious  instead  of  a  genuine  vac¬ 
cine  vesicle.  It  must  be  confessed,  how¬ 
ever,  that  when  every  allowance  has  been 
made  for  these  casualties,  the  number  of 
cases  of  small-pox  occurring  after  success¬ 
ful  vaccination,  is  proportionahly  much 
greater  than  the  number  in  which  a  second 
attack  of  small-pox  is  experienced  by  those 
who  have  either  had  that  disease  casually,  or 
in  whom  it  has  been  produced  by  variolous 
inoculation.  It  would  occupy  far  more  time 
than  we  have  at  our  command,  if  we  were 
to  attempt  to  enter  upon  the  inquiry  as  to 
the  causes  of  the  failure  in  the  protective 
power  of  vaccination.  Different  views  have 
been  taken  by  very  high  authorities  upon 
this  subject ;  but  there  is  one  important  fact 
concerning  which  nearly  all  are  agreed — • 
namely,  that  the  liability  to  a  subsequent 
attack  of  small- pox  is  almost  incalculably 
diminished  by  revaccination.  Considering, 
then,  how  simple  the  operation  is,  and  howr 
neaidy  painless  its  performance,  while  the 
benefit  to  be  obtained  by  it  is  so  inestimable, 
I  would  strongly  ui'ge  you  to  revacemate  all 
persons  turned  12  years  old,  even-  though 
they  had  been  vaccinated  with  the  most 
complete  success  in  their  infancy.'15 

But  although  we  should  take  a  compara¬ 
tively  low  estimate  of  the  value  of  vaccina¬ 
tion,  and  confess  to  the  fullest  extent  the 
failure  in  its  complete  preservative  virtue, 
we  shall  yet  find,  in  the  modifying  and  miti¬ 
gating  influence  which  it  exerts  over  small¬ 
pox,  more  than  enough  to  make  us  value  it 
as  a  priceless  boon.  Twenty  years  ago 
small-pox  raged  epidemically  at  Marseilles, 
where  it  attacked  almost  exclusively  persons 

*  For  facts  shewing  the  preservative  influence 
of  revaccinafion,  see  Steinbrenner,  Truitt  sur  la 
Vaccine.  8vo.  Paris,  1840,  p.  683 — 734. 


CHICKEN-POX — SYMPTOMS  AND  DIFFERENCES  FROM  SMALL-POX.  275 


tinder  30  years  of  age.  M.  Favart,*  who 
sent  an  account  of  this  epidemic  to  the 
Academy  of  Medicine  at  Marseilles,  esti¬ 
mated  the  number  of  the  inhabitants  under 
30  years  of  age  at  40,000.  Of  these,  about 
30,000  had  been  vaccinated,  2,000  had  had 
small-pox  casually  or  by  inoculation,  and 
8,000  had  had  neither  variola  nor  cow-pox. 
Of  this  last  class,  4,000,  or  1  in  2,  were 
attacked  by  small-pox,  and  1000  of  them, 
or  1  in  4,  died.  Of  those  who  had  had 
small-pox  previously,  only  20,  or  1  in  100, 
were  again  affected ;  but  4  of  these,  or  1  in 
5,  died  ;  while  of  the  vaccinated,  although 
2000,  or  1  in  15,  had  it,  yet  it  proved  fatal 
only  to  20,  or  1  per  cent. 

The  influence  of  vaccination  in  rendering 
attacks  of  small-pox  which  may  succeed  to 
it,  so  much  less  severe,  and  so  much  less 
dangerous,  than  the  unmodified  disease,  does 
not  in  many  instances  manifest  itself  in  any 
diminution  of  the  intensity  of  the  primary 
fever.  The  symptoms  with  which  modified 
small-pox  sets  in  are  often  as  severe  as  those 
of  the  unmodified  disease,  and  are  also  in 
general  of  the  same  duration.  So  soon  as 
the  eruption  begins  to  make  its  appearance, 
however,  the  difference  between  the  two 
diseases  in  general  becomes  apparent.  In 
many  instances,  notwithstanding  the  sharp 
onset  of  the  patient’s  illness,  the  eruption  is 
exceedingly  scanty,  not  more  than  from  20 
to  100  pustules  appearing  over  the  whole 
body.  In  other  instances  the  eruption  is 
much  more  abundant,  and  in  a  few  excep¬ 
tional  cases  the  pustules  are  actually  con¬ 
fluent.  But  even  when  they  are  most  nu¬ 
merous,  the  pustules  seldom  fail  to  follow  a 
different  course  from  that  which  they  pursue 
in  ordinary  variola,  and  run  through  their 
different  stages  within  little  more  than  half 
the  period  required  by  the  eruption  of  un¬ 
modified  small-pox.  The  small  size  of  the 
pocks, — the  frequent  absence  of  the  central 
depression, — their  imperfect  suppuration, — 
and  their  speedy  desiccation, — are  the  chief 
local  characters  of  this  affection  ;  while  the 
almost  complete  absence  of  the  secondary 
fever,  is  both  its  grand  constitutional  pecu¬ 
liarity  and  the  main  source  of  the  patient's 
safety. 

Besides  the  modified  small-pox  to  which 
reference  has  just  been  made,  there  is  ano¬ 
ther  and  still  milder  affection  often  observed 
in  children,  to  which,  from  the  extreme 
lightness  of  the  symptoms  that  usually 
attend  it,  the  diminutive  appellations  of 
varicella  or  chicken-pox  have  been  given. 
Much  difference  of  opinion  has  existed  with 
reference  to  the  relations  borne  by  this 
disease  to  small- pox  ;  and  even  at  the  pre¬ 
sent  day,  writers  are  not  quite  agreed  whe¬ 
ther  to  regard  it  as  an  extremely  mild  form 
of  variola,  or  as  an  affection  altogether  ais- 

*  As  reported  by  Steinbrenner,  op.  cit.  p.  166. 


tinct  from  it.  The  weight  of  evidence, 
however,  is  decidedly  in  favour  of  the  opi¬ 
nion  that  varicella  is  an  affection  distinct 
from,  and  wholly  independent  of,  small-pox, 
not  being  produced  by  any  modification  of 
the  poison  of  that  disorder,  nor  affording 
any  kind  of  protection  from  its  attacks. 

Varicella  is  almost  exclusively  a  disease  of 
childhood,  and  in  the  great  majority  of  cases 
it  occurs  prior  to  the  completion  of  the  first 
dentition.  Its  initiatory  fever,  which  is- 
scarcely  ever  severe,  is  sometimes  altogether 
wanting,  so  that  the  appearance  of  the  erup¬ 
tion  on  the  surface  is  the  first  occurrence 
that  calls  attention  to  the  child’s  condition. 
Now  and  then,  however,  exceptions  occur  to 
this  mildness  in  the  onset  of  the  disease  ; 
and  I  have  occasionally  seen  children  (chiefly 
those  in  whom  the  process  of  dentition  was 
going  on  with  activity  at  the  time  of  the  at¬ 
tack)  suffer  for  24  or  36  hours  from  febrile 
symptoms,  quite  as  severe  as  those  which 
precede  the  attack  of  measles,  or  as  accom¬ 
pany  a  sharp  attack  of  influenza.  The  dura¬ 
tion  of  this  premonitory  stage  of  chicken- 
pox  is  somewhat  uncertain ;  the  vesicles 
which  characterize  it  making  their  appear¬ 
ance  after  24  hours  in  some  cases, — not  for 
36  or  48  hours  in  others  ;  while,  as  already 
mentioned,  the  eruption  is  occasionally  the 
first  symptom  of  the  existence  of  the  disease. 

The  eruption  usually  consists  of  more  or 
less  numerous,  minute, circular,  vesicles,  con¬ 
taining  a  transparent  serum,  irregularly  dis¬ 
tributed  over  the  face,  head,  shoulders,  and 
trunk,  but  rarely  appearing  on  the  lower 
extremities  ;  and,  even  when  present  in  con¬ 
siderable  abundance,  being  very  seldom  con¬ 
fluent  at  any  part.  For  two  or  three  days 
they  increase  somewhat  in  size,  but  their 
contents  then  become  turbid  and  milky ; 
about  the  fourth  or  fifth  day  they  shrivel, 
and  then  dry  up  into  a  light,  pulverulent, 
scab,  which  falls  off  on  the  eighth  or  ninth 
day  of  the  disease.  It  very  seldom  happens 
that  any  cicatrix  is  left  after  the  detachment 
of  the  scab  of  varicella,  unless  the  skin  has 
been  irritated  by  the  patient  scratching  it  in 
order  to  relieve  the  itching,  which  is  some¬ 
times  very  troublesome.  Besides  these 
differences  between  the  eruption  cf  chicken- 
pox  and  that  of  variola,  another,  and  still 
more  striking  peculiarity  of  the  former 
disease,  consists  in  the  appearance  of  two  or 
three  successive  crops  of  vesicles,  so  that 
after  the  third  day  of  the  affection  vesicles 
may  be  observed  close  to  each  other  in  all 
stages  of  their  progress. 

The  disease  is  one  so  void  of  danger,  that 
it  requires  hardly  any  treatment  beyond  the 
adoption  of  a  mild  antiphlogistic  regimen ; 
and  no  complications  occur  during  its  course, 
nor  sequelee  remain  after  its  disappearance, 
concerning  which  any  thing  more  need  be 
added. 


276 


COLLECTION  OF  FACTS  ILLUSTRATIVE  OF 


Original  OommumcattensL 


A  COLLECTION  OF  FACTS  ILLUSTRATIVE  OF 
THE 

MORBID  CONDITIONS  OF  THE 
PULMONARY  ARTERY. 

AS  BEARING  UPON  THE  TREATMENT  OF 
CARDIAC  AND  PULMONARY  DISEASES. 

By  Norman  Chevers,  M.D. 
Assistant -Surgeon,  Bengal  Army. 
[Continued  from  p.  626  of  preceding  volume.] 


OBSTRUCTION  TO  THE  PULMONARY  ORIFICE 

CONSEQUENT  UPON  ENDOCARDITIS - 

CONTINUED. 

The  following  case  of  obstructive  disease  of 
the  pulmonary  valves,  with  which  I  have 
been  kindly  favoured  by  my  friend  Dr. 
Edward  Lloyd,  in  whose  practice  it  occurred, 
is  probably  the  most  remarkable  instance  of 
the  kind  on  record,  in  the  extent  of  the  dis¬ 
ease,  as  well  as  in  several  of  the  circum¬ 
stances  which  attended  its  progress :  it  ap¬ 
pears  to  me  to  afford  an  almost  unique, 
though  most  instructive,  example  of  cardiac 
disease  : — 

Amelia  S.,  aetat.  38,  came  under  the  care 
of  Dr.  Lloyd,  on  the  3rd  of  February,  1845. 
She  was  a  dark-complexioned  sallow  woman, 
with  a  very  anxious  and  haggard  expression 
of  countenance  ;  she  wras  by  occupation  a 
work-woman  at  a  dry-salter's,  where  she  had 
been  chiefly  employed  in  packing  galls,  in 
lifting  heavy  weights,  and  in  having  to  go  up 
and  down  flights  of  stairs.  She  had  always 
been  an  active  person,  and  in  these  habits  con¬ 
tinued  until  confined  by  her  last  illness.  Her 
habits  were  intemperate,  and  of  late  they 
had  been  more  so  than  usual.  In  the  pre¬ 
ceding  October,  she  was  run  over,  but  it  was 
not  certain  that  she  received  any  material 
injury  ;  still  her  head  was  cut,  and  her  hus¬ 
band  maintained  that  from  that  time  she 
became  less  healthy  than  formerly.  She, 
however,  returned  to  work,  and,  up  to 
Christmas-day,  continued  her  usual  avoca¬ 
tions  with  her  accustomed  activity,  frequently 
carrying  sacks  of  two  hundred-weight  up 
and  down  stairs  throughout  the  whole  day. 
She  had  been  subject  to  winter  cough,  and 
her  husband  appeared  to  think  that  she  used 
sometimes  to  have  attacks  of  fainting  pre¬ 
viously  to  her  last  illness,  but  her  employer 
maintained  that  she  was  never  short-breathed, 
and  that  he  had  never  heard  of  her  being 
faint :  his  expression  was  that  “  she  could  do 
the  wmrk  of  a  man.”  Her  attack  com¬ 
menced  on  Christmas-day,  or  soon  after¬ 
wards.  On  that  day  she  had  a  quarrel  with 
her  husband,  when  it  is  stated  that  he  struck 


her  several  blows  on  the  side,  and  she,  from 
that  time,  complained  of  pain  in  that  situa¬ 
tion.  This,  however,  does  not  appear  to 
have  attracted  much  attention,  except  that 
she  was  unable  to  go  to  work.  On  the  Sunday 
following,  she  had  another  quarrel  with  her 
husband,  when  the  neighbours  interfered. 
On  Monday  she  was  very  unwell,  and  on 
Tuesday  she  took  to  her  bed,  complaining 
of  pain  in  her  left  side,  which  she  ascribed 
to  a  blow  from  her  husband.  She  now  sent 
for  Dr.  Jewel :  that  gentleman  observed  the 
presence  of  a  cardiac  bruit.  On  the  3rd  of 
February,  when  Dr.  Lloyd  first  saw  her,  she 
had  been  ill  five  wreeks  ;  she  lay  on  her  left 
side,  with  an  anxious  expression  of  counte¬ 
nance,  and  peculiarly  harassed  though  not 
difficult  or  laborious  respiration,  with  every 
now  and  then  a  long  deep-drawn  breath, 
followed  by  a  number  of  short  inspirations. 
Respirations  36-40.  Pulse  130,  very  small, 
sharp,  and  slightly  irregular.  She  com¬ 
plained  of  pains  in  her  limbs,  knees,  and 
ankles,  but  particularly  in  the  right  arm,  on 
examining  which  an  abscess  was  subsequently 
found  over  the  biceps,  but  she  appeared  to 
suffer  chiefly  from  a  severe  pinching  pain, 
which  sometimes  gave  the  sensation  of  a 
knife  going  through  her  on  her  left  side. 
Skin  hot ;  bowels  relaxed  ;  sensorium  un¬ 
disturbed.  She  was  extremely  irritable. 
The  hurry  of  respiration  increased  when  she 
was  raised.  She  complained  of  cough,  with 
some  expectoration  of  a  mucous  character, 
not  allowing  her  any  rest  from  the  pain  it 
caused  in  her  left  side.  She  was  said  to  have 
eaten  nothing  for  a  wreek,  had  no  desire  for 
food,  and  could  not  sleep  at  night.  The  ex¬ 
treme  hurry  *of  respiration  was.  very  re¬ 
markable  indeed.  The  chest  was  resonant 
throughout  ;  the  respiration  coarse  and 
loud  at  the  apices  of  the  lungs, — there  was 
no  abnormal  pulmonary  sound,  with  the  ex¬ 
ception  of  a  slight  mucous  rale  heard  over 
the  right  scapula.  The  heart’s  sounds  were 
indistinct,  heard  more  clearly  at  the  apex 
than  at  the  base :  in  the  latter  situation 
there  wasan  abnormalsound,  (which appeared 
to  Dr.  Lloyd  to  have  the  characters  of  a 
pericardial  frottement ),  heard  over  a  space 
of  about  two  inches  in  diameter  from  the 
right  nipple  to  the  sternum,  but  not  at  all 
audible  in  any  portion  of  the  course  of  the 
aorta  or  carotid  arteries.  This  sound  was 
superficial  and  loud,  but  soft,  with  a  distinct 
back  stroke.  No  fremitus  could  be  felt.  She 
was  ordered  calomel  and  opium  at  night : 
serpentary  and  ammonia,  and  sago,  beef-tea, 
and  calves’-foot  jelly. 

On  the  4th,  she  was  much  in  the  same 
condition  ;  had  passed  a  very  restless  night ; 
her  cough  was  troublesome  ;  she  expecto¬ 
rated  frothy  mucus  tinged  with  blood.  The 
abdominal  cardiac  sound  was  unchanged; 
the  respiration  was  still  extraordinarily 


THE  MORBID  CONDITIONS  OF  THE  PULMONARY  ARTERY 


277 


hurried.  Pulse  135,  small  and  sharp.  The 
urine  was  found  to  be  slightly  coagulable. 
There  had  been  one  loose  motion  during  the 
night.  The  liver  could  be  felt  below  the 
ribs.  She  now  complained  of  pain  in  her 
right  side  on  auscultation  :  a  slight  rubbing 
was  heard  in  this  situation.  Emplast. 
Lyttae,  lat.  sinist.  ;  Hydrarg.  Chlor.  gr.  i.  ; 
Opii,  gr.  i.  nocte,  et  P. 

On  the  5th,  she  felt  better;  her  face  was 
less  anxious.  She  had  passed  a  comfortable 
night,  and  slept  a  good  deal  during  the  day. 
The  skin  was  perspiring  ;  she  was  extremely 
weak,  and  when  she  got  out  of  bed  she  was 
obliged  to  lie  on  the  floor  to  avoid  fainting. 
She  had  done  this  for  some  time  during  her 
illness.  The  tongue  was  clean  and  moist ; 
the  blister  had  risen  well.  Pulse  130,  small, 
and  irregular  in  the  duration  of  each  beat. 
The  cough  was  relieved,  but  respiration  was 
still  hurried.  After  a  severe  fit  of  coughing 
she  became  very  cold  and  faint,  and  hot 
bottles  and  flannel  were  necessary  to  keep 
her  warm.  Her  appetite  was  much  im¬ 
proved  ;  she  had  taken  calves’  foot  jelly. 
The  right  arm  was  painful ;  the  pain  in  the 
legs  was  less.  p.  m.  Habt.  Yin.  ~iv. 

6th. — Was  much  agitated  on  the  preced¬ 
ing  night ;  since  which  she  continued  to 
grow  worse.  The  countenance  was  more 
sunken  ;  the  respiration  very  hurried  ;  pulse 
slower,  100,  and  intermittent;  the  cough 
troublesome  ;  the  heart’s  sounds  were  much 
more  indistinct ;  and  the  abnormal  murmur 
feeble.  There  was  some  dulness  at  the  base 
of  the  left  lung,  with  some  oegophony.  The 
tongue  was  rather  brown;  lips  dry  and 
parched;  sordes  on  the  teeth.  She  had  not 
had  the  wine  ordered,  which  was  prescribed 
at  last  visit.  Brandy  ~iv. ;  Infus.  Serpen- 
tarise  C.  etTr.  ejusd.  c.  Ammon.  Sesquicarb. 
gr.  v.  quartis  horis. 

On  the  7th,  she  was  much  lower;  the 
abnormal  cardiac  sound  was  heard  over  a 
smaller  space  ;  the  heart’s  sound  was  irregu¬ 
lar  and  indistinct.  Respirations,  <10.  Pulse, 
114.  Tongue  brown  ;  teeth  covered  with 
sordes. 

On  the  following  day  she  was  much  the 
same;  the  pulse  was  slower,  about  90,  very 
weak,  and  hardly  to  be  felt.  Respiration 
was  very  hurried ;  there  was  subsultus,  and 
she  was  evidently  sinking.  She  died  on  the 
morning  of  the  10th,  having  sunk  gradually. 

Autopsy.' — The  body  was  very  spare  and 
thin.  The  abscess  on  the  fore  part  of  the 
right  arm  was  found  to  contain  about  an 
ounce  of  sanious  pus,  with  some  old  coagula 
of  blood.  Recent  and  soft  pleuritic  adhesions 
were  found  on  the  right  side  of  the  chest, 
with  puenmonic  consolidation,  approaching 
the  stage  of  grey  hepatization,  of  a  small 
patch  in  the  centre  of  the  lung.  The  base 
of  this  lung  presented  a  somewhat  congested 
appearance,  which  was  probably  cadaveric. 


Both  lungs,  when  cut  into,  yielded  a  large 
quantity  of  serum,  mixed  with  air-bubbles. 
On  the  left  side  there  were  a  few  old  pleuritic 
adhesions,  with  some  fluid  in  the  pleural 
cavity  ;  the  lung  itself  presented  no  other 
morbid  change  than  oedema.  The  peri¬ 
cardium  contained  about  two  drachms  and 
a  half  of  fluid,  and  was  perfectly  healthy. 
The  heart  was  of  a  normal  size,  and  not  at 
all  gorged  with  blood.  The  left  side  was 
healthy ;  both  aortic  and  mitral  valves  were 
sound.  There  was  no  hypertrophy  or  dila¬ 
tation.  The  tricuspid  valve  was  healthy. 
The  right  auricle  contained  a  coagulum,  but 
was  not  distended ;  the  right  ventricle  also 
contained  a  small  coagulum.  On  examin¬ 
ing  the  pulmonary  artery ,  a  hard  body  was 
felt  considerably  obstructing  its  canal,  but 
a  probe  was  easily  passed,  and  could  be 
moved  from  side  to  side  on  the  anterior  wall 
of  the  artery  ;  it  could  also  be  passed  be¬ 
tween  two  bodies  which  blocked  up  the 
valves.  On  carefully  laying  open  the  artery, 
its  orifice  was  found  to  present  two  tumors 
and  one  valve  ;  the  tumors  corresponding 
to  the  posterior  valves,  and  having  a  cres¬ 
centic  surface  on  their  ventricular  margin. 
One  of  these  masses  was  about  double  the 
size  of  the  other,  the  smaller  being  about 
the  size  of  a  large  walnut.  When  placed  in 
situ,  it  was  found  that  each  had  smooth 
corresponding  surfaces,  evidently  produced 
by  friction  between  the  two  bodies.  They 
were,  externally,  of  a  dark  grey  or  brownish 
colour,  having  generally  a  somewhat  warty 
and  roughened  surface.  On  laying  them  open 
with  a  scalpel,  they  exuded  a  gelatinous  fluid 
of  a  very  tenacious  character.  They  were 
hard,  and  apparently  organised,  with  fibres 
arranged  in  small  convolutions.  They  wTere 
light-coloured  internally :  their  bases  or 
ventricular  margins  were  apparently  in  a 
state  of  inflammatory  softening,  breaking 
down  on  the  slightest  touch,  and  separating 
from  the  substance  of  the  artery  without 
difficulty.  The  gelatinous  fluid  was  exa¬ 
mined  by  the  microscope,  and  found  to 
contain  nucleated  cells,  not  of  a  malignant 
character.  The  remaining  valve  was  covered 
with  some  shaggy  vegetations  or  fibrinous 
deposit :  it  was  of  normal  size,  and  smooth 
and  healthy  on  its  arterial  or  inner  surface. 
The  coronary  arteries  were  healthy  ;  there 
were  two  openings  to  either  artery.  The 
omentum  was  attached  to  the  abdominal 
parietes  by  old  adhesions.  The  liver  was 
much  enlarged,  stretching  down  to,  and 
encroaching  on,  the  umbilical  region:  it 
was  congested  and  coarse  in  structure,  and 
adherent  to  the  abdominal  parietes.  The 
spleen  was  also  large.  The  kidneys  were 
larger  than  usual,  and  of  coarse  structure; 
their  tunics  were  adherent,  and  they  were 
very  lacerable  and  pale.  The  ileum  was 
congested,  and  presented  some  spots  of 


278  THE  MORBID  CONDITIONS  OF  THE  PULMONARY  ARTERY. 


ecchymosis :  it  contained  nothing  but  a 
small  quantity  of  bilious  mucus. 

Among  other  valuable  remarks  which  Dr. 
Lloyd  has  appended  to  his  report  of  the 
above  case,  he  observes  that  it  proves  how 
great  an  amount  of  obstruction  may  continue 
to  be  borne  on  the  right  side  of  the  heart, 
provided  the  lungs  are  sound,  and  in  work¬ 
ing  condition.  He  considers  that  the  heart 
itself  shewed  no  evidences  of  obstruction, 
as  there  was  neither  hypertrophy  nor  dilata¬ 
tion,  nor  even  engorgement  of  its  cavities  : 
in  fact,  there  was  a  singular  absence  of 
marked  evidences  of  cardiac  obstruction 
both  before  and  after  death.  There  was  no 
impediment  to  the  return  of  blood  from  the 
jugulars,  no  blueness  of  the  lips,  conges¬ 
tion  of  the  countenance,  or  oedema  of  any 
part  of  the  body.  Dr.  Lloyd  very  justly 


accounts  for  this  absence  of  cardiac  engorge¬ 
ment  and  external  congestion  in  two  ways  : 
first,  the  quantity  of  the  circulating  fluid 
was  small,  the  patient  being  thin,  spare, 
and  at  rest,  and  must  have  become  smaller 
and  smaller  as  the  disease  of  the  valves  in¬ 
creased,  from  the  woman’s  taking  no  nou¬ 
rishment  of  any  kind,  and  also  from  the 
reducing  effects  of  treatment ;  and,  secondly 
and  principally,  he  thinks  this  circumstance 
accounted  for  by  the  remarkably  hurried 
action  of  the  lungs,  whereby  a  small  quan¬ 
tity  of  blood  was  sucked  up  by  atmospheric 
pressure  from  the  ventricle  at  every  re¬ 
spiration.  This,  frequently  repeated,  he 
believes,  answered  the  purpose  of  the  na¬ 
tural  and  slower  respiration,  and  larger 
supply. 


This  remarkable  specimen  is  preserved  in 
the  collection  at  Guy’s  (numbered  141353.) 
The  artery  has  the  appearance  of  being 
much  dilated.  Large  portions  of  the  clots 
have  been  removed,  but  the  remaining 
masses  are  still  of  extraordinary  size.  All 
the  valves  are  ruptured  at  their  lower  at¬ 
tachments,  but  this  has  occurred  subse¬ 
quently  to  removal,  owing  to  the  extremely 
softened  condition  of  the  parts. 

The  preparation  marked  141350  in  Guy’s 
museum  is  the  base  of  a  heart  in  which  the 
valves  are  more  or  less  generally  coated 
with  layers  of  recent  inflammatory  product. 
Those  portions  of  the  ventricular  surfaces  of 
the  'pulmonary  sigmoids  which  remain  free 
from  fibrinous  laminae  appear  to  be  pliable, 
and  free  from  thickening  or  marked  opacity. 
I  have  not  succeeded  in  obtaining  any  his¬ 
tory  of  the  case. 

Like  the  aortic  sigmoids,  the  valves  of 


the  pulmonary  artery  occasionally,  but 
rarely,  present  rows  of  minute  semitrans¬ 
parent  wart-like  vegetations,  which  are 
usually  arranged  in  the  form  of  double 
festoons  at  the  lowest  and  most  projecting 
parts  of  their  surfaces  of  contact.  I  have 
elsewhere  stated*  my  grounds  for  believing 
that  these  little  bodies  are  not  mere  adven¬ 
titious  deposits  from  the  blood,  but  or¬ 
ganised  growths  from  the  endocardial  sur¬ 
faces,  and  that,  under  circumstances  of 
disease,  they  are  intended  to  protect  the 
outlets  of  the  heart  from  undue  attrition,  as 
well  as  from  the  deposition  of  clots,  and 
also  to  prevent  the  occurrence  of  adhesion 
between  opposed  surfaces  of  inflamed  valves. 

[To  be  continued.] 


*  Guy’s  Hospital  Reports,  vol.  i.  N.  S.,  “  Ob¬ 
servations  on  tbe  Diseases  of  the  Orifice  and 
Valves  of  the  Aorta.” 


DR.  WHITE  ON  THE  PROXIMATE  CAUSE  OF  GOUT. 


279 


AN  INQUIRY  INTO  THE 

PROXIMATE  CAUSE  OF  GOUT  AND 
ITS  RATIONAL  TREATMENT. 

By  Anthony  White,  Esq.  M.B. 

Late  President  of  the  Royal  College  of  Surgeons 
of  England. 


I  have  for  some  time  been  engaged  in 
preparing  a  work  on  Diet,  wherein  I 
purpose  among  other  things  to  trace 
out  the  connection  between  sundry 
constitutional  disorders,  and  the  habi¬ 
tual  abuses  of  the  digestive  organs  in 
childhood  as  well  as  in  the  adult  age. 
I  had  intended  to  embody  in  that  work 
certain  theoretical  and  practical  views, 
which  long  experience  and  reflection 
have  led  me  to  entertain  on  the  subject 
of  gout ;  but  having  been  strongly  soli¬ 
cited  by  several  professional  friends 
not  to  delay  the  publication  of  that 
portion  of  my  notes,  I  have  here  thrown 
them  into  the  shape  of  a  separate 
paper. 

In  venturing  to  propound  a  new 
theory  of  gout,  I  do  not  conceal  from 
myself  the  hazards  I  incur.  The  very 
announcement  of  my  design  must,  I  am 
aware,  provoke  against  it  a  formidable 
array  of  prejudice,  since  it  is  natural 
to  predict  the  failure  of  every  fresh  ad¬ 
venturer  in  an  enterprise  so  often  and 
so  strenuously  essayed,  and  always  es¬ 
sayed  in  vain.  On  the  other  hand,  I 
submit  that  there  is  a  wide  distinction 
between  what  is  merely  improbable, 
and  what  is  impossible,  and  that,  how¬ 
ever  difficult,  be  the  problem  I  profess 
to  solve,  at  least  it  involves  no  absolute 
impracticability.  It  is  safe  to  reject 
d  priori,  the  claims  of  one  who  shall 
pretend  to  have  discovered  the  per¬ 
petual  motion,  or  the  elixir  vitse,  or  to 
have  unravelled  the  impenetrable  mys¬ 
teries  of  ontology  ;  but  an  inquiry  into 
the  natural  history  of  any  given  disease 
belongs  to  quite  another  category; 
nor  does  there  exist  any  reason  why 
science  should  ever  halt  in  despair  at 
any  unaccomplished  point  in  her  pro¬ 
per  business,  which  is  in  every  in¬ 
stance  to  trace  back  step  by  step  those 
trains  of  phenomena,  to  which,  as  we 
regard  them  in  their  unvaried  order  of 
sequence,  we  attribute  the  relationship 
of  cause  and  effect.  I  n  some  cases,  this 
kind  of  research  has  been  prosecuted 
almost  to  its  last  limits,  whilst  in  others 
it  has  stopped  short  at  any  early  stage, 


and  there  remained  for  centuries,  in 
spite  of  countless  efforts  to  discover 
the  missing  clue  to  the  next  step.  But 
soon  or  late  the  clue  will  be  found,  and 
the  further  step  achieved ;  for  no 
amount  of  lost  labour  can  exhaust  the 
persevering  energies  of  science — no 
lapse  of  time  can  subject  her  powers  to 
bar  or  prescription.  How  often,  to  use 
the  language  of  Sir  John  Herschel, 
how  often  have  we  *'  seen  obscurities, 
which  seemed  impenetrable,  in  physical 
and  mathematical  science,  suddenly 
dispelled,  and  the  most  barren  and  un¬ 
promising  fields  of  inquiry  converted, 
as  if  by  inspiration,  into  rich  and  inex¬ 
haustible  springs  of  knowledge  and 
power,  on  a  simple  change  of  our  point 
of  view,  or  by  merely  bringing  to  bean 
on  them  some  principle  that  it  had* 
never  occurred  before  to  try.” 

I  believe  that  without  arrogating  to 
myself  any  inordinate  share  of  acumen, 

I  may  affirm  that  through  one  of  those 
happy  accidents  adverted  to  in  the 
foregoing  extract,  I  have  been  prompted 
to  the  true  answer  to  that  hitherto  un¬ 
solved  question — What  is  the  proxi¬ 
mate  cause  of  gout  ? 

In  addition  to  the  ordinary  opportu¬ 
nities  of  a  long  professional  life,  my 
means  of  becoming  intimately  ac¬ 
quainted  with  this  disease  have  been 
in  part  of  a  peculiar  nature,  such  as 
falls  in  an  equal  degree  to  the  lot  of 
few  medical  practitioners,  and  such,  I 
may  boldly  assert,  as  no  man  will  be 
inclined  to  envy  me.  Corvisart’s 
classical  treatise  on  diseases  of  the 
heart  was  the  work  of  a  man  who 
was  himself  afflicted  with  one  of 
those  organic  maladies  he  so  ably  de¬ 
scribed.  The  symptoms  of  ulceration 
of  tbe  stomach  were  vividly  portrayed 
by  Beclard,  from  his  own  sad  personal 
experience.  The  connection  between 
organic  disease  of  the  brain  and  certain 
disorders  of  the  sensorial  functions-, 
were  illustrated,  as  they  could  never 
otherwise  have  been,  by  Dr.  Wollas¬ 
ton’s  description  of  his  own  case,  which 
he  studied  with  the  same  serene  saga¬ 
city  and  precision  as  characterised 
every  other  exertion  of  his  noble  in¬ 
tellect.  I  too,  however,  unfitted  to 
to  compare  in  other  respects  with  those 
illustrious  men,  have  this  at  least  in 
common  with  them,  that  I  have  learned 
from  my  own  sufferings,  some  facts 
likely,  as  I  trust,  to  prove  of  consi- 
siderableimportance  to  medical  science. 


DR.  WHITE  ON  THE  PROXIMATE  CAUSE  OF  GOUT 


280 


I  am  the  offspring  of  parents  both  of 
whom  were  constantly  the  subjects  ot 
gout— a  disease  which  was  inherited 
by  their  four  sons.  Two  of  the  latter 
(twins)  died  at  the  respective  ages  of 
45  and46,  worn  out  by  reiteratedattacks 
of  the  malady.  For  myself,  sharing 
largely  in  the  family  predisposition,  I 
very  early  in  life  began  to  exhibit  signs 
of  latent  gout,  shewn  in  the  ready  con¬ 
version  of  common  nutriment  into  acrid 
acidity  ;  and  among  my  earliest  recol¬ 
lections  are  my  mother’s  repeated  ad¬ 
ministrations  to  me  of  magnesia  and 
alkaline  preparations,  to  remedy  the 
heartburn  with  which  I  was  constantly 
tormented.  About  the  age  of  sixteen, 
a  fixed  aching  pain  occupied  the  middle 
flexor  tendon  of  my  right  hand  near 
*the  root  of  the  finger,  preventing  its 
flexure.  In  the  course  of  a  week  or 
two,  the  pain  in  the  finger  ceased  sud¬ 
denly,  and  was  almost  instantly  suc¬ 
ceeded  by  a  severe  attack  of  gout  in 
the  large  joint  of  the  great  toe,  ushered 
in  by  all  the  usual  precursory  symptoms. 
The  subsequent  visitations  of  the  disease 
have  extended  over  a  period  of  forty 
years,  during  which  it  has  successively 
affected  every  tissue  of  my  body.  Hence, 
I  have  had  abundant  opportunity  not 
only  to  experiment  upon  the  gout  in 
my  own  person  as  regards  dietetics  and 
therapeutics,  but  also  to  study  its  natu¬ 
ral  history  under  the  least  ambiguous 
conditions,  whenever,  as  not  unfre- 
quently  happened,  I  alloweda  paroxysm 
to  run  its  course,  and  effect  its  own 
cure.  It  was  chiefly  by  noticing  what 
took  place  under  such  circumstances 
that  I  was  led  to  entertain  those  views 
which  I  shall  presently  lay  before  my 
reader. 

But  first,  for  the  sake  of  clearness,  it 
will  be  well  to  define  the  actual  state  ot 
our  knowledge  as  to  the  intimate  nature 
of  gout ;  and  this  I  think  cannot  be 
better  expressed  than  in  the  following 
propositions,  wherein  Dr.  Holland  has 
comprised  all  that  is  ascertained,  or  to 
be  strongly  presumed  on  the  subject : — 

1.  “That  there  is  some  part  of 
bodily  organisation  disposing  to  gout, 
because  it  is  an  hereditary  disease. 

2.  “That  there  is  a  matemes  morbi , 
whatever  its  nature,  capable  of  accumu¬ 
lation  in  the  system,  of  change  of  place 
within  the  body,  and  of  removal  from 
it. 

3.  “  That  though  identity  be  not 
hitherto  proved,  there  is  a  presumable 


relation  between  the  lithic  acid  or  its 
compounds,  and  the  matter  of  gout ; 
and  a  connection  through  this  with 
other  forms  of  the  calculous  diathesis. 

4.  “  That  the  accumulation  of  this 
matter  of  the  disease  may  be  presumed 
to  be  in  the  blood ;  and  its  retrocession 
or  change  of  place,  when  occurring, 
to  be  effected  through  the  same  me¬ 
dium. 

5.  “  That  an  attack  of  gout,  so 
called,  consists  in,  or  tends  to  produce, 
the  removal  of  this  matter  from  the 
circulation,  either  by  deposition  in  the 
parts  affected,  by  the  excretions,  or  in 
some  other  less  obvious  way,  through, 
the  train  of  actions  forming  the  pa¬ 
roxysm  of  the  disorder. 

6.  “  That  there  is  an  intimate  rela¬ 
tion  between  the  condition  of  gouty 
habit  and  the  functions  of  the  kidneys 
and  liver,  both  in  health  and  disease. 

7.  “  And  that  the  same  state  of  habit 
or  predisposition  which  in  some  persons 
produces  the  outward  attack  of  gout, 
does  in  others,  and  particularly  in  fe¬ 
males,  testify  itself  solely  by  disorder 
of  internal  parts,  and  especially  of  the 
digestive  organs.”* 

The  opinion  that  hereditary  predis¬ 
position  to  gout  consists  solely  in  a 
peculiar  character  of  the  ligamentous 
and  other  associated  textures,  is  surely 
untenable,  although  it  has  been  advo¬ 
cated  by  some  authors  of  eminence. 
The  disease,  however  prone  to  affect 
the  joints  chiefly,  is  incident  likewise 
to  all  the  other  fibrous  textures  of  the 
body  without  exception.  The  consti- 
stutional  disturbance  that  precedes  its 
attacks, — the  many  functional  aberra¬ 
tions  of  the  assimilating,  secretory,  and 
excretory  organs  by  which  it  is  accom¬ 
panied,— its  erratic  character,  and  the 
rapidity  of  its  transitions  from  one 
part  to  another, — are  facts  tending 
most  strongly  to  the  conclusion  that 
the  immediate  cause  of  the  malady  is 
not  local,  but  general,  and  that  the 
vehicle  of  its  diffusion  over  the  whole 
system  can  be  nothing  else  than  the 
circulating  fluids. 

Furthermore,  did  we  suppose  that 
hereditary  transmission  of  gout  is  iden¬ 
tified  with  a  peculiar  condition  of  those 
solids  which  are  the  most  frequent  seat 
of  gouty  inflammation,  its  active  deve¬ 
lopment  would  then  have  to  be  ac- 


*  Medical  Notes  and  Reflections,  by  Henry 
Holland,  M.D.,  p.  116. 


AND  ITS  RATIONAL  TREATMENT. 


281 


counted  for  in  one  or  other  of  the  two 
following  ways: — Either  the  trans¬ 
mitted  peculiarity  in  question  is  an 
actual  materies  morbi  deposited  in  the 
vitiated  textures,  or  it  is  such  a  struc¬ 
tural  peculiarity  of  the  latter  as  renders 
them  especially  liable  to  the  noxious 
influence  of  a  morbid  principle  pro¬ 
duced  in  the  body  by  other  causes. 
Either  hypothesis  leads  to  the  conclu¬ 
sion  that  gout  is  a  blood  disease.  The 
second  of  the  two  does  this  directly 
and  immediately,  for  it  assumes  the 
independent  existence  of  an  exciting 
cause,  to  be  brought  in  contact  with 
the  morbidly  predisposed  parts  through 
the  medium  of  the  circulation  ;  whilst, 
on  the  first  hypothesis,  it  is  evident 
that  the  transmitted  materies  morbi 
must  be  taken  up  into  the  blood,  con¬ 
taminating  its  mass,  and  producing  in 
it  effects  analogous  to  those  caused  by 
other  animal  poisons  imbibed  from 
without. 

But  there  is  another  class  of  solids, 
namely,  those  concerned  in  the  func¬ 
tions  of  organic  life,  which  have  para¬ 
mount  claims  to  attention  in  every 
inquiry  like  the  present.  It  is  evident 
that  any  inherent  vice  in  one  or  other 
of  the  great  chylopoietic  viscera,  must 
of  necessity  induce  a  proportional  de¬ 
pravity  in  the  circulating  fluids.  Rea¬ 
soning,  then,  a  priori,  there  is  nothing 
unwarrantable  in  the  conjecture  that 
the  real  fans  malorum  transmitted  by 
the  gouty  to  their  offspring  is  an 
unwholesome  blood-making  apparatus. 
Such  a  conjecture,  I  repeat,  is  by  no 
means  improbable,  and  my  own  obser¬ 
vations  and  reflections  are  all  in  favour 
of  its  positive  truth. 

On  the  whole,  then,  we  may  safely 
admit  that  hereditary  gout  is  a  dispo¬ 
sition  to  generate  a  certain  morbid 
matter  within  the  body,  whether  that 
disposition  be  the  effect  of  some 
abnormal  organic  condition,  promoting 
its  formation  or  impeding  its  due  ex¬ 
cretion,  or  of  some  transmitted  impurity 
of  blood,  which  tends,  as  usual  in  such 
cases,  to  reproduce  and  continue  itself 
by  vitiating  the  nutritive  functions. 

The  same  disposition,  but  created 
by  other  causes,  must  obviously 
exist  in  those  cases  in  which  gout 
occurs  as  an  idiopathic  disease. 
Its  individual  or  ancestral  origin 
is  a  circumstance  which  may  in¬ 
fluence  the  intensity  of  its  develop¬ 
ment  and  its  pertinacity  in  the  system, 


but  in  no  way  affects  its  intrinsic 
nature.  Whether  hereditary  or  not,  it 
presents  the  same  general  characteris¬ 
tics,  and  is  of  course  attributable  to  the 
same  material  agent. 

Setting  out,  then,  from  this  cardinal 
principle  of  a  materies  morbi  circu¬ 
lating  with  the  blood,  we  have  next  to 
investigate  its  nature  and  its  origin. 
And  here  we  are  struck,  on  the  very 
threshold  of  the  inquiry,  by  the 
close  affinity  between  the  gouty  and 
the  lithic  acid  diathesis  —  an  affinity 
so  remarkable  that  a  very  general  dis¬ 
position  prevails  among  medical  writers 
to  consider  lithic  acid  as  the  true  gouty 
poison,  and  to  impute  its  presence  in 
the  system  to  the  impaired  action  of 
the  kidneys. 

As  to  this  latter  notion,  the  argu¬ 
ments  adduced  in  support  of  it  appear 
to  me  to  be  based  on  a  singular  mis¬ 
apprehension  of  patent  facts.  The 
discharge  of  lithic  acid  and  its  salts  in 
the  urine  is  a  salutary  process ;  and 
while  the  kidneys  are  actively  perform¬ 
ing  such  a  process,  it  is  strange,  in¬ 
deed,  to  charge  them  with  creating  the 
offensive  matter  they  only  serve  to 
remove.  It  is  not  from  the  presence 
of  lithic  acid  sediments  in  the  urine  of 
the  gouty,  but  from  their  absence,  that 
we  should  be  warranted  in  ascribing  to 
defective  action  of  the  kidneys  the 
accumulation  of  that  excrementitious 
matter  in  the  system.  If  the  blood 
was  manifestly  surcharged  with  lithic 
salts  or  their  equivalents,  while  none 
such  escaped  in  the  urine,  then,  in¬ 
deed,  we  should  have  reached  the  end 
of  our  inquiry  in  full  assurance  that 
the  kidneys  were  the  very  matrices  of 
gout.  But  it  is  not  so  in  reality  ;  and 
the  most  we  can  venture  to  assert  is, 
that  the  renal  functions,  in  common 
with  others,  are  secondarily  affected 
by  the  cause,  whatever  it  be,  of  the 
gouty  diathesis. 

I  think  it  the  more  necessary  to  in¬ 
sist  on  this  point,  as  it  is  one  on  which 
so  acute  and  lucid  a  reasoner  as  Dr. 
Holland  appears  to  have  fallen  into 
error.  “The  kidneys,”  he  says,  “are 
evidently  the  organs  of  the  body  upon 
the  disordered  or  deficient  action  of 
which  depend  those  changes  in  the 
circulating  fluids  which  have  the 
closest  relation  to  all  the  phenomena 
of  gout.”  He  would,  I  think,  have 
been  nearer  the  truth  if  he  had  said 
that  the  kidneys  are,  of  all  organs, 


282 


DR.  WHITE  ON  THE  PROXIMATE  CAUSE'  OF  GOUT 


those  whose  secretions  afford  the  most 
faithful  and  the  most  readily  discerni¬ 
ble  evidence  of  the  changes  aforesaid. 

However  intimate  the  connection 
between  the  gouty  and  the  lithic  acid 
diathesis,  evidence  is  yet  wanting  to 
establish  their  actual  identity.  If  the 
materies  morbi  we  are  in  search  of  was 
nothing  else  than  lithic  acid,  we  should 
naturally  expect  to  find  every  con¬ 
siderable  development  of  that  product 
followed  by  a  gouty  paroxysm.  But 
this  is  notoriously  not  the  case.  It  is 
no  uncommon  thing  to  find  the  urine 
constantly  loaded,  during  a  long  period, 
with  lithic  acid  sediments,  without  the 
occurrence  of  a  single  gouty  symptom ; 
while  on  the  other  hand,  it  is  known 
that  the  gouty  paroxysm  sometimes 
occurs  without  the  existence  of  an  ex¬ 
cess  of  lithic  acid  in  the  urine.  In¬ 
stances  of  this  kind,  occurring  in  asthe¬ 
nic  forms  of  the  disease,  have  been 
mentioned  by  Dr.  Todd  in  the  Croonian 
Lectures  for  the  year  1843  : — “  I  have 
remarked,”  he  says,  “a  peculiarity  be¬ 
longing  to  most  of  the  cases  of  this 
kind  that  I  have  met  with — namely, 
that  the  urine  .does  not  exhibit  the 
abundant  precipitate  of  lithates  which 
so  often  accompanies  the  gouty  parox¬ 
ysm.  In  some  instances  there  was  no 
precipitate  at  all ;  and  in  others  it  was 
very  slight.  And  the  specific  gravity 
of  the  urine  was  rather  below  than 
above  the  ordinary  standard,  indicating 
that  no  excessive  quantity  of  either 
ureaor  lithic  acid  was  held  in  solution.” 

The  gouty  poison,  then,  is  not  iden¬ 
tical  with  lithic  acid,  but  is  so  near 
akin  to  it  that  the  chemical  and  patho¬ 
logical  characteristics  of  the  latter  may 
probably  yet  serve  as  indices  to  guide 
us  to  the  discovery  of  the  former. 

“Organic  chemistry,”  says  Dr.  Hol¬ 
land,  “  has  taught  us  how  readily  the 
elements  out  of  which  all  animal 
matter  is  formed  are  displaced  from 
one  combination  and  enter  into  others; 
and  how  very  slight,  frequently,  are  the 
differences,  indicated  by  analysis,  be¬ 
tween  substances  eminently  noxious  to 
the  system,  and  those  indifferent  or 
beneficial  to  it.  We  owe,  further,  to 
recent  experiments  the  explicit  proof 
of  what  simple  observation  had  partly 
shewn  before— the  remarkable  effect 
upon  the  whole  mass  of  the  blood  of 
minute  quantities  of  certain  matters 
brought  into  the  circulation, — leading 
to  the  inference  of  analogous  effects 


from  an  increased  proportion  of  one  or 
other  of  its  principles  accumulating  or 
being  unduly  retained  in  the  body.  *  * 
These  circumstances,  now  familiar  to 
us,  do  certainly  not  identify  the  mate¬ 
rial  cause  of  gout  with  any  of  the  ani¬ 
mal  excretions  just  named  [lithic  acid, 
urea,  the  lithic  or  purpuric  salts,  &c.]  ; 
but  they  tend  to  concentrate  our  views 
towards  them,  and  give  a  much  more 
specific  direction  to  future  research. 
The  assured  connexion  of  the  gouty 
with  the  calculous  diathesis,  —  the 
chemical  nature  of  the  concretions  and 
deposits  in  the  former, — and  the  evi¬ 
dence  that  these  deposits  often  become 
in  part  a  substitute  for  the  more  active 
forms  of  the  disease :  all  concur  in 
further  sanctioning  the  same  gene¬ 
ral  view.  If  we  cannot  affirm  that  urea, 
the  lithic  acid,  or  other  animal  com¬ 
pounds  circulating  in  the  blood,  give 
cause  to  the  phenomena  of  gout,  under 
the  most  cautious  reasoning  we  are  at 
least  entitled  to  assume,  with  some 
confidence,  that  these  matters  secreted 
from  the  kidneys  are  the  equivalents  to 
gouty  matter  present  in  the  system, — 
that  they  have  certain  proportion  of 
quantity  to  each  other, — and  that  upon 
their  balance  depend  all  the  essential 
characters  of  the  disease, — its  modi¬ 
fications  being  determined  by  various 
causes:  some  of  them  topical,  some 
belonging  to  general  functions  impli¬ 
cated  in  the  effects  of  this  common 
cause.” 

I  particularly  invite  the  reader’s 
attention  to  the  words  above  printed  in 
italics.  They  imply  that  the  morbid 
development  of  lithic  acid  and  its  salts 
may  be  due  to  the  presence  of  some 
principle,  altogether  unlike  them  in 
sensible  properties  and  chemical  com¬ 
position. 

And  now  we  may  proceed  to  deal 
with  the  special  object  of  this  paper, 
which  aims  at  determining  the  primary 
seat,  and  the  essential  nature,  of  the 
disease  in  question.  To  this  end  I 
shall  succinctly  narrate  the  course  of 
induction  whereby  I  arrived  at  those 
views  which  I  desire  to  recommend 
to  the  candid  examination  of  my  pro¬ 
fessional  brethren. 

Having  endured  innumerable  visi¬ 
tations  of  gout,  and  having  had  recourse 
to  a  variety  of  medicaments,  some  of 
which  were  fearfully  destructive  to  mv 
general  health,  I  at  last  set  about 
watching  attentively  the  method  which 


AND  ITS  RATIONAL  TREATMENT. 


283 


nature  herself  adopts  for  the  cure  of 
this  disease.  Thus  it  frequently  hap¬ 
pened,  during  my  forty  years’  conflict 
with  my  hereditary  malady,  that  I 
submitted  to  the  old  plan,  of  patience 
and  flannel,  leaving  the  disorder  to  run 
its  course  and  wear  itself  out  by  its 
own  violence.  On  several  of  these 
occasions  I  was  attacked  with  sickness 
and  vomiting,  accompanied  by  acrid 
bilious  discharges  from  the  bowels ; 
and  these  evacuations  were  followed 
by  immediate  relief  as  to  every  local 
and  constitutional  symptom.  Some¬ 
times  the  result  w’asan  entire  cessation 
of  the  paroxysm  :  at  other  times  the 
alleviation  was  more  partial ;  but  re¬ 
peated  experience  convinced  me  that 
the  degree  of  relief  obtained  was 
always  proportioned  to  the  copiousness 
of  the  bilious  evacuations.  Pursuing 
this  hint  given  me  by  nature,  when 
the  spontaneous  diarrhoea  has  been  too 
scanty  I  have  assisted  it  with  five 
grains  of  calomel.  These  in  a  few 
hours  produced  copious  bilious  dis¬ 
charges  :  the  gout  departed,  and  I  was 
well  again. 

The  conclusion  forced  upon  my  mind 
by  these  facts,  recurring  again  and 
again  during  a  period  of  so  many  years, 
is,  that  not  to  the  stomach,  or  the  kid¬ 
neys,  or  to  the  impaired  functions  of 
any  other  viscus  than  the  liver,  is  the 
cause  of  gout  ascribable. 

In  corroboration  of  this  view  I  may 
appeal  to  the  character  of  all  those 
medicaments  which  at  various  times 
have  been  held  in  estimation  as  spe¬ 
cifics  against  gout.  One  property  is 
common  to  them  all — namely,  that 
of  strongly  stimulating  the  hepatic 
functions.  The  eau  medicinale ,  which 
was  introduced  into  this  country  about 
twenty  years  ago  from  France,  ivas  a 
remedy  of  this  class.  It  was  sold  in 
one-drachm  bottles  (this  was  the  dose), 
and  its  effects  were  certainly  very  re¬ 
markable:  frequently  removing  the 
most  painful  attacks  of  gout  in  one 
night.  The  composition  of  this  potent 
nostrum  long  remained  a  secret :  it  was 
conjectured  to  contain  white  hellebore; 
and  I  recollect  the  physicians  of  the 
Westminster  Hospital  prescribing  a 
vinous  infusion  of  the  latter,  in  one- 
drachm  doses,  with  great  success,  as  a 
substitute  for  the  eau  medicinale.  The 
revived  use  of  colchicum  or  meadow 
saffron,  which  I  believe  to  be  the  essen¬ 
tial  ingredient  in  the  eau  medicinale, 


has  put  us  into  possession  of  an  in¬ 
valuable  antidote  to  gout ; — but  how 
does  this  colchicum  act  beneficially  ? 
Assuredly  not  on  the  stomach,  which 
it  nauseates, — assuredly  not  on  the 
heart  or  circulation,  which  it  distresses: 
but  it  acts  on  the  secretions  of  the 
liver ;  and  long  personal  experience 
has  taught  me  that  until  the  functions 
of  that  organ  are  called  into  vigorous 
play,  the  colchicum  is  worse  than, 
useless. 

Latterly  it  has  been  my  practice  to 
use  colchicum  in  combination  with 
other  medicines  :  when  I  was  in  the 
habit  of  taking  it  singly,  my  dose  was 
generally  about  sixty  drops  of  the  wine 
of  the  seeds,  repeated  every  six  hours. 
After  three  or  four  such  doses  the 
bowels  were  acted  on  ;  the  evacuations 
had  the  odour  of  the  colchicum  ;  deeply 
tinted,  scalding  bile  wras  passed,  and 
I  was  wTell,  for  I  needed  no  more. 

Now,  if  a  spontaneous  evacuation  of 
bile  operates  critically  to  the  relief  of 
the  gouty  paroxysm;  if  five  grains  of 
calomel  produce  relief;  if  just  so  much 
colchicum  or  other  medicine  produces 
relief  as  is  sufficient  to  cause  a  copious 
discharge  of  bile,  then  is  it  demon¬ 
strated  that  the  diminished  or  altered 
state  of  the  hepatic  secretion,  which  is 
always  a  concomitant  of  gout,  is  not  to 
be  classed  among  the  secondary  pheno¬ 
mena  of  that  disease,  as  pathologists 
have  hitherto  invariably  supposed. 

Let  A  and  B  be  any  two  phenomena 
whatever  ;  and  suppose  that  B  is  never 
found  except  in  company  with  A,  then 
will  there  be  reason  for  concluding 
either  that  one  of  the  two  is  the  cause 
of  the  other,  A  of  B,  or  B  of  A,  or  else 
that  both  are  parallel  effects  of  some 
third  principle.  But  suppose  it  be 
found  that,  whereas  B  never  presents 
itself  unaccompanied  by  A,  yet  A  may 
exist  without  B,  and  that  when  both 
are  present,  the  removal  of  the  former 
is  invariably  followed  by  the  disappear¬ 
ance  of  the  latter,  then  it  will  be  mani¬ 
fest  that  A  is  the  cause  of  B. 

The  correctness  of  this  abstract  rea¬ 
soning  will,  I  presume,  be  admitted 
without  question.  To  apply  it  to  the 
subject  of  our  present  inquiry,  we  have 
only  to  substitute  for  A  and  B,  the 
phrases  “  impaired  functions  of  the 
liver,”  and  “  paroxysm  of  gout.” 

No  writer  that  I  am  aware  of  has 
ever  propounded,  or  even  surmised,  the 
doctrine  that  the  proximate  cause  of 


284 


DR.  WHITE  ON  THE  PROXIMATE  CAUSE  OF  GOUT. 


gout  is  a  functional  disorder  of  the 
liver;  and  I  cannot  overcome  the 
astonishment  that  possesses  me  when 
I  think  that  it  should  have  been  re¬ 
served  for  me  to  make  such  a  discovery. 
The  principle,  when  once  divulged, 
appears  so  plain  and  obvious,  that  it  is 
wonderful  it  should  have  been  over¬ 
looked  so  long.  Such  has  been  the 
feeling  expressed  by  several  of  my 
professional  brethren  to  whom  I  have 
communicated  my  views.  Seldom 
have  my  conclusions  failed  in  such  in¬ 
stances  to  receive  a  prompt  and  full 
assent,  and  to  elicit  from  each  of  my 
hearers  the  exclamation,  “  How  is  it 
possible  I  never  thought  of  that  be¬ 
fore  ?”  But  the  history  of  science  is 
full  of  examples,  showing  how  in¬ 
quirers  have  for  ages  been  shut  out  by 
the  filmiest  barriers  from  the  acquisi¬ 
tion  ot  precious  truths. 

The  derangement  of  the  liver  which 
always  accompanies  the  gouty  pa¬ 
roxysm,  and  manifests  itself  by  unequi¬ 
vocal  signs,  such,  for  instance,  as  the 
pale  colour  of  the  faeces,  is  too  obvious 
to  have  escaped  notice.  Accordingly, 
writers  on  the  disease  have  constantly 
adverted,  more  or  less  prominently,  to 
this  pathological  fact ;  but  they  have 
all  failed  to  assign  to  it  the  position  it 
really  occupies  in  the  train  of  symp¬ 
toms.  The  tendency  of  their  specula¬ 
tions  has  generally  been  to  consider 
the  disorder  of  the  liver  as  consequent 
upon  that  of  the  stomach,  whereas  the 
converse  doctrine  is  far  more  conso¬ 
nant  with  observation  and  with  phy¬ 
siological  principles.  Acidity  in  the 
stomach  is  an  unfailing  element  in  the 
gouty  diathesis.  Now  such  a  condi¬ 
tion  of  that  organ  may,  undoubtedly, 
react  on  the  liver,  and  impede  or  vitiate 
its  secretions.  On  the  other,  we  know 
that  a  very  important  office  performed 
by  bile  is  the  neutralization  of  the  free 
acid,  which  is  always  developed  in  the 
stomach  during  healthy  digestion,  and 
is,  therefore,  a  constant  ingredient  in 
chyme;  only  assuming  a  morbid  cha¬ 
racter  when  it  is  excessive  or  otherwise 
abnormal.  Hence,  given  two  coexist¬ 
ing  facts— acidity  of  stomach,  and  de¬ 
ficiency  or  faulty  composition  of  bile- — 
it  will  be  natural  to  surmise  that  the 
former  is  the  effect  of  the  latter,  and 
nothing  less  than  specific  proof  could 
justify  our  adoption  of  the  opposite 
conclusion. 

It  is  a  fact  of  great  importance  to 


the  decision  of  this  question,  that,  how¬ 
ever  the  administration  of  antacid  me¬ 
dicines  may  alleviate  the  heartburn 
and  the  other  distressing  effects  of 
acidity  in  the  primse  vise, such  remedies 
never  rise  above  the  rank  of  palliatives 
in  the  treatment  of  gout.  They  have 
not  the  least  efficacy  in  restoring  the 
healthy  action  of  the  liver ;  whilst,  on 
the  other  hand,  whatever  accomplishes 
that  object  never  fails  to  remove  every 
other  dyspeptic  symptom  likewise. 

The  liver,  then,  is  the  officina  in 
which  is  elaborated  the  materies  morbi 
on  which  the  whole  train  of  gouty 
symptoms  are  dependent.  What  may 
be  the  precise  nature  of  that  poison  I 
do  not  pretend  to  determine.  That 
remains  an  interesting  subject  for 
future  inquiry,  to  which  I  may  venture 
to  hope  that  1  have  given  a  fresh  im¬ 
pulse  and  an  increased  prospect  of 
success,  by  defining  its  proper  point  of 
departure,  and  the  direction  it  should, 
take.  The  one  new  leading  fact  which 
I  affirm  as  demonstrated,  is  sufficient 
to  indicate  very  distinctly  the  mode  of 
treatment  which  offers  the  only  rational 
hope  of  removing  the  gouty  diathesis, 
and  also  to  explain  the  success  which 
has  partially  attended  the  various 
empirical  methods  which  have  been 
adopted  for  the  cure  of  the  disease. 

The  main  object  to  be  pursued  to¬ 
wards  the  effectual  cure  of  the  gouty 
paroxysm,  by  the  removal  of  its  im¬ 
mediate  cause,  is  the  restoration  of  the 
natural  functions  of  the  liver,  as  indi¬ 
cated  by  a  copious  discharge  of  bile 
through  the  bowels.  This  object  may 
be  attained,  more  or  less  promptly  and 
sufficiently,  by  the  administration, 
either  of  calomel  or  colchicum,  or  of 
some  other  potent  deobstruent  of  the 
hepatic  system.  But  here,  as  in  other 
instances  familiar  to  the  minds  of  my 
readers,  the  principle  of  combining 
analogous  remedies  will  be  found  strik¬ 
ingly  advantageous.  My  own  practice 
has  long  been  to  rely  exclusively  for 
the  cure  of  gout  on  the  following  pre¬ 
scription  : — IjL  Hydr.  Chlorid.  Ext. 
Colchici  Acet.  Ext.  Aloes  purificati  aa. 
gr.  j. ;  Pulv.  Ipecac,  gr.  ii.  M.  et  fiat 
pilula  quartis  horis  sumenda. 

Two  or  three  of  such  pills  are  gene¬ 
rally  enough  to  produce  a  considerable 
disgorgement  of  the  liver,  which  I 
then  assist  with  one  or  two  doses  of 
the  compound  decoction  of  aloes.  By 
this  time  the  gouty  paroxysm  has 


VIEWS  OF  REINHARDT  ON  THE  EXUDATION  CORPUSCLE. 


285 


either  ceased,  or  there  is  a  marked 
subsidence  of  all  its  distressing  symp¬ 
toms.  The  pills  may  then  be  adminis¬ 
tered  at  longer  intervals,  varying  from 
eight  to  twenty-four  hours,  according 
to  circumstances. 

The  treatment  I  have  above  de¬ 
scribed  possesses  the  cardinal  and  pa¬ 
ramount  requisite  of  being  effectual  to 
the  end  proposed.  In  addition  to  this, 
it  is  important  to  know  that  the  com¬ 
bination  of  calomel  and  aloes  with  col- 
chicum,  while  quickening  and  corrobo¬ 
rating  the  specific  action  of  the  latter  on 
the  liver,  seems  also  to  neutralise  all 
the  noxious  properties  of  that  hitherto 
formidable  medicine. 

In  conclusion,  I  repeat,  that  what  is 
called  a  fit  of  gout,  is  only  a  peculiar 
manifestation  of  a  functional  disorder 
of  the  liver;  and  that  whatever  brings 
about  a  free  evacuation  of  bile  puts  an 
an  end  to  the  gouty  paroxysm. 

Parliament  Street,  Aug.  5,  1848. 


ANTICIPATION  OF  THE 

VIEWS  OF  REINHARDT 

ON  THE 

EXUDATION  CORPUSCLE, 

TOGETHER  WITH  SOME  PRELIMINARY  OB¬ 
SERVATIONS  ON 

EXUDATION  AND  THE  ELEMENTARY 
FORMS  of  MORBID  PRODUCTS. 

By  Andrew  Clark,  M.D. 

Assistant-Surgeon  in  the  Royal  Navy;  of  the 
Pathological  Department  of  the  Royal  Hospital 
at  Haslar,  &c. ;  formerly  Chief  Assistant  in  the 
Pathological  Theatre  of  the  Edinburgh  Royal 
Infirmary. 

Part  First  :  Prolegomena. 

Previous  to  the  introduction  of  the  mi¬ 
croscope  into  pathological  research,  the 
sensible  results  of  inflammation, — the 
physical  manifestations  of  its  presence, 
• — the  conditions  of  their  development, 
• — and  their  relations  to  each  other, 
were  but  imperfectly  known  and  un¬ 
derstood.  The  employment  of  that  in¬ 
strument  enabled  pathologists  to  deter¬ 
mine,  with  more  or  less  accuracy,  the 
conditions  under  w'hich  inflammation 
occurred,  and  to  describe  with  exacti¬ 
tude  the  organic  forms  assumed  by,  or 
developed  in  the  exudation  considered 
to  be  one,  and  the  principal  one,  of  its 
purely  physical  results.  Microscopic 
investigation  further  proved  that  exu¬ 


dation ,  though  an  ordinary  concomitant 
or  effect  of  the  morbid  conditions 
understood  by  the  term  inflammation, 
occurred  likewise  under  other  condi¬ 
tions  essentially  different  from  those 
with  which  that  term  is  customarily  as¬ 
sociated  :  it  induced  pathologists  to 
question  the  integrity  of  this  indefinite 
term — to  examine  more  narrowly  the 
conditions  essential  to  the  perform¬ 
ance  of  healthy  nutrition — and  to  con¬ 
sider  the  exudation  of  a  fluid  plasma  as 
the  great  starting  point  of  their  in¬ 
vestigations  into  the  nature  and  struc¬ 
tural  relations  of  morbid  products. 

Now7,  though  in  point  of  detail  these 
views  and  discoveries  have  increased, 
our  knowledge,  in  point  of  theory  they 
have  failed  to  remove  that  obscurity  in 
which  the  subject  is  still  involved. 
They  exhibit  to  us  the  fact  that  certain 
conditions  of  an  organ  are  followed  by 
a  fluid  interstitial  exudation,  w7hich, 
under  one  set  of  circumstances,  is  said 
to  develop  fibrous,  under  another  cellu¬ 
lar  forms ;  but  they  fail  to  exhibit  the 
nature  and  relations  of  these  conditions 
to  their  apparent  effects, — they  throw 
little  or  no  light  on  the  ultimate  cause 
of  this  process,  and  leave  the  primal 
question  of  development  unexplained. 

I  do  not  here  refer  to  the  discovery 
of  any  supposititious  unital  cause  of  that 
series  of  morbid  states  understood  by 
the  term  inflammation,  or  of  other  mor¬ 
bid  states  essential  or  accidental  ante¬ 
cedents  of  exudation.  I  do  not  believe 
that  for  this  or  any  other  series  of 
organic  phenomena  one  cause  can  be 
assigned  :  since  progressive  experience 
confirms  us  in  the  belief  that  there  is 
no  single  event  in  the  economy  of 
nature,  but  what  is  accompanied  by  a 
plurality  of  conditions,  or  dependent  on 
a  plurality  of  causes  essential  to  its 
development.  Moreover,  the  know¬ 
ledge  of  causes,  in  the  stricter  accepta¬ 
tion  of  the  term,  is,  we  fear,  too  ab¬ 
stract  and  profound  for  the  compre¬ 
hension  of  our  still  narrow7  and  fettered 
minds.*  We  must  admit,  indeed,  that 
to  know  the  conditions  necessary  for 
the  development  of  any  phenomenon, 
and  the  links  by  which  isolated  pheno¬ 
mena  may  be  associated  into  general 
laws, — to  be  able  to  foretel  with  certainty 
the  occurrence  of  any  event  from  the 
presence  of  circumstances  which  ordi- 

*  I  refer  here  to  the  present  as  one  of  other 
transitory  phases  of  man’s  psychological  develop¬ 
ment. 


286 


DR.  CLARK  ON  THE  EXUDATION  AND  ELEMENTARY 


narily  accompany  it,  and  arbitrarily  to 
produce  these  events  by  correlation  of 
the  circumstances  under  which  they 
are  developed, — to  be  able  to  infer  from 
truths  known,  truths  analogous  but  un¬ 
known,  and  safely  to  employ  these 
in  the  ultimate  construction  of  hypo¬ 
thesis  or  theory,  will  conjointly  afford 
us  as  much  insight  as  we  may  ever  hope 
to  obtain  into  the  intimate  nature  of 
vitality,  and  the  modifications  of  its 
sensible  manifestations.  But  even  were 
it  otherwise — were  there  no  such  limits 
to  our  knowledge, — the  mode  of  the 
operation  of  the  causes  of  disease, — the 
determination  of  the  nature  of  morbid 
actions,— and  the  genesis  or  evolution 
of  morbid  products,  constitute  pro¬ 
blems,  each  of  which  is  surrounded  by 
too  much  obscurity,  and  dependent  on 
too  many  complex  conditions,  to  be  dis¬ 
cussed  in  abstract  at  a  time  when  the 
light  of  truth  is  shining  with  just  suffi¬ 
cient  brilliancy  to  show  us  the  dark  and 
shadowy  outlines  of  what  we  have  still 
to  learn. 

Reverting  now  to  the  more  peculiar 
subject  of  these  observations,  and  waiv¬ 
ing  for  the  present  the  term  inflamma¬ 
tion ,  I  have  said  that  the  microscope 
has  enabled  us  to  determine  with  more 
or  less  accuracy  the  conditions  under 
which  abnormal  nutrition  occurs,  and 
to  describe  with  exactitude  the  organic 
forms  said  to  be  assumed  by,  or 
developed  in  the  exudation  considered 
to  be  its  chief  physical  result.  To  the 
conditions  of  this  process  of  exudation, 
however,  I  shall  not  now  refer,  and  to 
its  sensible  results  I  shall  advert  only 
in  so  far  as  they  may  be  found  to  bear 
on  the  subject  under  consideration. 

The  essential  condition  of  nutrition 
is  the  constant  transudation  through 
the  coats  of  the  capillaries  of  a  healthy 
liquor  sanguinis  (plasma),  and  its  ab¬ 
sorption  and  assimilation  by  the  adja¬ 
cent  tissues.  In  the  regular  perform¬ 
ance  of  this  function  there  is  no  over¬ 
plus — no  waste  of  material,  and  only 
so  much  plasma  is  exuded  as  is  capa¬ 
ble  of  being  assimilated  and  absorbed. 
In  the  healthy  liquor  sanguinis  there 
is  the  susceptibility  of  being  acted 
upon  (potentiality);  in  the  cells  or  per¬ 
sistent  nuclei  of  adjacent  textures,  the 
power  of  acting  upon  the  exuded 
plasma  (transition) ;  and  between  both 
a  delicately  balanced  relation,  which, 
in  its  continuance,  gives  development 
to  the  negative  condition — health  (nu¬ 


trition).  When  exuded  in  too  great 
quantity,  or  when,  the  quantity  being 
normal,  the  tissue  to  be  nourished  is 
incapable  of  fulfilling  the  function  of 
absorption,  the  plasma  collects,  is  in¬ 
filtrated  through  the  histological  ele¬ 
ments  of  the  part,  where,  becoming  the 
source  of  new  formations  ( pathological 
epiyetieses),  it  is  denominated  a  blas¬ 
tema.  This  blastema  is  originally 
fluid;  but  under  the  first  impetus  to 
development,  it  becomes  more  or  less 
solid,  and  either  concretes  bv  direct 
solidification  into  an  imperfect  fibrous 
tissue,  or  gives  development,  it  is  said, 
to  various  forms  of  cells.  The  fibril- 
lated  products  of  the  blastema  gene¬ 
rally  retain  their  primal  form  ;  but  the 
cellular  may  either  remain  in  that 
condition  or  attain  a  higher  phase  of 
existence  by  becoming  developed  into- 
elementary  textures.  Under  either  or 
all  of  these  conditions  there  is  a  fluid 
residuum  (serum),  which,  if  not  re¬ 
moved  by  the  absorbents,  collects  in 
cavities,  forming  dropsies  or  cysts,  or 
is  infiltrated  through  adjacent  tissues, 
producing  mdema. 

The  various  organic  forms  supposed 
to  arise  in  blastemata,  and  consi¬ 
dered  to  be  the  unequivocal  products 
of  exudation, — in  other  words,  the  ele¬ 
mentary  forms  of  morbid  structures, 
— have  been  already  accurately  de¬ 
scribed,*  and  are  now  pretty  generally 
known.  Admitting,  for  the  present , 

the  correctness  of  that  view  which 

considers  the  elementary  forms  of 
morbid  products  to  be  the  direct  results 
of  exudation,  they  may  be  judiciously 
considered  under  three  heads,  each  of 
which  will  represent  in  itself  the  type 
of  a  distinct  phase  of  organic  develop¬ 
ment,  thus  :  — 

Granular  products  of  exudation. 

Fibrous  „  ,, 

Cellular  „  ,, 

Without  reference  to  the  theory  of 
the  origin  of  these  elementary  forms,. 

I  have  been  accustomed,  in  my  lec¬ 
tures,  to  subdivide  these  heads  or 
genera  into  certain  species  and  varie¬ 
ties  of  the  primary  arrangement,  of 
which  the  following  table  will  afford  a 
rough  illustration : — 


*  I  mean  tlieir  physical  characters,  exclusive 
of  their  chemical  composition  and  morphological 
relations. 


FORMS  OF  MORBID  PRODUCTS. 


287 


*1.  Granular  products  of  exudation. 

1st  phase  of  development: — 

1.  Elementary  molecules. 

2.  Granules  of  evolution — plastic 
granules. 

3.  Granules  of  disintegration  — 
aplastic  granules. 

4.  Fatty  granules. 

5.  Earthy  granules. 

2.  Fibrous  products  of  exudation. 

2d  phase  of  development : — 

1.  Fibrillated  tissue. 

2.  Molecular  fibre. 

3.  Beaded  fibre. 

4.  Solid  fibre. 

5.  Nucleated  fibre. 

3.  Cellular  products  of  exudation. 

3d  phase  of  development : — 

1.  Corpuscle  of  evolution. 

2.  Pyoid  corpuscle  (Bennet  and 
Lebert). 

3.  Exudation  corpuscle. 

4.  Pus  corpuscle. 

5.  Tubercular  corpuscle. 

6.  Xanthoidy  corpuscle. 

7.  Cancerous  corpuscle. 

8.  Fluid  fat  globule. 

9.  Solid  striated  fat  globule. 

The  physical  characters  of  most  of 
the  products  just  enumerated  are  al¬ 
ready  accurately  known ;  but  their 
exact  mode  of  genesis  and  develop¬ 
ment  being  still  matter  of  dispute,  and 
their  morphological  relations  remain¬ 
ing  hitherto  unexplained,  the  mere 
determination  of  these  organic  forms, 
and  our  imperfect  acquaintance  with 
the  exact  chemical  and  vital  conditions 
of  exudation  as  a  modified  nutrition, 
fail  to  throw  any  decided  light  on  the 
nature  of  diseased  action.  Attention 
has  been  recently  directed,  therefore, 
to  the  composition  and  chemical  rela¬ 
tions  of  morbid  products ;  and  the 
results  of  this  new  method  of  inquiry 
promise  to  be  numerous,  novel,  and 
important.  Limited  as  these  results 
yet  necessarily  are,  they  tend,  among 
other  things,  to  show — 

1.  That  the  physical  characters  of 
blastemata,  wherever  their  seat,  and 


*  I  have  purposely  omitted  from  this  table  the 
following  forms  of  morbid  products  : — 

1.  Modifications  of  previously  existing  cells. 

2.  Common  and  plastic  serous  effusions. 

3.  Earthy  deposits  from  a  mother  liquid. 

4.  Animal  and  vegetable  parasites. 

t  I  give  this  name  to  a  cell  of  a  peculiar  struc¬ 
ture,  colour,  and  composition,  which  I  have  met 
with  in  tubercular  changes  of  the  bronchial 
glands,  liver,  lungs,  kidnev,  pancreas  (?)  and 
spleen. 


whatever  the  nature  of  their  products, 
are  almost  always  uniform. 

2.  That  the  difference  in  the  com¬ 
position  of  the  solid  products  of  blas¬ 
temata  is  due — 

a.  To  modified  conditions  (vital, 
chemical,  or  both)  of  the  circu¬ 
lating  plasma ; 

b.  To  the  influence  exerted  on 
blastemata  by  adjacent  living 
textures ; 

c.  To  chemical  changes  coincident 
with  the  act  of  development. 

3.  That  the  presence  of  fat  is  a  com¬ 
mon,  if  not  essential,  concomitant  of 
the  evolution  of  the  products  of  exuda¬ 
tion. 

4.  That  the  development  of  fat  in 
previously  existing  healthy  organisms 
\e.  y.  cellular  lining  of  the  tubuli 
uriniferi)  is  in  many  cases  the  only 
sensible  manifestation  of  the  presence 
and  persistence  of  diseased  action. 

5.  That  the  development  of  fat  is 
an  invariable  concomitant  of  the  retro- 
yressive  changes  exhibited  by  the 
products  of  exudation  and  other  or¬ 
ganic  forms. 

6.  That  the  development  of  the 
cellular  precedes,  in  point  of  time  and 
relation  to  the  exuding  surface,  the 
development  of  the  granular  or  fibrous 
products  of  exudation. 

Reflection  on  what  I  have  here  de¬ 
veloped  as  tendencies  of  modern  re¬ 
search,  and  on  the  typical  action  of 
nature  exhibited  in  the  manifestation 
of  ail  organic  phenomena,  led  me  about 
two  years  ago  to  investigate,  more 
systematically  than  I  had  previously 
done,  the  origin  and  morphological 
relations  of  the  elementary  forms  of 
morbid  products.  Through  the  kind¬ 
ness  of  Sir  William  Burnett*  I  have 
been  enabled  to  continue  these  re¬ 
searches  until  now.  To  their  special 
results,  however,  1  am  not  yet  prepared 
to  give  expression:  in  a  more  eligible 
form  I  may  be  enabled  shortly  to  sub¬ 
ject  them  to  the  judgement  of  my  pro¬ 
fessional  brethren.  Meanwhile,  I  may 
be  allowed  to  illustrate  generally  the 
conclusions  to  which  these  researches 
point.  Before  doing  so,  however,  it 
may  be  necessary  to  state  that  1  have 
been  led  to  enter  thus  prematurely  and 


*  I  feel  it  necessary  here  to  acknowledge,  for¬ 
mally,  the  many  facilities  which  our  Director- 
General  has  voluntarily  afforded  me  for  the  fur¬ 
therance  of  these  investigations. 


288  THE  PUBLIC  HEALTH  BILL  AND  ITS  OPPONENTS. 


generally  on  the  subject  by  the  perusal 
of  a  paper  of  Reinhardt’s  on  the  Exu¬ 
dation  Corpuscle,  first  published  in 
September  1847,  but  which  I  did  not 
have  the  opportunity  of  seeing  until  a 
fortnight  ago,  when  it  was  pointed  out 
to  me  by  a  friend.  The  views  developed 
in  that  paper  are  analogous  to  my  own, 
which,  in  point  of  publication,  have 
been  anticipated  by  that  histologist. 
The  views  there  developed  are  almost 
identical  with  those  which  I  have  en¬ 
tertained  for  the  last  two  years;  and 
which  I  first  promulgated  in  January 
1847,  in  a  series  of  lectures  delivered 
before  Sir  John  Richardson,  Drs.  An¬ 
derson,  Allan,  M‘Kechnie,  Stuart,  and 
others  of  the  medical  officers  of  this 
establishment.* 

From  one  of  these  lectures,  de¬ 
livered  on  the  second  Thursday  of 
January  1847,  the  following  passage  is 
extracted :  — 

“  We  see,  therefore,  that  this  body” 
[the  exudation  corpuscle]  “  is  a  com¬ 
mon  concomitant  of  normal  morpho¬ 
logical  developments  ;  that  it  occurs  as 
a  result  of  diseased  nutrition  indepen¬ 
dently  of  exudation ;  and  that,  in 
cellular  and  mucous  membranes,  its 
form  almost  always  corresponds  to  the 
normal  form  of  the  cells  of  the  part. 
From  these  facts,  and  from  the  con¬ 
siderations  previously  given,  we  are 
justified  in  stating  that  in  nine  cases 
out  of  ten  this  body  is  not  a  new  pro¬ 
duct  of  exudation,  but  a  modification 
merely  of  the  previously  existing 
healthy  cells  of  the  tissue  or  organ 
affected.” 

As  a  matter  of  personal  justice,  and 
in  compliance  with  the  wishes  of  my 
friends,  I  state  these  facts  now ;  but, 
waiving  any  further  discussion  of 
claims  to  priority  of  observation,  1 
shall  revert  generally  to  the  subject  of 
exudation,  and  particularly  to  the  histo¬ 
logical  characters  of  what  is  here 
termed  the  exudation  corpuscle,  in  my 
next  communication. 


*  Previous  to  the  delivery  of  the  lectures  here 
referred  to,  this  and  other  views  on  collateral 
subjects  were  detailed  privately  to  Inspector  Sir 
John  Richardson,  Deputy  Inspector  Dr.  Allan, 
and  Dr.  F.  J.  Brown  (Scholar  and  Medallist  of 
University  College,  now  of  H.M.S.  Howe),  who 
■were  acquainted  with  my  views  as  early  as 
October  1846,  and  to  whom  I  had  frequently 
demonstrated  the  facts  on  which  these  views  are 
based. 


MEDICAL  GAZETTE. 


FRIDAY,  AUGUST  18,  1848. 


The  opponents  of  the  Public  Health 
Bill  have  nearly  succeeded  in  muti¬ 
lating  it,  and  of  rendering  it  one  of  the 
abortive  measures  of  the  session.  All 
who  have  reflected  on  the  subject  must 
know  that  a  majority  of  rate-payers 
are  generally  opposed  to  any  measure 
which  is  likely  to  add  to  the  annual 
amount  of  rates.  The  benefit  to  the 
public  is  a  small  consideration :  the 
real  question  is — Will  the  rates  be  in¬ 
creased?  If  so,  the  measure,  coute  qui 
coute,  must  be  resisted.  The  Public 
Health  Bill  has  offered  no  exception 
to  this  pecuniary  rule.  It  has  had 
its  open  assailants  and  its  secret  ene¬ 
mies.  The  former  have  been  in  a 
minority,  and  their  efforts  failed  to  do 
more  than  protract  for  a  session,  the 
enactment  of  a  most  useful  law.  The 
latter  have  worked  insidiously,  and  had 
so  far  gained  their  object  as  to  send 
the  Bill  up  to  the  House  of  Lords  in  a 
form  which  would  have  effectually 
neutralised  its  most  important  provi¬ 
sions.  The  drainage,  sewerage,  and 
ventilation  of  towns,  must  not  be  op¬ 
tional,  but  compulsory.  The  optional 
system  has  been  tried,  and  failed  ;  and 
if  it  be  intended  that  there  should  be 
an  efficient  measure  of  sanitary  reform, 
the  clauses  must,  under  certain  equita¬ 
ble  limitations,  be  compulsory.  This 
attempt  to  defeat  the  provisions  of  the 
Bill,  will  be  best  understood  by  refer¬ 
ence  to  the  following  extract  from  the 
Times  :  — 

“  An  alteration  in  the  bill  had  been 
introduced  in  the  Lower  House  by  the 
opponents  of  the  measure,  which  pre¬ 
cluded  its  application  to  any  town 
unless  ‘one-tenth  of  the  inhabitants 
rated  to  the  relief  of  the  poor  in  any 
district  should  have  petitioned  to  be 


THE  PUBLIC  HEALTH  BILL  AND  ITS  OPPONENTS. 


289 


brought  under  its  operation.  This 
would  be  in  effect  to  nullify  the  pro¬ 
visions  of  the  bill.  What  chance 
wrould  there  be  of  obtaining  20,000 
signatures  in  London,  3,000  in  Man¬ 
chester  or  Liverpool,  2,000  in  Bristol  ? 
Consider  for  a  moment  the  powerful 
leverage  brought  to  bear  against  the 
obtaining  of  one  single  signature  to 
such  a  petition.  The  opulent  rate¬ 
payer,  whose  payment  of  rates  would 
be  disproportionately  increased,  would 
with  difficulty  be  brought  to  sign  a 
warrant  for  levying  money  on  himself. 
He  lives  in  a  wholesome  part  of  the 
town.  There  is  no  fetid  smell  from 
drain  or  sewer  on  his  basement  story. 
Why  should  he,  in  his  well-ventilated, 
well-cleansed  dwelling,  pay  a  large 
sum  for  the  purification  of  the  filthy 
quarters  of  the  town  inhabited  by  the 
nameless  poor  ?  The  poor  again — it 
is  the  old  story — are  under  the  influence 
of  their  fellow-townsmen  to  an  inde¬ 
finite  extent.  Who  can  tell  how  many 
patrons  would  be  displeased,  how  many 
customers  driven  away,  how  many 
employers  disgusted,  by  the  poor  man’s 
signing  such  a  petition  ?  Again,  all 
the  evidence  goes  to  shew  that  it  is  not 
the  destitute,  the  wretched,  and  the 
squalid  who  are  most  keenly  alive  to 
the  necessity  of  increased  cleanliness. 
The  sanitary  inquiries  all  tend  to  shew 
that  poverty,  filth,  and  apathy,  repro¬ 
duce  each  other  in  a  circle.” 

It  is  somewhat  extraordinary  that 
the  Government  should  have  as¬ 
sented  to  such  a  nullification  of  the 
new  measure  ;  but  it  can  excite  no  sur¬ 
prise  that  the  House  of  Lords,  the 
members  of  which  are  entirely  removed 
from  rate-paying  influences,  should 
have  endeavoured  to  avert  the  evil  con¬ 
sequences  of  the  amendment.  At  the 
suggestion  of  the  Bishop  of  London  a 
proviso  was  added,  to  the  effect  that 
this  option  on  the  part  of  the  rate¬ 
payers  should  be  taken  away  whenever 
in  any  town  the  deaths  from  zymotic 
diseases,  on  an  average  of  three  years, 
should  have  exceeded  the  average  of 
20  per  cent,  of  the  total  deaths.  In 
the  debate  on  the  Lords’  amendments, 
Lord  Morpeth  proposed — 

“  That  all  the  words  in  the  clause 


relating  to  particular  diseases  should 
be  omitted,  and  their  place  supplied 
by  other  words,  which  would  provide  that 
where  the  deaths  in  ‘any  city,  town, 
borough,  parish,  or  place’  should  amount 
to  23  to  a  thousand  of  the  population 
for  such  ‘  city,  town,  borough,  parish, 
or  place,’  the  General  Board  of  Health 
might  direct  inquiry  to  be  made  for  the 
purpose  stated  in  the  clause.  The  pro¬ 
portion  of  23  to  1000  would  afford  se¬ 
curity  that  the  act  would  not  be  put 
into  operation  except  in  cases  where 
there  w7as  such  a  manifest  amount  of 
unhealthiness,  indicated  by  the  high 
rate  of  mortality,  that  no  persons  pos¬ 
sessed  of  the  ordinary  feelings  of 
humanity,  would  object  to  the  appli¬ 
cation  of  sanitary  regulations.  The 
average  of  deaths  for  ail  England,  ac¬ 
cording  to  the  Registrar- General’s  re¬ 
turns,  was  21  to  1000  of  the  population. 
The  average  in  the  most  healthy  dis¬ 
tricts — Reigate,  Godstone,  and  Barnet, 
w7as  15  and  16  to  1000;  and  the  ave¬ 
rage  in  the  most  unhealthy  districts 
wms  29  and  30  to  1000.  When,  there¬ 
fore,  he  took  23  to  1000  as  the  propor¬ 
tion  of  deaths  necessary  to  justify  the 
application  of  the  act  to  any  district, 
it  could  not  wfith  justice  be  alleged  that 
he  had  fixed  upon  too  low  an  average.” 

Perhaps  this  is  the  best  compromise 
which  could  have  been  made;  and  the 
only  source  of  regret  now  is,  that  the 
City  of  London  should  have  been  ex¬ 
cluded  from  the  operation  of  so  bene¬ 
ficial  a  measure. 

The  alteration  proposed  by  Lord 
Morpeth  refers  to  the  increase  of 
deaths  from  any  cause ;  while  the 
amendment  suggested  by  the  Bishop 
of  London  required  that  the  increased 
mortality  should  be  due  to  diseases  of 
the  zymotic  class.  As  an  argument  in 
favour  of  his  proposition,  Lord  Mor¬ 
peth  stated,  on  the  authority  of  the 
Registrar-General,  that  the  fatality  of 
the  diseases  specified  by  the  Bishop  of 
London  would  not  alw'ays  afford  a  fair 
criterion  of  the  sanitary  condition  of 
a  district.*  We  agree  in  this  view;  but 

*  A  large  number  of  those  who  die  from  zy¬ 
motic  diseases  are  comprised  in  the  infantile  por¬ 
tion  of  a  population  which  is  not  only  the  most 
numerous,  but  at  the  same  time  the  most  exposed 
to  fatal  specific  diseases. 


290  CHLORIDE  OF  ZINC  FOR  ANATOMICAL  AND  OTHER  PURPOSES. 


the  argument  has  a  wider  application 
than  his  Lordship  appears  to  have 
contemplated  at  the  time  of  making  this 
statement.  A  document,  which  will 
he  found  elsewhere,*  has  been  going 
the  round  of  the  public  journals,  set¬ 
ting  forth,  in  an  alarming  point  of 
view,  the  great  increase  of  deaths  from 
zymotic  diseases  during  the  last  quar¬ 
ter.  The  decrease  of  deaths  from  other 
causes  is  not  published;  and  the  public 
are  left  to  infer,  from  this  record  of 
mortality,  that  the  health  of  the  metro¬ 
polis  is  in  a  most  unfavourable  condi¬ 
tion,  and  that  if  the  Asiatic  cholera 
should  make  its  appearance  among 
us,  it  cannot  fail  to  spread  with  fatal 
rapidity.  It  is,  however,  reassuring  to 
consider  that  this  isolated  document 
does  not  justify  the  terrible  inference 
which  the  timid  might  be  disposed  to 
draw  from  it. 

We  have  through  Lord  Morpeth’s 
official  announcement,  the  authority  of 
the  Registrar-General  for  asserting, 
that  deaths  from  diseases  of  the  zymo¬ 
tic  class  do  not  afford  a  fair'' criterion 
of  the  sanitary  condition  of  a  district; 
and  his  lordship’s  alteration  of  the 
amendment  in  the  Public  Health  Bill, 
is  in  accordance  with  this  view.  At 
the  same  time  we  must  take  leave  to 
remark,  that  the  publication  of  returns 
of  deaths  which  do  not  furnish  fair 
criteria  of  the  health  of  a  population, 
can  only  be  productive  of  mischief  by 
unnecessarily  exciting  the  fears  of  the 
public.-)- 

It  is  long  since  we  have  had  to  call 
the  attention  of  our  readers  to  the 
various  fluids  which  have  been  brought 
before  the  public  as  “disinfectants.” 
The  death  of  Colonel  Calvert  from  fever 
was  a  practical  refutation  of  the  alleged 
disinfecting  properties  of  M.  Ledoyen’s 
liquid  ;  and  when  fairly  put  to  the  test, 

*  Page  301. 

t  Since  this  was  written,  the  Bill  has  passed  the 
House  of  Lords,  and  is  now  waiting  for  the  Royal 
Assent. 


others  would  doubtless  be  found 
equally  inefficacious.  Liebig’s  supposi¬ 
tion,  that  the  entity  of  contagion  at¬ 
taches  itself  to  certain  noxious  gases, 
and  by  that  means  propagates  the  pecu¬ 
liar  disease  to  which  it  belongs,  has  led 
to  the  hasty  inference,  that  if  the  (jases 
are  capable  of  being  destroyed  by  an 
antibromic  liquid,  the  contagion  is  also. 
To  this  we  altogether  demur  :  as  a  sup¬ 
position  it  is  harmless,  but  when  it  is 
made  the  basis  of  a  theory,  and  carried 
into  practice,  it  may,  as  in  Colonel 
Calvert’s  case,  lead  to  a  false  security. 
The  removal  of  foul  smells  is  one  thing, 
the  neutralization  or  chemical  destruc¬ 
tion  of  contagion  another.  The  former, 
we  believe,  act  as  slow  poisons,  and 
may  predispose  the  body  to  the  attacks 
of  disease :  hence  any  safe  plan  by 
which  they  may  be  removed,  must-  be 
regarded  as  a  useful  discovery.  It  is  in 
this  light  that  we  are  inclined  to  view 
the  chloride  of  zinc,  which  has  been 
recommended  by  Sir  William  Barnett . 
Most  chemists  agree  that  with  regard 
to  those  compounds  which  owe  their 
offensive  odour  to  sulphur,  the  action 
of  a  solution  of  chloride  of  zinc  must 
be  limited.  Muriatic  acid  is  set  free 
by  the  decomposition,  and  when  this 
reaches  a  certain  degree  of  concen¬ 
tration,  the  chemical  action  is  ar¬ 
rested.  This  objection  is  removed  by 
employing  the  metallic  solution  in  a 
proportionally  larger  quantity,  or  in  a 
more  concentrated  form.  It  has  been 
objected  to  the  chloride  of  zinc,  that  it 
was  lately  used  for  the  purpose  of  dis¬ 
infecting  the  sewers  of  Westminster, 
and  entirely  failed,  as  the  opening  of 
the  sewers  was  followed  by  the  rapid 
diffusion  of  fever  in  a  malignant  form. 
The  report  of  the  Metropolitan  Sanitary 
Commissioners,  upon  which  we  have 
elsewhere  commented,*  has,  however, 
set  this  question  at  rest.  A  period  of 
eight  weeks  elapsed  between  the  empty  - 


*  Page  165. 


THE  RECENT  APPOINTMENTS  AT  UNIVERSITY  COLLEGE  HOSPITAL.  291 


ing  of  the  last  cesspool,  and  the  occur¬ 
rence  of  the  first  case  of  fever  !  This 
is,  medically  speaking,  sufficient  to 
show  that  these  events  could  not  have 
borne  to  each  other,  the  relation  of 
cause  and  effect. 

Setting  aside  the  alleged  disinfecting 
properties  of  the  chloride  of  zinc,  there 
are  results  obtained  by  the  use  of  this 
liquid  which  recommend  it  strongly  to 
anatomists.  An  experienced  surgeon, 
who  was  a  witness  to  the  experiment 
on  embalming,  reported  in  our  last  num¬ 
ber,*  has  assured  us  that  the  use  of  the 
chloride  of  zinc  according  to  the  simple 
method  suggested  in  his  letter,  had  the 
effect  of  completely  arresting  putrefac¬ 
tion.  For  a  corroboration  of  this  view 
of  the  utility  of  the  chloride  in  the 
dissecting-room,  we  need  only  refer  to 
the  evidence  of  Dr.  Sharpey,  Mr.  Petti¬ 
grew,  and  Mr.  Partridge,  quoted  in  a 
letter  on  this  subject,  inserted  in  the 
present  numberf. 

The  operation  of  the  chloride  in 
agriculture  is  less  intelligible  :  never¬ 
theless,  the  suggestion  of  our  corres¬ 
pondent,  that  it  should  be  employed  for 
the  purpose  of  arresting  the  progress 
of  the  potato-blight,  is  deserving  of 
attention.  Practice  is  often  in  advance 
of  theory,  and  from  what  has  been 
hitherto  discovered  respecting  the 
action  of  chloride  of  zinc,  useful  results 
may  be  obtained  in  cases  in  which  they 
could  not  have  been  anticipated  by 
any  a  priori  re  asoning. 


It  is  with  great  satisfaction  we  can 
announce  that  the  surgical  appoint¬ 
ments  at  University  College  have  been 
at  length  filled  up  in  a  manner  which 
reflects  credit  upon  the  Council.  The 
dissensions  which  have  so  recently 
occurred,  were  calculated  to  damage 
the  character  of  the  College  as  a  place 


of  instruction  ;  but  happily  these  have 
been  healed  by  a  judicious  selection  of 
new  men ;  and  there  is  now  every  pros¬ 
pect  that  the  October  session  will  be 
opened  under  the  most  favourable 
auspices.  As  we  announced  in  our 
number  of  the  28th  ult.,  Mr.  J.  M. 
Arnott,  W’hose  high  reputation  as  a 
practical  surgeon  is  so  w^ell  known  to 
the  profession,  has  accepted  the  office 
of  Surgeon  to  the  North  London 
Hospital,  and  Professor  of  Surgery  in 
University  College.  In  making  this 
appointment,  it  cannot  be  imputed  to 
the  Council  that  they  have  adopted  the 
practice  of  “  sending  for  strangers,”  or 
that  they  have  selected  an  untried 
man,  or  one  whose  reputation  had  yet 
to  be  made.  Mr.  Arnott,  by  his  long 
connection  w’ith  the  Middlesex  Hospital, 
has  become  completely  identified  wdth 
the  profession  of  the  metropolis;  and 
j  by  his  high  standing  as  a  surgeon,  he 
cannot  fail  to  perform  the  duties  of  his 
office  with  credit  to  himself  and  benefit 
to  the  pupils  of  the  College.  Upon  the 
propriety  of  this  appointment,  and  the 
judgment  of  the  Council  in  making  it, 
there  cannot,  we  think,  be  one  dissen¬ 
tient  voice.  Mr.  Richard  Quain  takes 
the  Professorship  of  Clinical  Surgery; 
and  Mr.  Morton  holds  the  office  of 
Surgeon  to  the  Hospital.  Mr.  J.  E. 
Erichsen  and  Mr.  Marshall  have  been 
appointed  Assistant  Surgeons.  It  was 
not  probable  that  the  last-mentioned 
appointments  could  be  made  without 
exciting  some  feeling  of  discontent. 
Every  disappointed  candidate  will  of 
course  condemn  the  Council  for  ex¬ 
cluding  himself;  but  there  is  good  rea¬ 
son  to  believe  that  the  appointments 
have  been  made  with  a  proper  regard 
to  the  claims  of  pupils,  and  to  the  in¬ 
terests  of  the  College.  Of  Mr.  Mar¬ 
shall’s  qualifications  we  are  unable  to 
speak;  but  of  those  of  Mr.  J.  E. 
Erichsen  there  can  be  only  one  opinion. 
His  name  has  been  before  the  profes- 


*  Page  259. 
t  Page  299. 


292  dr.  todd’s  cyclopaedia  of  anatomy  and  physiology. 


sion  for  some  years.  His  essays  on 
asphyxia,  on  burns  and  scalds,  and  on 
diseases  of  the  skin,  of  which  the  two 
latter  were  published  a  few  years  since 
in  the  pages  of  this  journal,  are  suffi¬ 
cient  to  show  that  he  is  not  only  an 
original  thinker,  but  a  man  possessed 
of  a  good  practical  knowledge  of  his 
profession. 

From  this  statement,  our  readers 
will,  we  think,  agree  with  us  that  the 
Council  of  University  College  have 
done  all  that  is  in  their  power  to 
restore  harmony  to  the  school.  We 
feel  ourselves  in  a  position  to  express 
an  unbiassed  opinion  on  this  subject, 
as  during  the  late  discussion  we  avoided 
making  this  journal  an  organ  of  party 
feeling,  and  declined  allowing  any  per¬ 
sonal  attacks  or  rejoinders,  anonymous 
or  otherwise,  to  appear  in  our  pages. 


ilftebtcfoS. 


The  Cyclopcedia  of  Anatomy  and  Phy¬ 
siology.  Part  XXXI.  Edited  by 
Robert  B.  Todd,  M.D.  F.R.S.  &c. 
London:  Longmans.  May,  1848. 

We  have  already*  anounced  the  publi¬ 
cation  of  this  part  of  Hr.  Todd’s  im¬ 
portant  work;  and  we  have  now  much 
pleasure  in  giving  a  short  notice  of 
ts  contents.  These  include,  first,  the 
remaining  few  pages  of  Dr.  Walshe’s 
paper  on  Adventitious  Products,  of 
which  we  have  already  spoken  fa¬ 
vourably.  Next,  we  have  a  very 
good  article  on  the  Prostate  Gland, 
by  Mr.  Adams,  who  has  given  a  care¬ 
ful  account  of  the  rough  anatomy, 
minute  structure,  and  probable  func¬ 
tions  of  this  organ,  together  with  a 
statement  of  its  more  common  diseases, 
and  a  glance  at  its  comparative 
anatomy.  He  has  introduced  a  good 
description  of  that  portion  of  the 
organ  which,  consisting  of  a  small 
oval  sac,  is  named  utriculus  pro - 
staticus,  from  its  constituting,  as  dis¬ 
covered  by  Professor  E.  H.  Weber, f 

*  Vol.  xli.  p.  1042. 

t  Zusatze  zur  Lehre  vom  Baue  und  den  Ver- 
richtungen  der  Geschlechts-Organe.  Leipzig, 


the  true  representative  of  the  female 
uterus.  Mr.  Adams  does  not  appear  to 
have  met  with  Prof.  Weber’s  account 
of  this  rudimentary  male  uterus,  or  he 
would  have  been  enabled  to  procure 
some  interesting  facts  especially  in 
relation  to  its  comparative  anatomy. 

We  are  glad  to  find  that  Protein  has 
found  a  friend  and  protector  in  Mr.  .J. 
E.  Bowman;  for  although,  in  a  supple¬ 
mentary  paragraph  appended  to  his 
subject,  this  gentleman  feels  bound  to 
allude  to  the  attacks  which  have  been 
recently  made  on  the  independence  of 
this  substance,  yet  we  would  hope 
that  the  prominent  position  it  is  al¬ 
lowed  to  occupy  in  Dr.  Todd’s  Cyclo¬ 
paedia  will  be  the  means  of  prolonging 
its  existence.  Safely  lodged  between 
the  Prostate  Gland  and  the  Pteropoda, 
it  may  bid  defiance  fo  the  assaults  of 
Liebig,  who,  after  long  maintaining  its 
existence  and  building  up  and  circu¬ 
lating  theories  on  the  base  of  it,  now 
repudiates  it. 

The  article  Pteropoda  is  furnished 
by  Mr.  T.  Rymer  Jones,  who  has 
latterly  contributed  largely  to  the 
valuable  matter  contained  in  the  pages 
of  this  Cyclopsedia.  Next  we  have  an 
elaborate  paper  on  the  Pulse,  by  Dr. 
Guy — elaborate,  at  least,  so  far  as  it 
goes,  for  it  is  limited  almost  exclu¬ 
sively  to  a  consideration  of  the  cir¬ 
cumstances  by  which  the  frequency 
of  the  pulse  is  influenced.  Whoever, 
therefore,  expects  to  find  in  it  any 
account  of  the  mode  of  production 
of  the  pulse,  the  physiological  condi¬ 
tions  upon  which  it  depends,  or  the 
circumstances  of  disease  by  which  it  is 
so  importantly  modified,  will  be  disap¬ 
pointed.  These  deficiencies  are  in  some 
measure  compensated  by  the  interest¬ 
ing  facts  which  Dr.  Guy  has  brought 
together  respecting  the  influence  of 
age,  sex,  posture,  exercise,  food,  and 
other  natural  causes,  upon  the  fre¬ 
quency  of  the  pulse.  No  one  could  be 
better  qualified  to  treat  of  this  part  of 
the  subject  than  Dr.  Guy,  whose  in¬ 
teresting  observations  on  the  variations 
of  the  pulse  have  at  different  times 
been  presented  to  the  profession. 

The  best  and  most  scientific  article 
in  this  number  of  the  Cyclopeedia,  is 
unquestionably  the  paper  by  Professor 
Vroiik,  on  the  Quadmanana.  To  com¬ 
parative  anatomists,  this  essay  will,  we 
have  no  doubt,  be  very  acceptable, 
although  to  the  general  reader  it  will 


m.  regnault’s  elementary  treatise  on  crystallography.  293 


be  somewhat  devoid  of  interest,  from 
the  dryness  of  anatomical  detail  of 
which  it  in  great  measure  necessarily 
consists.  Following  this  are  papers  by 
Mr.  W.Brinton;  one  on  the  Radial  and 
Ulnar  arteries,  the  other  on  the  Radio- 
Ulnar  articulations.  The  number  ter¬ 
minates  with  the  first  part  of  a  paper 
by  Dr.  G.  Johnson,  on  Ren,  the  notice 
of  which  we  will  defer  until  its  com¬ 
pletion*. 

From  the  above  summary  it  may  be 
inferred  that  we  entertain  a  favourable 
opinion  of  the  manner  in  which  this  use¬ 
ful  Cyclop eedia  is  now  progressing.  We 
regard  the  contents  of  the  present 
number  as  in  no  way  inferior  to  those 
of  its  predecessors,  or  wanting  in  the 
marks  of  talent  and  energy  which  have 
hitherto  been  displayed  in  the  work. 


An  Elementary  Treatise  on  Crystal- 
loyraphy.  By  M.  V.  Regnault, 
Member  of  the  French  Academy  of 
Science,  &c.  Illustrated  with  108 
wmod  engravings.  8vo.  pp.  70. 
London:  Bailliere.  1848. 

This  is  a  short,  but  scientific,  treatise 
on  crystallography,  from  the  pen  of  a 
man  who  has  acquired  a  high  reputa¬ 
tion  as  a  chemical  philosopher.  The 
principal  novelty  which  it  presents, 
consists  in  the  beautiful  illustrations 
of  crystalline  forms,  which  are  deli¬ 
neated  in  white  lines  on  a  black  ground. 
M.  Regnault  has  succeeded  in  making 
the  subject  of  crystallography  more 
simple  than  many  preceding  writers. 
He  divides  crystals  into  six  systems, 
the  greater  number  of  described  forms 
falling  under  the  regular  system ;  and 
these  are  made  still  more  extensive  by 
the  introduction  of  numerous  com¬ 
pound  forms.  Two  of  the  forms  of  the 
regular  system  are  new  to  us,  at  least 
in  name,  namely,  the  tetrakishexaedron 
and  the  triakisoctohedron.  There  are 
engravings  of  these  forms  which  render 
them  easily  intelligible ;  but  it  is  to  be 
lamented  that  no  other  than  these 
sesquipedalian  names  can  be  found  for 
them.  The  illustrations  are  more  beau¬ 
tiful  than  any  which  we  have  yet  seen 
in  a  work  on  crystallography ;  and  we 
would  especially  point  to  fig.  80,  at 
page  58,  representing  the  growth,  by 
transference,  of  the  crystals  of  alum. 
The  subject  is  ably,  but  concisely, 

*  Part  XXXII,  has  just  reached  us,  and  will  be 
shortly  noticed. 


treated.  Mathematics  are  but  spa¬ 
ringly  introduced,  which  we  consider  a 
great  recommendation,  as  the  essay  is 
intended  for  students  ;  and  the  working 
out  the  complements  and  supplements 
of  angles  of  crystalline  bodies,  which 
a  man  is  never  likely  to  see,  is,  to  say 
the  least,  a  most  profitless  labour. 
The  pamphlet  is  in  such  a  form  that  it 
will  admit  of  being  bound  up  with  any 
of  our  standard  popular  treatises  on 
chemistry. 

The  Treasury  of  Natural  History  ;  or , 
a  Popular  Dictionary  of  Animated 
Nature.  Illustrated  by  upwards  of 
eight  hundred  figures  on  wood.  By 
Samuel  Maunder.  8vo.  pp.  812. 
London :  Longmans.  1848. 

This  is  the  fifth  of  the  series  of  Trea¬ 
suries  brought  out  by  Mr.  Maunder,— 
all  of  them  most  useful  as  works  of 
reference  and  instruction.  The  pre¬ 
sent  volume  is  not  inferior  to  those 
which  have  preceded  it ;  and  although 
there  is  not  much  originality  in  its 
contents,  it  has,  in  an  easily  accessible 
form,  all  the  advantages  of  an  exten¬ 
sive  compilation  from  the  best  writers 
on  zoology.  The  natural  history  of 
animals  is  here  given  in  a  series  of 
short  articles,  arranged  alphabetically, 
and  often  illustrated  by  well-executed 
wood-cuts,  engraved  by  Branston.  The 
English  names  of  the  animals  are 
made  the  basis  of  the  arrangement, — 
a  plan  which  will  be  found  best  adapted 
for  the  purposes  of  ready  reference ; 
while  the  work  is  preceded  by  a  classi¬ 
fication  of  the  animal  kingdom,  includ¬ 
ing  its  orders  and  genera,  the  cha¬ 
racters  of  which  are  fully  described 
alphabetically.  Cuvier’s  arrangement 
has  been  here  followed,  with  some 
alterations  which  modern  researches 
have  shown  to  be  necessary.  Mr. 
Hepburn  has  contributed  an  essay  on 
Practical  Taxidermy,  or  the  art  of 
preparing  and  preserving  specimens  of 
animals  ;  and  the  volume  is  completed 
by  a  glossarial  appendix,  in  which  the 
beginner  will  find  a  full  explanation  of 
the  meaning  of  all  scientific  terms  con¬ 
nected  with  zoology.  Mr.  MaundePs 
Treasury  of  Natural  History  is  intended 
rather  for  the  public  than  the  profes¬ 
sion  ;  but  it  is  a  cheap  and  useful 
encyclopaedia  in  its  own  department : 
and  it  will  be  found,  by  all  zoological 
students,  most  serviceable  as  a  work 
of  reference. 


294 


THE  LAW  REGARDING  DEEDS  OF  APPRENTICESHIP. 


jjMctitcal  '©rials  ants  Inquests. 

HEREFORD,  AUGUST  3,  1848. 

(Before  Mr.  Baron  Rolfe.) 

HAWKINS  V.  CLUTTERBUCK. 

THE  LAW  REGARDING  DEEDS  OF  APPREN¬ 
TICESHIP —  ALLEGED  EVASION  OF  THE 
STAMP  ACT. 

Mr.  Godson  and  Mr.  Gray  were  counsel 
for  the  plaintiff ;  Mr.  Alexander  and  Mr. 
Whitmore  for  the  defendant. 

This  was  an  action  of  covenant  against  a 
surgeon  for  improperly  dismissing  and  re¬ 
fusing  to  educate  an  apprentice.  A  question 
on  the  construction  of  the  Stamp  Acts  arose 
under  these  circumstances  : — It  appeared  in 
evidence  that  the  plaintiff,  who  was  the  uncle 
of  the  apprentice,  agreed  at  first  with  the 
defendant  to  pay  him  £250  for  the  board, 
lodging,  and  education  of  the  apprentice,  for 
the  period  of  five  years,  but  that  before  the  ap¬ 
prenticeship  deed  was  executed,  he  suggested, 
in  order  to  avoid  the  stamp  duty  on  the  full 
sum  of  ,£250,  that  ,£90.  19s.  should  be  ap¬ 
propriated  for  the  education  simply  of  the 
apprentice,  and  that  the  deed  should  specify 
that  sum  and  that  object,  and  notes  for 
£150,  which  should  be  the  amount  appro¬ 
priated  for  the  board  and  lodging  of  the  ap¬ 
prentice,  should  be  given  to  the  defendant. 
This  was  done,  and  the  apprenticeship  deed 
was  accordingly  drawn  up  with  a  stamp  only 
for  £99.  19s.  fee,  and  stating  the  considera¬ 
tion  to  be  merely  the  instruction  of  the  young 
man,  who  entered  upon  his  apprenticeship, 
and  after  five  months  was  dismissed  by  the 
defendant  on  the  ground  of  improper  con¬ 
duct.  Upon  these  facts, 

Mr.  Alexander  objected  to  the  recep¬ 
tion  of  the  apprenticeship  deed  in  evidence, 
inasmuch  as  the  8th  Anne,  chap.  9,  secs. 
35  and  39,  provided  that  an  apprenticeship 
deed  should  not  be  received  or  be  available 
in  any  court  or  place,  or  for  any  purpose, 
which  did  not  truly  state  the  full  amount  of 
money,  or  consideration  directly  or  indirectly 
given.  Here  the  real  amount  of  considera¬ 
tion  was  £250,  and  the  insertion  of  £99.  19s. 
was  an  evasion  of  the  statute.  The  55th 
George  III.  chap.  84,  merely  specified  the 
amount  of  the  duty  to  be  paid,  and  did  not 
otherwise  affect  the  provisions  ot  the  act  of 
Anne.  “  R.  v.  Baildon,”  (3  B.  and  Ad., 
427);  R.  v.  Evershail,”  (4  Ad.  and  EL, 
498) ;  and  “  Jackson  v.  Warwick,”  (7  T. 
R.,,  121),  were  quoted  in  support  of  this 
objection. 

Mr.  Godson  and  Mr.  Gray  having  been 
heard  on  the  other  side, 

His  Lordship  said — I  think  I  must  re¬ 
ceive  the  deed  with  liberty  to  the  defendant 
to  enter  a  nonsuit.  My  opinion  is,  that  it 
is  receivable  on  this  ground — I  think  that 


while  the  matter  is  in  fieri  the  parties  may 
separate  the  sum  to  be  paid  if  they  think 
fit.  If  there  had  been  £250  agreed  to  be 
given  for  that  which  the  party  covenants  to 
supply,  that  would  have  been  within  the. 
statute.  Suppose  they  had  met  and  agreed 
that  the  apprenticeship  should  be  only 
for  two  years,  but  that  they  should  after¬ 
wards  go  on,  on  the  same  terms  for  a  longer 
period,  they  might  agree  for  a  fee  for  the  two 
years.  It  is  said  that  the  statute  is  evaded, 
— that  word  is  quite  improperly  used.  That 
question  came  often  before  the  law  officers 
of  the  Crown  when  I  was  Solicitor-General, 
The  Stamp  Act  is  not  intended  to  fetter  the 
proceedings  of  parties  ;  and  if  a  party  so  act 
as  not  to  be  hit  by  it  he  has  a  right  to  do  so- 
If  a  party  has  a  claim  for  £100,  he  may 
take  £99.  19s.  He  is  in  a  different  predica¬ 
ment  from  what  he  would  have  been  in  if  he 
had  inserted  all.  Suppose  lie  had  two  in¬ 
dentures,  one  for  providing  for  meat,  and 
another  for  teaching,  there  would  have  been 
no  objection. 

The  case,  and  two  other  actions  arising 
out  of  the  same  circumstances,  which,  how¬ 
ever,  were  not  for  trial  here,  having  been 
ultimately  compromised,  being  referred  to  his 
Lordship  while  the  jury  were  deliberating, 
and  at  once  disposed  of,  to  the  satisfaction, 
apparently,  of  both  sides,  the  above  point 
cannot  now  be  brought  before  the  Court 
above. 


COURT  OF  EXCHEQUER. 

( Sittings  in  Banco.) 

THE  LAW  REGARDING  BONDS  NOT  TO 
PRACTISE.' — ARE  THEY  BINDING  AFTER 
THE  DEATH  OF  THE  PRACTITIONER? 

DEMURRER  PAPER. 

HASTINGS  V.  WITLEY. 

This  was  an  action  by  the  executors  of 
Kendrick  Watson,  deceased,  in  which  they 
sought  to  enforce  the  penalty  of  £1000  for 
the  breach  of  a  bond,  entered  into  by  the 
defendant  with  the  testator  on  his  becoming 
his  assistant,  wherein  he  bound  himself  not 
to  practise  in  Stourport  as  a  surgeon  at  any 
time  after  the  expiration  of  the  term  of  the 
engagement  without  the  consent  of  Mr. 
Watson.  The  pleadings  in  the  case  raised 
the  important  question,  whether  such  a  bond 
was  binding  after  the  death  of  Mr.  Watson. 

Mr.  Gray  appeared  for  the  plaintiff,  and 
submitted  that  the  plea  was  bad  in  substance, 
and  that  the  bond  was  broken  by  the  de¬ 
fendant  setting  up  after  the  death  of  Mr. 
Watson. 

Mr.  Baron  Parke. — The  cases  have  got  as 
far  as  to  say  that  such  a  contract  is  good  for 
the  life  of  the  obligor  ;  but  we  have  not  got 
so  far  as  to  say  that  it  shall  be  binding  for 
ever. 


DEEDS  OF  PARTNERSHIP - INTRODUCTIONS  TO  PRACTICE.  295 


Mr.  Hill,  for  the  defendant,  argued,  that 
the  bond  was  too  large,  and  therefore  invalid 
as  being  in  restraint  of  trade.  The  obligor 
being  dead  his  consent  cannot  be  obtained, 
and  the  defendant  would  be  restrained  for 
ever. 

The  Court,  however,  was  of  opinion  that 
the  penalty  was  incurred.  The  defendant 
bound  himself  not  to  practise  at  any  time 
without  the  consent  of  Mr.  Watson,  and  the 
latter  clause  did  not  restrain  the  first,  for  it 
was  open  to  the  defendant  at  any  time  to 
have  obtained  that  consent,  and  he  may  even 
now  obtain  a  release  from  the  executors  of 
Mr.  Watson.  The  plea  was  therefore  bad, 
and  the  plaintiff  was  entitled  to  judgment. 

Judgment  accordingly. 


HERTFORD  ASSIZES. 

Hertford,  July  14. 

{Before  Mr.  Justice  Maule.) 

THE  LAW  REGARDING-  INTRODUCTIONS  TO 
PRACTICE. - DEEDS  OF  PARTNERSHIP. 

ROBARTS  V.  BRYAN. 

Mr.  Wells  and  Mr.  Clarke  were  counsel 
for  the  plaintiff ;  Mr.  O’Malley  and  Mr. 
Sanders  appeared  for  the  defendant. 

This  was  an  action  of  covenant  brought 
to  recover  damages  from  the  defendant  for 
the  alleged  breach  of  certain  clauses  in  a  deed 
for  the  dissolution  of  a  medical  partnership 
between  the  parties  to  the  action,  the  foun¬ 
dation  of  the  plaintiff’s  action  being,  that  the 
defendant  did  not,  as  he  covenanted  to  do, 
introduce  the  new  partner  of  the  plaintiff  to 
all  the  patients  of  the  old  firm,  -whom  he 
(the  defendant)  was  in  the  habit  of  attend¬ 
ing  at  Slough,  where  he  carried  on  a  branch 
of  the  practice,  while  the  plaintiff  did  the 
same  at  Burnham.  After  several  witnesses 
had  been  called  for  the  plaintiff  in  support 
of  the  breaches  alleged  in  the  declaration, 
and  subjected  to  cross-examination  on  behalf 
of  the  defendant,  it  appeared  that  he  had,  in 
fact,  introduced  many  patients  to  the  plain¬ 
tiff’s  partner,  and  that  of  those  whom  he 
was  charged  with  having  omitted,  many  were 
of  a  most  unprofitable  class,  being  chiefly 
paupers.  After  the  case  had  been  kept  up 
some  little  time,  against  the  opinion  of  the 
learned  judge,  and  of  the  jury  too,  the 
learned  counsel  for  the  plaintiff  submitted  to 
a  general  verdict  for  the  defendant  on  all  the 
material  issues. 


REWARD  OF  SCIENCE  IN  ENGLAND. 

The  door-keeper  of  the  House  of  Commons 
receives  £74  per  annum  more  than  the 
Royal  Astronomer  or  the  Principal  Librarian 
at  the  British  Museum ;  and  the  Board- 
Room  porter  at  the  Admiralty  enjoys  pre¬ 
cisely  the  same  stipend  as  the  third  Assistant 
Astronomer  Royal ! — Athenaeum. 


('Tocresponticncc. 


CHARGE  OF  ALLEGED  MALAPRAXIS  IN 

MIDWIFERY — TRIAL  AND  ACQUITTAL  OF 

W.  H.  FLINT.  -  REMARKS  UPON  THE 

EVIDENCE. 

Sir, — Having  been  one  of  the  medical 
witnesses  to  the  post-mortem  examination 
of  Elizabeth  Riley,  of  High  Sheen,  Stafford¬ 
shire,  and  for  the  death  of  whom  William 
H.  Flint,  of  Longmore,  was  tried  for  man¬ 
slaughter  at  the  Stafford  Assizes  on  the  25th 
ult.  (he  having  attended  her  professionally 
in  her  accouchement),  and  there  acquitted, 

I  beg  leave  to  forward  you  a  statement  of 
the  appearances  as  observed  at  the  autopsy, 
as  also  of  the  principal  facts  elicited  at  the 
coroner’s  inquest  and  Assizes,  and  the 
points  raised  on  the  prisoner’s  behalf ;  the 
whole  case  appearing  to  me  highly  important 
to  the  profession  generally,  both  with  refer¬ 
ence  to  the  practice  pursued,  and  to  the 
questions  of  medical  jurisprudence  raised  by 
the  prisoner’s  counsel  and  the  judge  on  his 
behalf.  f 

The  evidence  of  the  husband,  sister-in- 
law,  and  nurses,  proved  that  the  deceased, 
being  in  good  health,  was  seized  with  pains 
of  labour  at  about  11  a.m.  on  the  28th  of 
March  ;  that  she  became  worse  about  mid¬ 
night  ;  that  the  prisoner  was  sent  for,  and 
arrived  at  about  2  a.m.  of  the  29th;  that, 
after  talking  some  time,  he  made  an  exa¬ 
mination.  Upon  being  asked  by  the  nurse 
if  it  were  all  right,  he  did  not  answer.  On 
the  second  examination,  made  soon  after¬ 
wards,  he  said  it  was  a  cross  birth,  and  he 
must  turn  it.  On  the  third,  he  said  he  had 
turned  it,  and  it  was  all  right.  He  then 
went  to  lie  down,  and  gave  directions  to  give 
her  a  little  gruel  or  brandy,  and  to  let  her 
sit,  walk,  lie  down,  or  do  as  she  pleased. 

Between  7  and  8  o’clock  he  got  up  :  saw 
her  again  before  he  took  his  breakfast ;  exa¬ 
mined  her,  and  sent  for  his  instruments. 
About  9  o’clock  he  again  went  into  the 
room,  and  from  this  time,  for  about  an  hour 
and  a  half,  he  was  using  the  instruments, 
or,  at  least,  had  them  and  his  hands  under 
the  clothes.  During  this  time  he  was  re¬ 
peatedly  asked  if  he  would  have  further 
advice ;  to  which  he  answered  in  the  nega¬ 
tive — to  the  husband,  saying  there  was  no 
necessity, — and  to  the  sister-in-law  and 
nurse,  that  it  would  be  over  in  five,  ten,  or 
fifteen  minutes.  The  deceased  began  to 
moan  soon  after  the  prisoner  entered  the 
room.  At  length,  about  half  an  hour  pre¬ 
vious  to  her  death,  she  appeared  to  sink, 
having  convulsive  movements  of  the  eyes, 
vomiting,  and  difficulty  of  breathing.  The 
nurse  then  told  him  the  deceased  was  dying. 
He  said  “  No.” 


396 


CHARGE  OF  ALLEGED  MALAPRAX1S  IN  MIDWIFERY— 


Sarah  Mellor ,  the  third  witness  of  those 
present  during  the  accouchement,  went  into 
the  room  about  11  o’clock,  and  was  asked 
by  the  prisoner  to  assist  him.  Before  this 
time,  the  nurse’s  brother  and  the  husband 
of  deceased  came  to  the  door,  and  asked  the 
prisoner  if  he  would  have  any  more  assist¬ 
ance,  to  which  he  answered,  “  I  have  brought 
one,  and  shall  have  another  in  four  minutes, 
— nay,  in  two  :  I  shall  want  no  more  help.” 
The  nurse  then  said,  “  Let  us  look.”  He 
answered,  “  No  ;  I  can’t  have  her  exposed.” 
The  nurse  then  said  to  Sarah  Mellor,  “  She 
is  dying  ;  turn  the  clothes  off and  that, 
when  she  did  so,  she  saw  “  such  a  sight!” 
(this  was  said  with  a  tone  and  expression  of 
pity  and  horror)  ;  and,  when  told  to  ex¬ 
plain,  she  said  there  was  a  leg  and  foot,  and 
arm  and  hand,  and  something  like  intestines, 
hanging  out  nearly  a  foot ;  and,  in  her 
cross  examination,  added  that  she  never  saw 
anything  to  compare  to  it. 

Sarah  Mellor,  in  her  evidence,  stated, 
that  when  she  went  into  the  room,  the 
prisoner  was  then  pulling  at  the  hand  and 
foot,  which  she  detected  on  going  to  assist 
him  as  he  desired.  She  then  told  him  he 
was  doing  wrong,  it  being  impossible  to 
bring  a  child  into  the  world  by  the  leg  and 
arm,  and  then  added,  “  She  is  dying.”  The 
prisoner  then  said,  11  My  credit  is  gone 
and  she  replied,  “  And  her  life  is  gone.” 
After  this  the  deceased  survived  about  ten 
minutes,  and  died  about  12  o’clock.  The 
prisoner  must  therefore  have  been  using 
manual  force  and  instruments  for  at  least 
two  hours,  he  having  commenced  at  9 ; 
and,  as  Sarah  Mellor  gave  evidence  that 
he  was  still  employing  traction  when 
she  went  in,  soon  after  which  she  died, 
and  the  sister-in-law  said  this  took  place 
about  noon,  the  great  probability  is,  that 
it  was  some  time  past  eleven  when  Sarah 
Mellor  arrived.  When  the  prisoner  was 
mounting  his  horse,  some  time  afterwards, 
to  leave,  the  last  witness,  Sarah  Mellor,  said 
to  him,  Dr.  Flint,  tell  me  one  thing — “  You 
said  you  brought  forth  a  child  and  put  it 
away  ;  it  is  no  such  thing,  for  you  have  not.” 

“  What  was  that  substance,  then?”  he 
asked.  She  said,  “  You  are  a  doctor,  and 
ought  to  know  ;  I  never  saw  any  thing  like 
it,  but  I  think  it  was  a  part  of  her  womb, 
and  her  bowel  skin.”  This  she  had  pre¬ 
viously  found  under  the  chair  upon  which 
he  sat,  and  had  washed  and  replaced  it 
within  the  body.  She  further  deposed  to 
having  found  an  open  penknife  on  the  bed, 
covered  with  blood,  and  for  which  he  had 
previously  inquired.  Another  witness, 
Martha  Swindells,  deposed  that  she  called 
upon  the  prisoner  at  4  p.m.  ;  and  that,  in 
answer  to  her  questions,  he  said  she,  the 
deceased,  was  confined  of  one  child,  and 
that  another  would  have  been  born  in  a  few 


minutes  had  the  mother  lived ;  and  that  he 
could  not  account  for  her  death,  for  that  he 
had  no  more  thought  of  her  death  than  of 
his  own. 

Post-mortem  examination,  as  made  by 
Mr.  Simkins,  of  Alstonfield,  and  in  which  he 
was  assisted  by  Mr.  Goodwin,  of  Longnor, 
and  myself.  The  deceased  was  fleshy,  and 
well-formed  ;  the  pelvic  cavity  ample ;  the 
right  hand  and  left  foot  of  the  foetus  pro¬ 
truded  ;  on  the  latter,  near  the  heel,  was  a 
large  and  deeply  incised  wound  ;  and  with 
these  was  seen  a  loop  of  intestine,  which 
had  passed  through  the  lower  part  of  the 
uterus :  near  these,  and  just  within  the 
orifice,  were  found  the  piece  of  membranous 
substance,  as  referred  to  by  Sarah  Mellor, 
of  about  the  size  of  a  small  glove,  and  com¬ 
posed  of  mucous  membrane,  with  muscular 
fibres  ;  as  if  a  portion  of  the  vagina  and  uterus 
had  been  torn  away  ;  as  also  a  piece  of  intes¬ 
tine,  of  from  fifteen  to  eighteen  inches  in 
length,  with  dust  and  pieces  of  chaff  upon 
it,  and  which  had  evidently  been  replaced 
within  the  cavity  by  the  prisoner,  the  nurses 
not  having  seen  it.  The  perinseum  was 
destroyed  ;  the  orifices  of  the  vagina  and 
rectum  being  externally  continuous. 

On  opening  the  abdomen  the  left  shoulder 
and  dorsum  of  the  foetus  were  placed  ob¬ 
liquely  to  the  anterior,  and  covered  by  mem¬ 
brane  only — the  anterior  inferior  portion  of 
the  uterus  being  ruptured :  the  head  was 
lying  in  the  left  superior  side  of  the  abdomi¬ 
nal  cavity,  having  protruded  through  an  ex¬ 
tensive  laceration  or  rupture  of  the  uterus 
in  that  position. 

The  uterus  was  then  opened,  the  foetus 
removed,  and  the  umbilical  cord,  which  was 
perfect,  divided ;  the  placenta  was  in  the 
superior  part  of  the  uterus,  and  firmly  and 
entirely  attached.  The  foetus  was  full-grown, 
and  of  healthy  appearance,  but  much  muti¬ 
lated  ;  the  right  humerus  was  fractured  near 
the  shoulder, — there  was  dislocation  of  the 
eibow-joint, — a  punctured  wound  above  the 
clavicle, — a  deep  one  in  the  axilla ;  and  there 
were  several  wounds  upon  the  cranium — two 
of  them  having  passed  through  the  bone. 

In  the  posterior  walls  of  the  uterus  were 
also  found  several  wounds,  evidently  instru¬ 
mental,  as  were  of  course  those  upon  the 
foetus — some  having  passed  through  the 
uterus,  and  others  being  more  superficial. 

Through  a  large  rent  or  laceration  at  the 
anterior  inferior  part  of  the  uterus — now 
found — it  was  that  the  loose  intestine,  torn 
from  its  peritoneal  attachments,  protruded, 
— in  short,  the  abdominal  cavity  throughout 
shewed  proofs  of  extraordinary  instrumental 
and  manual  violence  :  as  the  nurse  said — “  I 
have  never  before  seen  anything  to  compare 
to  it,  and  I  trust  I  never  again  shall.” 

The  direct  examination  of  Mr.  Simkins 
elicited  the  following  answers  :■ — That  the 


TRIAL  AND  ACQUITTAL  OF  W.  H.  FLINT. 


297 


removal  of  the  portions  of  the  intestines 
would  cause  death, — that  the  ruptures  of  the 
womb  would  also  cause  death, — that,  taken 
altogether,  they  would  cause  death  more 
speedily, — that  in  all  probability  the  presen¬ 
tation  was  a  cross  one, —  that  the  birth  could 
not  ensue  in  such  a  position, — that  instru¬ 
ments  were  not  necessary, — that  a  skilful 
practitioner  would  have  endeavoured  to  make 
it  a  foot  presentation :  and  that  under  the 
circumstances  this  might  have  been  effected 
with  ordinary  skill  and  care.  Upon  this  the 
learned  judge  remarked — •“  How  can  any 
man  tell  that  unless  he  was  present  at  the 
time  ?  It  might  have  depended  upon  many 
things.”  To  this  dictum  permit  me  to  re¬ 
mark,  en  passant ,  that,  assuming  the  original 
presentation  to  have  been  a  foot  and  hand, 
in  the  apparently  strong  and  well-formed 
woman  whom  we  saw,  and  at  the  period 
when  the  prisoner  pretended  to  have  effected 
version,  I  for  one  believe  that  had  the  foot 
been  brought  well  down  the  mother’s  life 
would  have  been  saved,  and  very  probably 
the  child’s  also. 

Mr.  S.  having  answered  in  the  affirmative 
to — “  Can  a  skilful  medical  man  distinguish 
between  the  hand  and  the  foot,  while  being 
born,  by  the  touch  ?”  was  then  asked  by  the 
judge,  “If  it  were  not  sometimes  difficult 
to  distinguish  between  them  ?”  answered — 
*'  At  first,  but  not  when  the  os  uteri  dilates;” 
and  that  even  men  of  experience  might  at 
first  be  deceived ;  that  it  might  be  necessary 
to  make  several  examinations  ;  and  if  it 
proved  a  hand,  interference  would  be  neces¬ 
sary. — if  a  foot,  “Not;”  that  Mrs.  Riley 
was  an  apparently  healthy  person  ;  and  that 
there  was  no  appearance  of  malformation. 

The  cross-examination  of  Mr.  Simkins 
bore  upon  the  rupture  of  the  uterus, — 
whether  death  resulted  from  the  rupture  of 
the  uterus,  or  from  the  displacement  of  the 
intestines  (the  removal  of  a  portion  of  these, 
and  of  a  part  of  the  vagina  and  uterus,  not 
being  alluded  to), — whether  there  could  be 
any  doubt  of  the  rupture  of  the  uterus  hav- 
*  ing  killed  her, — whether  rupture  of  the 
uterus  does  not  frequently  occur  from  natu¬ 
ral  causes, — whether  it  does  not  happen  in 
the  proportion  of  three  to  one  in  the  case  of 
male  children,  from  the  size  of  the  head, — 
whether  it  is  not  often  found  in  every  grade 
of  life  and  state  of  health, — whether  not  of 
more  frequent  occurrence  in  the  second 
and  third  children  than  the  first  (this  was 
the  third), — if  not  often  found  to  occur 
without  symptoms  to  indicate  the  pro¬ 
bability  of  its  occurrence,  —  if  ruptures 
are  not  sometimes  accompanied  by  sinking, 
rolling  of  the  eyes,  and  vomiting  ;  whether 
the  medical  man  is  not  always  more  or  less 
blamed,  and  more  or  less  justly ;  whether 
when  ruptures  are  the  cause  of  death  they 
are  not  unfrequently  concealed  ;  and  whether 


medical  writers  do  not  attribute  a  large  pro¬ 
portion  of  deaths  in  cross  births  to  ruptures  ; 
whether  where  it  is  impossible  to  save  both 
mother  and  child,  the  mother  is  not  to  be 
saved ;  and  if  it  be  not  sometimes  necessary 
almost  to  cut  the  child  to  pieces.  The 
learned  counsel,  however,  omitted  to  make 
the  inquiry,  whether  it  was  not  necessary  to 
cut  away  part  of  the  intestines,  and  some 
of  the  womb  and  vagina,  in  order  to  effect 
this  ;  and  whether  it  might  or  might  not 
add  to  the  safety  of  the  mother  to  tear  about 
two  feet  of  the  intestine  from  its  peritoneal 
attachments.  Nor  did  he  think  it  important 
to  ask,  whether  it  were  not  much  more  pro¬ 
bable  that  the  ruptures  of  the  uterus  resulted 
directly  from  the  unskilful  and  improper  use 
of  instruments,  and  from  the  subsequent 
vain  attempts  to  withdraw  the  foetus  by  the 
foot  and  arm,  than  from  the  natural  efforts 
of  the  womb. 

Eventually  the  learned  judge  asked,  whe¬ 
ther,  from  the  inspection  made  of  the  in¬ 
ternal  parts  of  the  organs  of  generation,  a 
judgment  of  the  cause  of  rupture  might  be 
formed  ;  whether  the  wounds  and  punctures 
were  sufficient  to  cause  a  rupture  of  them¬ 
selves  ;  and  whether  the  rupture  through 
which  the  head  of  the  child  passed  was 
caused  by  natural  or  mechanical  means  :  and 
on  receiving  an  answer  not  in  the  negative , 
but  one  of  doubt,  observed, — “  How  is  it 
possible  to  proceed  in  this  case  ?  From  all 
we  hear,  the  appearances  may  have  resulted 
from  natural  causes  ( especially  the  vital 
parts  removed,  and  the  wounds  inflicted 
upon  both  mother  and  child,  by  instruments 
unnecessarily  used).  The  appearances  were 
quite  sufficient  to  show  that  a  combination 
of  natural  causes  might  have  produced 
death.”  He  then  proceeded — ' ‘  The  witness 
for  the  prosecution  says  that  the  cause  of 
death  was  rupture  of  the  uterus.  The  gut 
might  have  expedited  it,  but  the  primary 
cause  was  rupture :  which  proceeds  fre¬ 
quently  from  natural  causes,  more  especially 
in  the  case  of  cross  births,  and  with  a  second 
or  third  child.  How  can  the  jury,  then, 
take  a  jump  in  the  dark,  and  say  that  other 
injuries  were  the  cause  of  death?  They 
were  “  sufficient,  doubtless but  you  have 
got  a  rupture  of  the  uterus  here.  If  I  could 
discover  that  the  insertion  of  any  instrument 
into  the  womb  had  caused  this  mischief,  that 
would  be  another  case ;  but,  from  anything 
it  appears  to  the  contrary,  it  might  have 
proceeded  from  natural  causes.”  Upon  the 
judge’s  recommendation,  the  jury,  after  a 
few  minutes’  deliberation,  said,  “We  think 
the  death  might  have  arisen  from  natural 
causes,  and  therefore  we  say  he  is  Not 
Guilty.” 

Remarks. — Permit  me,  sir,  in  conclu¬ 
sion,  to  offer  a  few  remarks.  It  will  be 
observed,  that  in  the  evidence  given  for  the 


DRY  SCRUBBING  IN  HOSPITALS. 


298  LOCAL  ANAESTHESIA. 


prosecution,  there  was  positive  proof  of  the 
unnecessary  use  of  instruments  ;  of  severe, 
and  indeed  mortal,  injuries  inflicted  on  the 
mother,  and  probably  on  the  foetus  also, 
from  their  use  :  of  malapraxis  in  the  matter 
of  attempted  abduction  by  the  hand  and 
foot; — injuries  which  the  judge  himself,  in 
his  remarks,  acknowledged  were  sufficient, 
doubtless,  to  cause  death  ; — that  there  were 
no  assertions  on  the  part  of  Mr.  Simkins, 
that  the  rupture,  of  the  uterus  arose  from 
natural  causes ;  on  the  contrary,  it  was 
evident  from  his  answer  that  he  felt  very 
doubtful  upon  the  subject.  There  were  two 
other  medical  witnesses  who  were  present  at 
the  autopsy,  yet  unexamined ;  there  were 
two  others  also,  Dr.  Barry,  of  the  Lying-In 
Infirmary,  of  Birmingham,  and  Dr.  Hea¬ 
ton,  of  Leeds,  especially  subpoenaed  to  give 
evidence  on  these  points  after  having  heard 
all  the  other  witnesses  :  and  yet  a  case  of  so 
much  importance,  both  in  a  medical  and 
civil  point  of  view,  was  thus  summarily  dis¬ 
posed  of.  Human  life  cannot  be  of  much 
value  if  the  technicalities  of  law  can  screen 
practice  as  above  detailed. — I  am,  sir, 

Your  obedient  servant, 

Fred.  Crellin,  R.N., 
F.R.C.S.,  L.A.C. 
Repton,  near  Burton-on-Trent, 

Derbyshire,  August  1848. 

P.S. — I  may  add  that  the  accused, 
although  inserted  in  the  Medical  Directory 
as  Member  of  the  College  and  Licentiate  of 
the  Apothecaries’  Company,  is  not  so,  the 
prosecutor  having  written  to  both  places  to 
inquire.  He  also  used  the  printed  form  of 
register;  and  simply  said  “Parturition.” 
I  think  steps  might  be  taken  to  prevent  un¬ 
qualified  practitioners  from  using  them, 
which  would  naturally  lead  to  coroners’  in¬ 
quests  if  they  were  made  the  only  legal  form 
of  certificate. 

***  This  case  is  of  considerable  import¬ 
ance  in  relation  to  the  practice  of  midwifery, 
the  registration  of  medical  practitioners,  and 
the  state  of  the  law  in  regard  to  charges  of 
malapraxis.  We  shall  reserve  our  remarks 
upon  the  evidence  until  next  week. 


LOCAL  ANAESTHESIA. - THE  USE  OF  CHLO¬ 

ROFORM  IN  SPASMODIC  CHOLERA. 

Sir, — In  corroboration  of  the  interesting 
views  on  this  subject  so  well  expressed  by 
Professor  Simpson  in  his  communication  to 
your  journal,*  I  may  mention  the  benefit 
derived  from  the  local  use  of  chloroform  to 
relieve  the  cramp  of  the  extremities  in 
cholera. 

It  has  been  of  immediate  and  signal  relief 
in  my  hands.  The  remedy  has  in  some  cases 


acted  like  a  charm.  The  patients,  previous 
to  its  employment,  had  been  suffering  in¬ 
tensely  from  this  painful  symptom, — not 
daring  to  move  a  limb  for  a  moment.  The 
bed-clothes  being  raised  up,  and  a  few  drops 
being  sprinkled  on  the  sheet  under  and 
around  the  limbs,  and  the  vapour  retained 
by  tucking  in  the  bed-clothes,  the  benefit 
has  become  evident  immediately  ;  and  before 
a  few  seconds  have  passed,  the  limbs  have 
been  freely  moved  without  the  superinduc- 
tion  of  the  cramp. 

Notice  is  taken  in  this  communication  of 
Dr.  Simpson  of  the  topical  use  of  carbonic 
acid  gas.  Its  employment  has  in  this 
country  been  had  recourse  to  as  well  as  in 
Italy.  Nearly  thirty  years  ago,  a  clergyman, 
Dr.  Rowe,  at  that  time  resident  at  Bath, 
was  in  the  habit  of  employing  it  under  simi¬ 
lar  circumstances  to  those  in  which  it  was 
employed  by  Dr.  Rossi.  In  one  case,  with 
whose  sad  fate  I  am  well  acquainted — a  case 
of  carcinoma  uteri — it  was  employed  for 
some  months.  It  was  used  thrice  a-day,  and 
for  the  time  was  of  great  benefit  in  allaying 
the  pangs  of  the  sufferer. 

Whilst  on  the  subject  of  local  anaesthesia, 
I  wish  to  remind  the  profession  of  the  great 
advantage  of  belladonna  applied  locally.  A 
solution  of  a  drachm,  or  a  drachm  and  a 
half  of  the  extract,  to  an  ounce  of  water,  is 
a  most  manageable  form  for  its  use. 

This,  painted  freely  with  a  brush  or 
feather  of  a  pen  on  any  part  of  the  surface 
in  pain,  seldom  fails  to  be  of  benefit.  When, 
the  local  sensibility  is  greatly  exalted,  as  in 
gout  and  rheumatism,  it  readily  deadens  it. 
In  milk  fever,  and  at  weaning  time,  its  free 
application  over  the  breast  is  equally  bene¬ 
ficial. 

The  local  paralysis  suspends  the  secretion, 
and  the  mamma,  previously  hard  and  throb¬ 
bing,  become  flaccid  and  free  from  pain. 
Occasionally  I  have  found  it  used  so  vigo¬ 
rously  as  to  occasion  its  specific  influence  on 
the  retina  ;  but  this  was  an  inconvenience 
merely  temporary. — I  am,  sir, 

Your  obedient  servant, 

G.  F.  Girdwood. 

1,  Southwick  Crescent, 

1st  August,  1848. 

DRY  SCRUBBING  IN  HOSPITALS. 

The  editor  of  the  Medical  Gazette  will 
oblige  Chirurgus  by  informing  him  how  the 
dry  scrubbing  in  hospitals  is  effected  to  which 
allusions  have  been  made  at  the  meetings  of 
some  of  the  London  medical  societies. 

August  8,  1848. 

***  We  insert  this  in  order  that  our  cor¬ 
respondent  may  receive  an  answer  from  some 
of  those  who  are  able  to  speak  to  the  com¬ 
parative  merits  of  dry  and  wet  scrubbing. 


*  Page  1076,  July  14th. 


UTILITY  OF  CHLORIDE  OF  ZINC  FOR  ANATOMICAL  PURPOSES.  299 


ON  THE  UTILITY  OF  THE  CHLORIDE  OF  ZINC 

FOR  ANATOMICAL,  SANITARY,  AND  AGRI¬ 
CULTURAL  PURPOSES. 

{From  a  Correspondent.) 

As  reports  made  to,  and  printed  by  order 
of,  the  House  of  Commons,  are  not  likely  to 
fall  under  the  notice  of  our  readers,  we  shall 
give  a  few  extracts  from  those  just  cited, 
which  contain  much  information  of  great 
value  to  the  members  of  the  medical  pro¬ 
fession,  in  their  capacity  of  officers  of  pub¬ 
lic  health  :  confining  our  observations  princi¬ 
pally  to  authenticated  facts  which  demon¬ 
strate  the  varied  utility  of  the  chloride  of 
zinc — a  utility  which  is  daily  becoming  more 
apparent  and  remarkable,  whether  as  a  pre¬ 
servative  of  animal  or  vegetable  tissues,  or 
as  a  decomposing  agent  of  foetid  or  conta¬ 
gious  effluvia. 

In  the  earliest  of  the  reports  abundant 
evidence  is  afforded  that  by  its  employment 
in  hospitals  all  unpleasant  odours  arising 
from  water-closets,  dead  bones,  or  purulent 
discharges,  may  be  destroyed, — that  the 
colour  and  texture  of  parts  for  dissection  are 
abmirably  preserved,  as  are  wet  preparations 
of  morbid  anatomical  specimens,  at  a  price 
infinitely  less  than  that  of  spirits  of  wine. 
Further  reports  bear  upon  the  purifying 
ships  from  the  odour  of  bilge-water  ;  but  as 
this  is  chiefly  interesting  to  our  naval  breth¬ 
ren,  we  merely  extract  the  following  portions 
of  letters  from  Dr.  Sharpey,  Mr.  Pettigrew, 
and  Mr.  Partridge  : — 

“All  our  subjects  are  now  injected  with 
the  fluid  immediately  they  arrive,  and  I  do 
not  hesitate  to  say  that  our  dissecting-room 
is  more  free  from  unpleasant  odour  than 
any  room  of  the  kind  in  the  metropolis  ;  and 
the  great  advantage  this  fluid  possesses  over 
all  otherg  we  have  as  yet  tried  is,  that  it  has 
no  effect  upon  the  knives. 

“  I  cannot  but  consider  it  one  of  the 
greatest  boons  conferred  upon  the  profession. 
Dissections  may  be  carried  on  in  the  hottest 
weather,  without  the  slightest  injury  to 
health,  or  offence  from  smell.” 

*  *  *  * 

“  Further  trials,  and  eighteen  months’ 
further  experience  of  the  use  of  the  anti¬ 
septic  liquor,  have  only  served  to  confirm 
my  conviction  of  its  decided  efficacy  in 
checking  the  putrefaction  of  animal  sub¬ 
stances,  in  permanently  preserving  from 
decay  portions  of  the  animal  body  immersed 
in  it,  and  in  correcting  offensive  smells, 
arising  from  putrescent  animal  matter.” 

*  *  .  * 

“  I  have  now  given  a  careful  and  extended 
trial  to  the  use  of  the  antiseptic,  in  the 
preservation  of  animal  bodies,  and  I  can 
fully  corroborate  the  opinion  which  others 
have  given  of  its  utility.  No  body  is  now 
dissected  at  King’s  College  which  has  not 


been  previously  prepared  by  injecting  your 
antiseptic  into  the  arteries  ;  and  this  pre¬ 
liminary  proceeding  is  not  found  to  interfere 
with  the  subsequent  success  of  the  ordinary 
paint  injection,  which  should  be  thrown  in 
on  the  following  day.  As  the  parts  become 
exposed  in  the  progress  of  dissection,  it  is 
useful  to  moisten  them  with  a  little  of  the 
solution  by  means  of  a  soft  sponge,  and  the 
hollow  viscera  should  be  washed  out  with 
the  solution  by  the  aid  of  a  syringe. 

“  By  these  measures  the  different  struc¬ 
tures  of  the  body  are  fully  and  distinctly 
preserved ;  the  muscles,  however,  become 
paler  and  perhaps  a  little  more  fragile  than 
natural,  but  remain  quite  distinct.” 

In  the  second  report  very  remarkable  facts 
are  brought  forward,  proving  that  ships 
whose  holds  are  purified  by  the  chloride  of 
zinc  are  not  only  rendered  much  more  agree¬ 
able,  but  that  the  proportion  of  sick  is  much 
diminished.  This  is  proved  by  corresponding 
returns  from  ships  of  the  same  class,  on  the 
same  station,  in  which  the  use  of  this  agent 
had  been  both  applied  and  neglected. 

The  greater  part  of  the  two  reports  of  the 
Metropolitan  Sanitary  Commission — or 
rather  of  their  report  and  correspondence — 
relates  to  comparative  trials  of  the  chloride 
of  zinc,  the  nitrate  of  lead,  and  the  chloride 
of  iron,  as  deodorizing  agents  ; — the  Com¬ 
missioners  of  Sewers  having  had  a  series  of 
experiments  performed  on  cesspools,  drains, 
&c.,  with  the  view  of  rendering  the  cleansing 
of  these  receptacles  less  dangerous  to  these 
living  in  the  neighbourhood.  There  can  be 
no  doubt  that  the  noxious  gases  generated 
in  cesspools  not  only  may  be  diffused  in  the 
process  of  cleansing,  but  must  be,  to  a 
greater  or  less  extent,  however  carefully  the 
operation  be  performed :  and  the  effects 
would  vary  with  the  state  of  the  weather,  the 
prevalence  of  an  epidemic,  and  the  bodily 
power  of  the  surrounding  inhabitants. 

It  is,  therefore,  a  fact  of  great  import¬ 
ance,  and  one  which  the  profession  should 
bring  before  the  magistrates  of  their  district, 
that  all  receptacles  of  filth  may  be  emptied 
without  subjecting  neighbouring  persons 
to  inconvenience  or  injury  —  by  properly 
diluting  the  foetid  contents  with  water 
and  a  solution  of  chloride  of  zinc.  The 
public  are  under  great  obligations  to  Sir 
William  Burnett  for  the  establishment  of  this 
important  safeguard  :  these  claims  are  fully 
admitted  by  the  Commissioners  in  their 
report.  It  would  appear,  from  a  series  of 
experiments,  that  the  process  is  as  eco¬ 
nomical  as  any  which  has  yet  been  suggested. 

It  is  of  some  importance  to  agriculturists 
to  know  that  the  use  of  the  chloride  of  zinc 
does  not  injure  the  fertilizing  properties  of 
manure.  Without  entering  into  a  compli¬ 
cated  chemical  question,  the  simple  fact  is 
established  practically  in  a  letter  from  u  Mr. 


300 


PROGRESS  OF  ASIATIC  CHOLERA  IN  EUROPE  AND  ASIA. 


Ferar,  a  farmer  at  Watford,  to  Mr.  Stewart 
Marjoribanks,  shewing  that  a  free  applica¬ 
tion  of  a  dilute  solution  of  the  chloride  of 
zinc  before  sowing,  and  after  the  plants 
■were  above  ground,  greatly  improved  the 
crop.  The  potatoes  were  all  sound  and 
smooth  on  the  surface,  while  of  the  general 
crop,  “  those  not  done  with  the  chloride, 
and  grown  in  the  same  field,  and  some  of 
the  same  variety,  the  produce  in  quantity 
was  equal  to  those  done  with  the  chloride  ; 
but  when  taking  them  up,  I  found  many 
spotted,  some  quite  decayed,  and  a  great 
many  have  gone  bad  since.”  (p.  31). 

Now  that  the  potato  blight  and  its  attend¬ 
ant  miseries  are  again  threatened,  we  need 
not  add  that  our  readers  should  bring  this 
fact  before  their  agricultural  patients.  The 
medical  man  is  never  carrying  out  the  ob¬ 
jects  of  his  mission  more  generously  than 
in  bringing  his  scientific  knowledge  to  bear 
upon  the  improvement  of  the  productions  of 
the  country,  and  the  consequent  welfare  of 
the  industrious  classes. 

Omicron. 

August  1848. 


#Utstcal  SnteUigtnrc* 

THE  PROGRESS  OF  ASIATIC  CHOLERA  IN 
EUROPE  AND  ASIA. 

Six  large  cholera  hospitals  were  opened  in 
St.  Petersburgh  during  the  prevalence  of 


the  cholera, 

and  the  numbers  received  were 

Total 

Of 

under 

Fresh 

these 

Reco-  treat- 

cases. 

died. 

vered.  ment. 

On  July  11 

692 

396 

,,  12 

606 

386 

4006 

„  14 

525 

312 

218  3972 

„  15 

432 

274 

262  3843 

At  Abo  (Grand  Duchy  of  Finland),  on 
the  15th  of  July,  462  persons  had  been  at¬ 
tacked  with  cholera  ;  of  these  225  died,  and 
139  recovered,  or  were  convalescent. 

Since  then  the  cholera  has  disappeared 
from  Finland. 

Pesth. — Several  cases  of  cholera  had  oc¬ 
curred  at  Orsowa,  on  the  14th  of  July. 

Constantinople,  bth  July. — The  cholera, 
which  had  sensibly  increased  during  some 
days,  lessened  in  severity  after  the  occur¬ 
rence  of  a  violent  storm.  There  were  196 
deaths  during  the  last  seven  days.  The  epi¬ 
demic  is  declared  to  be  prevalent  in  Asia 
Minor  and  the  Dardanelles. 

Posen. — The  Kolner  Zeitung  has  a  letter 
from  Posen  of  the  5th  inst.  stating  that  a  case 
of  Asiatic  cholera  had  occurred  in  that  city. 
The  patient — a  woman — was  at  once  con¬ 
veyed  to  the  Cholera  Hospital,  where  it  is 
asserted  she  is  doing  well,  and  likely  to  re¬ 
cover.  Cholera  hospitals  have,  by  order  of 


the  Government,  been  prepared  in  all  the 
Prussian  towns  and  large  villages,  and  every 
care  is  taken  to  lessen  the  horrors  of  the  ap¬ 
proaching  pestilence. 

Letters  from  St.  Petersburgh  of  the  3d 
inst.  state  that  the  cholera  is  gradually  dis¬ 
appearing  in  that  city.  The  cholera  hospi¬ 
tals  have  been  shut  up  by  order  of  the 
Emperor. 

POPULAR  INSTRUCTIONS  FOR  THE  TREAT¬ 
MENT  OF  CHOLERA,  ISSUED  BY  THE 
RUSSIAN  GOVERNMENT. 

Our  readers  will  find  in  our  last  volume, 
page  71 7,  the  instructions  issued  by  the 
medical  department  of  the  Russian  Imperial 
army.  We  now  add  the  following,  which  is 
addressed  to  the  public  : — 

“  It  has  been  remarked  that  just  before 
the  appearance  of  the  cholera  in  a  district,  the 
inhabitants  are  troubled  more  than  usually 
by  diarrhoeas  and  other  complaints,  trifling 
under  ordinary  circumstances,  but  which,  in 
the  presence  of  the  epidemic,  are  apt,  if 
neglected,  to  degenerate  into  real  cholera 
cases. 

“  It  is  well  known,  from  the  experience 
obtained  in  1830  and  1831,  that  the  cholera 
is  in  itself  generally  not  contagious,  but  that 
it  may  become  so,  like  some  other  diseases, 
if  many  sick  are  kept  crowded  together. 

“  The  cholera  has  been  found  to  be  most 
destructive  in  villages  situated  on  low  and 
marshy  grounds,  or  near  bogs  and  stagnant 
pools,  and  particularly  where  the  inhabitants 
are  confined  within  narrow  space,  and  live 
unmindful  of  cleanliness. 

“  It  has  been  further  observed  that  those 
dejected  in  spirits  and  easily  alarmed  are 
more  subject  to  cholera  than  those  who  live 
in  confidence  and  are  of  good  courage. 

“  The  preceding  remarks  having  been 
made,  the  following  are  the  precautions  re¬ 
commended  for  observance  against  cholera: — 
“  To  beware  of  catching  cold,  and  par¬ 
ticularly  to  protect  the  stomach  from  cold, 
for  which  purpose  to  wear  a  broad  belt  of 
cloth  or  stout  flannel  upon  the  skin  around 
the  waist ;  not  to  lie  upon  the  bare  ground, 
nor  to  sleep  at  night  in  the  open  air.  After 
sleep  or  hard  labour,  when  in  perspiration, 
to  drink  no  water  or  other  beverage  cold  ; 
to  drink  no  acid  beverage,  and  never  much 
at  a  draught ;  to  bevrare  of  all  things  of  in¬ 
toxication  ;  to  use  light  food  and  moderately; 
to  eat  no  bread  insufficiently  baked,  no  crude 
vegetables,  no  unripe  fruits,  nor  meat  or 
fish  not  perfectly  fresh,  and  to  abstain  from 
salted  meats  and  pickled  fish  that  provoke 
thirst;  to  keep  .the  person  and  the  dwelling 
clean,  and  to  allow  of  no  sinks  close  to  the 
house,  to  admit  no  poultry  or  animals  within 
the  house,  and  to  keep  it  airy  by  ventilation. 
Where  there  are  sick  let  not  the  place  be 
crowded. 


DEATHS  FROM  ZYMOTIC  DISEASES  IN  THE  METROPOLIS.  301 


“  Notwithstanding  the  best  precautions, 
the  cholera  may  at  times  break  out.  The 
following  are  its  symptoms,  and  the  treat¬ 
ment  to  be  pursued  with  perseverance  and 
confidence : — 

“  A  person  in  good  health  may  be  sud¬ 
denly  attacked  by  cholera  ;  at  first  sickness, 
the  eye-sight  dimmed,  then,  after  a  shiver 
and  rumbling  in  the  bowels,  vomiting  and 
purging,  with  acute  pains  below  the  breast, 
under  the  ribs,  and  on  the  left  side,  attended 
by  quenchless  thirst.  If  the  patient  be  not 
quickly  succoured,  cramps  ensue  in  the  legs 
and  arms,  which  become  of  icy  coldness, 
extreme  weakness  comes  on,  and  a  deadly 
paleness,  the  whole  body  becomes  cold,  then 
a  hiccough,  and  other  signs  of  approaching 
death. 

“  On  the  appearance  of  the  first  symptoms 
let  medical  aid  be  immediately  called,  but  if 
that  cannot  be  obtained,  the  treatment 
necessary  is  as  follows  : — 

“  1.  Let  the  patient  be  warmly  covered. 

“  2.  Let  his  whole  body  be  well  rubbed 
with  warm  vinegar  or  brandy  ;  likewise  his 
hands  and  feet  and  pit  of  the  stomach  with 
clear  tar,  or,  if  none  can  be  had,  with  strong 
brandy. 

“  3.  Let  the  patient  take,  in  frequent  and 
small  quantities,  a  warm  and  light  infusion 
of  mint,  or  of  the  essence  of  mint,  one  or 
two  drops  at  a  time,  with  sugar. 

“  4.  If  there  be  no  abatement  of  pain  or 
vomiting,  a  blister  of  mustard  should  be 
applied  to  the  pit  of  the  stomach. 

“  5.  If  all  the  same  symptoms  still  con¬ 
tinue,  and  the  patient  be  of  a  strong  consti¬ 
tution,  then  apply  leeches  to  the  same  place, 
12  to  20  for  an  adult,  and  for  children  6  to 
10  ;  but,  if  of  a  weak  constitution,  let  no 
leeches  be  used  without  the  advice  of  a 
physician. 

“6.  A  warm  bath,  if  ready  and  near,  may 
be  used  with  benefit,  otherwise  a  vapour 
bath  may  be  prepared  at  home  thus : — Heat 
some  stones  or  bricks,  and  over  them  place 
a  bedstead  with  a  netted  bottom,  upon 
which  let  the  patient  be  stretched,  well 
covered ;  then  throw  the  vinegar  upon  the 
hot  stones,  whence  steam  will  arise  condu¬ 
cive  to  perspiration,  aided  by  the  frictions, 
which  must  not  be  discontinued.  For  want 
of  this  vapour  bath,  place  around  and  in 
contact  with  the  patient  bags  of  heated  sand 
or  ashes. 

“  Observations. — During  the  present  epi¬ 
demic  no  applications  have  been  found  so 
efficacious  as  strong  frictions,  either  with 
the  naked  hand,  with  a  cloth,  or  with  a 
brush,  using  clean  tar  or  some  other  irritant. 
The  essence  of  peppermint  may  be  used 
more  freely  than  heretofore  prescribed. 

“  Great  care  must  be  observed  during 
convalescence,  for  the  cholera  is  but  often 
followed  by  typhus  fever.” 


DEATHS  FROM  ZYMOTIC  DISEASES  IN  THE 
METROPOLIS  DURING  THE  LAST 
QUARTER. 

The  following  statement,  extracted  from  the 
Registrar-General’s  returns,  shews  the  pro¬ 
gress  of  epidemic,  endemic,  or  zymotic  dis¬ 
eases  in  the  metropolis  during  the  last 
quarter  : — 


Cause  of  death. 

Total. 

Weekly 
average  de¬ 
rived  from 
deaths  of 
1843-4-5-6-7. 

Zymotic,  Epidemic,  or 

Endemic  Diseases. 

Week  ending  April  22... 

252 

176 

„  29... 

238 

176 

,,  May  6... 

271 

271 

„  13... 

263 

271 

„  20... 

269 

176 

„  27... 

286 

176 

,,  June  3... 

278 

176 

„  10... 

294 

176 

„  17... 

289 

176 

, ,  24 . . . 

310 

176 

„  July  1... 

347 

176 

,,  8... 

338 

257 

,,  15... 

319 

257 

„  22... 

390 

257 

„  29... 

505 

257 

4649 

3154 

Excess  in  15  weeks,  1495. 


Cause  of 

For  the 

For  the 

Weekly 

death. 

week  end- 

week  end- 

average  of 

ingJuly22. 

ingJuly29. 

5  summers. 

Diarrhoea... 

94 

173 

66 

Cholera  ... 

21 

26 

7 

Deaths  from  excess  of  diarrhoea  in 
the  two  last  weeks  .  .  .  .135 

Excess  of  deaths  from  cholera  in 
the  two  last  weeks  ....  33 

CAUSES  OF  THE  SICKNESS  AND  MORTALITY 
AMONG  THE  EMIGRANTS  OF  1847- 

The  sickness  and  mortality  were  almost 
entirely  from  fever  (typhus  fever,  and  that 
variety  of  it  called  ship-fever)  and  dysentery  ; 
and  in  some  of  the  ships  sailing  from  ports 
in  Ireland,  or  from  Liverpool,  with  Irish 
emigrants,  we  may  reasonably  suppose  that 
some  of  the  passengers  might  embark  in¬ 
fected  with  typhus,  and  this  would,  in  a 
week  or  so,  develope  itself,  and  afterwards 
spread  among  the  passengers.  Dysentery 
arises  sometimes  from  improper  and  imper¬ 
fectly  cooked  food,  and  in  certain  circum¬ 
stances  it  also  is  occasionally  infectious,  so 
that  it  would  perhaps  spread  in  the  same 
way  as  the  fever. 


302 


INFLUENCE  OF  CELIBACY  ON  MORTALITY. 


The  spreading  of  these  diseases  would 
have  been  much  less  if  it  had  not  been  aided 
by  want  of  medical  advice,  an  over-crowded 
state  of  the  ship,  an  absence  of  due  cleanli¬ 
ness,  want  of  exercise  on  deck,  and  of  proper 
cooking  of  the  food. 

But,  on  the  other  hand,  in  many  of  the 
ships,  there  is  no  reason  to  suppose  that 
typhus,  or  its  infection,  or  dysentery,  was 
embarked,  and  the  fever  which  appeared 
after  leaving  port  is  sufficiently  accounted 
for  by  the  over-crowding  and  the  deficient 
ventilation,  aided  by  the  predisposing  cause 
of  low  diet.  Fever  arising  in  this  way 
afterwards  spreads  by  infection,  and  so  the 
remaining  passengers  ran  two  chances  of 
being  taken  ill — that  is,  from  the  original 
cause,  and  from  infection. 

The  same  remark  may  be  made  regarding 
the  dysentery  :  it  would,  in  the  first  instance, 
arise  from  the  uncooked  victuals  and  im¬ 
proper  diet,  and  would  then  both  continue 
to  be  produced  by  the  original  cause,  and, 
perhaps,  also  be  communicated  by  infection.* 
The  sickness  from  embarked  typhus,  or  its 
infection,  and  from  dysentery,  might  have 
been  much  checked,  and  the  sickness  from 
typhus  or  dysentery,  springing  up  on  board, 
might  have  been  prevented  by  proper  regu¬ 
lations.  In  some  ships,  from  obstacles 
thrown  in  their  way  with  regard  to  cooking, 
and  in  others,  from  laziness,  carelessness,  or 
whatever  it  may  be  called,  the  passengers 
often  did  not  cook  their  provisions  at  all. 
In  others,  in  obeying  the  calls  of  nature, 
they  invariably  did  so  into  the  hold,  and 
sometimes  would  not  even  leave  their 
sleeping-berths ;  sometimes  they  would  not 
allow  the  captain  or  crew  to  come  down 
among  them,  afraid  of  being  forced  to  wash, 
and  to  go  on  deck;  in  others,  again,  they 
were  smoked  out,  and  so  forced  to  go  on 
deck  ;  and,  however  well  intended  on  the 
part  of  the  master  this  may  have  been,  it 
cannot  be  forgotten  that  some,  and  perhaps 
many,  may  have  been  too  weak  either  to 
move  or  even  to  be  moved.  Considering  all 
these  things,  instead  of  wondering  that  the 
mortality  was  so  great,  we  may  feel  surprised 
that  it  was  not  greater. — Dr.  Stratton. 

I NFLUENCE  OF  CELIBACY  ON  MORTALITY. 

Dr.  Mayer  of  Besan^on,  has  recently  com¬ 
pared  the  rate  of  mortality  among  persons 
who  have  taken  the  religious  vow  of  celibacy, 
and  lay-individuals  occupied  in  the  different 
professions  of  society.  The  results  at  which 
he  has  arrived  are — 

1.  For  a  period  of  ten  years,  i.  e.  from  the 
age  of  sixteen  to  twenty-five  years,  the  rate 
of  mortality  is  2.68  per  cent,  among  monks 

*  Some  physicians  consider  that  dysentery  is 
not  infectious  ;  others  that  it  is  so  occasionally  ; 
and  others,  again,  that  it  is  so  only  when  com¬ 
plicated  with  infectious  fever. 


and  nuns  of  different  orders ;  while  it 
amounts  to  only  1*48  per  cent,  among  lay- 
individuals  of  the  two  sexes. 

2.  For  a  period  of  ten  years,  comprised 
between  the  thirty-first  and  fortieth  year, 
the  mortality  is  4 '4  per  cent,  among  monks 
and  nuns,  and  2*74  percent,  among  the  lay- 
portion  of  the  community. 

These  results  are  similar  to  those  obtained 
by  Deparcieux,  in  1746.  Dr.  Mayer  is  in¬ 
clined  to  think  that  they  do  not  justify  the 
inference,  that  the  exercise  of  the  sexual 
functions  has  any  influence  on  the  health  or 
duration  of  life  either  among  males  or 
females.  Celibacy  in  his  opinion  is  not  in¬ 
jurious,  but  on  the  contrary  favourable  to  a 
state  of  health  and  longevity.  He  considers 
that  the  differences  indicated  by  the  figures 
are  really  owing  to  the  influence  of  confine¬ 
ment,  and  the  want  of  mental  and  bodily 
occupation. 

INFLUENCE  OF  THE  CLIMATE  OF  ALGIERS 
ON  EUROPEAN  CONSTITUTIONS. 

According  to  M.  Boudin,  the  annual 
deaths  in  France  are,  23’6  to  1000  inhabi¬ 
tants.  The  population  of  the  province  of 
Algiers,  may  be  divided  into  Jews,  Maho¬ 
metans,  and  Europeans,  chiefly  French. 
The  deaths  in  1000  of  the  population  were, 
in 


1844 

1845 

Jews  . 

21-6  ... 

...  36-1 

Mahometans 

32-4  ... 

...  40-8 

Europeans ... 

42  9  ... 

...  45-5 

In  some  of  the  towns  the  deaths  of 
Europeans  reach  a  still  higher  number. 
Thus,  while  in  Algiers  they  are  36'4  to  1000 
of  the  population,  they  are — 


At  Oran . 

41*5 

Philippeville  . 

55-3 

Mustapha  . 

62-1 

Fondruck  . 

65' 

Blidah  . 

66-2 

El  Arouch . 

141*4 

The  latter  place  may  be  called  the  French 

man  s  grave. 

THE  BRITISH  ASSOCIATION 

FOR  THE 

ADVANCEMENT  OF  SCIENCE. 

The  meeting  of  this  Association  commenced 
at  Swansea,  on  Wednesday,  the  9th  inst. 
Sir  R.  H.  Inglis  took  the  chair,  which  he 
subsequently  resigned  to  the  Marquis  of 
Northampton,  who  is  the  elected  president 
of  the  meeting.  The  noble  Marquis  deli¬ 
vered  the  usual  address  on  the  benefits  con¬ 
ferred  by  the  society  on  the  nation,  in  a 
scientific  point  of  view  ;  and  on  the  general 
prospects  of  the  Association.  From  the 
financial  statement,  it  would  appear  that  the 
annual  subscriptions  have  fallen  off  consi¬ 
derably,  and  are  now  of  a  very  limited 


CONSUMPTION  OF  OPIUM.  ALLEGED  POISONING  OF  FISH.  303 


amount.  The  scientific  grants  had  almost 
drained  that  portion  of  the  life  subscriptions 
which  had  been  funded  ;  and  the  conse¬ 
quence  has  been  that  for  several  years  the 
expenditure  has  exceeded  the  income.  In 
order  to  restore  the  finances,  the  noble 
Marquis  suggested  that  the  visits  of  the 
Association  should  be  made  to  the  great  seats 
of  population  and  industry,  where  there  is 
likely  to  be  a  great  accession  of  annual  sub¬ 
scribers.  A  hint  was  also  thrown  out  that 
the  Association  might  find  it  necessary  to 
appeal  to  the  generosity  of  its  members. 

In  our  view,  a  most  undue  proportion  of 
the  funds  has  been  spent  on  astronomical 
and  tidal  observations.  Other  branches  of 
science  have  received  but  a  very  small  share 
of  the  subscriptions  for  their  encouragement. 
An  appeal  should,  therefore,  in  the  first 
instance,  be  made  to  the  generosity  of  the 
astronomers,  and  the  mathematical  members 
of  the  Association. 

TAPE-WORM  IN  FISH. 

M.  Ancelon  mentions  the  singular  fact, 
that  in  lately  examining  a  small  fish,  known 
under  the  name  of  rousse,  he  found  a  taenia 
about  eleven  inches  in  length,  precisely  re¬ 
sembling  the  entozoon  found  in  the  human 
intestines.  The  only  difference  was,  that 
the  head  instead  of  terminating  in  a  long  and 
very  narrow  neck,  ended  in  a  point  which 
the  animal  could  elongate  or  contract  at  will. 
He  was  unable  to  discover  any  trace  of  a 
mouth. 

THE  DEIAMBA  OR  CONGO  TOBACCO.  ANEW 
NARCOTIC. 

The  Deiamba  or  Congo  tobacco  is  a  plant 
which  grows  wild  on  the  marshy  banks  of 
the  Congo  or  Zaira.  When  full  grown  it  is 
six  or  seven  feet  in  height.  Its  long  spread¬ 
ing  branches  are  covered  with  small  leaves 
about  three  inches  long,  and  beneath  these 
are  the  flowers  containing  the  seeds.  These 
flowers  are  exposed  to  the  sun  for  several 
days,  and  dried  before  use.  If  when  smoked 
the  vapour  be  swallowed,  symptoms  of 
narcotic  poisoning  appear.  The  deiamba  is 
well  known  to  all  the  Portuguese  residents 
on  the  African  coasts.  It  is  used  by  the 
natives  both  as  an  article  of  luxury,  and  as  a 
medicine. 

CONSUMPTION  OF  OPIUM  IN  ENGLAND. 

The  monthly  returns  of  the  Board  of  Trade, 
issued  on  the  10th  inst.,  show  that  the  con¬ 
sumption  of  opium  has  largely  increased. 
In  the  first  half  of  1846,  it  was  9,300  lb.  ; 
in  that  of  1847,  it  was  27,208  lb.  ;  and  in 
1848,  it  has  been  36,985  lb. 

ROYAL  COLLEGE  OF  SURGEONS. 

Gentlemen  admitted  Members  on  the  31st 
ult. — J.  Dixon — J.  C.  Carver  —  E.  B. 
Machin — L.  Richardson — D.  H.  G.  Wild- 


boor- — J.  H.  Hemming — G.  M.  Burton — T. 
M.  Harding — C.  Drew. 

Gentlemen  admitted  Members  on  Friday, 
the  list  inst. — J.  Croston — T.  Crocker — L. 
Armstrong — R.  Thomason — G.  H.  Cook — 
F.  C.  F.  Malden — A.  Crompton — J.  G. 
Smith. 

Admitted  on  Monday,  August  14. — J.  S. 
Garthon — F.  Y.  Toms — J.  J.  Cooke — W. 
C.  May — W.  T.  H.  Burrow — E.  G.  Chap¬ 
man — T.  Michell. 

APOTHECARIES’  HALL. 

Names  of  Gentlemen  who  passed  their  ex¬ 
amination  in  the  Science  and  Practice  of 
Medicine,  and  received  certificates  to  prac¬ 
tise,  on  Thursday,  10th  August,  1848. — 
George  Keer,  Parham,  Suffolk — Leonard 
Armstrong,  Hexham,  Northumberland — 
William  Charles  Lake,  Teignmouth,  Devon — 
Frederic  Sopwith,  Tonbridge  Wells — James 
Ogden  Fletcher,  Manchester. 

OBITUARY. 

At  Kingston,  Jamaica,  on  the  20th  of 
June,  William  Arnold,  Esq.,  M.D.  F.R.S. 
&c.,  in  the  58th  year  of  his  age. 

On  the  14th  inst.,  at  Crewkerne,  Somer¬ 
setshire,  in  his  44th  year,  Edward  Silvester 
Burnard,  Esq.,  Surgeon. 


elections  from  pinnate. 


ALLEGED  POISONING  OF  FISH.  JUDICIAL 
EXAMINATION. 

It  was  supposed  that  some  fish  in  a  pond 
belonging  to  M.  Bourcy  had  been  wilfully 
poisoned  :  and  the  bodies  of  twyo  carp  were 
sent  to  MM.  Ancelon  and  Parisot  for  exa¬ 
mination.  The  intestinal  tube  in  each  fish 
was  empty,  pale,  and  free  from  any  trace  of 
inflammation.  The  other  viscera,  as  well  as 
the  air  bladder,  were  in  a  normal  state  :  the 
gills  were  of  a  deep  red  colour.  An  alcoholic 
extract  was  made  of  the  intestinal  tube,  but 
the  only  residue  procured  was  fatty  matter. 
The  substance  left  undissolved  by  alcohol 
was  treated  with  diluted  sulphuric  acid.  A 
colourless  acid  liquid  was  thus  procured, 
which  was  free  from  any  bitter  taste.  The 
surplus  acid  was  neutralized  by  carbonate  of 
lime  evaporated  to  dryness,  and  the  residue 
digested  repeatedly  in  alcohol.  The  alcoholic 
liquids  when  mixed  had  no  bitter  taste,  nor 
did  they  leave  any  bitter  residue.  A  part  of 
the  solid  extract  did  not  acquire  an  orange 
yellow  colour  when  it  was  treated  with  nitric 
acid.  The  residue  of  the  two  fish  was  carbo¬ 
nized  by  nitric  acid :  the  carbonaceous 
matter  gave,  with  distilled  water,  a  yellowish 
coloured  liquid,  which  was  submitted  to  the 
processes  of  Reinsch  and  Marsh,  and  to  a 
current  of  sulphuretted  hydrogen  gas,  with¬ 
out  yielding  any  evidence  of  the  presence  of 
arsenic. 

Some  carp  were  now  poisoned  by  throw- 


304  DICEPHALOUS  MONSTER.  USE  OF  CHLOROFORM  IN  SURGERY. 


ing  to  them  paste  balls  containing  cocculus 
indicus,  like  those  employed  by  poachers. 
It  was  observed  that  this  poison  began  to 
aet  on  the  fish  in  about  two  hours  :  and  the 
symptoms  were  irregular  motions  of  the 
body,  followed  by  a  kind  of  stupor  and  blind¬ 
ness.  The  fish  died  in  fifteen  or  twenty 
hours.  The  scales  had  lost  their  natural 
colour ;  the  gills  were  very  red ;  the  heart 
was  gorged  with  dark-coloured  blood  ;  the 
intestinal  tube  was  inflamed  throughout,  and 
filled  with  a  bloody  liquid. 

Nucc  vomica  was  found  to  operate  more 
slowly,  and  with  symptoms  of  a  less  marked 
character,  probably  owing  to  the  vomiting 
induced.  In  spite  of  the  administration  of 
repeated  doses,  this  poison  did  not  kill  the 
fish  until  after  the  lapse  of  from  twenty -four 
to  thirty-six  hours.  The  fish  when  affected 
by  it  assumed  a  vertical  position  ;  the  tail 
became  paralysed,  but  the  dorsal  fin  became 
exquisitely  sensible.  The  intestinal  tube  was 
inflamed,  and  contained  a  bloody  liquid,  as 
in  the  case  of  poisoning  by  cocculus  indicus. 

The  conclusions  drawn  by  the  reporters 
were : — 

1.  That  from  the  state  of  the  viscera  in 
the  carp  there  was  nothing  to  indicate  death 
from  poison. 

2.  That  no  poison  could  be  detected  by 
chemical  processes. 

3.  That  the  fish  had  probably  died  from 
the  effect  of  the  high  temperature  which  had 
recently  prevailed. — L' Union  Medicale. 

A  DICEPHALOUS  MONSTER  WITH  ONE  HEAD 
BLACK  AND  THE  OTHER  WHITE. 

M.  Prus  has  recently  addressed  to  the 
Medical  Society  of  Paris,  a  communication 
on  a  singular  case  of  monstrosity,  which 
occurred  at  Alexandria.  The  monster,  which 
was  born  dead,  had  two  heads  attached  to 
one  trunk.  The  heads  were  well  formed  : 
one  was  white,  and  appeared  to  correspond 
to  about  the  eighth  month  of  uterine  life ; 
the  other  was  black,  of  larger  size,  and  had 
apparently  reached  maturity.  In  other  re¬ 
spects,  the  child  which  was  a  male  was  nor¬ 
mally  developed.  The  shoulders,  trunk,  and 
upper  and  lower  extremities,  were  white. 
The  nails  were  imperfectly  formed,  and  re¬ 
sembled  those  of  an  immature  child.  The 
alteration  in  the  colour  of  the  skin  com¬ 
menced  about  the  level  of  the  neck  of  the 
black  head.  It  was  here  brown,  becoming 
gradually  deeper,  and  passing  imperceptibly 
to  a  deep  black,  extending  over  the  whole  of 
the  head  and  face.  M.  Prus  made  a  careful 
examination,  and  satisfied  himself  that  the 
change  of  colour  was  not  owing  to  any 
naevus, sanguineous  congestion,  or  other  mor¬ 
bid  condition.  When  the  epidermis  was  re¬ 
moved,  there  was  a  thick  layer  of  pigmentum 
nigrum  in  the  mucous  tissue  of  the  skin. 
He  therefore  referred  this  head  to  the  negro- 


type — an  inference  which  was  justified  by 
its  form  and  general  aspect.  The  parents 
were, fellahs — the  mother  was  from  25  to  30 
years  of  age  ;  and  the  father  about  30,  a 
labourer  in  the  port  of  Alexandria.  Like 
all  individuals  of  this  tribe,  they  had  a  brown 
skin,  with  a  yellowish  tint.  The  woman 
died  soon  after  her  delivery  :  she  had  pre¬ 
viously  had  five  well-formed  children,  of 
whom  four  had  been  born  dead. 

The  physiological  questions  which  arise  in 
respect  to  this  monster  are  difficult  of  solu¬ 
tion.  Did  the  two  heads  belong  to  different 
types,  fellah  and  negro  ?  Is  it  a  case  of 
superfoetation  in  which  two  ova  have  been  se¬ 
parately  fecundated,  the  one  by  a  negro,  and 
the  other  by  a  white;  the  ova  becoming 
fused  with  the  exception  of  the  two  heads  ? 
If  this  were  the  case,  it  is  difficult  to  under¬ 
stand  why  some  portion  of  the  skin  of  the 
trunk  and  extremities  should  not  have  been 
equally  black.  M.  Prus  remarks,  that  there 
are  negro  labourers  in  the  port  of  Alexandria, 
but  he  could  not  ascertain  whether  the 
mother  had  had  intercourse  with  one  of  that 
race.  A  committee  has  been  appointed  by 
the  Society,  to  draw  up  a  report  upon  this 
very  remarkable  case. — V  Union  Medicale . 

ON  THE  USE  OF  CHLOROFORM  IN  SURGERY. 

BY  M.  VALLEIX,  PHYSICIAN  TO  THE 

HOTEL  DIEU. 

[We  extract  the  following  communication 
from  a  late  number  of  the  Union  Medicale.] 

The  case  of  death  during  the  inhalation  of 
chloroform  which  has  been  presented  to  the 
Academy  of  Medicine  by  M.  Gorre,  and  the 
discussion  to  which  that  communication  gave 
rise,  prove,  it  appears  to  me,  that  if  the 
question  of  etherization  has  been  perfectly 
studied  experimentally  and  physiologically, 
it  has  not  been  so  practically.  I  do  not  see, 
in  fact,  any  mention  of  the  three  stages  of 
etherization,  whether  with  ether  or  chloro¬ 
form  ;  it  is  only  by  possessing  a  perfect 
knowledge  of  those  stages,  that  one  can 
practise  etherization  with  the  necessary 
safety. 

I  am  far  from  attributing  the  terrible 
accident,  of  which  M.  Gorre’s  patient  has 
been  the  victim,  to  any  defect  of  attention 
or  observation ;  it  appears  to  me,  as  well  as 
to  M.  Roux,  on  the  contrary,  to  result,  from 
the  details  furnished  by  that  surgeon,  for¬ 
merly  a  very  distinguished  interne  of  the  Pa¬ 
risian  hospitals,  that  the  cause  of  death  must 
be  sought  for  elsewhere  than  in  the  inhala¬ 
tion  of  chloroform.  But  it  appears  to  me 
that  many  medical  men  want  an  exact  appre¬ 
ciation  of  the  phenomena  produced  by  chlo¬ 
roform  ;  that  the  unfortunate  case  just  re¬ 
lated  is  one  of  a  nature  to  inspire  lively  fears 
in  those  not  familiarised  to  the  use  of  this 
substance ;  and  that  it  would  be  well  to  take 
this  opportunity  to  specify  the  signs  which 


M.  VALLE1X  ON  THE  USE  OF  CHLOROFORM  IN  SURGERY. 


305 


announce  the  degree  of  etherization,  and  the 
moment  when  it  should  be  arrested.  If  all 
this  can  be  rigorously  determined,  one  need 
no  longer  fear  the  painful  doubt  remaining 
in  the  mind  after  sudden  death  in  the  course 
of  operation ;  and  if  the  moment  when  we 
ought  to  discontinue  the  chloroform  has  been 
well  observed,  or  if  the  stages  are  regularly 
shown,  we  shall  be  able  to  say,  with  a  cer¬ 
tainty  almost  mathematical,  whether  the 
death  ought  or  ought  not  to  be  attributed  to 
etherization.  If  these  rules  had  been  well 
established,  M.  Gorre  would  not  have  pro¬ 
scribed  the  use  of  chloroform  in  so  many 
operations. 

For  myself,  who  have  employed  etheriza¬ 
tion  in  a  very  great  number  of  painful 
but  slight  operations  (as  cauterization  and 
moxas),  I  am  not  at  all  disposed  to  give  it  up, 
for  I  have  always  been  able  to  arrest  its  ac¬ 
tion  in  time.  I  am  about  to  give  the  result  of 
my  experience.  There  is  doubtless  nothing 
new  in  what  I  am  about  to  say,  but  I  believe 
that  there  will  be  found  in  the  following  ex¬ 
pose  a  little  more  precision  than  in  the  usual 
descriptions  ;  and  it  is  exactly  this  precision 
that  is  important.  It  is  with  the  employ¬ 
ment  of  chloroform  as  with  the  administra¬ 
tion  of  certain  very  active  poisons  :  we  ought, 
before  giving  them,  to  know  exactly  what 
phenomena  they  produce,  so  as  to  stop  just 
at  the  moment  when  the  therapeutical  action 
ceases  and  the  poisonous  begins,  otherwise 
we  are  liable  to  the  most  serious  results. 

Ether  and  chloroform  produce  exactly  the 
same  phenomena,  only  the  latter  acts  with 
an  incomparably  greater,  sometimes  an  ex¬ 
treme,  rapidity.  But,  even  in  these  latter 
cases,  we  may  observe  three  marked  stages. 

In  the  first  stage,  the  phenomena  of  suffo¬ 
cation  first  show  themselves,  and  then  of 
stupefaction.  The  patient  struggles,  but  his 
movements  are  still  subject  to  his  will :  thus 
■we  often  see  him  carry  his  hands  to  the  ap¬ 
paratus  to  withdraw  it  from  his  mouth,  and 
push  aside  those  engaged  in  the  inhalation. 
He  still  answers  questions,  and  usually  com¬ 
plains  of  a  humming  noise  or  sound  like  the 
wheels  of  a  water-mill.  Sensibility  remains. 

In  the  second  stage,  he  can  still  speak, 
but  he  no  longer  answers  questions :  he 
speaks  of  very  different  things,  which  have  no 
relation  to  surrounding  objects ;  it  is  a  true 
delirium,  absolutely  like  that  of  drunken¬ 
ness.  Sometimes  there  are  neither  cries, 
nor  songs,  nor  loquacity ;  but  we  notice  a 
phenomenon  which  is  never  absent, — it  is  a 
stiffening  of  all  the  limbs ;  sometimes,  also, 
violent  efforts  are  made  by  the  patient  to 
escape  from  those  who  hold  him. 

Finally,  the  beginning  of  the  third  period 
is  marked  by  one  or  several  deep  inspira¬ 
tions,  and  the  rapid  relaxation  of  the  limbs. 

Experience,  then,  has  shown  me  that  while 
the  patient  is  in  the  two  first  stages  there  is 


|  nothing  to  fear  for  him  ;  but,  on  the  con¬ 
trary,  when  he  arrives  at  the  third  stage,  we 
must  immediately  discontinue  the  inhalation  : 
bad  effects  may  come  so  quickly  at  this  mo¬ 
ment,  that  we  may  find  it  difficult  to  bring 
the  patient  to  himself.  This  occurred  to  me 
several  times  formerly,  but  not  since  I  have 
been  accustomed  to  watch  attentively  for  the 
moment  I  have  pointed  out. 

What  renders  this  surveillance  difficult  is* 
as  I  have  said  above,  that  the  progress  of 
the  two  first  stages  may  be  excessively  rapid  ; 
I  have  seen  it  scarcely  half  a  minute.  This 
time  is  so  short,  that  one  might  believe  the 
first  stage  not  yet  passed,  although  the  third 
has  already  arrived.  This  is  the  danger.  A 
very  attentive  examination  is  necessary  to 
recognise  this  point. 

I  think  that  medical  men  who  have  not 
yet  practised  etherization,  ought  at  first  to 
study  these  stages  from  the  action  of  ether. 
It  will  occupy  them  some  minutes  longer, 
but  they  will  see  the  stages  succeed  each 
other  very  distinctly,  and  they  will  easily 
recognise  them  during  the  action  of  chloro¬ 
form. 

It  will  necessarily  lessen  the  danger,  if 
the  operation  be  commenced  before  the  third 
period  manifests  itself.  We  know  that  this 
produces  no  inconvenience,  for  if  the  patients 
do  cry,  they  have  but  a  very  indistinct  con¬ 
sciousness  of  the  pain  they  undergo ;  they 
suffer  as  if  in  a  dream,  and  that  can  have  no 
injurious  influence. 

As  to  slight  operations,  if  there  be  any 
fear,  it  is  only  needful  to  perform  them  dur¬ 
ing  the  second  period ;  the  trifling  concern 
of  the  patient  after  the  operation, — on  the 
contrary,  his  air  of  gaiety, — prove,  in  fact, 
that  he  has  experienced  very  little  pain. 

Finally,  in  great  opei’ations,  etherization 
ought  to  be  confided  to  some  one  who  will 
not  allow  his  attention  to  be  distracted  by 
the  operation,  or  it  may  be  well  to  wait 
until  the  beginning  of  the  third  stage,  and 
then  remove  the  inhaling  apparatus  before 
beginning  the  operation. 

What  makes  me  think  that,  in  the  case 
related  by  M.  Gorre,  there  was  some  special 
cause  of  death,  is  this,  that  insensibility 
supervened  immediately,  and  while  the  pa¬ 
tient  was  in  the  act  of  speaking,  that  is  to 
say,  in  the  first  stage.  Sudden  and  unex¬ 
pected  death  is  more  frequent  than  is  usually 
supposed  ;  and  not  only  may  it  be  produced 
by  very  slight  causes,  but  it  may  cccur  with¬ 
out  any  assignable  cause.  MM.  Roux  and 
Velpeau  have  acted  wisely  in  throwing  doubt 
on  the  fatal  action  of  chloroform  in  this  un¬ 
fortunate  case.  The  employment  of  this 
substance  is  become  more  precious,  since,  by 
statistics,  we  have  learned  that  the  results  of 
operations  are  markedly  more  favourable 
when  they  are  performed  under  its  influence. 
We  ought  only  to  admit,  after  the  most  at- 


30C 


DR.  JUNGKEN  ON  THE  INFLUENCE  OF  THE  VAPOUR  OF 


tentive  examination,  and  after  having  sub¬ 
mitted  them  to  the  most  severe  criticism, 
those  cases  which  would  tend  to  make  us 
reject  from  the  practice  of  surgery  this,  the 
so  precious  discovery  of  our  day. 

Valleix, 

Physician  to  the  Hotel  Dieu. 

From  M.  Valleix’s  letter,  it  appears  that 
the  successive  stages  of  chloroform,  so 
thoroughly  understood  here,  have  not  yet 
been  recognised  in  France,  where  this  com¬ 
munication  will  be  of  service. 

M.  Valleix’s  first  stage  is  evidently  the 
combined  effect  of  chloroform  too  suddenly 
administered,  and  of  the  want  of  a  proper 
supply  of  air.  It  is  very  seldom  observed 
here  that  the  patient  feels  suffocated,  com¬ 
plains  of  tinnitus  aurium,  or  attempts  to 
push  aside  the  inhaler.  It  appears  that 
French  inhalers  admit  an  imperfect  supply 
of  air,  like  the  early  English  ether  inhalers  ; 
and  that,  in  France,  the  chloroform  is  given 
of  the  full  strength  at  first ;  hence  the  sense 
of  choaking,  and  the  attempts  to  withdraw 
the  apparatus. 

.  M.  Valleix’s  second  stage  corresponds  ex¬ 
actly  to  our  second  and  third  stages  of  chlo- 
roformization.  The  first,  with  us,  being  the 
stage  of  excitement ;  the  second,  that  of  in¬ 
toxication  ;  the  third,  that  in  which  there  is 
unconsciousness,  stiffening  of  the  limbs,  and, 
in  most  instances,  contraction  of  the  pupils. 
The  latter  part  of  this  third  stage,  that  of 
sopor,  is  the  proper  time  to  commence 
operating. 

M.  Valleix’s  third  stage  is  our  fourth, 
being  that  of  complete  muscular  relaxation, 
dilatation  of  pupil,  and,  in  fact,  coma;  it 
is,  in  truth,  the  stage  of  danger,  and  ought 
only  to  be  reached  in  attempting  to  reduce 
hernia  or  dislocations. 

The  successive  stages  pass  gradually  one 
into  the  other. 

If  chloroform  is  to  be  used  in  the  severe 
minor  surgery  of  cauterization  and  moxas, 
so  seldom  resorted  to  here,  it  is  well  that  the 
exhibition  should  only  be  pushed  to  the  state 
of  semi-consciousness,  as  M.  Valleix  ad¬ 
vises.  This  will  not,  however,  answer  in 
dental  and  minor  operations  :  in  minor  ope¬ 
rations,  the  patient  should  be  quiet ;  and  in 
dental  surgery,  the  chloroform  must  be 
pushed  to  the  stage  of  relaxation  or  that  of 
danger,  as  the  stiffening  of  the  muscles  of 
the  jaw  must  be  overcome  before  the  opera¬ 
tion  can  commence — an  insuperable  objec¬ 
tion  to  chloroformization  in  such  cases. 

M.  Valleix,  and  the  French  surgeons 
generally,  do  not  seem  to  recognise  or  bear 
in  mind  Dr.  Snow’s  important  discovery  of 
the  accumulative  effects  of  chloroform. 

2 


INFLUENCE  OF  THE  VAPOUR  OF  PHOSPHO¬ 
RUS  IN  PRODUCING  NECROSIS  OF  THE 
JAW.  UY  DR.  JUNGKEN. 

It  having  latterly  become  a  subject  of  fre¬ 
quent  observation  that  the  workmen  en¬ 
gaged  in  the  manufacture  of  lucifer  matches 
are  liable  to  be  affected  with  necrosis  of  the 
jaw,  and  a  suspicion  having  in  consequence 
arisen  that  the  disease  was  excited  by  the 
vapours  of  the  phosphorus  employed  in  this 
species  of  manufacture,  Dr.  Jiingken  has 
been  lately  investigating  the  subject  with 
considerable  care.  The  disease  by  which 
the  fabricators  of  phosphorus  matches  are 
frequently  attacked  appears  to  be  ordinary 
necrosis  affecting  a  portion  or  the  whole  of 
the  jaw-bone.  The  dead  bone  usually  ex¬ 
cites  inflammation  and  suppuration  of  the 
surrounding  parts,  and  in  unhealthy  persons 
is  frequently  followed  by  a  cachectic  state 
which  may  prove  fatal.  This  affection  is, 
however,  by  no  means  confined  to  workmen 
engaged  in  this  species  of  manufacture  :  it 
was  observed  before  phosphorus  matches 
were  made,  and  it  occurs  also  among  arti- 
zans  employed  in  other  occupations.  Hav¬ 
ing  alluded  to  the  various  circumstances 
which  are  usually  supposed  to  occasion  ne¬ 
crosis  of  the  jaw,  such  as  mechanical  or 
chemical  injuries,  the  presence  of  carious 
teeth,  and  the  like,  and  having  described  the 
various  phenomena  by  which  the  progress 
and  termination  of  the  disease  is  charac¬ 
terised,  Dr.  Jiingken  proceeds  to  inquire 
whether  any  other  than  the  ordinary  causes 
of  the  affection  occur  to  persons  employed 
in  the  making  of  phosphorus  matches.  This 
species  of  manufacture  being  very  easy,  and 
requiring  no  great  expenditure  of  strength, 
and  consequent  fatigue,  is  usually  followed 
by  individuals  who  by  their  physical  weak¬ 
ness  are  incapacitated  from  more  laborious 
occupations.  Hence  persons  of  a  cachectic 
habit  of  body,  and  belonging  to  the  female 
sex,  are  very  commonly  employed  in  it.  Of 
those  whom  Dr.  Jiingken  found  to  become 
affected  with  necrosis  of  the  jaw,  the  majority 
had  already  suffered,  before  they  entered 
upon  this  occupation,  from  caries  of  the 
teeth  and  from  rheumatic  affections,  espe¬ 
cially  rheumatic  pains  of  the  teeth.  Many 
of  them  had  in  consequence  lost  several  of 
their  teeth  by  extraction.  In  some  of  the 
individuals  the  rheumatic  pains  of  the  teeth 
had  ensued  more  frequently,  and  with 
greater  severity,  after  they  had  become  en¬ 
gaged  in  the  manufacture  of  matches  ;  and 
in  some  cases  were  severe  enough  to  lead  to 
the  extraction  of  diseased  teeth.  In  these 
cases  the  necrosis  of  the  jaw  frequently 
commenced  shortly  after  the  extraction  of 
the  teeth  ;  and  the  phenomena  of  its  onset 
were  exactly  similar  to  those  by  which  the 
commencement  of  the  diseaseis  characterised, 


PHOSPHORUS  IN  PRODUCING  NECROSIS  OF  THE  JAW. 


307 


•when  arising  under  circumstances  entirely 
unconnected  with  any  possible  influence  of 
phosphorus.  The  progress  of  the  cases,  also, 
presented  nothing  peculiarly  different  from 
what  is  usually  observed  in  ordinary  forms 
of  the  affection.  On  account  of  the  vapours 
continually  arising  from  the  phosphorus 
employed  in  the  manufacture  of  matches, 
constant  strong  currents  of  air  are  necessarily 
kept  up  in  the  rooms  in  which  the  work 
people  are  engaged.  The  cold  to  which  the 
individuals  are  thus  continually  exposed  will 
probably  in  some  measure  account  for  the 
frequent  affections  of  the  teeth  and  jaw 
with  which  they  are  troubled,  and  to  which, 
from  their  previous  weak  and  unhealthy 
state,  they  are  especially  subject.  In 
many  of  the  workshops,  the  phosphorus 
mixture  in  which  the  matches  are  dipped  is 
not  exposed,  but  confined  in  iron  ovens  ;  yet 
even  in  such  cases  the  work-people  are 
equally  exposed  to  cold,  for  the  same  cur¬ 
rents  of  cold  air  are  kept  continually  passing 
through  the  room,  because  of  the  heat  given 
out  by  the  ovens.  This  circumstance  pro¬ 
duces  a  continual  proneness  to  rheumatic 
affections  of  various  parts  ;  and  when  re¬ 
peated  attacks  of  this  kind  affect  the  perios¬ 
teum  of  the  jaw  already  in  an  unhealthy 
state  from  the  irritation  produced  by  de¬ 
cayed  teeth,  they  are  readily  succeeded  by 
necrosis  of  this  bone,  especially  if  to  the 
several  causes  of  irritation  an  additional  one 
be  added  by  the  mechanical  injury  attending 
extraction  of  a  tooth.  In  the  occurrence  of 
the  disease  from  such  causes,  nothing  can 
well  be  attributed  to  the  nature  of  the  em¬ 
ployment  in  which  the  individuals  are  en¬ 
gaged. 

It  may,  however,  be  objected  to  the  above 
explanation,  that  necrosis  of  the  jaw  is  a 
disease  of  rare  occurrence  among  work¬ 
people  in  other  trades  in  which  the  artizans 
are  exposed  to  equal  or  even  greater  vicis¬ 
situdes  of  temperature  in  consequence  of  the 
currents  of  air  continually  passing  through 
their  work-places  :  e.  g.  in  smelting-houses, 
salt-works,  and  the  like.  Persons  employed 
in  such  trades  are  constantly  liable  to  at¬ 
tacks  of  rheumatic  periostitis ;  but  the  dis¬ 
ease  commonly  affects  the  limbs  and  certain 
other  parts  of  the  body,  usually  sparing  the 
jaw.  This  Dr.  Jiingken  explains  by  the 
fact  that,  the  nature  of  these  trades  being 
very  difficult  and  laborious,  persons  of 
robust  health  alone  are  usually  employed  in 
them  ;  and  this  state  of  good  general  health 
is  commonly  combined  with  a  sound  state 
of  the  teeth,  which  thus  preserves  the  jaw 
from  predisposition  to  become  the  seat  of 
a  rheumatic  affection,  and  so  guards  against 
the  necrosis  which  is  apt  to  follow  repeated 
attacks  of  such  rheumatic  affection. 

It  is  quite  natural  that  the  frequent  occur¬ 
rence  of  necrosis  of  the  jaw  among  the 


workers  in  match-shops  should  excite  the 
suspicion  that  the  vapour  of  phosphorus 
has  an  important  influence  in  causing  the 
disease,  especially  when  such  a  view  is 
maintained  by  many  practitioners  and  che¬ 
mists.  If,  however,  it  be  assumed  that, 
from  the  vapours  of  phosphorus  which  arise 
in  these  manufactures,  phosphoric  or  phos¬ 
phorous  acids  are  formed,  their  quantity 
must  be  so  small  as  to  preclude  all  proba¬ 
bility  of  their  acting  injuriously  upon  the 
jaw,  especially  when  it  is  remembered  that 
in  their  properties  these  acids  are  very  mild, 
and  are  frequently  administered  internally 
with  considerable  advantage  in  cases  of 
affections  of  the  bones.  Besides,  if  the 
vapour  of  phosphorus  can  in  this  or  any 
other  way  exert  an  injurious  influence  upon 
the  bones,  it  must  be  held  as  very  remark¬ 
able  that  it  does  not  act  upon  other  bones 
as  much  exposed  to  its  influence  as  the  jaw, 
e.  g.  the  nasal  bones  and  the  bones  of  the 
skull.  But  there  is  no  evidence  that  among: 
match-makers  any  other  bones  than  the 
jaws  are  ever  affected  with  necrosis.  Again, 
if  it  be  assumed  with  some  practitioners 
that  the  vapour  of  phosphorus  produces  its 
injurious  effects  by  rendering  unhealthy 
the  mucous  membrane  covering  the  jaw, 
and  thus  secondarily  leading  to  an  affection 
of  the  subjacent  bone,  the  question  still  pre¬ 
sents  itself,  why  the  mucous  membrane  of  the 
nostrils  does  not  become  similarly  diseased, 
exposed,  as  it  is,  even  more  directly  to  the 
action  of  the  vapour  than  is  that  of  the 
cavity  of  the  mouth. 

The  results  of  his  several  observations, 
therefore,  led  Dr  Jiingken  to  the  conclu¬ 
sion  that,  as  yet  at  least,  we  are  not  justified 
in  ascribing  to  the  action  of  phosphorus  the 
necrosis  of  the  jaw  frequently  found  to 
occur  among  persons  engaged  in  the  manu¬ 
facture  of  phosphorous  matches.  The 
various  facts  on  which  his  opinion  is  based 
are — first,  that  necrosis  of  the  jaw  is  not  a 
new  disease  which  has  made  its  appearance 
only  since  the  invention  of  phosphorous 
matches,  its  existence  having  been  long 
known  ;  secondly,  that  this  disease  occurs 
in  persons  who  are  in  no  way  exposed  to 
the  influence  of  phosphorus  ;  thirdly,  that 
when  it  attacks  the  workmen  employed  in  the 
manufacture  of  matches,  it  presents  no  symp¬ 
toms  different  from  those  which  it  manifests 
when  occurring  under  other  circumstances  ; 
fourthly,  that  the  persons^mployed  in  this 
species  of  work  are  much  exposed  to  condi¬ 
tions  which,  occurring  in  other  individuals, 
are  liable  to  be  followed  by  necrosis  of  the 
jaw;  fifthly,  that  a  specific  action  of  the 
vapour  of  phosphorus  upon  bones  has  been 
by  no  means  proved  ;  and,  if  it  exists,  there 
is  no  reason  why  it  should  not  affect  the 
bones  more  exposed  to  its  influence  than 
those  of  the  jaw.  These  several  circum- 


308  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY,  ETC. 


stances  seem  to  shew  that  necrosis  of  the 
jaw  cannot  with  certainty  be  ascribed  to  the 
phosphorus.  The  frequent  occurrence  of 
the  disease  among  the  makers  of  matches, 
into  the  composition  of  which  phosphorus 
largely  enters,  is,  however,  a  fact  too  im¬ 
portant  to  be  overlooked  ;  and  it  renders 
necessary  further  observations  on  the  cause 
of  the  affection  before  the  question  can  be 
considered  settled.  —  Casper’s  Wochen- 
schrift,  Mai  1848.  A 


BIRTHS  &  DEATHS  in  the  Metropolis 
During  theweeJc  ending  Saturday,  Aug.  12. 


Births. 
Males ....  704 
Females..  659 


1363 


Deaths. 
Males....  556 
Females..  503 


1059 


Av.  of 

Males ....  495 ' 
Females..  477 

972 


West— Kensington;  Chelsea;  St.  George, 
Hanover  Square;  Westminster;  St.  Martin 
in  the  Fields;  St.  James  ..  (Pop.  301,326)  149 
North  —  St.  Marylebone  ;  St.  Pancras  ; 
Islington  ;  Hackney . (Pop.  366,303)  205 

Central — St.  Giles  and  St.  George;  Strand; 
Holborn;  Clerkenwell ;  St.  Luke;  East 
London ;  West  London  ;  the  City  of 
London  . . . (Pop.  374,759)  187 


East — Shoreditch ;  Bethnal  Green  ;  White¬ 
chapel  ;  St.  George  in  the  East ;  Stepney ; 
Poplar . (Pop.  393,247)  253 


South  —  St.  Saviour;  St.  Olave  ;  Ber¬ 
mondsey  ;  St.  George,  Southwark  ; 
Newington;  Lambeth;  Wandsworth  and 
Clapham  ;  Camberwell  ;  Rotherhithe  ; 
Greenwich . (Pop.  479,469)  265 


Total .  1059 


Causes  of  Death. 

All  Causes . 

Specified  Causes . 

1.  .Zy?re0(«c(orEpidemic, Endemic, 

Contagious)  Diseases . . 
Sporadic  Diseases,  viz. — 

2.  Dropsy,  Cancer,  &c.  of  uncer¬ 

tain  seat  . 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  . 

4.  Lungs  and  other  Organs  of 

Respiration . 

5.  Heart  and  Bloodvessels  . 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion  . 

7.  Diseases  of  the  Kidneys,  &c.. . 

8.  Childbirth,  Jiiseases  of  the 

Uterus,  &c™ . 

9.  Rhematism,  Diseases  of  the 
Bones,  Joints,  &c . 

10.  Skin,  Cellular  Tissue,  &c . 

11.  Old  Age . 

12.  Violence,  Privation,  Cold,  and 

Intemperance . ! 


Av.  of 

1 

5  Sum. 

1059 

972 

1056 

968 

452 

257 

29 

45 

106 

120 

53 

80 

25 

28 

64 

79 

8 

8 

7 

10 

5 

7 

4 

1 

26 

50 

19 

8 

The  following  is  a  selection  of  the  numbers  of 
Deaths  from  the  most  important  special  causes : 


Small-pox  .  34 

Measles  .  22 

Scarlatina  . 124 

Hooping-cough..  25 

Diarrhoea  _ :.110 

Cholera  .  19 

Typhus  .  66 

Dropsy. .  12 

Sudden  deaths  ..  7 

ydroceplial  us . .  29 
Apoplexy .  26 


j  Paralysis .  1 

i  Convulsion .  32 

Bronchitis .  21 

Pneumonia .  22 

Phthisis . 129 

Dis.  of  Lungs,  &c.  3 

Teething .  6 

Dis.  Stomach,  &c.  7 
Dis.  of  Liver,  &c.  14 

Childbirth .  3 

Dis.  of  UteruSj&c.  4 


Remarks. — The  total  number  of  deaths  was 
87  above  the  weekly  average.  This  increase  is 
chiefly  due  to  the  extraordinary  fatality  of  scarlet 
fever.  The  deaths  from  this  disease  during  the 
week  were  no  less  than  124  to  a  weekly  summer 
average  of  37 !  Of  these,  120  deaths  occurred 
among  infants.  Diarrhoea  infantum  has  been 
less  fatal  during  the  week. 


'  METEOROLOGICAL  SUMMARY. 

Mean  Height  of  Barometer .  29’77 

“  “  Thermometer1  .  58’2 

Self-registering  do.b _ max.  95’  min.  37* 

“  in  the  Thames  water  —  65*  —  62‘2 

a  From  12  observations  daily.  b  Sun. 

Rain,  in  inches,  1*12:  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological. — The  mean  temperature  of  the 
week  was  nearly  3°  below  the  mean  of  the  month. 
The  last  two  weeks  have  been  remarkable  for  an 
unusually  low  temperature,  and  the  fall  of  an 
enormous  quantity  of  rain. 


BOOKS  received  during  THE  WEEK. 

Handbuch  der  allgemeinen  und  speciellen  Gewe- 
belehre  des  Menschlichen  Korpers  fur  Aerzte 
und  Studirende  von  Dr.  Jos.  Gerlach. 

Dr.  W.  T.  Gairdner  on  the  Pathology  of  the 
Kidney. 

On  the  Blow-hole  of  the  Porpoise,  by  Francis 
Sibson,  Esq.  from  the  Phil.  Trans. 

Maunder’s  Treasury  of  Natural  History. 

The  Law  of  the  Nutrition  of  Animals,  by  F. 
Knapp,  Ph.  D. 

The  American  Journal  of  the  Medical  Sciences, 
July  1848. 

British  Record  of  Obstetric  Medicine,  Aug.  15. 

Proceedings  of  the  State  Medical  Conventien, 
Lancaster,  Pennsylvania,  1S48. 

Journal  de  Chimie  M^dicale,  Aofit  1848. 

Todd’s  Cyclopaedia  of  Anatomy  and  Physiology, 
Part  xxxi i. 


NOTICES  to  CORRESPONDENTS. 

The  Lecture  of  Mr.  Bowman,  and  the  communi¬ 
cations  of  Dr.  A.  T.  Thomson  and  Dr.  Snow, 
will  be  inserted  in  the  following  number. 

Mr.  A.  J.  Simkins.  —  Our  correspondent  will 
perceive  that  Mr.  Crellin’s  report  is  inserted. 
A  copy  of  the  Staffordshire  Advertiser  has  been 
received. 

Mr.  Swan’s  request  shall  be  attended  to. 

Mr.  L.  Richardson. — The  names  were  acciden¬ 
tally  omitted.  They  are  inserted  this  week. 

Mr.  White’s  communication  on  the  Upton-on- 
Severn  Union  was  too  late  for  the  present 
number. 

Received.— Mr.  Bowman.— Mr.  C.  Braddon. 


309 


&cmTtott  iSlfi3tcal 


Ecctum. 


LECTURES 

ON  THE 

DISEASES  OF  INFANCY  AND 
CHILDHOOD, 

Delivered  at  the  Middlesex  Hospital. 

By  Charles  West,  M.D. 

Physician-Accoucheur  to  the  Middlesex  Hospital, 
and  Senior  Physician  to  the  Royal  Infirmary 
for  Children. 


Lecture  XXXIX. 

Measles  and  scarlatina — once  confounded 
together ,  though  essentially  different  dis¬ 
eases.  Symptoms  of  measles  —  their 
chief  danger  due  to  the  supervention  of 
bronchitis  or  pneumonia — treatment  of 
measles. 

Scarlatina — great  differences  in  its  severity 
in  different  cases.  Symptoms  of  each  of 
its  three  varieties — sequelae  of  the  disease 
— diagnosis  from  measles — treatment. 

When  the  short-lived  prejudices  which  at 
■first  were  entertained  against  vaccination 
had  been  removed,  men  passed  as  they  not 
seldom  do  to  the  opposite  extreme,  and  over¬ 
estimated  the  worth  of  that  discovery  which 
they  had  before  undervalued.  Physicians 
rejoiced  in  it,  as  a  means  of  getting  rid  for 
ever  of  a  disease  which  might  well  be  counted 
among  the  opprobria  of  their  art, — philan¬ 
thropists  exulted  in  the  probab’e  extermina¬ 
tion  of  one  of  the  most  fearful  scourges  of 
the  human  race  ;  and  statisticians  counted  the 
increase  brought  .to  the  population,  and 
drew  up  elaborate  tables  to  illustrate  their 
bright  anticipations  of  the  future.*  In  these 
over-sanguine  calculations,  however,  they 
almost  entirely  lost  sight  of  the  fact,  that 
not  all  who  were  preserved  from  small-pox, 
would  be  added  to  the  useful  population  of 
the  country,  but  that  the  life  of  many  would 
be  prolonged  only  for  a  short  season,  to  be 
cut  off  soon  by  some  other  disease,  against 
which  neither  science  nor  fortunate  accident 
has  hitherto  discovered  a  talisman.  Ex¬ 
perience  has  proved  the  truth  of  what  calm 
reflection  might  have  suggested,  and  with 
the  diminution  in  the  frequency  of  small-pox, 
there  has  been  an  increase,  though  not  to  an 
equal  extent,  in  the  prevalence  of  measles  and 
scarlatina. 

It  is  not  easy  to  state  with  exactness  the 
amount  of  mortality  which  these  two  diseases 
occasion  ;  for  though  they  are  never  alto- 

*  As  an  instance  of  which  may  be  mentioned, 
the  work  of  Duvillard,  De  l’influence  de  la  petite 
Vdrole  sur  la  mortality.  4to.  Paris,  1806. 

xlii.— 1082.  Aug.  25,  1848. 


gether  absent  from  a  large  city  like  London, 
yet  their  frequency  and  their  fatality  vary 
much  in  different  years.  At  one  time  they 
occur  sporadically,  and  are  then  in  most  in¬ 
stances  mild  in  their  character,  and  readily 
amenable  to  treatment;  while  at  another 
time  they  prevail  as  epidemics,  and  are  at¬ 
tended  with  alarming  symptoms,  which  it  is 
often  not  in  the  power  of  medicine  to  con¬ 
trol.  Dr.  Gregory,  who,  in  his  work  on 
the  Eruptive  Fevers,  has  collected  together 
with  much  labour  the  statistics  of  those  dis¬ 
eases,  presents  us  with  a  table,  from  which 
it  appears  that,  on  an  average  of  five  vears, 
very  nearly  six  per  cent,  of  the  mortality  of 
London,  is  due  to  measles  and  scarlatina. 
This  number,  indeed,  is  not  so  great  as  at 
once  to  impress  us  with  the  formidable 
nature  of  those  two  affections  ;  but  it  should 
not  be  forgotten,  that  (according  to  the  fifth 
Report  of  the  Registrar- General),  81  per 
cent,  of  this  mortality  occurs  in  children 
under  five;  and  97  per  cent,  in  children 
under  ten  years  old ;  while  no  figures  can 
accurately  represent  the  instances  in  which 
death  is  occasioned  by  their  complications  or 
sequelae. 

These  two  diseases  present  many  points  of 
resemblance, — so  many,  indeed,  that  they 
were  long  supposed  to  be  but  varieties  of 
the  same  malady  ;  and  the  essential  differ¬ 
ences  between  them  have  not  been  recognized 
for  more  than  seventy  years.  It  is,  however, 
on  many  accounts  important  to  distinguish 
between  them, — for  not  only  are  they  not 
attended  by  the  same  degree  of  danger,  but 
this  danger  arising  from  dissimilar  causes, 
the  treatment  which  they  require  is  in  many 
respects  different.  We  shall  presently  exa¬ 
mine  into  some  of  those  peculiarities  in  their 
symptoms  on  w7hich  we  chiefly  rely  in  form¬ 
ing  our  diagnosis  between  the  two  affections  ; 
but  I  may  even  now  state  some  of  the  broad 
distinctions  between  them. 

Measles  is  still  more  eminently  than 
scarlet  fever  a  disease  of  early  childhood, — 
for  of  1293  deaths  which  it  occasioned  in 
London  in  1842,  93'8  percent,  occurred  in 
children  under  five  y*  ars  old,  and  99  per 
cent,  in  those  under  the  age  of  ten  ;  while 
of  1224  deaths  from  scarlatina,  31  per  cent, 
occurred  after  five,  and  10  per  cent,  after  ten 
years  of  age.  Though  there  are  great  fluc¬ 
tuations  both  in  its  prevalence  and  in  the 
mortality  which  it  occasions,  yet  its  varia¬ 
tions  in  these  respects  are  less  considerable 
than  those  of  scarlet  fever ;  while  the  num¬ 
ber  of  persons  who  pass  through  life  without 
having  experienced  its  attack,  is  smaller  than 
of  those  who  die  without  having  ever  been 
affected  with  scarlatina.  Though  a  more 
universally  prevalent  disease,  however,  it  is 
fortunately  less  dangerous,  its  mortality  not 
exceeding  3  per  cent,  of  the  patients  at¬ 
tacked  by  it;  while  the  medium  rate  of 


310  SYMPTOMS  OF  MEASLES - THEIR  AGGRAVATION  ONLY  TEMPORARY. 


mortality  from  scarlet  fever  is  estimated  at 
at  least  double  that  amount.  When  measles 
proves  fatal,  too,  it  is  very  seldom  the  fever 
itself  which  occasions  the  patient’s  death, 
but  generally  its  complication  with  inflam¬ 
matory  disease  of  the  respiratory  organs. 
Scarlet  fever,  on  the  contrary,  destroys  its 
victims  in  all  stages  of  the  disease  ;  and  in 
many  of  the  worst  cases,  in  which  death 
takes  place  early,  no  organic  change  is  left 
behind  which  the  scrutiny  of  the  anatomist 
can  discover. 

The  symptoms  that  attend  the  onset  of 
5 measles  present  little  besides  their  greater 
severity,  to  distinguish  them  from  those  of 
ordinary  catarrh.  A  child,  previously  in 
perfect  health,  becomes  suddenly  restless, 
thirsty,  and  feverish,  and,  if  able  to  talk, 
generally  complains  of  head-ache.  The  eyes 
grow  red,  weak  and  watery,  and  are  unable 
to  bear  the  lierht ;  the  child  sneezes  very  fre¬ 
quently,  sometimes  almost  every  five 
minutes,  and  is  troubled  by  a  constant, 
short,  dry  cough.  On  the  fourth  day  from 
the  commencement  of  these  symptoms,  a 
rash  makes  its  appearance  on  the  face, 
•whence  it  extends  in  the  course  of  about 
forty-eighty  hours  to  the  rest  of  the  body 
and  the  extremities,  travelling  in  a  direction 
from  above  downwards.  The  rash  is  made 
up  of  a  number  of  minute,  deep  red,  circular 
stigmata,  not  unlike  flea-bites,  slightly  ele¬ 
vated,  especially  on  the  face,  and  though  close 
together,  yet  usually  distinct  from  each 
other ;  the  skin  in  the  interspaces  between 
them  retaining  its  natural  colour.  On  the 
cheeks,  the  spots  sometimes  become  con¬ 
fluent,  and  then  form  irregular  blotches, 
about  a  third  of  an  inch  long  by  half  that 
breadth  ;  while  the  spots  elsewhere  often 
present  an  indistinctly  crescentic  arrange¬ 
ment.  The  eruption  fades  in  the  same 
order  as  that  in  which  it  appeared,  and  after 
the  lapse  of  forty-eight  hours  from  its  ap¬ 
pearance,  at  which  time  it  is  at  its  height  on 
the  trunk,  it  is  beginning  to  disappear  from 
the  face.  On  the  7th  day  of  the  disease,  the 
rash  grows  faint  on  the  body  generally,  and 
on  the  8th  or  at  latest  the  9th  day,  it  has 
entirely  vanished,  leaving  behind  either  a 
little  general  redness  of  the  surface,  or  a  few 
yellowish  red,  spots,  corresponding  to  some 
of  the  situations  which  the  eruption  itself 
bad  occupied.  In  some  cases  a  partial  des¬ 
quamation  of  the  cuticle  takes  place  after  the 
rash  has  disappeared,  but  this  is  by  no  means 
a  constant  occurrence,  while  the  epidermis 
separates  in  minute  branny  scales,  never  in 
large  portions,  as  it  often  doesafter  scarlatina. 

Unlike  small-pox,  in  which  the  appearance 
of  the  eruption  is  immediately  followed  by 
the  subsidence  of  all  the  previous  symptoms, 
the  constitutional  disturbance  of  measles  is 
in  many  instances  not  at  all  alleviated  on  the 
outbreak  of  the  rash.  The  reverse,  indeed, 


is  frequently  the  case  ;  and  in  many  in¬ 
stances,  for  24  or  48  hours  afterwards,  the 
fever  is  aggravated,  and  the  cough  more 
troublesome  than  before,  while  the  voice 
often  becomes  hoarser,  and  the  throat  is 
somewhat  sore  in  consequence  of  the  inflam¬ 
mation  of  the  palate  and  fauces,  which  may¬ 
be  seen  to  be  the  seat  of  a  punctated  redness, 
resembling  that  produced  by  the  eruption  on 
the  skin. 

The  aggravation  of  the  symptoms,  how¬ 
ever,  when  it  does  occur,  is  only  tempo¬ 
rary  :  and  on  the  sixth  day  of  the  disease,  if 
not  sooner,  an  amelioration  in  the  patient’s 
condition  becomes  apparent;  the  fever 
diminishing,  the  cough  growing  looser  and 
less  frequent,  and  moist  sounds  becoming 
audible  in  the  lungs,  where  previously  no¬ 
thing  was  heard  but  rhonchus  or  sibilus.  In 
cases,  however,  in  which  the  disease  takes  a  less 
favourable  turn,  this  is  the  period  when  the 
supervention  Of  serious  thoracic  complication 
is  most  to  be  feared.  It  happens,  indeed, 
occasionally,  that  the  disorder  of  the  respira¬ 
tory  organs  is  severe  from  the  very  com¬ 
mencement  of  the  child’s  illness,  and  that  it 
merely  becomes  aggravated  with  the  progress 
of  the  disease.  But,  in  the  majority  of 
cases,  it  is  not  until  the  eruption  has  already 
reached  its  acme,  or  is  just  beginning  to 
fade,  that  serious  inflammation  of  the 
larynx  or  bronchi,  or  of  the  substance  of  the 
lungs,  is  set  up,  while  the  symptoms  of  any 
such  occurrence  need  to  be  watched  all  the 
more  carefully  at  this  period,  from  the 
rapidity  with  which  they  tend  to  a  fatal  issue. 
Still,  although  the  danger  from  mischief  in 
the  chest  is  most  imminent  at  this  stage  of 
the  disease,  yet  the  same  symptoms  may 
come  on  at  a  later  period,  when  the  eruption 
has  already  faded  for  one  or  two  days,  or 
even  later,  and  when  a  sort  of  incomplete 
convalescence  is  already  established.  I  need 
not  now  do  more  than  remind  you  of  the 
croupal  symptoms  which  sometimes  come  on 
at  thedecline  of  measles,  and  which,  as  I  men¬ 
tioned  some  days  ago,*  are  so  dangerous  and 
intractable.  At  this  period,  too,  inflamma¬ 
tion  of  the  substance  of  the  lungs  is  to  be 
dreaded,  and  all  the  more  from  its  coming  on 
almost  imperceptibly,  unattended  wuth  much 
cough  or  dyspnoea,  and  associated  with  such 
considerable  sympathetic  disturbance  of  the 
stomach  and  bowels  as  very  readily  to  lead 
into  error  with  reference  to  the  seat  of  the 
disease.  The  course  of  the  affection  of  the 
lungs  in  this  case  is  usually  chronic  :  the 
child  loses  flesh, — becomes  the  subject  of  an 
irregular  hectic  fever  ;  and  when  the  thoracic 
symptoms  at  length  become  more  apparent 
than  at  first  they  had  been,  and  the  cough 
grows  more  frequent  and  attended  with  more 


*  See  Lecture  XX.,  in  the  Gazette  for  January 
28, 1848, 


TREATMENT  OF  MEASLES.  SCARLET  FEVER. 


311 


expectoration,  the  case  so  closely  resembles 
one  of  tubercular  phthisis  that  it  is  exceed¬ 
ingly  difficult  to  avoid  an  erroneous  diag¬ 
nosis. 

The  treatment  of  measles  is  usually  very 
simple  :  in  mild  cases,  indeed,  little  is  needed 
beyond  confinement  to  a  warm  chamber,  a 
spare  diet,  and  gentle  antiphlogistic  remedies. 
The  cough,  which  is  the  most  troublesome 
symptom, — frequently,  indeed,  the  only  one 
that  calls  for  much  attention,  —  is  often 
very  much  relieved  by  the  application,  for 
three  or  four  hours,  of  a  small  blister,  no 
bigger  than  a  shilling,  to  the  trachea,  at  the 
point  just  above  the  sternum  ;  and  this 
slight  counter-irritation,  which  seldom  pro¬ 
duces  any  vesication  of  the  surface,  may  be 
repeated  during  the  course  of  the  affection. 
If  more  than  this  be  needed,  small  doses  of 
antimonial  and  ipecacuanha  wine,  with  lau¬ 
danum  or  the  compound  tincture  of  cam¬ 
phor,  may  be  given  every  few  hours.  The 
imperfect  desquamation  that  sometimes  takes 
place  as  the  eruption  declines,  is  often  at¬ 
tended  with  very  distressing  itching  of  the 
whole  surface;  while  the  cough  is  sometimes 
frequent  and  troublesome  at  night,  and  the 
child  is  thus  prevented  from  sleeping.  To 
relieve  these  troublesome  symptoms,  as  well 
as  to  check  that  tendency  to  diarrhoea  which 
often  comes  on  at  the  decline  of  measles,  it 
is  desirable  to  follow  the  plan  pursued  by 
Sydenham,  and  to  give  an  opiate  every 
night, — a  small  dose  of  Dover’s  powder 
being  the  best  form  in  which  it  can  be  ad¬ 
ministered. 

But  though  these  simple  measures  are 
amply  sufficient  in  the  great  majority  of 
cases,  we  yet  must  not  allow  ourselves  to  be 
betrayed  into  inertness  when  any  indications 
of  mischief  in  the  chest  make  their  appear¬ 
ance.  Such  symptoms  sometimes  come  on 
early  in  the  disease,  and  before  the  eruption 
has  well  appeared,  the  child  seeming  much 
oppressed,  and  experiencing  considerable 
dyspnoea,  although  the  auscultatory  evidences 
of  disease  in  the  chest  may  be  but  small. 
This  nervous  dyspnoea  is  often  relieved  by 
the  application  of  a  mustard  poultice  to  the 
chest,  and  by  placing  the  child  in  a  hot  bath 
— a  proceeding  which  will  very  frequently  be 
followed  by  the  appearance  of  the  rash  abun¬ 
dantly  over  the  whole  surface.  Should  these 
measures,  however,  fail  to  produce  relief,  or 
should  the  symptoms  from  the  first  be 
alarming,  the  distress  and  dyspnoea  very 
considerable,  and  the  rash  not  merely  scanty, 
hut  of  a  dark  or  livid  hue  wherever  it  has 
appeared,  the  abstraction  of  blood  is  urgently 
required ;  and  general  depletion  should, 
under  such  circumstances,  be  employed  in 
preference  to  merely  local  bleeding.  When 
bronchitis  or  pneumonia  comes  on  at  a  later 
period  of  the  disease,  when  the  rash  has 
ilready  fully  appeared,  or  is  beginning  to 


decline,  the  question  of  bleeding,  as  well  as 
of  the  mode  in  which  the  depletion  shall  be 
practised,  must  be  determined  entirely  by 
the  severity  of  the  chest  symptoms,  and  is 
little  if  at  all  modified  by  any  considerations 
drawn  from  the  circumstance  of  their  coming 
on  during  the  course  of  another  disease.  The 
unfavourable  conditions  under  which  infants 
are  placed  in  the  Hopital  des  Enfans  at 
Paris,  has  induced,  on  the  part  of  French, 
physicians,  a  dread  of  depletion  in  the  course 
of  measles  which  is  certainly  not  justified 
by  the  characters  that  the  disease  presents  in. 
this  country.  A  repetition  of  depletion  is, 
however,  not  generally  either  necessary  or 
useful,  especially  if  the  first  abstraction  of 
blood  be  followed  up,  as  it  ought  to  be,  by 
the  free  employment  of  the  tartar  emetic- 
The  dyspnoea  which  is  frequently  exacerbated 
towards  evening  in  the  course  of-  the  pneu¬ 
monia  and  bronchitis  that  accompany 
measles,  is  generally  much  relieved  by  mus¬ 
tard  poultices ;  but  the  application  of  blisters 
under  these  circumstances  is  hazardous, 
since  the  sores  which  they  produce  are  often, 
very  intractable  ;  and  the  irritation  and  suf¬ 
fering  they  occasion  proves,  in  many  in¬ 
stances,  seriously  prejudicial  to  the  children- 
It  is  important,  too,  to  bear  in  mind  that 
little  reliance  can  be  placed  on  mercurial 
remedies  in  the  treatment  of  active  rubeo- 
lous  pneumonia,  though  small  doses  of  the 
Hydr.  c  Greta,  with  Dover’s  powder,  are 
often  exceedingly  useful  in  cases  where  a 
hepatized  state  of  the  lung  is  left  behind 
after  the  subsidence  of  the  fever,  and  of  the 
more  acute  inflammatory  symptoms.  I 
spoke  so  fully  some  days  since  concerning 
the  treatment  of  croup  supervening  on 
measles,  that,  it  cannot  be  necessary  to  repeat 
the  remarks  which  were  then  made  ;  neither 
need  I  add  anything  to  what  I  said  on  a 
former  occasion  about  cancrum  oris — which 
distressing  affection  occasionally  supervenes 
on  the  decline  of  measles. 

I  will  now,  in  conclusion,  briefly  sketch 
the  more  striking  features  of  scarlet  fever. 
To  describe  it  minutely  would  indeed  require 
much  time,  for  there  are  few  diseases  whose 
characters  vary  so  widely  in  different  instances. 
In  one  case  it  presents  itself  as  an  ailment 
so  trifling  as  scarcely  to  interrupt  a  child’s 
cheerfulness  even  for  a  day  ;  in  another  case 
it  is  so  deadly  that  medicine  is  unable  to  stay 
its  course  even  for  a  moment ;  and  that  it 
destroys  life  in  a  few  days — sometimes  even 
in  a  few  hours.  Such  a  disease  might  seem 
to  merit  a  very  minute  investigation  at  our 
hands  :  and  on  this  it  would  be  my  duty  to 
enter,  did  I  not  feel  that  after  all  that  has 
been  written  on  the  subject  of  the  eruptive 
fevers,  it  will  be  enough  for  me  on  the 
present  occasion  to  recal  to  your  recollection 
some  of  those  points  concerning  each  of  them 
which  are  of  the  greatest  practical  moment. 


312 


SCARLATINA - GREAT  DIFFERENCES  IN  ITS  SEVERITY. 


It  is  hardly  necessary  to  remind  you  that 
the  remarkable  differences  in  the  severity  of 
the  affection,  and  in  the  symptoms  which 
attend  it,  have  given  rise  to  its  subdivision 
into  the  three  varieties  of  scarlatina  simplex, 
scarlatina  anginosa,  and  scarlatina  maligna. 
In  the  first  of  these  the  patient  experiences 
an  attack  of  fever,  often  very  mild,  always 
of  very  short  duration,  and  accompanied  by 
the  appearance  of  a  bright  scarlet  rash  over 
the  whole  surface,  and  generally  by  a  slight 
degree  of  sore  throat.  In  the  second  the 
fever  is  more  intense,  and  subsides  less 
speedily,  while,  as  its  name  implies,  the 
attendant  sore-throat  is  very  severe  :  and  in 
the  third  the  fever  generally  assumes  a  ty¬ 
phoid  character,  sloughing  of  the  inflamed 
tonsils  not  unfrequently  occurs,  and  a  variety 
of  complications  in  many  instances  super¬ 
vene,  by  which  the  patient’s  danger  is  still 
further  aggravated. 

In  cases  of  moderate  severity  the  attack 
of  scarlet  fever  is  usually  ushered  in  by 
vomiting,  which  is  in  many  instances  often 
repeated,  and  which  is  accompanied  by  very 
intense  heat  of  skin,  by  great  rapidity  of  the 
pulse,  by  headache  or  heaviness  of  the  head; 
and  by  so  considerable  a  degree  of  sensorial 
disturbance  as  to  give  rise  to  delirium  in 
many  children  who  are  old  enough  to  mani¬ 
fest  this  symptom.  On  the  following  day, 
often  within  twenty-four  hours  from  the 
commencement  of  the  patient’s  illness,  the 
rash  of  scarlatina  makes  its  appearance.  It 
usually  shews  itself  first  on  the  neck,  breast, 
and  face,  whence  it  extends,  in  the  course  of 
twenty-four  hours,  to  the  trunk  and  extremi¬ 
ties.  Its  colour  is  a  very  bright  red,  due  in 
part  to  a  general  flush  of  the  skin,  in  part  to 
the  presence  of  innumerable  red  dots  or 
spots,  which  look  like  minute  red  papillae, 
though  often  they  communicate  no  sense  of 
roughness  to  the  hand.  To  this,  however, 
there  are  occasional  exceptions  :  the  rash  on 
the  chest  and  body  presenting  sometimes, 
when  at  its  height,  a  slightly  papular  charac¬ 
ter  ;  and  now  and  then  minute  sudaminaare 
intermingled  with  the  eruption.  In  some 
instances  the  redness  of  the  surface  is  uni¬ 
versal,  but  in  other  cases  the  rash  appears  in 
patches  of  uncertain  size  and  irregular  form 
on  the  trunk  ;  but  these  patches  never  affect 
any  definite  shape,  and  never  present  a 
clearly  circumscribed  margin-.  For  three 
days  the  rash  usually  continues  to  become  of 
a  deeper  colour,  and  more  generally  diffused 
over  the  whole  surface ;  it  then  slowly  de¬ 
clines,  hut  does  not  ■wholly  disappear  until 
the  seventh,  or  sometimes  the  eighth  day  of 
the  disease.  The  appearance  of  the  eruption 
is  not  in  general  succeeded  by  any  immediate 
diminution  in  the  other  symptoms  ;  but  on 
the  contrary,  they  often  increase  in  severity 
until  the  eruption  has  reached  its  acme, 
when  they  slowly  decline  with  the  disappear¬ 


ance  of  the  rash.  Sometimes,  indeed,  when 
the  case  is  very  mild,  the  fever  abates  so  soon 
as  the  rash  is  fully  out ;  and  the  child  re¬ 
gaining  its  cheerfulness  on  the  third  day, 
shews  no  further  sign  of  illness,  though  the 
rash  remains  visible  for  two  or  three  days 
longer.  Now  and  then,  too,  especially  in 
young  infants,  the  affection  throughout  con¬ 
sists  of  little  more  than  of  an  eruption  on 
the  skin,  the  presence  of  which  is  almost  the 
only  evidence  of  their  having  been  attacked 
by  a  disease  sometimes  so  deadly.  Such, 
however,  are  exceptional  cases ;  and  in  most 
instances,  even  when  the  disease  is  mild,  a 
slight  degree  of  soreness  of  the  throat  comes 
on  on  the  second  or  third  day,  the  palate  and 
tonsils  appear  red,  and  the  latter  are  generally 
somewhat  swollen,  and  deglutition  is  slightly 
impeded.  The  tongue  also  is  preternatu- 
rally  red,  and  its  papillae,  which  are  very 
prominent,  project  through  the  white  or 
yellowish  fur  which  coats  it,  and  thus  form 
an  appearance  as  characteristic  of  scarlatina 
as  the  rash  itself.  The  redness  fades  from 
the  fauces,  and  the  fur  disappears  from  the 
tongue,  as  the  eruption  declines ;  but  the 
prominence  of  the  papillae  often  continues 
for  some  days  longer.  As  the  rash 
subsides,  that  process  of  desquamation 
of  the  epidermis  generally  commences,  the 
uninterrupted  performance  of  which  I  men¬ 
tioned  to  you  a  few  days  ago  as  so  essential 
to  the  complete  recovery  of  a  person  con¬ 
valescent  from  scarlet  fever.  The  cuticle 
peels  off  from  the  hands  and  feet  in  large 
flakes,  but  on  the  face  and  trunk  the  desqua¬ 
mation  usually  takes  place  in  furfuraceous 
scales.  Both  its  degree  and  duration  vary 
much  in  different  cases  :  sometimes  it  is  over 
in  five  or  six  days  ;  while  in  other  cases  the 
cuticle  is  reproduced,  and  then  desquamates 
several  times  in  succession,  and  the  process 
is  thus  protracted  for  three  or  four  weeks, 
or  even  longer.  It  is  not  possible  to  assign 
a  cause  for  these  differences.  Some  epi¬ 
demics  of  scarlatina  are  characterised  by  the 
abundance  of  the  desquamation,  and  its 
almost  universal  occurrence,  while  at  other 
times  it  is  scanty,  and  often  wanting. 

The  danger  of  this  disease  is  by  no  means 
in  proportion  to  the  abundance  of  the  rash, 
but  rather  to  the  degree  of  the  affection  of 
the  throat,  the  severity  of  which  is  the  dis¬ 
tinguishing  feature  of  scarlatina  anginosa. 
In  this  form  of  the  affection  the  premonitory 
symptoms  are  usually  much  more  severe 
than  in  the  scarlatina  simplex  :  they  are  also 
often  of  longer  duration,  the  rash  not  shew¬ 
ing  itself  until  the  end  of  the  second,  and 
sometimes  even  not  until  the  third  day.  It 
is,  moreover,  less  generally  diffused  over  the 
surface  than  in  the  milder  form  of  the  dis¬ 
ease,  but  appears  in  the  form  of  large 
scarlet  patches  irregularly  distributed  over 
different  parts  of  the  body,  especially  on  the 


SYMPTOMS  OF  SCARLATINA  ANGINOSA. 


313 


back.  Almost  from  the  commencement  of 
the  patient’s  illness,  soreness  of  the  throat 
is  experienced,  attended  with  difficulty  of 
deglutition,  and  often  with  considerable 
stiffness  of  the  neck,  and  pain  and  difficulty 
in  moving  the  lower  jaw,  due  in  part  to 
the  swelling  of  the  submaxillary  glands. 
On  examining  the  throat,  it  is  seen  to 
be  intensely  red,  and  the  tonsils  both  red 
and  swollen.  The  swelling  of  the  tonsils 
increases  rapidly,  until  they  almost  block 
up  the  entrance  to  the  pharynx,  and  thereby 
render  the  attempt  to  swallow  so  difficult 
that  fluids  are  often  returned  by  the  nose. 
An  adhesive  mucus  collects  about  the  back 
of  the  throat,  and  often  seems  to  cause 
great  annoyance  to  the  patient,  and  specks 
or  patches  of  lymph  form  upon  the  tonsils, 
aud  look  like  sloughs  covering  ulcers, 
though,  on  detaching  them,  it  is  seldom  that 
any  breach  of  surface  appears  beneath.  In 
some  of  the  severest  cases,  a  very  troublesome 
coryza  comes  on,  and  an  adhesive,  yellowish, 
matter  is  secreted  in  abundance  by  the  mucous 
membrane  of  thenares,  whence  it  runs  down 
upon  the  upper  lip,  excoriating  the  skin  over 
which  it  passes,  and  causing  still  more  se¬ 
rious  suffering  by  the  obstacle  which  it  pre¬ 
sents  to  free  respiration.  In  some  epide¬ 
mics  the  inflammation  extends  to  the  parotid 
glands,  and  to  the  cellular  tissue  about  the 
neck,  the  parts  thus  affected  becoming 
rapidly  swollen,  acquiring  a  great  size  and  a 
stony  hardness.  In  some  cases  this  affec¬ 
tion  is  confined  to  one  side  ;  in  others,  both 
sides  are  attacked  in  succession,  while  some¬ 
times  the  two  are  involved  simultaneously  ; 
and  the  integuments  under  the  chin  and  in 
front  of  the  neck  becoming  likewise  in¬ 
flamed,  and  tense  and  swollen,  the  lower 
jaw  is  so  firmly  fixed,  that  the  attempt  to 
swallow  is  rendered  almost  impracticable, 
and  the  patient  is  exposed  to  a  new  source 
of  danger,  from  the  difficulty  of  taking  nutri¬ 
ment  in  quantity  sufficient  to  support  the 
feeble  powers  of  life.  Coupled  with  this 
severe  local  affection,  there  is,  as  might  be 
expected,  a  corresponding  intensity  in  the 
constitutional  disturbance.  The  heat  of 
skin  is  very  great,  the  pulse  extremely  fre¬ 
quent,  and,  though  not  small,  is  yet  from 
an  early  period  very  easily  compressed  ;  the 
sensorial  disturbance  is  considerable,  and  the 
restlessness  extreme.  The  tongue  does  not 
present  that  appearance  which  I  mentioned 
as  being  characteristic  of  scarlatina  in  its 
milder  form,  but  is  coated  with  a  dirty 
brown  fur,  though  red  at  its  tip  and  edges, 
and  often  becomes  dry  at  a  very  early 
period  of  the  disease, — partly,  no  doubt,  in 
consequence  of  the  swelling  of  the  tonsils 
and  of  the  glands,  compelling  the  patient  to 
breathe  with  his  mouth  open. 

Between  the  severer  forms  of  scarlatina 
anginosa  and  that  still  more  dangerous 


variety  of  the  disease  to  which  the  name  of 
malignant  has  been  applied,  the  differences 
are  of  degree  rather  than  of  kind.  Symp¬ 
toms  such  as  have  been  just  enumerated  are 
present  in  many  cases  of  malignant  scarlet 
fever  ;  but  the  fever  very  early  assumes  a 
typhoid  character,  and  death  takes  place 
sooner  than  the  amount  of  the  local  lesions 
suffices  to  explain  ;  whilst  in  the  scarlatina 
anginosa  a  direct  proportion  always  exists 
between  the  severity  of  the  local  mischief 
and  the  degree  of  constitutional  disturb¬ 
ance. 

A  little  girl,  5  years  old,  went  to  bed 
quite  well  on  the  night  of  the  20th  May, 
but  awoke  vomiting  at  4  a.m.  on  the  21st. 
Through  the  whole  of  the  21st,  the  child 
seemed  very  ill,  and  her  bowels  were  much 
purged.  Towards  evening,  a  red  rash  ap¬ 
peared  on  her  body,  and  she  complained  of 
sore  throat.  On  the  following  day  the 
soreness  of  her  throat  increased,  and  the 
submaxillary  glands  began  to  swell.  On 
the  23d  I  saw  her :  she  was  lying  in  her 
mother’s  lap,  with  her  face  of  a  deep  scarlet, 
verging  on  a  crimson  hue,  and  the  rash, 
which  was  generally  diffused  over  the  whole 
body,  presented  the  same  colour ;  her  eyes 
were  half  open,  and  the  conjunctivse  in¬ 
jected  ;  the  submaxillary  glands  somewhat 
swollen  ;  the  tonsils  very  red,  covered  with 
shreds  of  mucus  ;  deglutition  difficult ;  re¬ 
spiration  hurried  ;  pulse  too  frequent  and 
too  feeble  to  be  counted.  She  had  been, 
delirious  during  the  whole  of  the  preceding 
night.  Ammonia  was  given  in  doses  of 
gr.  iij.  every  four  hours  ;  but  at  4  p.m.  on 
the  24th,  I  found  her  lying  on  her  back  in 
a  semi-comatose  condition,  though  capable 
of  being  roused  ;  her  surface  quite  cool,  of 
a  generally  livid  red  colour  ;  her  pulse  ex¬ 
ceedingly  feeble  ;  her  respiration  noisy  and 
difficult,  rendered  so  in  part  by  an  abundant 
secretion  of  yellow  adhesive  matter  in  the 
nares.  The  swelling  on  the  right  side  of 
the  throat  was  much  the  same  as  on  the 
previous  day,  but  the  left  parotid  was 
greatly  swollen,  and  of  a  stony  hardness; 
the  tonsils  were  more  swollen  ;  deglutition 
difficult,  and  a  large  quantity  of  tenacious 
mucus  was  collected  about  the  fauces.  The 
diarrhcea  still  continued,  and  at  10  o’clock 
the  same  night  the  poor  child  died,  within 
90  hours  from  the  commencement  of  her 
illness. 

Although  the  affection  of  the  throat  was 
in  this  case  rapidly  on  the  increase,  yet  it 
was  not  to  that  alone  that  the  child's  death 
could  be  attributed,  but  rather  tc  the  de¬ 
pression  of  all  the  vital  powers,  Much  was 
so  considerable  that,  on  my  first  visit  to  the 
child,  little  more  than  forty-eight  hours 
after  her  seizure,  the  pulse  could  no  longer 
be  counted.  Even  in  the  malignant  form  of 
scarlatina,  however,  it  is  seldom  that  death 


3J4 


SYMPTOMS  OF  SCARLATINA. 


takes  place  so  early,  but  the  patient  more 
commonly  survives  to  the  end  of  the  sixth 
or  seventh  day,  and,  under  these  circum¬ 
stances,  the  affection  of  the  throat  generally 
goes  on  increasing  in  severity.  The  inflam¬ 
mation  of  the  tonsils  terminates  in  the 
formation  of  several  small,  but  excavated, 
unhealthy  ulcerations,  or  sometimes  a  more 
extensive  sloughing  involves  the  parts  at  the 
back  of  the  throat.  The  coryza  to  which 
reference  was  made  just  now  is  generally 
very  severe,  and  both  that  and  the  swelling 
of  the  parotids  add  greatly  to  the  patient’s 
sufferings.  These  glandular  swellings  are 
remarkable  for  the  stony  hardness  which 
they  present,  and  for  the  very  slight  ten¬ 
dency  which  they  shew  to  suppurate,  and, 
if  matter  form,  it  is  usually  in  the  cellular 
tissue  about  the  glands,  not  in  the  glands 
themselves.  Although  the  affection  of  the 
nares  and  fauces,  and  the  swelling  of  the 
parotid  glands,  often  present  a  very  serious 
obstacle  to  respiration,  yet  true  croupal 
symptoms  are  not  of  common  occurrence ; 
and  in  the  epidemics  which  I  have  wit¬ 
nessed  in  London,  I  have  not  met  with 
either  diphtheritis  or  oedema  of  the  glot¬ 
tis.  You  must  remember,  however,  that 
in  almost  every  epidemic  of  scarlatina  there 
is  some  peculiarity  in  the  course  that  the 
disease  takes,  and  that  those  complications 
which  one  year  are  frequent  and  perilous, 
are  in  another  year  but  seldom  met  with,  or 
attended  with  comparatively  little  danger. 

Even  though  the  patient  should  survive 
the  immediate  peril  of  the  fever,  a  long 
catalogue  of  sequelae  remains,  some  of  which 
may  endanger  or  even  destroy  life.  Some¬ 
times,  indeed,  the  patient  passes  through 
the  first  week  of  the  disease  with  few  or  no 
symptoms  to  excite  anxiety  ;  and  then,  when 
the  rash  is  already  on  the  decline,  swelling 
of  the  parotid  glands  comes  on ;  sloughing 
ulcers  form  on  the  tonsils,  which  had  not 
seemed  to  be  very  much  inflamed  previously  ; 
an  acrid  discharge  takes  place  from  the 
nostrils,  and  death  follows  in  the  course  of 
four  or  five  days.  In  the  majority  of  in¬ 
stances,  however,  the  glandular  swellings 
which  come  on  after  the  lapse  of  a  week 
from  the  commencement  of  the  disease, 
though  tedious  and  painful,  yet  do  not  en¬ 
danger  life.  Occasionally,  indeed,  death 
occurs  in  consequence  of  the  matter  formed 
by  the  inflammation  of  the  glands,  or  of  the 
cellular  tissue  around  them,  burrowing 
backwards  behind  the  pharynx,  instead  of 
pointing  externally.  In  these  cases  of 
retro-pharyngeal  abscess,  after  more  or  less 
evident  indications  of  inflammation  in  the 
neighbourhood  of  the  parotid  or  sub¬ 
maxillary  glands,  accompanied,  in  all  proba¬ 
bility,  with  a  swelling  on  one  or  other  side 
of  the  neck  or  jaw,  the  patient  begins  to 
experience  difficulty  in  deglutition,  which 


goes  on  increasing  until  the  attempt  to 
swallow  becomes  quite  impracticable.  As  the 
dysphagia  increases,  respiration  becomes  also 
very  difficult,  but  the  dyspnoea  continues  to 
increase  progressively,  and  is  not  aggravated 
in  paroxysms,  as  in  cases  of  cynanche  tra- 
chealis,  though  the  effort  to  swallow  will 
sometimes  bring  on  threatening  suffocation. 
Moreover,  there  is  seldom  any  modification 
in  the  tone  of  the  voice,  such  as  occurs  in 
croup,  though  the  voice  becomes  by  degrees 
whispering  and  then  extinct :  while  if  the 
throat  be  examined,  the  tonsils  are  observed 
to  be  free  from  swelling  ;  and  sometimes 
neither  they  nor  the  soft  palate  show  the 
slightest  increase  in  redness  or  other  token 
of  inflammation.  The  general  symptoms, 
coupled  with  the  negative  results  afforded 
by  examination  of  the  fauces,  point  tolerably 
plainly  to  the  real  nature  of  this  affection  ; 
but  positive  certainty  concerning  it  can  be 
obtained  only  by  a  means  which  Mr. 
O’Ferrall,  of  Dublin,  was,  to  the  best  of  my 
knowledge,  the  first  to  point  out,  and  which 
consists  in  passing  the  finger  for  some  dis¬ 
tance  down  the  throat,  when  the  presence  of 
a  tumor  pressing  forward  the  posterior  wall 
of  the  pharynx  or  oesophagus,  will  at  once 
reveal  the  cause  of  the  patient’s  suffer¬ 
ings. 

Coupled  with  the  swelling  of  the  parotid 
glands,  and  sometimes  independently  of  it, 
inflammation  of  the  internal  ear  is  sometimes 
met  with  as  a  consequence  of  scarlatina. 
This  otitis  terminates  in  abundant  purulent 
discharge,  which  sometimes  continues  for 
many  weeks  ;  and  occasionally  it  completely 
destroys  the  organ  of  hearing,  and  renders 
the  patient  hopelessly  deaf  for  the  remainder 
of  his  life.  Another,  but  fortunately  a  very 
rare,  sequela  of  the  disease  is  the  inflamma¬ 
tion  of  some  of  the  larger  joints.  One  in¬ 
stance  only  of  this  has  come  under  my 
notice  ;  in  the  case  of  a  little  boy  whose 
right  humerus  became  permanently  anchy- 
losed  to  the  scapula,  in  consequence  of  in¬ 
flammation  which  attacked  his  shoulder- 
joint  after  scarlet  fever. 

I  have  already  spoken,  in  a  previous  lec¬ 
ture,  of  that  very  frequent  and  very  serious 
occurrence,  the  dropsy  which  succeeds  to 
scarlet  fever,  and  need  not,  therefore,  refer 
to  that  subject  now.  But  there  are  other 
cases  in  which,  without  any  definite  local 
complication,  the  convalescence  from  scarlet 
fever  is  fluctuating  and  protracted.  In  such 
cases  the  bowels  are  irregular  in  their  action, 
alternately  relaxed  and  constipated  ;  the  eva¬ 
cuations  unhealthy  ;  the  tongue  red  and  raw  ; 
and  aphthous  ulcerations  sometimes  appear 
on  the  inside  of  the  mouth  ;  while  an  irregu¬ 
larly  remittent  fever  harasses  and  weakens 
the  child.  These  symptoms,  however,  which 
closely  resemble  those  which  sometimes 
come  on  during  convalescence  from  measles, 


DIAGNOSIS  AND  TREATMENT  OF  SCARLATINA. 


are  of  much  less  frequent  occurrence  as  con¬ 
sequences  of  scarlatina. 

The  diagnosis  of  scarlatina  is  not  in 
general  attended  with  much  difficulty  ;  and 
the  points  of  difference  between  it  and 
measles  are  so  well  marked,  that  it  does  not 
seem  easy  to  understand  how  the  two 
diseases  should  so  long  have  been  con¬ 
founded  together.  Their  period  of  incuba¬ 
tion  is  different ;  that  of  scarlatina  not 
exceeding  a  week,  that  of  measles  often  ex¬ 
tending  to  two.  Their  premonitory  symp¬ 
toms  are  very  dissimilar — that  of  measles 
closely  resembling  the  signs  of  a  severe 
catarrh  ;  while  the  attack  of  scarlatina  is 
announced  by  sickness,  succeeded  by  intense 
heat  of  skin,  by  sore  throat,  great  sensorial 
disturbance,  and  extreme  rapidity  of  the 
pulse.  There  is  no  other  disease  of  child¬ 
hood,  indeed,  in  which  the  two  last-named 
symptoms  supervene  so  speedily  after  the 
commencement  of  illness  ;  and  their  ap¬ 
pearance  will  often  enable  you,  even  be¬ 
fore  the  appearance  of  the  rash,  or  any 
complaint  of  sore-throat,  to  form  a  correct 
conclusion  with  reference  to  the  nature  of 
the  affection.  The  premonitory  stage  of 
measles  usually  continues  for  three  or  four 
days — that  of  scarlet  fever,  in  its  regular 
form,  only  for  twenty-four  hours;  while  the 
other  symptoms  which  appear  in  cases  of 
scarlet  fever,  in  which  the  rash  is  delayed, 
are  such  as  quite  to  forbid  the  supposition 
of  the  patient  being  affected  with  measles. 
The  character  of  the  two  eruptions  is  so 
dissimilar,  that  I  need  not  here  dwell  on 
their  peculiarities,  nor  do  more  than  remind 
you  that,  while  in  measles  the  great  danger 
to  life  arises  from  the  supervention  of  bron¬ 
chitis  or  pneumonia,  the  two  great  sources 
of  hazard  in  scarlet  fever,  are  the  affection 
of  the  throat  during  its  progress,  and  the 
occurrence  of  dropsy  after  its  decline.* 

With  a  few  words  on  the  treatment  of 
scarlatina,  I  will  bring  this  subject,  and  the 
present  course  of  lectures,  to  a  close.  The 
milder  forms  of  the  disease  require,  as  you 
know,  but  little  interference  ;  and  you  fulfil 
every  indication  by  keeping  the  child  in  a 
cool  and  well- ventilated  chamber,  placing 
him  on  a  spare  diet,  giving  some  mild  an¬ 
tiphlogistic  medicine  during  the  progress 
of  the  fever,  and  sponging  the  surface  occa¬ 
sionally  with  tepid  water  if  the  heat  of  the 
skin  be  considerable.  When  the  eruption 
is  on  the  decline,  the  hot  bath  every  night  is 
often  very  useful  in  favouring  the  process  of 


*  I  have  purposely  omitted  to  say  any  thing 
concerning  the  diagnosis  between  scarlatina  and 
the  kindred  exanthema,  called  Rotheln  by  Ger¬ 
man  writers  (the  rubeolse  of  some  continental 
nosologists  who  restrict  the  term  morbilli  to 
measles);  for  though  I  believe  there  to  be  a 
foundation  for  this  distinction,  my  own  oppor¬ 
tunities  have  not  enabled  me  to  come  to  any 
positive  conclusion  on  the  subject. 


315 


desquamation  ;  while  the  child  must  be  kept 
strictly  within  doors,  his  diet  must  still  be 
mild  and  unstimulating,  and  due  attention 
must  be  paid  to  the  state  of  the  bowels 
until  the  period  has  passed  when  there  is 
much  ground  for  fearing  the  supervention 
of  dropsy.  For  some  time  after,  much  cau¬ 
tion  must  be  exercised  in  not  allowing  the 
child  to  go  out  when  the  air  is  cool,  and  in 
avoiding  all  errors  of  diet ;  while  it  is  also 
expedient  that  flannel  should  be  worn  next 
the  skin  for  some  time  after  apparent  con¬ 
valescence  from  scarlet  fever. 

Even  in  severer  cases  of  the  disease,  you 
must  not  be  in  too  great  a  hurry  to  resort 
to  active  measures,  for  you  will  remember 
that  a  somewhat  stormy  onset  is  characte¬ 
ristic  of  all  but  the  very  mildest  form  of  scar¬ 
latina.  That  disturbance  of  the  sensorium, 
for  instance,  which,  when  the  child  is  suffi¬ 
ciently  old,  shows  itself  by  the  early  occur¬ 
rence  of  delirium,  must  not  lead  you  to  have 
recourse  hastily  to  depletion,  either  general 
or  local,  in  order  to  quiet  the  disorder  of  the 
brain.  The  results  afforded  by  depletion  in 
scarlet  fever,  even  when  the  disease  occurs 
in  the  adult,  are  by  no  means  encouraging, 
and  in  the  child  the  loss  of  blood  under 
these  circumstances  is  even  less  well  borne ; 
so  that,  unless  the  patient  be  robust  and 
plethoric,  the  cerebral  disturbance  very  se¬ 
rious,  and  the  evidences  of  congestion  of  the 
brain  very  marked,  you  should  content  your¬ 
selves  with  the  application  of  cold  to  the 
head,  perhaps  employing  cold  affusion,  and 
with  cold  sponging  of  the  surface.  In  the 
malignant  forms  of  the  disease  there  is  often 
very  considerable  disturbance  of  sensorium, 
great  restlessness,  alternating  with  a  state  of 
stupor  ;  but  the  frequent  and  feeble  pulse  at 
once  forbids  depletion  in  such  cases,  and 
points  out  the  necessity  for  adopting  every 
means  to  support  the  feeble  powers  of  life. 
If  there  be  much  sore-throat,  and  the  child 
seem  likely  to  bear  the  loss  of  a  little  blood, 

I  sometimes  apply  a  few  leeches  to  the  angle 
of  the  jaw;  but.  have  hardly  ever  carried  de¬ 
pletion  beyond  this  point  among  my  patients 
at  the  Children’s  Infirmary.  It  is  very 
likely  that  the  low  type  whicii  a  disease  such 
as  scarlatina  is  almost  sure  to  assume  in  the 
crowded  dwellings  of  the  poor,  has  rendered 
my  practice,  in  this  respect,  somewhat  dif¬ 
ferent  from  that  which  might  be  advantage¬ 
ously  pursued  in  the  case  of  children  more 
favourably  situated.  To  the  same  circum¬ 
stance  it  is  also  probably  due  that  in  a  large 
proportion  of  cases  I  have  found  it  desirable 
to  give  ammonia  almost  from  the  outset  of 
the  disease ;  a  practice  which  has  been  re¬ 
commended  as  universally  applicable,  and 
which  (though  the  remedy  does  not  deserve 
the  too  indiscriminate  encomiums  that  have 
been  lavished  on  it)  you  will  do  well  to 
follow,  whenever  the  pulse  presents  the  cha- 


316 


DR.  TODD’S  CLINICAL  REMARKS  ON  PARALYSIS. 


racters  of  frequency  and  softness  combined. 
The  state  of  the  throat  must  be  carefully 
watched  in  every  case  of  scarlet  fever  :  and 
whenever  thei'e  is  much  swelling  of  the  ton¬ 
sils,  if  the  child  be  too  young  to  gargle,  a 
slightly  acidulated  lotion  should  be  injected 
into  the  back  of  the  throat,  by  means  of  a 
syringe,  every  few  hours,  in  order  to  free  it 
from  the  mucus  which  is  so  apt  to  collect 
there,  and  to  be  the  source  of  much  discom¬ 
fort.  If  there  be  much  deposit  of  lymph 
upon  the  tonsils,  it  is  generally  desirable  to 
apply  the  strong  hydrochloric  acid,  mixed 
with  honey,  in  the  proportion  of  about  one 
part  of  the  former  to  six  of  the  latter,  by 
means  of  a  dossil  of  lint,  or  a  camel’s-hair 
pencil,  two  or  three  times  in  the  twenty-four 
hours ;  but  the  strength  of  the  application 
must  be  increased  if  the  tonsils  be  ulcerated, 
or  if  any  disposition  to  sloughing  should 
appear.  The,  coryza  which  is  so  distressing 
and  so  ill-omened  a  symptom  in  cases  of 
severe  scarlatina,  is  best  treated  by  throwing 
a  small  quantity  of  a  solution  of  gr.j.  or 
gr.ij.  of  nitrate  of  silver  in  ^j.  of  distilled 
water,  up  the  nostrils  every  four  or  every 
six  hours.  The  glandular  swellings  are  very 
difficult  to  relieve.  When  considerable  they 
do  not  seem  to  be  benefited  by  leeches  ;  the 
employment  of  which  is  also,  in  many  cases, 
contraindicated  by  the  feeble  state  of  the 
patient’s  powers  ;  while  they  show  very  little 
disposition  to  suppurate,  and  consequently 
are  not  relieved  by  lancing :  so  that  the 
constant  application  of  a  warm  poultice  is 
often  all  that  can  be  done  to  afford  ease 
to  the  patient.  Children  in  whom  the  local 
affection  is  severe,  or  in  whom  the  disease 
assumes  a  malignant  character,  require  all 
those  stimulants,  and  that  nutritious  diet, 
which  we  are  accustomed  to  give  to  patients 
in  certain  stages  of  typhus  fever ;  though, 
unfortunately,  the  best  devised  means  will, 
in  many  such  cases,  prove  ineffectual. 


CLINICAL  LECTURE 
ON 

PARALYS  I  S, 

1 Delivered  at  King's  College  Hospital , 

By  R.  B.  Todd,  M.D.  F.R.S. 

Physician  to*  the  Hospital. 

(Reported  by  Mr.  S.  J.  A.  Salte  r,  A.K.C.) 

Lecture  III. 

In  the  lecture,  gentlemen,  that  I  shall  de¬ 
liver  to  you  to-day,  I  have  to  direct  your 
attention  to  the  concluding  history  of  the 
two  cases  of  diseased  brain  which  I  brought 
before  you  in  my  last  lecture.  Both  of 
these  cases  have  terminated  fatally,  as  we 
had  anticipated ;  and  we  have  thus  the  op¬ 


portunity  of  comparing  the  diseased  condi¬ 
tion  of  the  brain  with  the  symptoms  noticed 
during  life. 

The  first  of  these  cases  was  that  of  a  man 
named  Hardwick.  You  will  remember  that 
he  was  suffering  from  hemiplegia,  with 
rigidity  of  the  paralysed  muscles ;  and  you 
must  also  recollect  that  we  treated  him  with 
galvanism,  and,  as  is  usually  the  case  where 
there  is  recent  rigidity  of  the  paralysed 
muscles,  they  were  more  affected  by  the 
galvanic  current  than  those  upon  the 
sound  side, — a  circumstance  which  is  due, 
as  I  think,  to  the  exalted  polarity  of  the 
nerves  supplying  the  rigid  muscles.  You 
will  recollect,  further,  that  we  derived  from 
the  application  of  the  galvanism  some  aid 
to  our  diagnosis,  and  drew,  from  its  greater 
influence  on  the  palsied  than  on  the  sound 
limb,  the  inference  that  the  lesion  of  the 
brain  was  one  of  an  irritative  kind.  In 
the  diagnosis  that  I  then  gave  of  this  case,  I 
said  I  believed  it  to  be  one  of  meningeal 
disease  primarily,  and  that  the  brain  itself 
was  secondarily  affected.  This  patient’s 
death  was  preceded  by  symptoms  of  effu¬ 
sion  :  he  became  comatose  for  a  day  or  two 
previous  to  his  death.  Upon  making  a 
post-mortem  examination,  we  found  effusion 
into  the  lateral  ventricles  :  it  was  evidently 
recent,  for  the  brain  did  not  appear  to  have 
suffered  much  compression  from  its  pre¬ 
sence. 

In  making  the  diagnosis  in  this  case,  you 
will  remember  that  I  spoke  with  confidence 
respecting  the  nature  of  the  disease,  but 
hesitatingly  as  to  its  locality.  The  various 
segments  of  the  encephalon  are  so  closely 
connected  with  each  other  by  commissural 
and  other  fibres,  that  the  parts  in  the  im¬ 
mediate  vicinity  of  the  diseased  part  sympa¬ 
thize  with  it  to  a  very  great  extent — almost 
as  much  as  if  they  were  themselves  diseased. 
Hence  it  is  that  it  is  very  difficult,  and 
sometimes  impossible,  to  distinguish  disease 
of  the  optic  thalamus  from  disease  of  the 
corpus  striatum,  the  intimate  union  of  these 
two  bodies  causing  a  close  sympathy  between 
them,  and  that  lesion  of  the  hemispheres,  if 
situate  close  to  the  corpus  striatum,  gives 
rise  to  symptoms  similar  to  those  which 
would  arise  from  disease  of  that  body  itself; 
and,  for  the  same  reason,  deep-seated  lesion 
of  the  cerebellum  causes  the  same  symptoms 
as  would  be  caused  by  lesion  of  one  side  of  the 
pons  Varolii.  On  this  account  it  is  that  you 
will  find  it  exceedingly  difficult  to  diagnose 
the  exact  locality  of  cerebral  lesions.  Cer¬ 
tain  broad  distinctions  may  be  sufficiently 
accurately  made  with  due  attention  to  the 
general  principles  which  physiology  points 
out  as  to  the  functions  of  the  great  sub¬ 
divisions  of  the  brain  ;  but  I  look  upon  it  as 
impossible  to  determine  the  position  of  cere¬ 
bral  lesions  with  that  minuteness  of  accuracy 


DR.  TODD’S  CLINICAL  REMARKS  ON  PARALYSIS. 


317 


with  which  we  can  discover  the  locality  of  le¬ 
sions  of  other  organs — the  lungs,  for  instance. 

I  stated  to  you  that  we  should  probably 
find  in  this  case  the  disease  principally 
located  in  the  dura  mater,  the  arachnoid,  and 
pia  mater,  near  the  fissure  of  Sylvius,  and 
at  a  part  corresponding  to  the  squamous 
portion  of  the  temporal  bone.  I  also 
thought  that  the  optic  nerves  or  optic  tracts, 
and  the  third  nerves,  would  be  involved  in 
the  disease,  either  at  their  origin  or  in 
some  part  of  their  course.  I  was  princi¬ 
pally  influenced  in  coming  to  this  conclusion, 
as  far  as  regards  the  meningeal  disease,  from 
the  fixed  pain  which  the  patient  suffered 
about  the  squamous  portion  of  the  temporal 
bone,  and  just  in  front  of  the  meatus  audi- 
torius  externus.  I  had  at  first  thought  that 
the  optic  thalamus  was  the  principal  seat  of 
the  disease ;  but  this  opinion  I  afterwards 
gave  up  from  observing  the  intensity  and 
constancy  of  position  of  the  pain ;  and 
though  I  was  quite  prepared  to  find  disease 
of  a  part  so  nearly  connected  with  the  optic, 
and  the  third  pair  of  nerves  as  the  optic 
thalamus,  still  I  did  not  give  it  that  import¬ 
ance  which  I  had  at  first  deemed  it  worthy 
of,  and  which  our  post-mortem  examination 
showed  that  it  really  deserved. 

I  particularly  wish  to  call  your  attention, 
gentlemen,  to  this  subject  now,  while  the  de¬ 
tails  of  the  post-mortem  examination  are  fresh 
upon  your  memories;  andthe  more  so  because 
the  diagnosis  does  not  appear  to  have  been 
quite  exact.  It  is  a  duty  we  owe  ourselves 
to  scrutinize  particularly  any  errors  we  com¬ 
mit,  either  in  diagnosis  or  practice.  Depend 
upon  it,  if  you  do  this  faithfully,  you  will  de¬ 
rive  great  benefit  from  it :  your  experience 
will  be  infinitely  more  profitable  than  if  you 
slur  over  your  mistakes  without  explanation 
or  inquiry.  On  this  account,  I  make  it  a 
rule  never  to  pass  by  any  mistake  made 
here  in  diagnosis  or  practice  ;  and  I  feel  that 
in  commenting  upon  such  to  you,  I  am  far 
more  likely  to  benefit  both  you  and  myself, 
than  were  I  to  dilate  at  length  upon  success¬ 
ful  cases.  The  successful  cases  speak  for 
themselves  ;  the  failures  we  would  fain 
throw  a  veil  over :  but  be  assured,  in  so 
doing,  we  benefit  neither  science  nor  our¬ 
selves. 

A  diagnosis  may  be  erroneous  in  two 
ways  :  one  in  which  it  is  altogether  incor¬ 
rect  ;  the  other,  where  the  principles  upon 
which  the  diagnosis  is  conducted  are  sound, 
and  have  not  been  violated,  but  still  the 
details  of  the  diagnosis  may  not  be  abso¬ 
lutely  correct.  The  first  of  these  is  likely  to 
happen  when  our  examination  of  the  pa¬ 
tient’s  condition  has  not  been  sufficiently 
careful  ;  -and  when  we  have  neglected  to 
question  him  as  to  his  symptoms  with  all  that 
accurate  scrutiny  by  which  alone  we  can  ex¬ 
pect  to  ascertain  what  is  his  real  state  ;  — cr 


where  the  information  supplied  to  us,  not¬ 
withstanding  careful  inquiry,  has  been  in¬ 
complete  or  inaccurate  ;  but  the  second  may 
occur  from  the  absence  of  symptoms  of  a 
sufficiently  distinctive  character  to  give  us 
the  precise  information  we  require,  or  where 
the  attention  has  been  unduly  occupied  by 
the  inordinate  development  of  some  par¬ 
ticular  symptom  :  I  say  that,  under  such  cir¬ 
cumstances,  although  our  diagnosis  has  been 
conducted  upon  perfectly  sound  principles,  it 
may  still  be  erroneous  in  detail,.  Now  I 
must  tell  you  that,  in  this  case,  the  diagnosis 
has  been  perfectly  correct  in  principle,  but 
erroneous  in  some  of  the  details ;  and  I 
think  the  error  has  been  caused  partly  by 
the  difficulty  to  which  I  have  already  alluded 
of  determining  the  precise  locality  of  lesions 
in  brain  diseas'e,  and  partly  to  the  promi¬ 
nence  which  the  pain  assumed,  and  to  its 
very  local  character,  pointing  to  a  spot  not 
exactly  corresponding  with  that  at  which  the 
disease  was  situated: 

I  founded  my  diagnosis  principally  upon 
the  pain ,  the  imperfect  paralysis,  and  the 
spastic  state  of  the  muscles,  denoting  that 
the  paralysing  lesion  was  of  a  kind  which 
likewise  caused  nervous  irritation.  Acute 
pain  of  the  head  is  a  symptom  which  indi¬ 
cates  the  site  of  the  disease  as  either  in  the 
membranes  themselves,  or  in  some  superfi¬ 
cial  part  of  the  brain  in  contact  with  them  ; 
and  it  very  commonly  is  felt  at  the  same  spot 
in  the  head  as  corresponds  to  the  diseased 
part  within  the  skull.  Again,  the  imperfect 
character  of  the  paralysis  indicated  that  the 
morbid  change  was  of  some  superficial  part ; 
for  we  find  that  the  most  complete  paralyses 
are  those  caused  by  deep  lesion — the  nearer  the 
lesion  is  to  the  surface,  or  the  further  it  is 
from  the  corpus  striatum  and  the  crura 
cerebri,  the  less  the  paralysis,  and  vice 
versa :  and  experience  has  also  shown,  that 
an  irritated  state  of  the  nerves  and  of  the 
muscles  of  the  palsied  part  is  most  frequently 
connected  with  superficial  lesionof  the  brain, 
or  with  disease  of  the  membranes. 

I  shall  now  detail  to  you  the  results  dis¬ 
closed  by  the  post-mortem  examination,  and 
point  out  how  far  they  correspond  or  differ 
from  the  diagnosis  formed  during  the  life  of 
the  patient. 

In  the  first  place,  we  found  that  the  dis¬ 
ease  was  on  the  left  side  of  the  brain,  the 
opposite  to  that  on  which  the  palsy  existed, 
— so  far  principles  have  not  been  violated  ; 
next,  we  found  extensive  meningeal  disease, 
this  also  comporting  with  the  inference  which 
principles  led  us  to  draw  from  the  persis¬ 
tence  and  the  severity  of  the  pain  on  the 
left  side  of  the  head  ;  thirdly,  we  ascertained 
that  the  disease  was  inflammatory,  for  the 
products  of  inflammation  were  distinctly  de¬ 
veloped, — and,  in  this  point  likewise,  the 
diagnosis  was  correct  in  principle. 


318 


DR.  TODD’S  CLINICAL  REMARKS  ON  PARALYSIS 


It  was  wrong,  however,  in  assigning  the 
dura  mater  as  being  involved  in  the  disease, 
for  this  membrane  was  healthy  ;  and  it  was 
equally  wrong  in  fixing  the  site  of  the  dis¬ 
ease  as  at  the  anterior  inferior  angle  of  the 
parietal  bone ;  it  failed,  likewise,  in  not 
having  indicated  that  the  optic  thalamus  was 
the  part  of  the  brain  secondarily  affected  by 
the  meningeal  disease. 

The  membrane  principally  diseased  was 
the  pia  mater,  and  that  part  of  the  arach¬ 
noid  connected  with  it,  just  where,  at 
the  fissure  of  Bichat,  the  former  mem¬ 
brane  is  extended  into  the  ventricles 
of  the  brain  as  the  velum  interpositum, 
passing  over  the  quadigeminal  bodies,  and 
closely  connected  with  the  optic  thalamus. 
Here  the  pia  mater  was  much  thickened  by 
the  deposition  of  lymph  :  it  was  extremely 
red,  and  its  vessels  much  enlarged.  It 
formed,  indeed,  quite  a  large,  soft,  vascular 
tumor,  which  must  have  exerted  a  good  deal 
of  irritating  pressure  on  the  subjacent  ner¬ 
vous  matter.  In  this  disease  of  the  pia 
mater  there  was  quite  enough  to  explain  the 
severe  pain  in  the  head,  and  the  other  signs 
of  irritation  present;  but  it  is  difficult  to 
understand  the  precise  localisation  of  it  to  a 
part  so  much  anterior  to  the  seat  of  disease 
as  the  anterior  superior  angle  of  the  parietal 
bone;  and  this  circumstance  no  doubt  con¬ 
tributed  very  much  to  lead  us  astray.  The 
optic  thalamus  on  the  diseased  side  appeared 
to  be  double  its  natural  size,  and  by  its 
great  bulk  compressed  the  crus  cerebri  of 
that  side,  which  became  flattened  out  by  the 
pressure,  and  obliterated  the  locus  perforatus. 
The  crus  cerebri  of  the  right  side  must  like¬ 
wise  have  suffered  some  compression.  This 
extensive  compression  necessarily  affected 
the  third  pair  of  nerves  on  both  sides,  chiefly, 
of  course,  on  the  left ;  and  thus  we  obtained 
a  satisfactory  explanation  of  the  peculiar  con¬ 
vulsive  movements  of  the  eyeballs  which  this 
patient  exhibited. 

The  corpus  striatum  was  essentially 
healthy,  but  somewhat,  though  slightly, 
compressed  ;  and  its  function  was  probably 
weakened. 

The  great  augmentation  of  size  in  the 
optic  thalamus  in  this  case  was  more  appa¬ 
rent  than  real ;  for,  in  truth,  the  thalamus 
itself  was  in  part  wasted.  A  large  quantity 
of  new  material  v,'as  deposited  beneath  the 
inflamed  pia  mater,  which  added  conside¬ 
rably  to  the  apparent  bulk  of  the  thalamus. 
In  cutting  into  this  body  it  was  found  to  be 
at  one  part  soft  and  gelatinous,  and  at 
another  indurated.  The  first  portion  was 
that  in  immediate  connection  with  the  pia 
mater,  and  consisted  of  more  or  less  per- 
ectly  formed  pus.  The  second  portion, 
f which  consisted  of  the  posterior  third 
of  the  optic  thalamus,  exhibited  much 
change  in  the  proper  texture  of  this  part  of 


the  brain.  At  one  part,  quite  close  to  its 
posterior  extremity,  there  was  a  small  cyst 
about  the  size  of  a  pea,  which  contained  pure 
pus,  as  determined  by  the  microscope. 
Here  and  there  we  found  minute  spots  of 
opaque,  somewhat  gritty  matter,  in  which 
the  microscope  detected  masses  of  phosphate 
of  lime.  Similar  concretions  of  phosphate 
of  lime  were  found  in  the  diseased  pia  mater. 

This  indurated  portion  of  the  optic  thala¬ 
mus  was  submitted  to  chemical  analysis,  by 
my  friend  and  pupil,  Mr.  Lionel  Beals,  jun., 
to  whose  skill  and  expertness  as  an  analytic 
chemist  I  have  been  indebted  on  several  oc¬ 
casions.  He  found  that  the  indurated  por¬ 
tion  of  the  thalamus  contained  as  much  as 
6'9  per  cent,  of  the  phosphatic  salts  ;  healthy 
cerebral  matter  containing,  according  to  F. 
Simon,  no  more  than  OT  per  cent.  This 
remarkable  retention  of  the  phosphates  in 
the  diseased  portion  is  no  doubt  connected 
with  inflammation,  and  the  arrest  in  the 
proper  nutrient  changes  produced  by  it. 

Thus  the  post-mortem  inspection  afforded 
us  the  most  satisfactory  evidence  of  the  in¬ 
flammatory  nature  of  the  cerebral  lesion: 
the  red  and  thick  pia  mater, — the  puriform 
matter  beneath  it  and  upon  the  optic  thala¬ 
mus, — the  cyst  in  this  body  containing  pus, 
— the  indurated  portion  of  the  thalamus  :  all 
these  were  signs  of  cerebral  inflammation 
which  even  the  most  sceptical  could  not 
gainsay. 

And  it  likewise  proved  the  correctness  of 
the  diagnosis  as  to  the  cause  of  the  paralysis. 
You  will  remember  that  I  stated  that  the 
paralysis  was  caused  by  pressure,  exerted 
not  immediately,  but  indirectly,  on  the  cen¬ 
tre  of  volition.  The  pressure  was  found  to 
be  exerted  on  the  optic  thalamus,  and 
through  it  on  the  corpus  striatum  and  the 
inferior  layer  of  the  crus  cerebri,  both  of 
which  parts  form  a  portion  of  the  great 
centre  of  volition. 

The  inflammatory  or  irritative  nature  of 
the  paralysing  lesion  corresponds  in  the  most 
interesting  manner  with  the  augmented  ex¬ 
citability  of  the  paralysed  muscles  to  gal¬ 
vanism,  as  we  had  ascertained  more  than 
once  during  the  life  of  the  patient.  The 
explanation  of  this  augmented  excitability 
which  seems  to  me  to  be  the  correct  one,  is 
this,  not  that  the  muscles  have  experienced 
any  augmentation  in  their  irritability,  but 
that  the  polarity  of  the  nerves  is  augmented 
by  the  propagation  of  irritation  from  the 
compressed  and  inflamed  brain  to  that  seg¬ 
ment  of  the  cord  iu  which  they  are  im¬ 
planted.  The  nerves,  in  these  cases,  are 
more  or  less  in  the  condition  into  which  they 
are  apt  to  be  thrown  by  strychnine  :  their 
vital  force — their  polarity — is  exalted,  and 
they  are  excitable  by  the  slightest  stimulus. 

In  fine,  we  learn  from  the  review  of  this 
case  that  our  diagnosis  was  sufficiently  cor- 


DR.  TODD’S  CLINICAL  REMARKS  ON  PARALYSIS. 


819 


rect  for  all  practical  purposes — that,  follow¬ 
ing  the  general  principles  which  our  present 
knowledge  of  cerebral  physiology  indicates,  we 
obtained  all  the  information  we  could  desire 
for  the  proper  treatment  of  the  case.  This 
treatment  possibly  might  have  been  com¬ 
pletely  successful  had  the  patient  been  sub¬ 
mitted  to  it  at  a  sufficiently  early  period. 

The  subject  of  our  second  case,  Catherine 
Williams,  lingered  on  for  some  weeks;  no 
improvement  whatever  took  place  in  the 
condition  of  the  paralytic  limbs :  they  be¬ 
came  extensively  anasarcous,  and  the  muscles 
extremely  attenuated  ;  and  the  patient  died 
from  sheer  exhaustion. 

The  post-mortem  inspection  afforded  very 
satisfactory  proof  of  the  correctness  of  the 
diagnosis  in  this  case,  both  as  to  the  nature 
and  as  to  the  locality  of  the  lesion.  The 
disease  was  in  the  very  centre  of  the  right 
corpus  striatum,  one-third  of  which  must 
have  been  destroy  e  1  by  it.  The  whole  brain 
was  shrunk  ;  and  the  quantity  of  external 
fluid — subarachnoid  effusion — was  increased. 
Several  of  the  arteries  at  the  base  of  the 
brain  were  studded  with  atheromatous  spots. 
The  convolutions  were  small,  and  the  sulci 
between  them  large. 

The  general  shrinking  of  the  brain  ex¬ 
plained  the  increased  quantity  of  the  sub¬ 
arachnoid  fluid. 

As  to  the  nature  of  the  disease  :  the  mid¬ 
dle  third  of  the  corpus  striatum  was  exca¬ 
vated  into  a  small  cavity,  which  was  filled 
by  fluid  and  softened  brain-substance,  pro¬ 
bably  also  by  half- dissolved  softened  clots  of 
blood.  On  examining  the  contents  of  this 
cyst  by  the  microscope,  we  could  find  no 
trace  of  any  inflammatory  product ;  there 
were  some  remains  of  nerve  tubes,  and  the 
rest  consisted  of  an  undefined  granular  mat¬ 
ter,  derived  probably  from  the  destruction 
of  the  vesicular  matter  of  the  corpus 
striatum. 

I  think  there  can  be  no  doubt  that  in  this 
case  there  was  first  simple  softening,  without 
any  discolouration  of  the  middle  third  of  the 
corpus  striatum  ;  next  came  the  giving  way 
of  some  of  the  fibres  of  the  corpus  striatum, 
and,  at  the  same  time,  the  rupture  of  some 
small  vessels,  and  the  effusion  of  blood,  not 
in  large  quantity.  At  this  time  the  limbs 
became  paralysed  ;  and  from  the  total  de¬ 
struction  of  the  brain-substance  in  so  im¬ 
portant  a  part  as  the  corpus  striatum,  and 
the  entire  absence  of  any  reparative  effort, 
they  never  evinced  the  least  sign  of  improve¬ 
ment. 

It  would  be  difficult  to  find  a  more  per¬ 
fect  example  of  a  brain  suffering  from  im¬ 
perfect  nutrition  than  this.  No  doubt  the 
local  softening  was  due  to  some  defect  in 
the  local  nutrition,  the  precise  nature  of 
which,  however,  we  were  not  able  to  detect. 


The  nerves  of  the  paralytic  limbs  were  no 
doubt  depressed  in  their  vital  powers  :  the 
want  of  their  wonted  stimulus,  the  will,  suf¬ 
fered  them  to  fall  into  decay  ;  and  very  pro¬ 
bably  the  morbid  state  of  the  striated  body 
exercised  a  depressing  influence  upon  them. 
Hence  their  polarity  was  much  below  par  ; 
and  the  galvanic  stimulus,  which  excited  free 
action  in  the  sound  limbs,  produced  little 
or  no  effect  on  the  paralysed  limbs. 

There  is  one  point  in  which  these  cases 
present  an  interesting  contrast  with  each 
other,  to  which  I  must  allude  before  I  con¬ 
clude  this  lecture.  The  man,  Hardwick,  as 
you  will  remember,  died  comatose,  and  we 
found  an  undue  quantity  of  fluid  within  the 
ventricles,  and  no  subarachnoid  fluid  around 
the  brain.  The  woman,  Williams,  died 
from  exhaustion,  without  any  symptom  im¬ 
mediately  referrible  to  the  brain.  In  this 
case,  the  subarachnoid  fluid  was  abundant, 
but  there  was  no  fluid  in  the  ventricles. 

You  will  find,  I  think  I  may  say  invari¬ 
ably,  that  the  accumulation  of  fluid  in  the 
ventricles,  when  it  exceeds  a  certain  amount, 
produces  coma.  In  the  adult  the  comatose 
symptoms  come  on  earlier,  and  with  a  less 
amount  of  effusion,  than  in  the  child,  from 
the  resisting  nature  of  the  cranial  wall  in 
the  former,  whilst,  in  the  latter,  the  still 
open  state  of  the  fontanelles,  and  of  some  of 
the  sutures,  allows  the  skull  to  expand  as 
the  fluid  in  the  ventricles  increases  in 
quantity. 

On  the  other  hand,  the  increase  in  the 
subarachnoid  fluid  is  not  in  itself  accom¬ 
panied  by  any  special  symptoms.  This  aug¬ 
mentation  of  a  fluid  which  naturally  occupies 
the  subarachnoid  space,  is  due  entirely  to  a 
shrinking  or  diminution  in  the  bulk  of  the 
brain,  from  whatever  cause ;  and  its  quan¬ 
tity  bears,  too,  an  inverse  proportion  to  the 
bulk  of  the  brain.  You  find  it  in  large 
quantity  in  the  crania  of  persons  dying 
anaemic,  and  also  when  the  brain  has  been 
much  impaired  in  its  nutrition,  so  as  to 
cause  a  diminution  of  its  bulk  ;  and  even  if 
there  be  a  local  diminution  of  bulk,  as  when 
one  or  two  convolutions  have  shrunk,  or  have 
sunk  in  from  the  destruction  of  the  subja¬ 
cent  cerebral  substance,  you  will  find  an 
accumulation  of  fluid  opposite  the  shrunk  or 
depressed  convolutions. 


ROYAL  COLLEGE  OF  SURGEONS. 

Gentlemen  admitted  members  on  the  18th 
inst.  : — Messrs.  S.  W.  Aldred — R.  H.  Ho- 
tham — G.  B.  Sweeting — R.  W.  Gillespie — - 
J.  G.  Thompson — T.  G.  Copetake — C.  B. 
Bassano — J.  Stevenson — W.  V.  E.  Reynolds 
—  W.  A.  Jacob — B.  E,  Holwell — D.  Asbury 
— J.  H.  Jerwood — and  W.  Naismith. 


20 


MR.  BOWMAN  ON  THE  CRYSTALLINE  LENS. 


LECTURES, 

Delivered  at  the  London  Ophthalmic 
Hospital ,  Moorfields,  July  1847. 

By  William  Bowman,  F.R.S. 


Lecture  IV. 

Of  the  Crystalline  Lens. — Position , 
shape,  size — Anterior  chamber  small  in 
infancy — Occasional  consequent  of  this. 
Capsule  of  the  Lens — Experiment  illus¬ 
trating  its  endosmodic  power  and  its 
elasticity  —  Thickness  not  uniform  — 
Proneness  to  opacity  during  life — Cha¬ 
racters  of  the  opacity.  Body  of  the 
Lens — Its  fibres  and  laminae — Nucleus — 
Central  planes— their  use — their  com¬ 
plexity  in  the  human  lens  — Mode  of 
union  of  the  fibres — Use  of  the  toothed 
margins  —  Intracapsular  cells  —  The 
“  liquor  Morgagni”  a  result  of  disease  or 
post-mortem  change — The  “  capsule  of 
the  aqueous  humour”  does  not  exist — 
Remarks  on  some  appearances  of  cata- 
ractous  lenses. 

Gentlemen, — We  proceed  to-day  with  the 
consideration  of  the  structure  of  the  crys¬ 
talline  lens  and  its  capsule — a  subject  not 
more  interesting  to  the  anatomist  than  to 
the  ophthalmic  surgeon,  on  account  of  the 
large  share  of  his  attention  which  that  im¬ 
portant  and  common  disease,  the  cataract, 
must  always  engross. 

The  crystalline  lens,  you  will  remember, 
is  placed  at  the  front  of  the  vitreous  body 
behind  the  iris,  and  is  held  in  place  there 
chiefly  by  a  special  fibro- membranous  Sus¬ 
pensory  apparatus  passing  between  its  cap¬ 
sule  and  the  ciliary  processes,  but  partly  by 
its  adhesion  to  that  portion  of  the  vitreous 
body  which  is  hollowed  out  to  receive  it. 

Size  and  shape. — The  lens  is  an  almost 
perfectly  transparent  structure,  about  one- 
third  of  an  inch  wide,  and  one-sixth  of 
an  inch  thick,  more  convex  behind  than 
in  front.  It  has  been  doubted  whether  the 
curves  of  the  lens  are  spherical  or  spheroidal 
— a  question  of  much  interest  with  reference 
to  the  corrections  of  an  optical  nature  of 
which  the  eye  is  the  seat,  but  not  strictly 
bearing  on  the  object  before  us  in  these  lec¬ 
tures.  The  most  accurate  admeasurements, 
however,  of  the  mammalian  lens,  w’hich  are 
those  of  Chossat,  make  it  probable  that  the 
figure  of  the  human  lens  is  like  that  gene¬ 
rated  by  an  ellipse  revolving  round  its  lesser 
axis,  the  curvature  being  greater  for  the 
lateral  than  for  the  central  parts. 

The  lens  in  early  life  is  soft  and  nearly 
spherical,  and  grows  larger  and  flatter  with 
age,  as  well  as  harder,  and  somewhat  amber- 
coloured.  These  circumstances  should  be 


remembered  with  reference  to  the  diseases 
of  the  part  at  the  several  periods  of  life. 
The  globular  shape  of  the  infant’s  lens 
renders  the  aqueous  chamber  small,  and  the 
iris  almost  in  contact  with  the  cornea ; 
but  in  the  adult  the  iris  is  usually  not 
at  all  thrown  forwards  by  the  prominent 
centre  of  the  lens.  Nevertheless,  in  per¬ 
sons  of  full  or  declining  age,  who  are 
the  common  subjects  of  hard  cataract,  the 
surgeon  is  accustomed  to  meet  with  very 
varying  dimensions  of  the  anterior  chamber. 
This,  however,  depends  rather  on  variation 
in  the  size  of  the  lens  than  in  its  shape,  and 
sometimes  a  prominent  iris  betokens  an  en¬ 
larged  vitreous  body,  or  chronic  engorge¬ 
ment  of  the  ciliary  body  of  the  choroid.  In 
consequence  of  the  prominence  of  the  lens 
in  infancy,  it  sometimes  acquires  a  minute 
opacity  in  the  very  centre  or  most  promi¬ 
nent  point  of  its  anterior  surface,  from 
coming  in  contact  with  the  cornea,  where 
this  membrane  is  inflamed  in  cases  of  puru¬ 
lent  ophthalmia.  There  is  often  a  corre¬ 
sponding  speck  on  the  posterior  surface  of 
the  cornea,  precisely  opposite. 

Of  the  capsule  of  the  lens. — The  lens  is 
enclosed  in  a  capsule  of  perfectly  transpa¬ 
rent,  homogeneous,  and  very  elastic  mem¬ 
brane — a  part  that  should  engage  the  special 
study  of  every  one  who  proposes  to  operate 
on  the  eye.  It  is  an  entire  unbroken  layer, 
separating  the  lens  from  all  that  surrounds 
it,  but  very  permeable  by  fluids,  and,  there¬ 
fore,  the  medium  through  which  the  nutri¬ 
tion  of  the  lens  is  carried  on.  Its  elasticity, 
which  is  one  of  its  most  remarkable  proper¬ 
ties,  is  evinced  by  a  curious  experiment 
which  presented  itself  to  me  accidentally 
when  I  was  occupied  in  a  series  of  researches 
into  the  anatomy  of  these  parts.  When  re¬ 
moved  from  the  eye,  and  placed  in  water, 
the  lens  imbibes  fluid  through  its  capsule, 
which  thereby  becomes  distended  and  sepa¬ 
rated  from  the  contained  lens,  being  raised 
in  the  form  of  a  vesicle.  If  it  be  taken  from 
the  wrater,  and  punctured  with  a  needle,  the 
fluid  is  ejected  with  violence  by  the  resilience 
of  the  distended  capsule,  which  instantly 
resumes  its  former  bulk,  and  grasps  the 
lens  closely.  The  capsule  is  also  very 
brittle,  is  easily  torn  in  any  direction  when 
once  a  breach  is  made  in  it,  and  yet  very 
tough,  so  as  to  offer  considerable  resistance 
to  a  blunt  instrument  which  may  be  thrust 
against  it.  We  see  these  points  exemplified 
in  the  operations  for  cataract  and  artificial 
pupil.  In  the  former,  when  the  sharp- 
pointed  needle  touches  the  capsule  (provided 
the  membrane  be  sound),  it  enters  and  tears 
it  with  the  utmost  facility ;  while  in  the 
latter,  the  blunt  hook  often  used  to  engage 
and  draw  aside  the  pupillary  margin  of  the 
iris  seldom  does  any  injury  to  the  capsule, 
though  it  must  almost  always  touch  it,  and 


32 


STRUCTURE  OF  THE  BODY  OF  THE  LENS. 


that  sometimes  somewhat  rudely,  in  spite  of 
the  operator’s  caution.  When  ruptured, 
the  capsule  rolls  up  at  the  edges,  whatever 
the  direction  of  the  laceration,  and  it  is 
curious  that  the  outer  or  convex  surface 
always  lies  innermost  in  the  roll,  so  that, 
like  the  posterior  elastic  lamina  of  the 
cornea,  which  it  nearly  resembles  in  other 
respects,  it  appears  to  be  developed  or  laid 
down  in  a  curve  contrary  to  that  which  its 
elasticity  inclines  it  to  assume.  It  is  a  hard 
and  dense  structure,  and  determines  the 
exact  ou‘line  of  the  lens. 

Thickness  of  the  capsule  not  uniform. — 
The  thickness  of  the  capsule  of  the  lens  is 
different  in  different  parts  ;  particularly  it  is 
thicker  in  front  than  behind.  This  I  al¬ 
luded  to  in  the  last  lecture,  in  speaking  of 
the  suspensory  ligament  or  zonule  ;  but  I 
shall  here  repeat  it,  because  of  its  impor¬ 
tance.  The  anterior  part  of  the  capsule  in 
the  greater  portion  of  its  extent,  in  all  its 
central  region,  and  as  far  outwards  as  to 
within  one-sixteenth  of  an  inch  of  its  margin, 
where  the  suspensory  ligament  is  attached, 
is  four  or  five  times  thicker  than  the  pos¬ 
terior  part.  The  diminution  in  thickness 
commences  rather  suddenly  at  the  attach¬ 
ment  of  the  zonule,  and  continues  gradually 
as  you  proceed  over  the  border  to  the  pos¬ 
terior  surface,  where  the  minimum  thickness 
is  soon  attained.  This  I  have  ascertained 
by  careful  examination.  I  need  hardly 
point  out  to  you  how  a  knowledge  of 
this  fact  may  help  us  to  understand  some 
of  the  morbid  processes  met  with  in  this 
part,  and,  by  indicating  with  precision  the 
direction  in  which  lies  the  chief  strength 
of  the  support  of  the  lens  in  its  position, 
may  aid  the  surgeon,  and  give  him  con¬ 
fidence  in  certain  of  his  nice  and  delicate 
manipulations. 

The  capsule  retains  its  transparency 
after  death ,  but  is  prone  to  lose  it  during  , 
life. — The  capsule  of  the  lens  retains  its  ! 
transparency  under  the  action  of  acids,  of 
alcohol,  and  of  boiling  water,  and  will  resist 
the  putrefactive  process  for  a  great  length  of 
time  :  at  least,  I  have  frequently  found  it 
remain  transparent  after  the  lens  itself  had 
been  completely  destroyed  by  putrefaction, 
and  the  centre  of  the  lens  is  itself  very  slow 
to  putrefy.  But,  however  difficult  it  may 
be  to  render  it  opaque  after  removal,  it  is 
rather  prone  to  become  so  in  the  living 
body.  An  injury,  such  as  laceration  or 
puncture,  is  there  almost  sure  to  be  followed 
sooner  or  later  by  a  loss  of  its  transparency, 
and  we  often  see  it  of  a  decided  dead  white. 
The  same  also  occurs  in  many  cases  where 
the  opacity  is  primarily  in  the  lens  itself. 
After  the  operation  for  cataract  by  the 
needle,  this  opaque  capsule  is  a  not  infre¬ 
quent  source  of  annoyance  to  the  surgeon, 


obstructing  the  access  of  light  to  the  retina, 
and  demanding  removal. 

This  proneness  of  the  capsule  to  become 
opaque  only  while  it  continues  a  part  of  the 
living  body,  seems  to  shew  that,  hard  and 
structureless  as  it  appears,  it  is  yet  the  seat 
of  unceasing  nutritional  change — that  its 
substance  is  in  continual  flux ;  for  we  can 
only  regard  the  opacity  as  a  result  of  de¬ 
praved  nutrition,  the  new  material  being 
laid  down  in  an  abnormal  form.  In  some 
rare  examples,  one  of  which  presented  itself 
here  during  the  present  summer,  minute 
vessels  are  developed  upon  the  capsule,  pro¬ 
bably  in  lymph  previously  deposited  there 
as  a  consequence  of  inflammation.  They 
are  continuous  with  those  of  the  ciliary 
processes  or  adherent  iris.  It  is  interesting 
to  observe  that  the  opacity  is  usually  denser 
when  it  takes  place  in  the  anterior  part  of 
the  capsule  than  when  in  the  posterior, 
because  of  the  greater  thickness  of  the 
former  portion.  But,  besides  this,  the 
anterior  seems  more  prone  to  become  opaque 
than  the  posterior.  When  opacity  occur*, 
the  capsule  usually  loses  its  brittleness,  and 
becomes  tough.  The  opacity  assumes  an 
irregular  figure,  in  flakes  or  patches,  if  the 
body  of  the  lens  remains,  and  may  thus 
be  distinguished  from  a  similar  change  in 
the  lenticular  substance  ;  but  the  opacity  is 
more  uniform  if  the  capsule  has  been  rent 
and  the  body  of  the  lens  absorbed.  The 
opaque  parts  may  even  become  so  com¬ 
pletely  altered  from  their  original  texture  as 
to  be  the  seat  of  earthy  deposits ;  but  this  is 
rare. 

Of  the  structure  of  the  body  of  the  lens. 
— If  we  now  turn  our  attention  to  the  lens 
itself,  that  solid  transparent  mass  thus  en¬ 
closed  and  protected,  we  find  it  to  be  soft 
and  pulpy  in  the  outer  portions,  more  firm, 
dense,  and  glutinous  towards  the  centre, 
which  is  distinguished  as  the  nucleus.  Not 
that  there  is  any  special  plane  of  division 
between  the  nucleus  of  the  lens  and  its 
exterior  or  superficial  portions  :  the  change 
to  more  and  more  density  is  very  gradual. 
No  language  derived  from  other  objects  can 
adequately  describe  the  precise  texture  of 
the  lens,  as  appreciated  by  the  finger, 
simply  because  it  is  not  a  homogeneous 
texture,  but  one  highly  complicated  and 
peculiar,  which  it  will  require  some  atten¬ 
tion  to  understand. 

Fibres  of  the  lens. — The  lens  is  composed 
of  flattish  riband-like  albuminous  fibres, 
having  an  average  thickness  of  of  an 

inch,  united  side  by  side,  so  as  to  form 
plates,  w  hich  are  placed  one  within  the 
other,  somewhat  like  the  leaves  of  an  onion. 
The  fibres  all  pass  from  the  front  to  the 
back,  so  that  each  has  two  extremities,  an 
|  anterior  and  posterior ;  and  a  middle  part, 


322  NUCLEUS  OF  THE  LENS.  OBJECT  OF  THE  CENTRAL  PLANES. 


which  is  directed  towards  the  side  or  rim  of 
the  lens.  In  the  lens  of  simplest  construc¬ 
tion — the  spherical  or  spheroidal  lens  of 
many  fishes,  reptiles,  and  birds — the  ends  of 
the  fibres  all  meet  in  the  antero-posterior 
axis  ;  and  the  surface  of  such  a  lens,  viewed 
either  before  or  behind,  has  the  appearance 
of  a  globe  marked  by  the  lines  of  longitude 
passing  from  pole  to  pole.  The  same  ap¬ 
pearance,  too,  is  seen  after  removing  any 
number  of  the  layers  of  fibres  down  to  the 
centre.  The  individual  fibres  are  of  course 
narrower  at  the  extremities  and  broader  in 
the  middle  ;  and  they  would  come  to  quite 
a  point  in  the  axis  were  it  not  that  their 
lateral  union  becomes  so  intimate  as  they 
approach  it,  that  the  eye  can  no  longer  dis¬ 
tinguish  them  individually,  nor  the  skill  of 
the  anatomist  isolate  them.  Moreover,  it 
would  appear  that  those  coming  from  oppo¬ 
site  sides  do  not  form  a  firm  junction  across 
the  axis,  but  rather  that  the  axis  is  occupied 
by  a  substance  of  less  density  than  the  fibres 
themselves ;  so  that,  under  ordinary  cir¬ 
cumstances,  the  lens  may  be  made  to  break 
up,  and  its  opposite  sides  to  fall  asunder 
along  that  line.  In  the  lenses  I  am  now  re¬ 
ferring  to  it  is  not  uncommon  to  find  a  cup¬ 
shaped  depression — a  kind  of  crater  at  each 
pole ;  but  I  have  never  seen  this  so  large  as 
in  the  prolate-spheroidal  lens  of  the  cuttle¬ 
fish. 

Nucleus  of  the  lens. — It  is  further  to  be 
observed  that  the  individual  fibres  become 
narrower  and  denser,  as  well  as  more  inti¬ 
mately  held  together,  as  they  approach  the 
centre  of  the  lens  ;  and  it  is  obvious  that 
they  must  also  become  shorter  and  shorter. 
The  degree  in  which  their  density  augments, 
varies,  however,  very  widely:  in  the  bird,  for 
instance,  it  is  far  less  than  in  the  fish  ;  so 
that  the  lens  of  the  former  is  soft  and  pulpy, 
even  to  the  centre,  while  the  nucleus  of  the 
latter  is  often  of  almost  stony  hardness. 

What  I  have  now  said  as  to  the  shape  and 
texture  of  the  lenticular  fibres  applies  in 
general  to  the  eyes  of  most  animals.  These 
fibres  are  always  narrowest  at  their  ends, 
shorter  and  denser  towards  the  centre  of  the 
lens.  The  mode,  however,  in  which  their 
extremities  are  arranged  at  the  poles,  ex¬ 
hibits  many  very  curious  modifications,  as 
to  the  use  and  meaning  of  which  we  are  still 
very  much  in  the  dark,  but  which,  in  the 
meantime,  vail  repay  a  few  moments’  atten¬ 
tion  as  instances  of  elaborate  mechanism,  in 
which  may  be  concealed  some  clue  both  to 
the  nature  of  the  nutritive  changes  in  the 
organ,  and  possibly  to  the  better  compre¬ 
hension  of  eome  of  its  morbid  states,  and 
the  means  for  their  relief.  The  effect,  also, 
of  these  modifications  of  structure  on  the 
transmitted  light  should  not  be  lost  sight  of 
in  considering  their  design. 


Central  planes. — The  first  departure  from 
the  simple  arrangement  already  mentioned — 
in  which  all  the  fibres  diverge  from,  and 
terminate  in,  the  antero-posterior  axis  of  the 
lens — is  met  with  in  some  fishes  and  some 
mammalia,  of  which  the  porpoise  is  one. 
Looking  at  the  front  of  the  lens  we  see  a 
straight  line  passing  through  the  pole,  and 
reaching  about  one  quarter  or  one-third  of 
the  way  towrards  the  margin  or  equator  on. 
each  side.  From  this  line  the  fibres  diverge 
in  an  uniform  manner,  and  passing  over  the 
edge,  may  be  traced  converging  on  the  op¬ 
posite  surface  to  a  line  of  similar  length 
passing  through  the  pole,  but  at  right  angles 
to  the  first, — so  that  if  the  one  is  vertical 
the  other  is  horizontal.  This  being  so,  a 
moment’s  consideration  will  enable  you  to 
understand  that  none  of  the  fibres  reach  half 
round  the  lens — that,  for  instance,  one  which 
starts  from  the  anterior  pole  (or  the  centre 
of  the  anterior  line)  cannot  reach  the  poste- 
terior  pole,  but  terminates  at  the  extremity 
of  the  posterior  line  ;  while  one  which  starts 
from  the  end  of  the  anterior  line  is  neces¬ 
sarily  brought  to  the  posterior  pole  ;  and  the 
intermediate  ones  in  a  similar  manner,  ac¬ 
cording  to  their  position.  Now,  if  we  re¬ 
move  the  more  superficial  strata  of  fibres, 
we  still  find  the  deeper-seated  fibres  diverg¬ 
ing  from  similar  lines,  and  discover,  in  fact, 
that  the  lines  seen  on  the  surfaces  are  but 
the  edges  of  planes  which  penetrate  even  to 
the  central  region  of  the  lens, — these  planes 
being  productions  or  expansions  of  that  axis 
in  which,  in  the  spherical  variety  of  lens,  all 
the  fibres  meet. 

Object  of  the  central  planes. — These 
planes  are  widest  where  they  appear  on  the 
surface  of  the  lens,  and  are  gradually  nar¬ 
rower  inwards  ;  and  those  of  opposite  sides 
meet,  although  at  right  angles,  somewhere 
in  the  antero-posterior  axis,  at  a  point  the 
position  of  which  (or  in  other  words,  the 
respective  depth  attained  by  the  planes,) 
is  determined  by  the  various  curvatures  of 
the  opposite  surfaces  of  the  lens.  But  as 
every  fibre  has  in  each  plane  a  point  answer¬ 
ing  to  one  of  its  extremities,  it  follows  that 
the  area  of  the  two  planes  must  in  all  pro¬ 
bability  be  equal,  and  therefore  that  where 
one  passes  from  the  pole  more  deeply  into 
the  lens,  the  other  must  extend  more  widely 
towards  the  margin. 

It  certainly  appears  to  me  that  the  expan¬ 
sion  of  the  axis  into  the  planes  now  described, 
and  the  concomitant  complexity  of  the  ar¬ 
rangement  of  the  fibrous  constituents  of  the 
lens,  are  designed  to  furnish  the  mechanical 
means  of  producing  a  different  curvature  on 
opposite  surfaces. 

If  we  pass  to  the  examination  of  other 
bases,  further  modifications  of  the  axial 
planes,  and  consequently  of  the  arrangement 


CENTRAL  PLANES — THEIR  SIMPLICITY  IN  THE  HUMAN  FCETUS.  323 


of  the  fibres,  are  met  with.  For  example, 
in  some  of  the  cetacea  I  have  found  the 
planes  to  bifurcate  irregularly,  and  to  a  vari¬ 
able  extent,  towards  the  margin  of  the  lens 
— a  disposition  not,  I  believe,  before  ob¬ 
served  ;  but  the  most  elegant  arrangement  is 
certainly  that  of  the  mammalia  in  general, 
in  which  three  equidistant  planes  diverge 
from  the  axis, — those  of  the  front  and  back 
holding  intermediate  positions,  precisely  as 
in  the  more  simple  case  already  described. 

Their  complexity  in  the  adult  human  lens. 
— But  of  all  the  specimens  that  have  come 
under  my  own  observation,  those  of  the  adult 
human  lens  have  presented  the  greatest 
multiplication  or  subdivision  of  these  planes; 
for  while  our  own  lens  adheres  to  the  ordi¬ 
nary  mammalian  type  in  possessing  a  triple 
divergence  from  the  pole,  each  of  the  three 
planes  is  almost  immediately  branched,  if  I 
may  use  the  term,  and  this  not  once  only, 
but  twice  or  more, — so  that  instead  of  three 
segments  we  have  as  many  as  twelve  or 
sixteen,  the  numbers  being  irregular  no  less 
than  the  course,  direction,  and  extent  of 
each. — Fig.  11. 

Fig.  11. 


A.  Division  of  central  planes  as  seen  on  pos 
terior  surface  of  an  adult  human  lens. 
b.  Same  from  the  foetus  of  nine  months. 


Fig.  1 1 ,  copied  with  accuracy  from  an  adult 
human  lens,  will  convey  a  better  idea  of  the 
arrangement  of  these  planes  than  mere  words 
can  express  ;  and  if  you  will  endeavour  to 
picture  the  opposite  surface  as  if  seen  through 
this  one,  and  intersected  with  a  somewhat 
similar  radiation  of  planes,  placed  inter¬ 
mediately  to  these  and  receiving  the  opposite 
ends  of  the  fibres,  you  will  understand  the 
extraordinary  intricacy  of  the  construction 
of  this  organ  in  our  own  eye. 

Their  simplicity  in  the  human  foetus. — I 
may  mention  in  this  place  an  interesting  fact 
which  I  noticed  in  comparing  the  fibres  of 
the  foetal  and  adult  lens  in  the  human  sub¬ 
ject.  It  is  this — that  as  development  pro¬ 
ceeds,  and  the  lens  becomes  wider  and  flatter, 
the  central  planes  extend  themselves  further 
and  further  from  the  axis,  and  at  the  same 
time  branch  again  and  again,  so  as  to  multi¬ 
ply  the  segments,  into  which  they  divide  the 
lens. — See  fig.  11. 

From  this  it  may  be  inferred  that  the 
multiplication  of  the  mesial  planes  outwards 
is  a  process  necessary  to  the  expansion  and 
flattening  of  the  organ,  and  takes  place  by 
the  deposition  of  new  fibres  on  the  surface 
of  the  old  ;  and  also,  that  even  in  the  adult 
lens  the  planes  remain  simply  tripartite  in 
the  nucleus,  being  only  multiplied  in  the 
more  superficial  layers. 

Having  thus  endeavoured  to  convey  to 
you  some  general  idea  of  the  arrangement  of 
the  lenticular  fibres,  we  will  consider  briefly 
the  mode  in  which  they  are  united  into  the 
forms  I  have  described,  and  organically 
attached  to  the  capsule, — for  it  would  be  a 
mistake  to  regard  them,  as  we  are  apt  to  do, 
simply  in  the  light  of  independent  parts 
placed  in  artificial  juxtaposition.  And  more 
especially  is  it  necessary  to  consider  the  lens 
as  a  whole,  if  we  would  form  a  correct  notion 
of  the  actions  which  contribute  to  the  main¬ 
tenance  of  its  organic  life,  and  comprehend 
the  reason  of  the  alterations  of  texture  which 
it  exhibits  under  accident  or  disease. 

Mode  of  union  of  the  fibres. — As  the  ends 
of  the  fibres  approach  the  central  planes  in 
which  they  terminate,  they  are  found  to  be 
more  or  less  fused  together  into  a  solid 
hyaline  mass,  which  retains  for  a  short  way 
only  a  trace  of  the  interval  between  the  con¬ 
tiguous  fibres.  Sometimes  the  fibres  may 
be  torn  up  as  far  as  the  central  planes  ;  at 
others  they  break  off  short,  rather  than  split 
up,  as  they  approach  the  planes  :  and  this 
is  more  the  case  towards  the  nucleus.  Near 
the  planes,  therefore,  we  cannot  properly 
say  that  they  have  a  well-defined  border  or 
limit ;  but  in  the  intermediate  portions  of 
their  extent  their  edges  are  found  to  be 
doubly  bevilled,  so  that  one  fibre  is 
adapted  by  each  of  its  edges  to  two  other 
fibres— one  a  little  above,  and  the  other  a 
little  below  it ;  and  if  we  consider  these 


324  THE  “  CAPSULE  OF  THE  AQUEOUS  HUMOUR”  DOES  NOT  EXIST. 


bevillings  as  separate  sides,  each  fibre  would 
be  six-sided.  But  we  further  remark  that 
the  bevilled  margins  are  more  or  less  jagged, 
and  that  the  projections  and  sinuosities  of 
the  opposed  fibres  mutually  interlock.  Thus 
each  fibre  is  intimately  united  by  its  toothed 
edges  to  four  others,  and  by  its  smooth 
flattened  surfaces  it  touches  two  others — one 
over  and  the  other  under  it.  The  lateral 
union  of  the  fibres  being  the  more  intimate, 
determines  the  division  of  the  lens  into 
layers  enclosed  one  within  another,  rather 
than  into  segments.  But  if  we  obtain  a  for¬ 
tunate  view  of  the  fibres  in  situ  and  in  sec- 
tion,  it  is  easy  to  perceive  that  the  lateral 
junctions  of  the  fibres  of  successive  layers 
lie  in  regular  order  one  below  another  ;  and 
that  if  the  splitting  of  the  lens  could  be 
made  to  follow  these  joinings,  we  should 
reduce  the  organ  to  a  number  of  segments, 
the  thickness  of  which  would  correspond 
with  the  width  of  one  fibre. 

The  indented  margins  of  the  fibres  are 
much  more  obvious,  and  are  no  doubt  really 
much  more  developed,  in  some  classes  of 
animals  than  in  others.  It  was  in  the  eye 
of  the  cod  that  Sir  David  Brewster  first 
detected  them,  and  they  are  nowhere  more 
evident.  The  teeth  have  a  certain  average 
size  ;  but,  like  those  of  the  cranial  sutures, 
they  are  irregular  in  shape,  and  have  been 
manifestly  formed  by  the  shooting  together 
of  contiguous  parts  during  growth.  In  the 
lens  of  the  bird,  and  in  that  of  mammalia 
and  man,  they  are  even  less  regular  in  size, 
and  far  less  defined  ;  and  it  is  often  difficult 
to  see  more  than  a  soft  woolly  margin.  The 
toothed  borders  are  usually  most  apparent 
when  the  albuminous  basis  of  the  fibres  has 
been  hardened  by  heat,  or  a  chemical  reagent. 

Use  of  the  toothed  margins  of  the  fibres. 
—What,  now,  is  the  use  of  the  serrations  of 
the  fibres  of  the  lens,  and  why  do  they  exist 
only  at  the  sides  ?  In  the  fish,  which  has 
the  fibres  very  flat,  and  consequently  with 
thin  edges,  and  a  small  surface  for  lateral 
contact,  the  teeth  are  large,  stiff,  and  well 
defined ;  whereas  in  the  higher  animals, 
where  the  fibres  are  thicker,  and  their  be¬ 
villed  edges  present  a  broader  surface  of 
union  with  those  on  either  hand,  the  teeth 
are  softer  and  less  developed  :  and  in  all 
cases  the  broad  surfaces  of  the  fibres  are  not 
toothed  at  all.  We  may  therefore  regard 
the  serrations  simply  as  an  artificial  mode  of 
increasing  the  points  of  union  between  the 
fibres,  according  as  their  shape  renders 
necessary.  If  the  fibres  had  been  six-sided, 
and  the  sides  equal,  we  may  suppose,  either 
that  there  would  have  been  no  teeth  at  all, 
or,  if  any,  that  they  would  have  been  de¬ 
veloped  to  an  equal  extent  on  all  the  sides. 
Thus  far,  perhaps,  it  is  legitimate  to  specu¬ 
late  on  the  final  cause  of  this  remarkable 
and  elegant  structure. 


Intra-capsular  cells  of  the  lens. — Imme¬ 
diately  within  the  capsule,  separating  it  from 
the  superficial  fibres,  is  a  layer  of  cells,  ex¬ 
tremely  thin  and  transparent,  of  unequal  size, 
and  nucleated.  These  cells  form  an  organic 
union  between  the  body  of  the  lens  and  its 
capsule,  and  it  is  through  them  that  the  nu¬ 
trition  of  the  fibrous  part  is  conducted.  It 
is  by  the  multiplication  and  successive  trans¬ 
formation  of  these  cells  into  fibres  that  the 
body  of  the  lens  increases  in  size  ;  and  when 
its  growth  is  complete,  a  single  layer 
of  them  remains.  The  superficial  fibres, 
even  of  the  adult,  often  retain  some  of  the 
nuclei,  in  an  extremely  transparent  form,  at 
irregular  distances  in  their  substance. 

The  liquor  Morgagni  a  result  of  disease 
or  post-mortem  change. — When,  after  death, 
the  lens  is  placed  in  water,  or  allowed  to  lie 
in  contact  with  the  aqueous  humour,  the 
w'ater  passes  through  the  capsule,  and  dis¬ 
tends  and  bursts  these  cells,  collecting  be¬ 
tween  the  lens  and  the  capsule,  and  raising 
the  capsule  as  I  mentioned  at  an  earlier 
period  of  the  lecture ;  but  no  fluid  exists 
during  life  between  the  capsule  and  fibres  of 
the  lens,  except  what  belongs  to  the  texture 
of  the  cells.  There  is,  then,  no  such  fluid 
as  the  liquor  Morgagni  in  the  healthy  lens. 
When  this  fluid  exists  in  the  cataractous 
lens,  between  the  body  and  the  capsule,  or 
when  it  is  found  there  after  death,  it  is  to  be 
regarded  as  a  morbid  or  false  condition,  in¬ 
dicative  of  the  destruction  of  the  layer  of 
cells  which  has  been  just  described. 

The  “  capsule  of  the  aqueous  humour  ” 
does  not  exist. — Some  authors  speak  of 
another  layer  of  cells  on  that  portion  of  the 
outer  surface  of  the  capsule  which  contri¬ 
butes  to  form  the  posterior  chamber  of  the 
aqueous  humour  behind  the  iris,  and  they 
consider  it  to  resemble,  and  to  be  a  continua¬ 
tion  of,  the  epithelium  lining  the  back  of 
the  cornea,  and  which  I  have  termed  the 
epithelium  of  the  aqueous  humour.  Such  a 
layer  has  been  imagined  necessary  for  the 
completion  of  that  serous  sac  which  has  been 
very  generally  supposed  to  enclose  the  aque¬ 
ous  humour,  and  which  has  passed  under 
the  name  of  the  aqueous  capsule ,  or  capsule 
of  the  aqueous  humour.  Now,  with  regard 
to  its  existence  on  the  front  of  the  lens,  I 
can  only  say  that  I  have  sought  for  it  with 
great  care,  but  in  vain  ;  and  I  therefore  do 
not  believe  that  it  exists.  Taking  the  per¬ 
fectly  fresh  eye  of  a  large  animal,  I  have  re¬ 
moved  the  cornea  by  a  circular  cut  with 
scissors,  without  allowing  the  cornea  to 
touch  or  rub  against  the  lens.  I  have  then, 
with  equal  caution,  cut  away  the  iris,  so  as 
fully  to  expose  the  front  of  the  lens  ;  I  have 
then  most  carefully  made  a  circular  incision 
in  the  front  of  the  capsule,  near  its  rim,  and 
have  placed  the  portion  so  detached  on  glass, 
flat  or  variously  folded,  and  always  without 


ON  SOME  APPEARANCES  OF  CATARACTOUS  LENSES. 


325 


being  able  to  distinguish  any  trace  of  such 
cells.  Now,  with  far  less  nicety,  it  is  most 
easy  to  see  the  posterior  epithelium  of  the 
cornea,  and  the  intra-capsular  cells  of  the 
lens  ;  and  the  evidence,  therefore,  seems  to 
me  sufficient  for  disbelieving  in  the  existence 
of  the  layer  now  spoken  of :  particulaxdy  as 
I  am  not  aware  that  any  author  who  has 
described  it  has  stated  that  he  has  actually 
seen  it. 

I  shall  now  say  a  few  words  on  some 
varieties  of  cataract,  the  appearances  of 
which  (capable  of  being  discriminated  during 
life)  derive  illustration  from  what  I  have 
now  explained  of  the  structure  and  arrange¬ 
ment  of  the  lenticular  fibres. 

Remarks  on  some  appearances  of  cata- 
ractous  lenses. — The  congenital  opacity  of 
the  lens,  so  frequent  in  children,  affects  the 
entire  substance.  We  may  sometimes  ob¬ 
serve  upon  its  front  surface  the  simple  trili  - 
near-  division  into  segments  which,  in  the 
human  subject,  is  peculiar  to  early  life. 

In  the  commencing  cataract  of  middle  or 
declining  age,  we  not  uncommonly  find  the 
posterior  surface  of  the  lens  first  affected,  so 
that  we  look  through  the  transparent  lens 
upon  an  obviously  concave  opacity.  This 
opacity  sometimes,  and  indeed  generally, 
encroaches  from  the  margin  in  distinct 
streaks  of  irregular  thickness,  length,  num¬ 
ber,  and  distance  apart ;  and  we  usually 
find  that,  when  the  pupil  is  widely  dilated 
by  belladonna,  some  at  least  of  these  streaks 
are  traceable  round  the  margin  for  some 
way  over  the  anterior  surface.  So  long  as 
small  portions  of  the  hinder  surface  of  the 
lens  remain  clear,  the  body  and  front  being 
also  clear,  it  is  surprising  how  much  visual 
power  may  remain.  At  a  subsequent  period, 
the  centre  of  the  lens  begins  to  be  cloudy, 
and  then  the  progress  towards  blindness  is 
more  rapid.  Now  I  can  entertain  no  doubt 
that  the  streaks  in  these  cases  are  sets  or 
bundles  of  the  superficial  layer  of  lenticular 
fibres,  reduced  to  a  state  of  opacity  by  some 
nutritional  change.  There  seems  to  be  a 
disposition  in  the  fibres  of  the  lens  to  become 
opaque  in  their  entire  length  when  once  they 
are  morbidly  altered  at  a  single  point,  and 
hence  the  linear  figure  of  the  opacity.  The 
opacity,  probably,  commences  in  the  middle 
part  of  the  fibres,  near  the  margin  of  the 
lens ;  and  the  arrangement  of  the  fibres 
would  account  for  the  different  length  of  the 
streaks,  some  approaching  nearer  than  others 
to  the  central  point  on  the  surface. 

In  another  variety  of  opacity  in  adults, 
closely  allied  to  the  last,  there  are  streaks 
visible,  either  on  the  anterior  or  posterior 
surface,  before  the  nucleus  manifests  any 
tendency  towards  dulness,  but  instead  of 
converging  from  the  border  of  the  lens,  they 
rather  diverge  from  the  central  point.  These 
streaks  are  also  irregular  in  number  and  di¬ 


rection  ;  and  it  has  never  occurred  to  me  to 
distinguish  in  them  any  exact  representation 
of  the  edges  of  the  mesial  planes  as  they  are 
seen  on  the  surface  of  the  prepared  lens : 
never,  certainly,  any  trilinear  figure.  But 
a  glance  at  the  representation  above 
given  of  the  complex  arrangement  of  the 
mesial  planes  in  the  adult  human  lens,  will 
suffice  to  explain  why  they  are  rarely  seen  in 
such  opacities.  In  the  natural  lens  they  are 
in  reality  too  near  together,  and  too  irregu¬ 
lar,  to  be  detected  without  a  glass.  The 
triple  divergence  from  the  axis  can,  even 
then,  only  be  recognised  for  a  short  distance, 
beyond  which  the  planes  seem  to  diverge 
and  branch  without  any  attempt  at  geome¬ 
trical  precision.  We  cannot,  therefore, 
wonder  that  an  opacity,  spreading  from  the 
centre  of  the  surface  of  the  lens,  and  which 
consists  of  broad,  ill-shapen  streaks,  should 
fail  to  disclose  the  delicate  and  complex  ra¬ 
diation  of  the  mesial  planes  :  although  it 
seems  highly  probable  that  its  seat  is,  pri¬ 
marily  and  essentially,  x-ather  in  the  edges  of 
those  planes,  than  in  the  fibres  themselves.* 

In  the  lenticular  catai'act  of  adults,  the 
glistening,  silky,  fibrillation  of  the  lens  may 
be  often  seen  ;  but  you  will  fail,  even  in  the 
best- marked  of  these  cases,  to  discover,  with 
the  naked  eye,*  any  thing  like  regularity  in 
the  mode  in  which  the  fibi’es  pass  off  fx*om 
the  central  region.  Before  becoming  ac¬ 
quainted  with  the  complex  arrangement  of  the 
planes  in  the  human  lens,  I  could  not  satisfy 
myself  why  the  triple  line  of  the  mammalian 
lens  should  be  unseen  ;  but  the  actual  com¬ 
plexity  is  a  sufficient  l’eason.  It  explains, 
too,  the  appearances  of  many  cases  of  opa¬ 
city  of  the  body  of  the  lens,  where  the 
fibrous  texture  is  in  general  obvious  enough, 
but  where,  towards  the  centre,  an  amor¬ 
phous,  indefinable,  obscurity  exists. 

*  Since  this  lecture  was  delivered,  I  have  seen, 
two  cases  (one  under  the  cai’e  of  Mr.  Dixon)  in 
which  the  opacity  radiated  from  the  centre  in 
clearly-defined  branching  lines,  corresponding 
exactly  in  character  with  the  branchings  of  the 
central  planes.  The  opacity  was  confined  to  the 

Fig. 12. 


the  lens,  and  some  of  the  fibres  at  the  ciixum- 
fercnce.  The  pupils  dilated  by  atropine. 

surface  of  the  lens,  and  did  not  dip  in  the  direc¬ 
tion  of  the  planes  ;  neither  did  it  occupy  all  the 
divisions  of  the  central  planes.  It  was  accom¬ 
panied,  in  both  cases,  with  other  st  eaks  of  opa¬ 
city  at  the  border  of  the  lens,  evidently  in  some 
of  the  fibres. 


326  dr.  a.  t.  Thomson’s  report  of  a  case  of 


©rfgtnal  ©ommumcattong. 


REPORT  OF 

A  CASE  OF  GENERAL  PARALYSIS 

OF  THE 

INSANE  TERMINATING  IN 
RECOVERY. 

ByAnthony  Todd  Thomson,  M.D.  F.L.S. 

Fellow  of  the  Royal  College  of  Physicians, 
&c.  &c. 


The  following  case  of  general  paralysis 
of  the  insane,  is  brought  before  the 
profession,  not  with  any  claim  of  merit 
for  its  treatment,  but,  as  far  as  a  solitary 
case  can  be  of  value,  to  set  aside  the 
too  prevalent  opinion,  that  this  form 
of  paralysis  is  necessarily  fatal.* 

Case. — Joseph  Bond,  set.  36,  was 
admitted  into  University  Hospital,  31st 
May,  1848,  under  I)r.  A.  T.  Thomson. 
He  is  of  a  sanguineo-nervous  tempera¬ 
ment;  a  carpenter  by  trade,  married, 
and  has  always  been  a  regular,  tempe¬ 
rate  person.  About  a  year  ago  he  was 
thrown  out  of  work  from  the  failure  of 
his  master;  and  not  being  able  to  get 
fresh  employment  he  became  extremely 
anxious  and  depressed  in  spirit;  and, 
from  his  poverty,  incapable  of  procur¬ 
ing  proper  nourishment  either  for  him¬ 
self  or  his  family.  Five  weeks  previous 
to  his  admission  into  the  hospital,  he 
was  attacked  with  a  convulsion,  fol¬ 
lowed  by  trembling  in  all  his  limbs, 
inability  to  stand,  and  loss  of  speech. 
He  was  also  mentally  deranged ;  a 
state  which  lasted  for  three  days,  dur¬ 
ing  which  time  he  attempted  suicide. 

A  medical  gentleman  who  was  called 
to  see  him,  blistered  him  twice  on  the 
nape  of  the  neck,  and  gave  him  some 
medicines.  He  recovered  his  senses ; 
but  he  was  unconscious  of  every  thing 
that  had  occurred  during  the  time  he 
lost  his  senses.  He  continued  for  some 
time  after  he  entered  the  hospital  in  a 
state  of  great  debility,  with  tremors  in 
both  upper  and  lower  extremities,  and 
extreme  difficulty  of  articulation.  He 
could  not  walk  without  assistance;  and 
when  he  tried  to  walk  alone  he  dis¬ 
played  a  strong  inclination  to  move 
either  backwards  or  sideways.  His 

*  Neither  Royer-Collard  nor  Esquirol  has  ever 
seen  a  case  of  it  cured. 


articulation  was  thick  and  indistinct; 
and  he  moved  his  lips,  as  in  the  act  of 
tasting,  before  he  could  speak.  He, 
also,  had  much  difficulty  in  selecting 
the  words  he  meant  to  employ,  and 
often  used  one  word  for  another.  He 
[  complained  of  pain  in  the  forehead, 
especially  over  the  left  eye,  the  pupil 
of  which  was  somewhat  more  contract¬ 
ed  than  that  of  the  right  eye.  He  had 
much  pain  on  pressure  being  applied 
over  the  loins  ;  and,  indeed,  this  pain, 
although  less,  was  felt  along  the  whole 
course  of  the  spine.  During  his  ill¬ 
ness,  large  red  blotches  appeared  on 
different  parts,  and  disappeared  after 
two  or  three  days.  His  bowels  were 
regular ;  the  tongue  was  clean,  but 
dry,  fissured,  and  tremulous  when  pro¬ 
truded;  the  pulse  was  small,  weak, 
and  70.  He  still  saw  visions ;  but  he 
had  no  ambitious  monomania.  (j^o 
Sp.  Amm.  Arom.  f^ij. ;  Fer.  Arnmonio- 
citratis  3j.,  Infusi  Quassise  f 3 v j .  sum. 
4ta.  pars  ter  quotidie.  Middle  diet.) 
3d  June.  His  power  of  walking  is  im¬ 
proved;  for,  although  he  inclines  to 
one  side,  yet  he  now  feels  no  inclination 
to  move  backwards.  He  articulates 
better  ;  and  much  of  the  tremor  of  the 
extremities  has  subsided.  The  pain  of 
the  loins  is  less  on  pressure ;  the  bowels 
are  open  ;  the  tongue  is  less  tremulous ; 
the  urine  is  acid,  and  of  sp.  gr.  1030  : 
clear,  high-coloured,  and  scanty ;  it 
contains  no  albumen.  He  has  still 
pain  of  the  head. — (Mittantur  sang, 
ope  C.  C.  nucha,  ^xij.  Pergat  in  usa 
misturee.) — 7th.  He  is  not  so  well.  The 
tongue  is  dry,  and  slightly  furred.  He 
complains  of  nausea,  and  pain  at  the 
epigastrium.  The  articulation  is  worse. 
The  bowels  are  confined.  He  was  de¬ 
lirious  in  the  night. — (Omittatur  mis- 
tura.  l)o  Calomel,  gr.  iv.  ;  Muc.  q.  s. 
ft.  pilula  h.  s.  sumenda  ;  haust.  purg. 
primo  eras  mane.)— 8th.  Feels  more 
comfortable.  The  bowels  were  freely 
opened.  The  urine  is  natural.  Pulse 
soft,  72. — (1^  Liq.  Ammon.  Acet. 

Pot.  Nitrat.  gr.  xv. ;  Mist.  Camph.  f^j. 
M.  ;  haust.  4ta.  q.  q.  hora.) —  13th. 
Much  better.  Pie  perspires  freely;  the 
bowels  are  open  ;  the  urine  is  acid,  and 
contains  crystals  of  oxalate  of  lime. 
The  tremor  of  the  limbs  is  nearly  gone; 
but  the  articulation  is  not  much  im¬ 
proved. — (Perstat  in  usu  medicam.) — 
17th.  The  tremor  of  the  limbs  has 
again  increased;  and  he  walks  un¬ 
steadily.  The  tongue  is  also  tremulous 


GENERAL  PARALYSIS  OF  THE  INSANE  TERMINATING  IN  RECOVERY.  327 


when  protruded ;  but  it  is  clean. — 
(Omit.  Mistur.  Applicetur  Emplast. 
Canth.  Ion  gum  spino  dorsi.  ^  Mag. 
Sulph.  5hj. ;  Tinct.  Jalap®  f^j..  Mist. 
Camph.  f 3j . ;  haust.  mane  quotidie. 

Hydrargyri  c.  Greta,  gr.  iv. ;  Muc. 
q.  s.  ft.  pi  1 .  h.  s.,  quotidie  sumenda. 
Middle  diet,  with  beef-tea  and  milk.)  — 
.20th.  The  tremors  of  the  arms  are  not 
much  relieved  ;  and  the  articulation 
continues  the  same.  The  bowels  are 
freely  opened;  the  tongue  is  clean  but 
dry;  the  urine  sp.gr.  1018.  He  com¬ 
plains  of  want  of  sleep,  and  of  delusions 
in  the  night. — (Perstat  in  usu  Pilul®  et 
haustus.  Ijb  Morphi®  Acet.  gr.  ss., 
Mic®  panis  gr.  j.,  ft.  pil.  h.  s.  suinend.) 
— 21st.  He  slept  better,  but  feels  weak 
and  vertiginous.  He  is  purged ;  the 
tongue  is  furred.  The  pulse  is  small, 
sharp,  and  96.  He  has  lost  his  appe¬ 
tite  ;  and  says  that,  although  he  sleeps 
better,  yet  he  still  sees  devils  around 
his  bed.  His  gums  have  suddenly 
become  spongy  and  tender.  The  urine 
is  acid,  sp.gr.  1018. — (Omitt.  med.  ])b 
Morphi®  Hydrochlor.  gr.  ss.  ;  Mic® 
panis  gr.j,  ft.  pil.  h.  s.  quotidie  su¬ 
menda.  Sod®  Bicarb.  5j*;  Tinct. 
Camph.  C.  foiij. ;  Mist.  Camph.  f^vss. 
M.  Sum.  4ta.  pars.,  4ta.  q.  q.  bora. 
To  have  meat  daily.) — 26th.  He  com¬ 
plains  of  stiffness  of  the  neck  and  sore 
throat ;  and  the  tongue  is  white  and 
dry.  He  continues  weak,  and  feels 
vertiginous  on  attempting  to  walk. — 
(Perstat  in  usu  Mist.  1^  Liq.  Ammon, 
fort,  fjiij. ;  Olei  Ricini  f^vj . ;  01.  Oliv® 
f5iv. ;  ft.  lin.  cervici  applicandum.) — 
27th.  He  is  vomited  and  purged,  and 
feels  griping  pains  in  the  abdomen. 
The  pulse  is  small,  feeble,  104;  the 
tongue  dry;  the  urine  clear,  and  slightly 
alkaline,  sp.  gr.  1022:  it  deposits  earthy 
phosphates.  The  uneasiness  of  the 
mouth  and  soreness  of  the  throat  con¬ 
tinue.  On  examining  the  liver,  its 
vertical  dulness  extends  from  tvro 
inches  below  the  right  nipple  to  one 
inch  below  the  false  ribs:  and  horizon¬ 
tally  to  one  inch  left  of  the  median 
line.  Breath  sounds  are  rougher  than 
usual.  The  heart’s  dulness  is  five 
inches  by  four,  extending  from  the  left 
nipple  to  one  inch  to  the  right  of  the 
median  line ;  second  sound  sharper 
than  natural,  and  prolonged  at  the 
base  and  mid-heart ;  first  sound  shorter 
at  the  apex  than  natural.  There  is 
great  tenderness  over  both  renal  re¬ 
gions ;  the  pulse  is  sharp,  108;  the 


tongue  white  and  glazed ;  and  the 
bowels  regular.  The  tonsils  are  swollen 
and  red  ;  the  interior  of  the  cheeKs  is 
aphthous;  and  an  herpetic  eruption 
has  broken  out  around  the  mouth. — . 
(1^)  Morph.  Ac.  gr.£;  Ext. Humuli  gr.iij. 
ft.  Pilula  h.  s.  Sumenda.  J)o  Potass® 
Bicarbon.  3j.,  Infusi  Quassi®  f^jss.  M. 
haust. ;  c.  Tinct.  Ferri  Sesquichlor. 
nqxv.,  ter  quotidie,  sumendus.)— 29th. 
No  improvement ;  he  continues  to  lose 
strength ;  his  nights  are  restless ;  the 
bowels  are  now  confined ;  and  the  ex¬ 
pression  of  his  countenance  is  most 
anxious.  —  (Admoveantur  hirud.  viij. 
cervici.  Omitt.  med.  Potass.  Nit. 
5ij.,  Infusi  Ros®  acid.  f^vj. ;  Gargar. 
s®pe  utendum.  1^  Ammon.  Sesquic. 
gr.vj.;  Acaci®  Pulv.  5ss.,  Mist.  Camph. 
f^jss. ;  haust.  4ta  q  q.  hord  sumend. 
I;!  Sol.  Morphi®  Bimeconatis  itpxviij. ; 
Aqu®  f^j.  haust.  h.  s.  sum.)  —30th. 
The  narcotic  procured  no  sleep.  The 
throat  and  mouth  are  worse ;  he  is 
unable  tomasticate  solids,  and  swallows 
liquids  with  difficulty.  His  articulation, 
is  very  indistinct.  The  mouth  has 
much  of  the  appearance  which  cancrum 
oris  presents.  The  pulse  is  small,  120; 
the  tremor  of  the  limbs  great;  the 
anxiety  of  the  countenance  increased. 
The  urine  is  scanty  and  high  coloured, 
sp.  gr.  1015. — (Perstat  in  usu  Mist,  et 
haust.  Anod.;  addendo  mistur®  Arnmo- 
ni®  Sesquicar.  gr.ij.  sing,  dosibus.  Let 
the  ulcers  of  the  tongue  be  touched 
with  a  solution  of  5j.  of  nitrate  of  silver 
in  fgj.  of  water,  acidulated  with  nitric 
acid.) — 4th.  The  ulcers  of  the  tongue 
and  mouth  display  a  tendency  to  heal ; 
the  tonsils  are  less  inflamed;  and  the 
power  of  deglutition  is  improved.  He 
still  complains  of  headache. — (Perstat 
in  usu  medic. — 6th.  The  mouth  and 
throat  are  much  better;  he  now  sleeps 
well,  and  is  in  better  spirits.  The 
bowels  are  regular;  the  pulse  is  soft, 
and  96.  The  urine  is  rather  turbid. 
He  still  complains  of  headache.— 
(App.  Emplast.  Canth.  longum  inter 
scapulas.) —8ih.  Although  the  tongue 
is  better,  yet  the  throat  is  worse, 'and 
he  swallows  with  great  difficulty-  The 
submaxillary  glands  are  enlarged  and 
tender.  He  is  still  extremely  weak 
and  emaciated. — (Omitt.  Mistura;  Per¬ 
stat  in  usu  Haust.  Anod.  ^  Atn- 
moniffi  Sesquicarbon.  gr.  v.  ;  Acaci® 
Pnlv.  Oj.;  Decocti  Cinch,  fjjss. ;  T. 
Camph.  Comp.  f’5j -  Haust.  ter  die 
sumendus.)  10th.  —  The  mouth  and 


dr.  a.  t.  Thomson’s  report  of  a  case  of 


328 

- - -  -  - -  -  _ -  - - - - -  •••  - —"**"*--  -J 


throat  are  greatly  better;  all  the  ulcers 
are  cicatrized,  and  the  submaxillary 
gland  is  no  longer  tender.  He  still 
feels  weak;  the  pulse  is  small,  and  92, 
hut  he  sleeps  well.—  (Perstat  in  usn 
Med.)  15th. —  He  is  improving  ra¬ 
pidly.  The  throat  and  mouth  are 
well ;  the  tremor  of  the  extremities 
and  the  indistinctness  of  articulation 
are  gone.  The  pulse,  however,  is 
feeble,  and  72;  and  he  still  feels  weak. 
— (Perstat  in  usu  Misturce.)  18th. — * 

He  is  gaining  strength,  and  eats  his 
meals  with  an  appetite.  The  tongue 
is  red,  and  somewhat  glazed.  — 
Sodee  Biboratis,  3j.  ;  Tinct.  Aconiti, 
ITfv. ;  Infusi  Calumbae,  fiyjss.  Haust. 
ter  quotidie  sumend.  Omitt.  Mistura 
c.  Ammonias  Sesquicarbonate. 

22d. — He  continued  to  gain  strength, 
and  was  this  day  discharged  cured. 

Remarks. — In  reviewing  this  case, 
its  connection  with  general  paralysis 
affecting  the  insane  is  so  obvious  that 
it  may  be  regarded  as  one  of  the  few 
recorded  cases  of  recovery  from  that 
disease.  If  we  look  at  the  circum¬ 
stances  of  the  individual  prior  to  the 
attack,  we  find  them  to  be  such  as,  in 
the  opinion  of  a  high  authority,* 
render  men  liable  to  diseases  of  the 
brain — namely,  a  life  of  inactivity  and 
depression  succeeding  a  life  of  inces¬ 
sant  toil.  The  poor  man  had  worked 
hard  at  his  laborious  occupation,  when 
he  was  suddenly  thrown  out  of  work  ; 
consequently  he  became  inactive,  and 
the  morbid  influence  of  this  state  was 
farther  increased  by  his  disappoint¬ 
ment  in  not  finding  fresh  employment, 
and  by  the  anxiety  connected  with  his 
consequent  poverty.  He  was  also  of  a 
temperament  (the  sanguineo-nervous) 
and  an  agef  the  most  liable  to  such  an 
attack ;  and  this  temperament,  with 
deficient  diet,  are  the  only  predisposing 
causes  to  which  the  history  of  the  case 
enables  us  to  refer  the  disease.  It  is 
unnecessary  to  look  beyond  his  anxie¬ 
ties  and  disappointments  for  the  ex¬ 
citing  causes. 

The  primary  symptoms  differed  in 
some  respects  from  those  most  common 
to  general  paralysis  of  the  insane. 
That  disease  seldom  commences  with 
convulsions,  although  we  can  have  no 


*  Esquirol. 

t  M.  Bayle  regards  the  period  from  thirty  to 
sixty  that  in  which  the  disease  most  frequently 
appears. 


difficulty  in  believing  that  tremors, 
depending  on  such  a  condition  of 
the  brain  as  must  have  existed  in  our 
patient,  might  give  rise  to  convulsions. 
Tremulous  protrusion  of  the  tongue, 
indistinct  articulation,  and  tremor  first 
of  the  upper,  and  next  of  the  lower 
limbs,  are  the  commencing  symptoms 
of  the  disease  ;  but  in  this  instance 
both  the  upper  and  the  lower  extremi¬ 
ties  were  simultaneously  affected.  The 
features  had,  however,  the  same 
ghastly  and  fatuitous  expression  which 
usually  characterises  this  form  of 
paralysis.  At  no  time  was  the  tremor 
of  the  arms  so  great  as  to  prevent  a 
glass  being  carried  to  the  mouth. 
When  he  lost  the  tremor  of  the  lower 
limbs  and  he  walked  firmly,  on  the  10th 
day  after  the  treatment  commenced, 
the  tremor  of  the  hands  and  the  im¬ 
peded  articulation  remained  unabated; 
but  this  early  improvement  of  the 
lower  limbs  is  not  uncommon  even  in 
hemiplegia.  The  intermittent  charac¬ 
ter  of  the  disease  also  displayed  itself 
in  this  instance.  After  a  decided  im¬ 
provement  on  the  13th,  all  the  bad 
symptoms  returned  on  the  17th,  and 
intermitted  once  afterwards.  Through¬ 
out  the  progress  of  the  symptoms  there 
was  no  loss  of  sensation;  the  sphincters 
were  not  affected;  and  although  there 
were  hallucinations  and  delirium  at 
night,  yet,  after  the  patient  entered 
the  hospital,  he  displayed  no  trace  of 
mental  aberration  during  the  day. 
The  diarrhoea  which  supervened  on 
the  21st  is  not  uncommon  in  the  third 
stage  of  the  disease  :  it  continued  until 
the  27th,  when  it  was  accompanied 
with  vomiting,  and  that  train  of  symp¬ 
toms  which  indicate  the  most  alarming 
state  of  depression ;  but  instead  of 
gangrene  of  the  lungs,  and  complete 
paralysis  of  the  muscles  of  deglutition, 
which  usually  precedes  the  fatal  ter¬ 
mination  of  general  paralysis  of  the 
insane,  the  cancrum  oris,  the  sore-throat, 
swelling  of  the  submaxillary  glands, 
with  painful  deglutition,  depending  on 
the  ulcerated  state  of  the  fauces,  super¬ 
vened.  The  patient  rapidly  lost  flesh ; 
'and  the  prognosis  at  this  time  was  any 
thing  but  favourable.  This  is  gene¬ 
rally  the  case ;  indeed,  some  of  the 
best  writers*  on  insanity  consider  the 
disease  incurable :  it,  is  rare  that  a 
recovery  so  perfect  as  in  the  present 


*  Royer-Collaril,  Esquirol,  Pinel. 


general  paralysis  of  the  insane  terminating  in  recovery.  329 


instance  occurs  ;  for,  in  every  recorded 
case,  some  traces  of  paralysis  still  re¬ 
mained.  In  our  patient  the  recovery 
seems  perfect ;  but  there  is  no  certainty 
for  the  future  :  for  in  a  case  recorded  by 
M.  Rodrigues,  the  patient  remained 
well  for  nine  months,  and  then  termi¬ 
nated  his  life  by  suicide.* 

Any  opinion  that  might  be  advanced 
with  respect  to  the  pathological  condi¬ 
tion  of  the  brain,  must  be  purely  hypo¬ 
thetical.  It  may  be  presumed  the 
cerebellum  was  implicated,  from  the 
inclination  of  the  patient  to  walk  back¬ 
wards,  and  the  staggering  and  lateral 
inclination  of  the  body  when  he  at¬ 
tempted  to  walk.  In  the  experiments 
of  Flourens,  when  the  cerebellum  was 
removed  the  animal  lost  the  faculty  of 
grouping  the  actions  of  muscles  of 
volition,  and  its  gait  was  like  that  of  a 
drunken  man.  The  spinal  chord,  also, 
most  probably  was  in  a  state  of  hype- 
rsemia  in  its  motor  tract;  but  whilst 
we  admit  that  these  inferences  are 
merely  conjectural,  there  can  be  little 
doubt  that  some  portion  of  the  brain 
connected  with  the  voluntary  move¬ 
ments  was  morbidly  affected.  Whether 
this  was  the  cause  or  the  effect  of  the 
convulsions  which  ushered  in  the  in¬ 
sanity,  is  not  easily  determined. 

In  the  treatment  of  this  case,  the 
depressed  condition  of  the  patient  in¬ 
duced  me  to  order  a  moderately  stimu¬ 
lant  tonic,  with  the  view  of  restoring 
strength,  and  consequently  diminishing 
excitability.  The  cupping  prescribed 
with  the  intention  of  relieving  the 
headache,  was  at  leasts  not  productive 
of  any  beneficial  effects;  and  indeed, 
although  blood-letting  is  strongly  re¬ 
commended  by  Rodrigues,  yet,  in  my 
opinion,  it  is  contraindicated  by  the 
debility  and  the  state  of  the  pulse: 
and  as  I  conceived  that  headache 
might  be  augmented  by  the  preparation 
of  iron,  the  Ammonio-citrate  was  dis¬ 
continued.  Some  improvement  appa 
rently  followed  the  use  of  the  simple 
saline  alterative  ordered  after  the 
Ammonia-citrate  was  discontinued  and 
the  bowels  were  freely  opened  :  but,  as 
the  remedies  were,  at  first,  merely 
palliatives,  and  were  varied  with  the 
change  of  symptoms,  little  general 


beneficial  influence  can  be  ascribed  to 
any  of  them.  The  narcotics,  certainly, 
were  beneficial  in  allaying  irritation 
and  procuring  sleep, — effects  of  the 
utmost  importance  in  such  a  case. 
When  the  symptoms  closely  resem¬ 
bling  Cancrum  oris  displayed  them¬ 
selves,  and  the  salivary  discharge  be¬ 
came  redundant  when  no  mercurial 
was  taken,  acccompanied  with  great 
irritative  fever,  the  indications  to  be 
fulfilled  became  more  obvious.  Gene¬ 
rous  diet,  except  in  the  form  of  strong 
beef-tea  and  wine,  could  not  be  taken, 
consequently  it  was  not  ordered  ;  and  I 
relied  chiefly  on  the  powerful  influence 
of  the  Sesquicarbonate  of  Ammonia, 
combined  with  the  compound  Tincture 
of  CamphorandDecoction  of  Cinchona: 
a  combination  which  I  have  never  seen 
to  fail  in  relieving  and  promoting  the 
cure  of  Cancrum  oris.  Touching  the 
ulcers  of  the  mouth  with  a  solution  of 
Nitrate  of  Silver,  slightly  acidulated 
with  Nitric  Acid,  sooner  cleans  them, 
and  favours  cicatrization  than  any 
means  which  I  have  tried;  and  the 
same  solution  applied  over  the  surface 
threatened  with  bed-sores  instantly 
arrests  their  progress. 

Although  the  patient  was  discharged 
apparently  perfectly  well;  and  procured 
work  almost  immediately  after  leaving 
the  hospital,  yet  he  is  still  regulating 
his  diet,  and  taking  a  gentle  tonic.  By 
these  means,  and  as  the  brain  is  not 
likely  to  be  too  severely  exercised  by 
one  in  his  rank  of  life,  there  is  every 
reason  for  believing  he  may  remain 
well.  How  far  the  treatment  pursued 
in  this  case  may  suggest  a  more  suc¬ 
cessful  mode  of  managing  other  cases, 
can  only  be  determined  by  experience. 

30,  Welbeck  Street, 

12th  August,  1848. 


APOTHECARIES*  HALL. 

Names  of  gentlemen  who  passed  their  exa¬ 
mination  in  the  science  and  practice  of  medi¬ 
cine,  and  received  certificates  to  practise,  on 
Thursday,  August  17,  1848  : — Draper  Mac¬ 
kinder,  Barton-under-Nedwood,  Stafford¬ 
shire — George  Robert  Cubitt,  Norwich, 
Norfolk — Frederic  Charles  Cory,  London — 
John  Seager  Gundry,  London  —  George 
Grayling,  Sydenham. 


*  Traitd  de  la  Paralysis,  General,  Chronique, 
&c.  Par  Hubert  Rodrigues,  Prof.  Agreg^  a  la 
Faculty  de  Montpelier,  &c.  1847. 


330  DR.  SNOW  ON  NARCOTISM  BY  THE  INHALATION  OF  VAPOURS. 


ON 

NARCOTISM  by  the  INHALATION 
OF  VAPOURS. 

By  John  Snow,  M.D. 

Vice-President  of  the  Westminster  Medical 
Society. 

[Continued  from  vol.xli.  p.  1078.] 


On  bromoform ,  bromide  of  ethyle,  and 
Dutch  liquid — General  results  of  the 
experiments — 'The  strength  of  nar¬ 
cotic  vapours  in  the  inverse  ratio  of 
their  solubility  in  the  blood. 

on  of  the  physiological 
" oform . 

Bromoform, 

This  is  a  volatile  liquid  of  the  same 
composition  as  chloroform,  except  that 
three  atoms  of  bromine  occupy  the 
place  of  the  same  proportion  of  chlo¬ 
rine.  It  is  made  in  the  same  way  as 
chloroform,  bromide  of  lime  being  used 
instead  of  chloride.  I  have  repeatedly 
made  it,  but  have  never  -succeeded  in 
obtaining  more  than  a  few  grains  in  a 
purified  state,  although  I  used  an 
ounce  of  bromine  in  making  the  bro¬ 
mide  of  lime  on  each  occasion  ;  con¬ 
sequently  it  is  very  expensive.  It  is 
extremely  fragrant,  having  an  odour 
that  is,  in  my  opinion,  much  pleasanter 
than  that  of  chloroform  or  any  other 
of  this  class  of  substances  with  which 
I  am  acquainted.  It  boils  at  about 
184°  Fall.;  but,  as  its  vapour  is  twice 
as  heavy  as  that  of  chloroform,  it  is  in 
point  of  fact  nearly  as  volatile  as  that 
liquid.  It  is  very  pleasant  to  inhale, 
but  I  have  never  breathed  more  than  a 
few  grains  at  a  time,  and,  therefore, 
cannot  speak  of  its  operation  on  the 
human  subject.  Its  effects  on  animals 
closely  resemble  those  of  chloroform 
The  two  following  experiments  will 
serve  to  illustrate  the  action  of  biomo- 
form,  and  to  determine  the  quantity  in 
the  blood  : — 

Exp.  35. — A  common  mouse  was 
placed  in  a  jar  containing  400  cubic 
inches,  in  which  three  grains  of  bro¬ 
moform  had  been  diffused.  In  the 
course  of  four  or  five  miuntes  it  became 
unsteady  in  its  walking,  and  ceased  to 
regard  objects  in  its  way.  It  did  not 
get  further  affected,  except  to  become 
rather  sluggish,  and,  when  removed  at 


Descript, i 
of  chlo 


the  end  of  twenty  minutes,  was  capable 
of  voluntary  motion.  It  did  not  regard 
a  slight  pinch,  but  flinched  when  the 
soft  part  of  its  foot  was  pinched  se¬ 
verely.  It  recovered  gradually,  and 
was  pretty  well  re-established  in  half 
an  hour. 

Exp.  36. — Another  mouse  was  placed 
in  the  same  jar  with  six  grains  of  bro¬ 
moform  :  it  was  more  quickly  affected, 
and,  at  the  end  of  five  minutes,  all 
voluntary  motion  had  ceased,  and  it 
lay  breathing  naturally  and  rather 
deeply.  It  was  removed  at  the  end  of 
a  quarter  of  an  hour,  and  did  not  stir 
on  being  pinched.  It  began  to  recover 
voluntary  motion  in  ten  minutes,  but 
staggered  at  first.  In  a  little  more 
than  half  an  hour  it  had  recovered. 

In  the  first  of  these  experiments  the 
second  degree  of  narcotism  was  caused 
by  three-quarters  of  a  grain  of  bromo¬ 
form  to  each  100  cubic  inches  of  air. 
The  specific  gravity  of  the  vapour  of 
bromoform  is  stated,  in  Thompson’s 
Chemistry  of  Organic  Bodies,  to  be 
8*785,  which  gives  0*275  of  a  cubic 
inch  as  the  quantity  of  vapour  that 
three-quarters  of  a  grain  would  yield  ; 
and  I  find  that  fifteen  cubic  inches  of 
this  vapour  are  contained  in  100  of 
air  saturated  with  it  at  the  tempera¬ 
ture  of  100°  ;  consequently  the  air  of 
the  jar  contained  0*275-?- 15=0 0183; 
or  nearly  one  fifty-fourth  part  of  what 
it  would  take  up  if  saturated  at  100°, 
and,  according  to  the  principles  ex¬ 
plained  in  a  former  part  of  these 
papers,*  the  blood  of  the  mouse  would 
contain  just  th<f  same  proportion — one 
fifty-fourth  of  what  it  could  dissolve, 
In  the  other  experiment,  the  fourth 
degree  of  narcotism  was  produced  by 
twice  the  quantity — a  grain  and  a  half 
to  each  100  cubic  inches,  which,  by 
the  same  computation,  gives  about,  one 
twenty-seventh  part  of  what  the  blood 
would  take  up.  These;'proportions  are 
nearly  the  same  as  inAhe  case  of  most 

►  . f  . 

of  the  substances  previously  examined. 

I  have  not  ascertained  the  exact  solu¬ 
bility  of  bromoffirm,  and  consequently 
cannot  compute  the  absolute  quantity 
in  the  blood,  but  it  resembles  chloro¬ 
form  in  being  very  sparingly  soluble. 

I  have  not  heard  that  any  one  else 
has  examined  the  effects  of  the  vapour 
of  bromoform;  but.  Dr.  Glover  men- 


*  Vol.  xli.  p.  850. 


DR.  SNOW  ON  NARCOTISM  BY  THE  INHALATION  OF  VAPOURS.  83  J 


tions  an  experiment  in  his  valuable 
paper  On  Bromine  and  its  Compounds,* 
in  which  bromoform  in  the  liquid 
state  was  introduced  into  the  stomach 
of  a  rabbit,  with  the  same  results  as  in 
other  experiments  wiih  similar  bodies  : 
these  were  death,  with  congestion  of 
the  lungs  and  stomach. 

Bromide  of  Ethyle. 

Bromide  of  ethyle,  or  hydrobromic 
ether,  is  a  very  volatile  liquid,  boiling, 
as  [  have  found,  at  104°.  It  has  a 
pleasant  but  somewhat  pungent  taste 
and  smell.  It  was  discovered  by 
Serullas  in  1827,  and  is  formed  by  the 
action  of  phosphorus  on  a  solution  of 
bromine  in  alcohol.  I  am  not  aware 
that  its  physiological  effects  have  been 
examined  except  in  a  few  experiments 
which  I  have  performed  with  its  va¬ 
pour.  I  will  cite  two  of  them  to  illus¬ 
trate  its  effects.  The  bromide  of  ethyle 
was  made  by  myself. 

Exp.  37. — Eight  grains  of  bromide  of 
ethyle  were  introduced  into  a  jar  con¬ 
taining  400  cubic  inches,  and  the 
vapour  which  instantly  resulted  was 
equally  diffused  by  moving  the  jar.  A 
mouse  was  then  put  in.  In  about  four 
minutes  it  began  to  stagger  and  fall 
over,  and  was  quite  regardless  of  ex¬ 
ternal  objects.  It  did  not  get  affected 
beyond  this  extent,  except  that  it  be¬ 
came  rather  feeble.  It  was  taken  out 
at  the  end  of  a  quarter  of  an  hour, 
having  the  power  of  voluntary  motion, 
but  rolling  over  in  its  attempts  to  walk.  1 
It  flinched  with  severe,  but  not  with 
slight  pinching.  In  ten  minutes  it  had 
pretty  well  recovered. 

Exp.  38. — Another  mouse  was  placed 
in  the  same  jar  with  sixteen  grains  of 
bromide  of  ethyle.  In  two  minutes  it 
had  ceased  to  move,  not  having  shewn 
any  signs  of  excitement.  It  lay  mo¬ 
tionless,  breathing  at  first  deeply, 
afterwards''  more  naturally.  it  was 
removed  at  -die  end  of  a  quarter  of  an 
hour,  arid  was  found  to  be  totally  in¬ 
sensible.  "fti  five  minutes  it  began  to 
move,  but  rolled'  over  in  its  first  at¬ 
tempts  to  walk,  'twenty  minutes  after 
its  removal,  it  appeared  to  have  reco¬ 
vered  from  the  effects  of  the  vapour. 

Connected  with  the  great  volatility 
ol  this  liquid  is  the  increased  quantity 
of  it  required  io  be  present  in  the  air 


to  produce  a  given  effect, — in  accor¬ 
dance  with  the  law  which  requires 
that  the  blood  must  be  impregnated  to 
a  certain  extent  relatively  to  what  it 
could  imbibe.  In  one  experiment  I 
performed  with  this  substance,  one 
grain  to  each  100  cubic  inches  of  air 
produced  no  appreciable  effect  whatever 
on  a  mouse  confined  for  twenty  minutes 
in  it,  although  with  that  quantity  of 
several  less  volatile  bodies  complete 
insensibility  would  have  been  in¬ 
duced. 

In  experiment  37  two  grains  to  each 
100  cubic  inches  of  air  produced  the 
second  degree  of  narcotism  ;  and  in  the 
following  experiment  four  grains  pro¬ 
duced  the  fourth  degree.  The  specific 
gravity  of  the  vapour  of  bromide  of 
ethyle  is,  I  find,  3*78,  thj  atom  being 
represented  by  two  volumes.  Two 
grains  will  consequently  occupy  1*706 
cubic  inches  in  the  form  of  vapour.  At 
the  temperature  of  100°  the  vapour  of 
bromide  of  ethyle  almost  excludes  the 
air,  and  occupies  82  8  per  cent,  of  its 
place.  So  1*706-4-92*8  gives  0*0183,  or 
nearly  one  fifty-fourth,  as  the  relative 
saturation  of  the  blood  with  this  vapour 
for  the  second  degree  of  narcotism  ; 
and  there  Vould  be  twice  as  much,  or 
one  twenty- seventh,  for  the  fourth 
degree. 

1  have  not  ascertained  by  direct  ex¬ 
periment  how  much  bromide  of  ethyle 
serum  will  dissolve,  but  I  find  that 
water  dissolves  about  one-sixtieth  of  its 
volume  of  it ;  and  as  the  solubility  of 
liquids  of  this  kind  is  nearly  the  same 
in  water  as  in  serum,  this  may  safely 
be  taken  as  the  standard; — when,  if 
we  consider  the  average  quantity  of 
serum  in  the  human  body  to  be  410 
fluid  ounces,  as  in  a  former  part  of 
these  papers,  and  make  the  kind  of 
calculation  there  made,*  we  shall  find 
that  one  fluid  drachm  and  ten  minims 
is  the  average  quantity  that  there 
would  be  in  the  blood  of  a  human  sub¬ 
ject  in  the  second  degree  of  narcotism ; 
and  two  drachms  and  twenty  minims 
in  the  fourth  degree. 

Dutch  Liquid. 

In  recent  works  on  chemistry  this 
substance  is  called  the  hydrochlorate 
of  chloride  of  acetyle.  It  is  funned  by 
the  combination  of  equal  volumes  of 
olefiant  gas  and  chlorine.  It  has  a 
taste  at  once  sweet  and  hot,  and  a  pun¬ 
gent  ethereal  odour.  It  boils  at  180Q, 


*  Edin.  Med.  and  Surg.  Jour.,  Oct.  1842. 


832  DR.  SNOW  ON  NARCOTISM  BY  THE  INHALATION  OF  VAPOURS. 


and  not  at  148°,  as  Dr.  Simpson  states 
in  some  brief  remarks  on  it  in  the 
Edinburgh  Monthly  Journal  for  April 
last,  where  he  informs  us  that  its  va¬ 
pour,  when  inhaled,  causes  so  great 
irritation  of  the  throat  that  few  per¬ 
sons  can  persevere  in  inhaling  it  long 
enough  to  produce  anaesthesia ;  but 
that  he  had,  however,  “  seen  it  inhaled 
perseveririgly  until  this  state,  with  all 
its  usual  phenomena,  followed ;  and 
without  excitement  of  the  pulse  or 
subsequent  headache.”  My  experi¬ 
ments  with  it  have  been  confined  to 
animals ;  and  the  two  following  will 
serve  as  a  sample  of  them 

Exp.  39. — One  grain  and  a  half  of 
Dutch  liquid  was  diffused  through  the 
air  of  a  jar  cbntaining  400  cubic  inches, 
and  a  mouse  was  introduced.  After 
ten  minutes  had  elapsed  it  began  to 
stagger  in  its  walk,  and  it  continued  to 
do  so  till  it  wras  removed  at  the  end  of 
half  an  hour.  It  was  occasionally  lying 
stiil,  but  always  began  to  walk  in  an 
unsteady  manner  when  the  jar  was 
moved.  It  was  sensible  to  pinching 
on  its  removal,  and  in  a  quarter  of  an 
hour  had  recovered  from  its  inebriation. 
It  continued  well. 

Exp.  40. — A  mouse  was  put  into  the 
same  jar  after  three  grains  of  Dutch 
liquid  had  been  diffused  in  it.  It 
began  to  stagger  sooner  than  that  em¬ 
ployed  in  the.  last  experiment  ;  and  at 
the  end  of  ten  minutes  had  ceased  to 
move,  without  having  had  any  strug¬ 
gling  or  rigidity  ;  and  it  was  not  dis¬ 
turbed  on  the  jar  being  moved.  It  lay 
breathing  naturally  till  it  was  taken 
out  at  the  end  of  half  an  hour,  when  it 
was  found  to  be  totally  insensible  to 
pinchmg.  In  ten  minutes  after  its  re¬ 
moval  it  began  to  move,  but  rolled  over 
in  its  efforts  to  walk  ;  when  half  an 
hour  had  elapsed  it  appeared  to  have 
recovered  entirelv  from  the  narcotism, 
but  was  less  lively  than  before ;  and 
two  or  three  hours  afterwards  it  was 
observed  to  be  suffering  with  difficulty 
of  breathing,  and  it  died  in  the  course 
of  the  day.  The  lungs  were  congested 
and  of  a  deep  vermilion  colour,  pro¬ 
bably  the  result  of  inflammation,  occa¬ 
sioned  by  the  irritating  nature  of  the 
vapour.  The  right  cavities  of  the  heart 
were  distended  with  dark-coloured 
coagulated  blood.  The  same  appear¬ 
ances  were  met  with  in  another  mouse 


that  died  in  the  same  way  after  breath¬ 
ing  this  vapour. 

In  the  first  of  these  two  experiments 
the  second  degree  of  narcotism  was 
effected  by  three- eighths  of  a  grain  of 
vapour  to  each  100  cubic  inches  of  air; 
and  as  the  specific  gravity  of  this  va¬ 
pour  is  3*4484,  three-eighths  of  a  grain 
must  occupy  0*35  of  a  cubic  inch.  I 
find  that  air,  when  saturated  with  va¬ 
pour  of  Dutch  liquid  at  100°.  contains 
1 7*5  per  cent.,  and  therefore  0*35  -f- 17*5 
gives  0*02,  or  one-fiftieth,  as  the  relative 
saturation  of  the  blood  in  this  degree. 
In  the  other  experiment  the  fourth 
degree  of  narcotism  was  caused  by 
twice  as  much  vapour,  or  three-quarters 
of  a  grain  to  each  100  cubic  inches, 
and,  consequently,  the  blood  would 
contain  twice  as  much,  or  one  twenty- 
fifih  part  of  what  it  would  hold  in 
solution  if  saturated.  I  have  ascer¬ 
tained  that  Dutch  liquid  requires  about 
100  parts  of  water  for  its  solution,  and 
taking  its  solubility  in  the  serum  to  be 
the  same,  the  blood  would  contain  one 
part  in  5000  in  the  second,  and  one 
p  art  in  2500  in  the  fourth  degree  of 
narcotism,  which  in  the  human  subject 
would  be,  on  an  average,  46  minims 
and  92  minims  respectively. 

General  results  of  the  experiments. 

We  have  now  seen  the  result  of  this 
experimental  inquiry  into  the  action  of 
eight  volatile  substances,  viz. :  chloro¬ 
form,  ether,  nitrate  of  oxide  of  ethyle, 
bisulphuret  of  carbon,  benzin,  bromo- 
form,  bromide  of  ethyle,  and  Dutch 
liquid.  We  find  that  the  quantity  of 
each  substance  in  the  blood,  in  corre- 
sponding  degrees  of  narcotism,  bears  a 
certain  proportion  to  what  the  blood 
would  dissolve — a  proportion  that  is 
almost  exactly  the  same  for  all  of 
them,  with  a  slight  exception  in  the 
case  of  benzin,  which  I  believe  is  more 
apparent  than  real.  The  actual  quan¬ 
tity  of  the  different  substances  in  the 
blood,  however,  differs  widely  ;  being 
influenced  by  their  solubility  When 
the  amount  of  saturation  of  the  blood 
is  the  same,  then  it  follows  that  the 
quantity  of  vapour  required  to  produce 
the  effect  must  increase  with  the  solu¬ 
bility,  and  the  effect  produced  by  a 
given  quantity  must  be  in  the  inverse 
ratio  of  the  solubility,  as  I  announced 
some  time  ago.*  This  rule  holds  good 


*  Medical  Gazette,  March  31. 


DR.  SNOW  ON  NARCOTISM  BY  THE  INHALATION  OF  VAPOURS.  333 


with  respect  to  all  the  substances  of 
this  kind  that  I  have  examined;  in¬ 
cluding,  in  addition  to  those  enume¬ 
rated  in  this  paper,  bichloride  of  car¬ 
bon,  iodide  of  ethyle,  acetate  of  oxide 
of  ethyle,  nitrate  of  oxide  of  methyle, 
acetate  of  oxide  of  methyle,  pyroxilic 
spirit,  acetone,  and  alcohol.  The  exact 
proportion  in  the  blood,  in  the  case  of 
the  three  last  mentioned,  cannot  be 
ascertained  directly  by  experiments  of 
the  kind  detailed  above;  for,  being 
soluble  to  an  unlimited  extent,  they 
continue  to  be  absorbed  as  long  as  the 
experiment  lasts  :  but  from  the  large 
quantity  of  these  substances  that  is 
required  to  produce  insensibility,  they 
confirm  the  rule  stated  above  in  a  re¬ 
markable  manner. 

This  general  law,  of  course,  does  not 
apply  to  all  narcotics;  not,  for  in¬ 
stance,  to  hydrocyanic  acid,  but  only 
to  those  producing  effects  analogous  to 
what  are  produced  by  ether,  and  hav¬ 
ing,  I  presume,  a  similar  mode  of 
action.  I  am  not  able  at  present  to 
define  them  better  than  by  calling 
them,  that  group  of  narcotics  whose 
strength  is  inversely  as  their  solubility 
in  water  (and  consequently  in  the 
blood).  In  estimating  their  strength, 
when  inhaled  in  the  ordinary  way, 
another  element  has  to  be  taken  into 
the  account,  viz.,  their  volatility  ;  for 
that  influences  the  quantity  that  would 
be  inhaled.  By  multiplying  together 
the  number  of  parts  of  water  that  each 
substance  requires  for  its  solution,  and 
the  number  of  minims  of  each  substance 
that  air  will  hold  in  solution  at  60°,  we 
get  a  set  of  figures  expressive  of  the 
relative  strength  of  each,  when  breathed 
in  the  ordinary  way  ;  and  by  another 
method  of  calculation  the  time  might 
be  expressed,  in  minutes  and  seconds, 
that  it  would  take,  on  an  average,  to 
render  persons,  breathing  in  the  usual 
way,  insensible  by  each  substance : 
but  I  shall  here  confine  myself  to  enu¬ 
merating  the  bodies  I  have  examined 
in  two  columns  ;  arranging  them,  in 
the  first  column,  in  the  inverse  order 
of  their  solubility,  which  is  the  direct 
order  of  their  actual  potency  ;  and  in 
the  second  column,  in  the  order  in 
which  they  stand  after  their  volatility 
is  taken  into  the  account,  which  is  the 
order  of  their  potency  when  mixed 
with  air  till  it  is  saturated  at  any  con¬ 
stant  temperature. 


Bisulphuretof  Carbon 
Bichloride  of  Carbon 
Chloroform 
Bromoform 
Benzin 
Dutch  Liquid 
Iodide  of  Ethyle 
Bromide  of  Ethyle 
Nitrate  of  Oxide  of 
Ethyle 

Nitrate  of  Oxide  of 
Methyle 

Oxide  of  Ethyle 
(Ether) 

Acetate  of  Oxide  of 
Ethyle 

Acetate  of  Oxide  of 
Methyle 
f  Acetone 
<  Pyroxilic  Spirit 
(  Alcohol 


Bisulphuret  of  Carbon 
Chloroform 
Bichloride  of  Carbon 
Bromoform 
Bromide  of  Ethyle 
Benzin 

Iodide  of  Ethyle 
Dutch  Liquid 
Oxide  of  Ethyle 
(Ether) 

Nitrate  of  Oxide  of 
Ethyle 

Nitrate  of  Oxide  of 
Methyle 

Acetate  of  Oxide  of 
Ethyle 

Acetate  of  Oxide  of 
Methyle 
Acetone 
Pyroxilic  Spirit 
Alcohol 


The  general  law,  stated  above,  re¬ 
specting  the  solubility  of  these  liquids 
in  the  blood,  applies  also,  with  certain 
modifications,  to  a  number  of  bodies 
which  are  gaseous  at  ordinary  tempera¬ 
tures,  and  there  are  several  important 
conclusions  to  be  deduced  from  it. 
But  before  proceeding  further  in  the 
attempt  to  give  a  general  history  of 
narcotic  vapours  and  gases,  and  to  de¬ 
termine  what  substances  should  be  in¬ 
cluded  in  the  list  or  otherwise,  it  will 
be  well  for  me  to  describe,  more  parti¬ 
cularly  than  I  have  done,  the  nature  of 
the  narcotism  produced  by  the  class  of 
bodies  we  are  considering,  of  which 
chloroform  may  very  properly  be  taken 
as  the  type.  I  shall,  therefore,  next 
proceed  to  give  the  best  description 
that  I  can  of  the  effects  of  chloroform, 
having  especially  in  view  the  practical 
importance  of  the  agent ;  and  shall 
make  all  the  remarks  that  I  am  able 
to  include  in  a  brief  space,  on  the 
administration  of  chloroform  in  sur¬ 
gical  operations,  medicine,  and  mid¬ 
wifery. 

Description  of  the  effects  of  Chloroform. 

I  may  premise,  that  in  applying  the 
term  narcotic  to  chloroform  and  other 
volatile  substances,  I  employ  it  in  the 
extended  sense  in  which  it  is  used  by 
writers  on  materia  medica  and  toxico- 
logy,  who  make  it  include  all  the  sub¬ 
stances  which  act  on  the  nervous  sys¬ 
tem  ;  and  I  apply  the  term  narcotism 
to  designate  all  the  effects  of  a  narcotic, 


334  DR.  SNOW  ON  NARCOTISM  BY  THE  INHALATION  OF  VAPOURS. 


as  1  am  entitled  to  do  by  strict 
etymology,  and  do  not  confine  it,  as  the 
practice  has  generally  been,  to  express 
a  state  of  complete  insensibility.  I  do 
not  object  to  the  term  anaesthetic,  but 
I  use  that  of  narcotic  as  being  more 
comprehensive,  and  including  the  other 
properties  of  these  vapours  as  well  as 
that  of  annulling  common  sensibility. 

To  facilitate  the  description,  I  divide 
all  the  effects  of  chloroform  short  of  the 
abolition  of  life,  into  five  degrees.  I 
use  the  term  degree  in  preference  to 
stage,  as,  in  administering  chloroform, 
the  slighter  degrees  of  narcotism  occur 
in  the  latter  stages  of  the  process,  dur¬ 
ing  the  recovery  of  the  patient,  as  well 
as  in  the  beginning. 

The  division  into  degrees  is  made 
according  to  symptoms,  which,  I  be¬ 
lieve,  depend  entirely  on  the  state  of 
the  nervous  centres,  and  not  according 
to  the  amount  of  anaesthesia,  which  I 
shall  give  good  reason  for  believing 
depends  very  much  on  local  narcotism 
of  the  nerves. 

In  the  first  degree  I  include  any 
effects  of  chloroform  that  exist  while 
the  patient  possesses  perfect  conscious¬ 
ness  of  where  he  is,  and  what  is  occur¬ 
ring  around  him.  As  the  sensations 
caused  by  inhaling  a  small  quantity  of 
chloroform  have  been  experienced  by 
nearly  every  medical  man  in  his  own 
person,  I  need  not  attempt  to  describe 
them.  They  differ  somewhat  with  the 
individual,  but  may  be  designated  as  a 
kind  of  inebriation,  which  is  usually 
agreeable  when  induced  for  curiosity, 
but  is  often  otherwise,  when  the  patient 
is  about  to  undergo  an  operation  :  in 
such  cases,  however,  this  stage  is  very 
transitory.  Although  it  is  the  property 
of  narcotic  vapours  to  suspend  the 
functions  of  different  parts  of  the  ner¬ 
vous  system  in  succession,  yet  they 
probably  influence  every  part  of  that 
system  from  the  first,  but  in  different 
degrees. 

I  have  found  that  my  vision  became 
impaired  when  inhaling  chloroform, 
whilst  I  should  have  thought  it  as  good 
as  ever,  had  it  not  been  that  the  seconds 
pointer  disappeared  from  the  watch  on 
the  table  before  me;  and  I  could  only 
discover  it  again  by  stooping  to  within 
a  few  inches  within  it.  Common  sen¬ 
sibility  becomes  also  impaired,  so  that 
the  pain  of  disease,  which  is  generally 
due  to  a  morbid  increase  of  the  common 


sensibility,  is  in  many  cases  removed, 
or  relieved,  according  to  its  intensity. 
And  hence  it  is  that  patients  are  able 
to  inhale  chloroform  and  ether,  without 
assistance,  for  the  relief  of  neurakia, 
dysmenorrhuea,  and  other  painful  affec¬ 
tions;  the  latter,  which  acts  less 
rapidly,  being  the  best  adapted  for  this 
kind  of  domestic  use — chloroform  being 
perhaps  not  perfectly  safe.  The  suffer¬ 
ings  attendant  on  parturition,  when  not 
unusually  severe,  may  generally  be 
prevented,  as  stated  by  Dr.  Murphy,* 
without  removing  the  patient’s  con¬ 
sciousness  ;  but  I  have  met  with  no  in¬ 
stance  in  which  the  more  severe  kind 
of  pain  caused  by  the  knife  was  pre¬ 
vented,  whilst  complete  consciousness 
existed,  except  in  a  few  cases,  for  a 
short  time,  as  the  patients  were  re¬ 
covering  from  the  effects  of  the  va¬ 
pour,  having  just  before  been  un¬ 
conscious. 

In  the  second  degree  of  narcotism, 
there  is  no  longer  correct  conscious¬ 
ness.  The  mental  functions  are  im¬ 
paired,  but  not  altogether  suspended. 
Generally,  indeed,  the  patient  neither 
speaks  nor  moves,  but  it  is  possi¬ 
ble  for  him  to  do  both  ;  and  this  de¬ 
gree  may  be  considered  to  be  analogous 
to  delirium,  and  to  certain  states  of  the 
patient  in  hysteria  and  concussion  of 
the  brain  ;  and  it  corresponds  with 
that  condition  of  an  inebriated  person, 
who  is  not  dead  drunk,  but  in  the  state 
described  by  the  law  as  drunk  and  in¬ 
capable.  It  is  so  transitory,  however, 
that  the  patient  emerges  to  conscious¬ 
ness  in  a  very  few  minutes  at  the 
farthest,  if  the  chloroform  is  discon¬ 
tinued.  This  degree,  any  more  than 
the  others,  cannot  properly  be  com¬ 
pared  to  natural  sleep,  for  the  patient 
cannot  be  roused  at  any  moment  to  his 
usual  state  of  mind.  Persons  some¬ 
times  remember  what  occurs  whilst 
they  are  in  this  state,  but  generally 
they  do  not.  Any  dreams  that  the 
patient  has,  occur  whilst  he  is  in  this 
degree,  or  just  going  into,  or  emerging 
from  it,  as  I  have  satisfied  myself  by 
comparing  the  expressions  of  patients 
with  what  they  have  related  afterwards. 
There  is  generally  a  considerable 
amount  of  anaesthesia  connected  with 


*  Tamphlet  on  chloroform  in  the  practice  of 
midwifery. 


WHAT  CONSTITUTES  MALAPRAXIS  IN  MIDWIFERY  ? 


335 


this  degree  of  narcotism,  and  I  believe 
that  it  is  scarcely  ever  necessary  to  pro¬ 
ceed  beyond  it  in  obstetric  practice, 
not  even  in  artificial  delivery,  unless 
for  the  purpose  of  arresting  powerful 
uterine  action,  in  order  to  facilitate 
turning  the  foetus.  For,  on  the  one 
hand,  obstetric  operations  are  less 
painful  than  those  in  which  the  knife 
is  used,  and,  on  the  other,  it  is  not  so 
necessary  that  the  patient  should  be 
perfectly  motionless  during  their  per¬ 
formance,  as  when  the  surgeon  is  cut¬ 
ting  in  the  immediate  vicinity  of  vital 
parts.*  There  is  sometimes  a  conside¬ 
rable  amount  of  mental  excitement  in 
this  degree,  rendering  the  patient 
rather  unruly  ;  but  a  further  dose  of 
the  vapour  removes  this  by  inducing 
the  next  degree  of  narcotism,  and  there 
is  less  difficulty  from  this  source  with 
chloroform  than  with  ether,  since  its 
action  is  more  rapid,  and  two  or  three 
inspirations  often  suffice  to  overcome 
the  excitement.  Very  often,  however, 
the  patient  is  quiet,  and  to  a  certain 
extent  tractable  in  this  degree,  and  if 
sufficient  anaesthesia  can  be  obtained, 
there  are  certain  advantages  in  avoid¬ 
ing  to  carry  the  narcotism  beyond  it  for 
minor  operations,  especially  tooth¬ 
drawing,  as  I  shall  explain  when  I 
enter  on  the  uses  and  mode  of  apply¬ 
ing  chloroform,  at  the  end  of  this 
sketch  of  its  physiological  effects.  The 
patient  is  generally  in  this  degree  dur¬ 
ing  the  greater  part  of  the  time  occu¬ 
pied  in  protracted  operations;  for, 
although,  m  most  cases,  it  is  necessary, 
as  I  have  formerly  stated,  to  induce  a 
further  amount  of  narcotism  before  the 
operation  is  commenced,  it  is  not 
usually  necessary  to  maintain  it  at  a 
point  beyond  this'. 

[To  be  continued.] 


*  Mr.  Gream  and  Dr.  Wm.  Merriman,  who 
have  done  me  the  honour  of  quoting'  from  my 
essays  on  ether  and  chloroform,  in  their  pam¬ 
phlets,  have  applied  to  midwifery,  what  I  meant 
to  apply  only  to  delicate  and  serious  surgical 
operations,  and  have  grounded  objections  on  the 
supposed  necessity  of  producing  a  deep  state  of 
narcotism. 


MEDICAL  GAZETTE. 


FRIDAY,  AUGUST  25,  1848. 

We  are  at  a  loss  to  understand  the  rules 
of  law,  which  apply  to  charges  of 
malapraxis  in  Midwifery.  A  man  is 
not  to  be  made  criminally  responsible 
for  a  mere  error  in  judgment,  or  for  an 
untoward  accident,  which  one  possessed 
of  ordinary  skill  and  competency,  could 
neither  foresee  nor  avert, — nor,  should 
any  legal  responsibility  fall  on  him, 
because  fatal  consequences  ensue  by 
reason  of  his  not  having  adopted  com¬ 
mon  principles  of  practice,  when  he 
acted  with  a  bond  fide  conviction,  that 
he  was  pursuing  a  course  which  seemed 
to  him  best  adapted  for  the  safe  delivery 
of  a  female.  For  instance,  the  treat¬ 
ment  of  placenta  prccvia  is  yet  a  quccstio 
vex ata  with  even  experienced  obstetri¬ 
cians  ;  and  it  would  be  a  hard  case,  if 
those  who  lost  patients  by  conscien¬ 
tiously  following  the  new  plan  of  treat¬ 
ment,  were  to  be  tried  for  jman- 
slaughter.  Such  a  system  would  put 
an  end  to  all  attempted  improvements 
in  practice,  and  the  lives  of  females 
would  be  sacrificed  to  the  heavy  re¬ 
sponsibility  which  a  practitioner  might 
feel  he  was  incurring,  by  adopting  in 
an  emergency  some  new  method  of 
treatment,  for  which  the  common  rules 
of  practice  had  not  provided. 

In  all  these  cases,  the  conduct  of 
medical  practitioners  should  be  judged 
most  leniently ;  we  wall  go  one  step 
further,  and  say  that  this  leniency 
should  be  especially  an  exclusive  privi¬ 
lege  of  those  who,  by  the  possession  of 
a  diploma  or  certificate,  can  show  that 
they  have  not  commenced  the  practice 
of  a  difficult  art,  without  endeavouring 
to  make  themselves  acquainted  with 
those  principles  adapted  for  their  gui¬ 
dance  w'hich  have  been  accumulated 
by  experienced  men.  There  is,  how'"- 


336 


WHAT  CONSTITUTES  MALAPRAXIS  IN  MIDWIFERY  ? 


ever,  another  class  of  midwifery  cases, 
which  may  be  called  the  “  disembowel¬ 
ling”  or  “  eviscerating”  cases,  of  which 
within  the  last  three  years  we  have 
had  to  record  several  remarkable  in¬ 
stances,  that  appear  to  us  to  require  a 
different  mode  of  treatment.  But, 
strange  to  say,  the  law,  as  applied  to 
such  cases,  is  often  so  strained  in  favour 
of  an  unlicensed  practitioner,  that  the 
removalof  the  greater  part  of  a  woman’s 
intestines  through  an  aperture  in  the 
uterus,  is  considered  to  be  only  one  of 
those  casualties  which  may  attend 
natural  labour :  in  short,  it  has  been 
held  to  furnish  no  proof  of  incom¬ 
petency  or  unskilfulness ! 

In  our  last  week’s  number,*  our 
readers  will  find  in  an  authentic  form, 
the  particulars  of  a  “  disembowelling” 
case,  which  has  been  recently  made  the 
subject  of  a  trial  for  manslaughter.  Of 
the  practitioner  who  was  concerned  in 
the  case,  Mr.  W.  H.  Flint ,  we  know 
nothing.  From  the  statement  of  our 
correspondent,  Mr.  Crellin,  it  would 
appear  that  he  is  not  a  medical  man — 
at  any  rate,  that  he  does  not  hold  the 
license  of  the  Hall,  or  the  diploma  of 
the  College  of  Surgeons,  and  yet  in 
the  Medical  Directory  for  1848,  his 
name  occurs  thus — f 

Flint.  William  Harding,  Longnor,  Staf¬ 
fordshire,  M.R.C.S.  1844;  L.S.A.  1844; 
Medical  Officer  of  the  Bakewell  Union. 

This  discrepancy  requires  explana¬ 
tion,  or  it  will  tend  materially  to  shake 
the  confidence  of  the  profession  in  the 
accuracy  of  the  Medical  Directory. 
On  this  we  shall  have  a  remark  to  make 
hereafter. 

It  would  appear  from  a  summary  of 
the  evidence,  derived  not  from  news¬ 
papers,  but  from  an  authentic  source, 
that  Mr.  Flint  was  called  to  attend  the 
deceased,  Elizabeth  Riley,  while  in 
labour.  On  examining  the  woman 


three  times,  he  said  it  was  a  cross¬ 
birth,  and  he  had  turned  it.  About 
seven  hours  afterwards,  having  sent 
for  his  instruments,  he  employed  them, 
as  it  appeared,  for  about  an  hour  and 
a  half,  under  the  bed-clothes.  He 
declined  having  further  advice,  al¬ 
though  this  was  suggested  to  him  by 
the  friends.  The  deceased  appeared 
to  sink,  and  died,  undelivered,  about 
12  o’clock,  i.  e.  between  two  and  three 
hours  after  the  accused  commenced  his 
manipulations  with  the  instruments 
under  the  bed-clothes.  He  told  a  wit¬ 
ness  that  he  had  brought  one  child  into 
the  world,  and  there  would  be  another 
in  a  few  minutes.  An  attendant,  per¬ 
ceiving  that  the  woman  was  dying, 
turned  the  clothes  off,  and  saw  “  a  leg 
and  foot,  an  arm  and  a  hand,  and 
something  like  intestines,  hanging  out 
nearly  a  foot.”  There  was  also  an 
open  penknife  lying  on  the  bed  covered 
with  blood,  and  for  which  the  accused 
had  previously  inquired.  The  child 
which  Mr.  Flint  - said  he  had  brought 
into  the  world,  turned  out  to  be  a  por¬ 
tion  of  the  woman’s  bowrels,  with  a 
part  of  the  vagina  and  uterus  attached 
to  it;  this  was  found  under  the  chair 
in  which  the  accused  had  been  sitting! 
The  inspection  showed  that  there  was 
no  deformity  of  the  pelvis ;  that  a  hand 
and  foot  of  the  child  were  protruding, 
the  latter  having  on  it  a  deeply-incised 
wound.  With  these  there  was  project¬ 
ing  a  loop  of  intestine,  which  had 
passed  out  through  the  lower  part  of 
the  uterus.  The  perinseum  was  de¬ 
stroyed,  and  the  orifices  of  the  vagina 
and  rectum  were  continuous.  The 
uterus  was  ruptured  at  its  anterior  in¬ 
ferior  portion :  the  head  was  lying  on 
the  left  superior  side  of  the  abdominal 
cavity,  having  protruded  through  an 
extensive  laceration  or  rupture  of  the 
uterus  in  that  position.  There  were 
several  wounds  about  the  body  of  the 
foetus  and  the  posterior  walls  of  the 


*  Page  295. 


f  Page  131, 


THE  LONGNOR  CASE. 


337 


uterus ;  and  the  abdominal  cavity 
throughout  showed  proofs  of  extraor¬ 
dinary  instrumental  and  manual  vio¬ 
lence. 

We  have  been  obliged  to  enter  into 
these  horrible  details  in  order  to  make 
our  comments  intelligible.  At  the 
trial  of  the  accused,  the  line  of  de¬ 
fence,  by  cross-examination,  was,  — 
that  the  deceased  female  had  died 
from  a  rupture  of  the  uterus,  and 
that  it  could  not  be  determined,  whe¬ 
ther  the  rupture  had  arisen  from  the 
manual  interference  of  the  prisoner,  or 
from  natural  causes.  It  was  suggested 
that  the  injuries  to  the  viscera  might 
have  operated  secondarily  in  accelerat¬ 
ing  death  ;  but  that  the  rupture  of  the 
uterus  was  the  real  cause.  Upon  this 
the  judge  stopped  the  case,  and  sum¬ 
marily  directed  an  acquittal. 

There  can  be  no  objection  to  the 
legal  principle,  that  every  accused  per¬ 
son  should  have  the  full  benefit  of 
every  reasonable  doubt.  On  the  other 
hand,  the  lives  of  the  public  require  to 
be  protected,  especially  when,  as  it  is 
alleged  in  this  instance,  persons  not 
legally  qualified  to  practise,  will  take 
upon  themselves  the  responsibility  of 
attending  a  female  in  labour.  Now, 
the  question  here  was,  as  it  appears  to 
us,— Did  this  patient  die  from  the 
gross  ignorance,  or  criminal  inatten¬ 
tion,  of  the  person  who  undertook  to 
attend  her  in  a  medical  capacity? 
Would  she  have  died  but  for  the  want 
of  knowledge  on  his  part  to  adopt  the 
proper  measures  for  her  delivery  ?  An 
accident  might  occur  to  any  one ;  but 
the  plan  pursued  by  the  prisoner  ap¬ 
pears  to  us  to  have  been  in  violation 
of  all  professional  rules,  and  such  that 
could  not  fail  to  lead  to  the  death  of 
any  female  so  situated.  That  the 
uterus,  near  the  seat  of  the  rupture, 
had  been  improperly  interfered  with 
by  the  violent  use  of  instruments, 
was  rendered  in  the  highest  degree 


probable  from  the  discovery,  on  its 
posterior  wall,  of  several  wounds,  evi¬ 
dently  instrumental  ;  some  being  su¬ 
perficial,  and  others  having  passed  en¬ 
tirety  through  the  organ.  As  the  pri¬ 
mary  cause  of  death  was  assigned  to 
rupture  of  the  organ,  we  consider  this 
to  have  been  a  most  important  fact 
for  the  consideration  of  the  jury  ; 
but  no  further  evidence  was  allowed 
to  be  gone  into,  although,  as  we 
are  informed,  some  accoucheurs  of 
great  experience  were  present  to 
speak  to  the  probable  cause  of  the 
rupture  and  death.  In  the  cross- 
examination  of  Mr.  Simkins,  the 
usual  ingenious  plan  was  adopted  of 
extracting  an  answer  to  a  general 
question,  and  then  making  it  applica¬ 
ble  to  a  particular  case.  Ruptures  of 
the  uterus  may  undoubtedly  occur  under 
the  hands  of  the  most  skilful,  and  lead 
to  death  ;  but  the  question  here  was, 
whether  on  this  particular  occasion  the 
rupture  had  not  proceeded  from  gross 
ignorance  and  unskilfulness  in  the  use 
of  instruments.  The  wounds  upon  the 
uterus,  evidently  caused  by  instru¬ 
ments  which  had  passed  through  it, 
furnished  primct  facie  evidence  against 
the  suggested  occurrence  of  the  two 
extensive  ruptures  from  natural  causes. 
We  think  additional  evidence  should 
have  been  received,  and  the  jury  have 
been  allowed  to  form  their  judgment 
from  the  whole  of  the  facts,  whether  a 
sufficient  amount  of  gross  ignorance  on 
the  part  of  the. accused  had  not  been 
proved  to  account  for  the  death  of  the 
woman.  As  it  was,  the  case  was 
hastily  stopped,  the  facts  were  not  laid 
fully  before  them,  and  the  only  in¬ 
ference  that  we  can  draw  is,  that,  be¬ 
cause  a  fatal  injury  may  occur  spon¬ 
taneously  under  the  hands  of  a  skilful 
man,  or  be  occasioned  by  the  unskilful 
use  of  instruments,  its  origin  will  be 
imputed  to  natural  causes  in  spite  of 
evidence  from  wounds  through  the 


338  UPTON- ON -SEVERN  UNION - MEDICAL  ETHICS  UNDER  THE  POOR-LAW. 


walls  of  the  uterus  and  involving  the 
surrounding  viscera  of  the  abdomen. 
We  do  not  think  such  verdicts  likely  to 
give  satisfaction ;  and,  as  the  law  thus 
declares  itself  to  be  inoperative  for  the 
protection  of  females  who  have  their 
bowels  removed  by  such  extraordinary 
instrumental  manipulations  with  pen¬ 
knives,  &c.  during  a  delivery,  it  is  the 
duty  of  the  Colleges  to  take  the  matter 
in  hand,  and  to  insist  that  the  practice 
of  Midwifery  shall  be  entrusted  only 
to  those  who  are  really  qualified  to 
practise.  We  fear,  however,  there 
will  be  great  difficulty  in  procuring  the 
enactment  of  such  a  law,  although  its 
necessity,  for  the  preservation  of  the 
lives  of  the  poorer  class  of  females,  is 
rendered  apparent  by  the  not  unfre¬ 
quent  occurrence  of  these  disembowel¬ 
ling  cases. 

We  shall  conclude  these  remarks  by 
asking  how  it  is  that  Mr.  Flint’s  name 
finds  a  place  in  the  Medical  Directory 
as  a  Member  of  the  College  of  Sur¬ 
geons,  and  Licentiate  of  the  Apothe¬ 
caries’  Society,  of  so  recent  a  date 
as  1844,  when  it  turns  out,  accord¬ 
ing  to  an  application  made  to  those 
bodies,  that  he  is  not  an  admitted 
member  of  either  institution.  It  shews 
that  a  return  to  a  circular  letter  which 
involves  no  penal  consequences  for  a 
false  or  knowingly  erroneous  state¬ 
ment,  cannot  be  relied  on  as  evidence 
of  a  person  being  a  member  of  the 
profession.  Until  there  is  a  legalised 
system  of  registration,  we  would  advise 
the  conductors  of  this  publication  to 
insert  no  qualifications  to  persons 
whose  names  are  not  found  in  the  lists 
of  the  College  and  Hall  of  the  dates 
returned.  Their  names  should  stand 
in  a  separate  list,  so  that  the  state¬ 
ments  of  their  qualifications  may  be 
announced  to  be  on  their  own  responsi¬ 
bility.  This  will  undoubtedly  give 
trouble  in  the  first  instance;  but  it 
will  prevent  the  occurrence  of  such  a 


serious  mistake  as  is  alleged  to  have 
been  made  on  the  present  occasion— a 
mistake  which  is  likely  to  create  doubt 
and  distrust  with  respect  to  all  other 
names  not  known  to  the  individual 
who  consults  the  work.  For  the  pur¬ 
poses  of  the  trial,  it  was  readily  ascer¬ 
tained  that  the  accused  was  not  a  mem¬ 
ber  of  either  College  or  Flail ;  and  we 
do  not  think  there  would  be  any 
greater  difficulty  in  obtaining  this  in¬ 
formation  for  the  useful  objects  of  the 
directory.  The  labour  of  compilation 
in  each  succeeding  year  would  be  small. 
Our  own  and  other  journals  publish 
weekly  the  names  of  those  gentlemen 
who  have  been  duly  licensed  to  prac¬ 
tise  ;  and  this  information  is  derived 
from  officers  connected  with  the  College 
and  Hall. 


We  refer  those  of  our  readers  who  are 
interested  in  the  subject  of  poor-law 
medical  relief  to  the  address  of  Messrs. 
Braddon  and  White,  elsewhere  in¬ 
serted.*  These  gentlemen  have  acted 
in  a  proper  and  independent  spirit : 
they  have  insisted  upon  a  fair  remune¬ 
ration  for  their  services,  and  in  conse¬ 
quence  they  have  not  been  re-elected 
by  the  liberal  Upton  Board  of  Guar¬ 
dians.  We  learn  from  the  address, 
however,  that  three  medical  men  have 
been  found  to  act  as  a  forlorn  hope  to 
the  Board,  and  have  just  enabled  them 
to  gain  a  triumph  over  the  four  practi¬ 
tioners,  who,  so  long  as  they  held  office, 
discharged  their  parochial  medical 
duties  with  credit  and  ability.  This 
may  be  to  the  temporary  injury,  but  it 
will  doubtless  be  to  the  ultimate  gain, 
of  Messrs.  Braddon  and  White,  and 
their  colleagues.  They  have  bv  their 
conduct  in  this  affair  won  the  good 
opinion  of  the  respectable  portion  of  the 
profession,  while  those  who  have  thrust 


*  Page  347. 


UPTON-ON-SEVERN  UNION.  DEATH  OF  BERZELIUS. 


themselves 
such  degrading  circumstances  cannot 
fail  to  lose  it.  We  cannot  express 
our  surprise  at  the  result  of  the  elec- 
tion; — the  tribe  of  Shakspeare’s  apothe¬ 
caries  is  not  yet  extinct ;  and  there 
is  no  office,  whatever  may  be  its  name 
or  emoluments,  for  which  there  will 
not  be  some  medical  candidates.  Until 
we  have  in  our  profession  a  system  of 
discipline  like  that  which  prevails  in 
the  law,  and  until  medical  ethics  be¬ 
come  not  merely  a  name  but  a  reality, 
such  occurrences  must  take  place,  and 
give  rise  to  bitterness  of  feeling  and 
professional  animosity.  Among  bar¬ 
risters  any  unbecoming  or  unpro¬ 
fessional  mode  of  dealing  is  soon 
checked  by  an  appeal  to  an  Inn  of 
Court.  There  is  no  such  tribunal  for 
the  medical  practitioner,  and  thus  pro¬ 
fessional  remuneraiion  has  become  de¬ 
generated  to  the  rivalry  of  trade. 

In  a  code  of  medical  ethics  submitted 
in  1847  to  the  Philadelphia  Medical 
Convention,  we  find  the  following 
article  in  reference  to  the  duties  of 
medical  men  in  support  of  professional 
character ; — 

“  Every  individual  on  entering 

THE  PROFESSION,  AS  IIE  BECOMES  THERE¬ 
BY  ENTITLED  TO  ALL  ITS  PRIVILEGES 
AND  IMMUNITIES,  INCURS  AN  OBLIGATION 
TO  EXERT  HIS  BEST  ABILITIES  TO  MAIN¬ 
TAIN  ITS  DIGNITY  AND  HONOUR,  TO 
EXALT  ITS  STANDING,  AND  EXTEND  THE 
BOUNDS  OF  ITS  USEFULNESS.” 

Do  those  medical  practitioners  who 
have  taken  offices  resigned  by  other 
medical  men  from  the  notorious  ina¬ 
dequacy  of  the  salary,  consider  that 
they  have  acted  in  conformity  with 
this  plain  and  reasonable  rule  ?  But 
it  is  idle  to  ask  the  question  :  they 
have  a  deontology  of  their  own  which 
we  trust  few  will  be  found  to  adopt. 


339 


It  is  with  regret  that  we  have  to  an¬ 
nounce  the  death  of  this  illustrious 
chemist.  Many  months  since,  he  had 
a  severe  attack  of  paralysis,  and  this 
appears  to  have  been  the  cause  of  his 
death.  He  fully  retained  his  intellect, 
although  he  had  for  a  long  time  lost 
all  bodily  power.  His  death  took 
place  at  Stockholm  on  the  7th  inst. 
We  hope,  in  a  future  number,  to  give 
a  short  memoir  of  his  life. 


MODERN  CHEMISTRY  IN  THEORY  AND 
PRACTICE.  GALVANIC  AGRICULTURE. 

Chemistry  deals  with  the  first  properties 
of  matter,  and  the  laws  of  its  combination, 
and  just  in  proportion  as  it  determines  the 
one  and  expresses  the  other,  does  it  throw 
light  on  those  wonderful  compounds  built  up 
of  material  cells  which  we  call  animals  and 
plants.  The  discoveries  of  Berzelius  and 
Mulder,  and  the  theories  ( hypotheses  ?)  of 
Liebig,  have  astonished  the  world ;  and  we 
have  been  called  to  regard  as  the  result  of 
chemical  laws,  many  of  those  processes  to 
which  the  mysterious  term  life  had  been 
hitherto  applied.  As,  however,  in  the  his¬ 
tory  of  all  science,  the  theoretical  part  of 
these  inquiries  has  mostly  arrested  the  popu¬ 
lar  mind,  the  theories  of  Liebig  have  been 
much  more  highly  appreciated  than  the  dis¬ 
coveries  of  Mulder;  and  the  natural  result 
has  followed,  that  he  has  produced  a  greater 
number  of  imitators.  In  almost  every  de¬ 
partment  of  knowledge  to  which  the  laws  of 
chemistry  apply,  we  find  crude  and  hasty 
generalizations  usurping  the  place  of  earnest 
inquiry  and  intelligent  observation.  Homoeo¬ 
pathy,  hydropathy,  and  mesmerism,  have 
all  seized  upon  the  facts  and  generalizations 
of  the  chemist  as  a  support  to  their  erroneous 
views.  But  of  all  the  classes  which  have  been 
thus  led  away,  there  has  been  none  which 
has  been  so  far  misguided,  as  the  sober  one 
of  farmer.  It  is  to  him  that  the  vegetable 
quack  appeals,  offering  in  the  application  of 
chemical  manures,  electricity,  magnetism, 
and  other  agents,  harvests  more  golden  than 
the  world  had  ever  seen  before.  It  is  only 
a  short  time  since,  that  the  announcement 
was  made,  that  by  surrounding  a  field  with 
galvanic  wires,  its  produce  might  be  doubled 
or  trebled  !  The  plan  was  extensively  put 
in  action,  and  turned  out,  as  might  have  been 
expected,  a  complete  failure. — Athenaeum. 


into  their  places  under 


340 


ORATIO  ANNIVERSARIA  HARVEIANA. 


Mebtefosi. 


Oratio  Anniversaria  Harveiana,  a 

Francisco  Hawkins,  M.D.,  Coll. 

Reg.  Med.  Lond.  Soc.  et  Regis- 

tario,  &c.  4to.  p.  27.  Londini : 

Prostat  apud  Johannem  Churchill. 

MDCCCXLYIII. 

We  have  had  much  pleasure  in  reading 
this  excellent  Latin  oration  frofn  the 
pen  of  Dr.  Francis  Hawkins,  and  are 
not  a  little  surprised  to  find  the  readi¬ 
ness  and  facility  with  which  passing 
occurrences  are  noticed  in  a  language 
which,  except  among  the  learned,  has 
been  extinct  as  a  medium  of  inter¬ 
course  for  many  ages.  The  Oration  is 
truly  Harveian.  Dr.  Hawkins  dwells 
upon  the  life,  conduct,  and  opinions  of 
Dr.  Harvey,  who,  in  an  age  of  com¬ 
parative  darkness  and  ignorance,  stood 
forth  as  one  of  the  bright  lights  of  our 
profession.  But  while  Harvey  occu¬ 
pies  the  most  prominent  place,  those 
illustrious  men  who  succeeded  him 
have  a  full  meed  of  praise  awarded  to 
them. 

Harvey,  it  is  well  known,  was  one  of 
those  who  spurned  authority  where  it 
was  opposed  as  an  obstacle  to  the 
proper  investigation  of  nature.  In  his 
pursuit  of  science,  he  was  guided  by 
the  light  of  an  inductive  philosophy  of 
his  own;  and  to  this  independent  mode 
of  research  may  be  ascribed  his  grand 
discovery  of  the  circulation  of  the 
blood. 

“  Quod  ad  Physicam  scientiam  attinet, 
cum  prseceptis  aureis,  turn  prseclarissimo 
exemplo  suo,  nos,  quicunque  in  rebus  me- 
dicis  versamur,  hortatus  est  Harveius,  ut 
vanis  opinionum  commentis  ablegatis,  nullius 
in  verba  magistri  jurantes,  Naturam  inter- 
rogemus  ipsam,  et  per  experimenta  inter- 
pretemur.  Inierat  igitur,  et  praeceperat 
illam  ipsam  viam,  quam,  brevi  postea, 
monstravit  omnibus  et  munnivit  Veruliamus. 
Scilicet,  ‘  a  sensu  et  particularibus  ascen- 
dendo  continenter  et  gradatim,  ut  ultimo 
loco  perveniatur  ad  maxime  generalia:’  vero 
experientise  ordine,  videlicet,  qui  ‘  primo 
lumen  accendit,  deinde  per  lumen  iter  de¬ 
monstrate  Exinde  feliciter  fieri  coeptum 
est  ut  auctore  et  duce  Harveio,  tandem 
aliquando  resipuerint  Medici,  prius  Galeni 
tarn  fautores  inepte,  ut  si  quis  illius  auctori- 
tatem  ausus  fuerit,  vel  in  minimis,  immi- 
nuere,  hunc  animadversione  et  psenis,  et,  pro 
pudor  !  carcere,  coercendum  censuerunt.” 
(p.  13.) 


But  although  Harvey  was  an  enemy 
to  all  authority  where  it  interfered  with 
the  free  scope  of  thought  and  research, 
he  did  not  despise  the  labours  of  those 
who  had  gone  before  him.  He  was  a 
great  advocate  of  the  study  of  the 
Classics. 

“  At  vero  Harveius  qui  Naturam,  oculis 
quam  maxime  intentis,  contemplari  solebat 
num  veterum  auctoritatem  negligebat  ? 
Num  literas  parvi  pendebat  ?  Iramo,  vetus- 
tatis  exempla  monumentaque  diligenter  reco- 
lebat;  historicos,  politicos,  poetas  adamabat. 
Janus  banc  ipsam  orationem  Latine  haberi 
jussit.  Et  sine  controversia,  fuit  omnis  vel 
scientise,  vel  doctrinee,  summe  studiosus.” 
(p.  14.) 

The  orator  then  proceeds  to  enume¬ 
rate  the  merits  of  other  medical  wor¬ 
thies  who  have  conferred  honour  on 
the  College  of  Physicians.  Among 
them  we  find  the  names  of  Linacre, 
Canis,  Gilbert,  Caldwell,  Glisson,  Wil¬ 
lis,  Lower,  Wharton,  Sloane,  Baillie, 
Young,  Wollaston,  and  Halford.  Of 
Dr.  Lambe,  wdio  was  the  first  to  point 
out  the  danger  arising  from  the  forma¬ 
tion  of  carbonate  of  lead  in  water  kept 
in  leaden  cisterns,  it  is  said — 

“  Particulas  plumbeas  in  aquis  latitantes 
scite  evocavit.  Simplex  erat  et  apertus  et 
mores  ejus  modestissimi,  vita  integerrima.” 

(p.  20.) 

An  apology  is  offered  for  his  strange 
antipathy  to  animal  food  : 

“  Quod  si  paulo  inconsultius  carnem  no¬ 
bis  omnino  interdicere  vellet,  ignoscendum 
est  tamen.  Cuinam  enim  nocuit  ?  Nemo 
quod  sciam,  illi,  de  hac  re,  nisi  ipse  sibi, 
dicto  fuit  audiens.”  (p.  20.) 

Had  Dr.  Lambe  lived  in  these  days, 
his  chemical  knowledge  would  probably 
have  removed  a  prejudice  which  mo¬ 
dern  science  has  proved  to  be  without 
any  foundation.  The  nitrogenous 
principles  of  the  animal  and  vegetable 
kingdoms  are  now'  proved  to  be  so  nearly 
allied  that  the  difference  is  merely 
nominal. 

On  an  occasion  like  this,  we  cannot 
be  surprised  that  Dr.  Hawkins  should 
take  an  opportunity  of  referring  to  his 
evidence  before  the  Parliamentary 
Committee  on  Medical  Registration. 
It  appears  that  the  following  question 
was  put  to  him  by  Mr.  Wakley — 
“  Have  you  not  often  found  that  the 
men  who  w;ere  best  acquainted  w’ith 
literature  and  science  were  the  w7orst 
practitioners  ?”  Dr.  F.  Hawkins — “  I 


ORATIO  ANNIVERSARTA  HARVEIANA. 


341 


would  not  say  the  worst,  because  I 
have  found  that  the  worst  practitioners  $ 
of  all  are  those  who ,  without  general 
education ,  have  a  little  practical  expe¬ 
rience,  of  which  they  are  very  proud, 
and  fancy  that  their  knowledge  is  much 
greater  than  it  really  is”  This  is  the 
best  answer  with  which  we  have  met, 
to  a  question  which  embraces  a  popu¬ 
lar  but  very  unsound  view  of  the  in¬ 
fluence  of  scientific  researches  upon 
medicine.  We  have  heard  the  micros¬ 
cope  ridiculed,  because  scientific  medi¬ 
cal  men  have  employed  it  in  order  to 
enable  them  to  form  an  opinion  on 
the  nature  of  urinary  deposits.  The 
researches  of  Liebig1,  Mulder,  and 
others,  in  Organic  Chemistry,  have 
been  despised  for  the  same  reason. 
Chemistry,  in  the  hands  of  Prout  and 
Bright,  has,  however,  thrown  great  light 
upon  practical  medicine  ;  and  even  the 
“small  practical  men”  to  whom  Dr. 
Hawkins  alludes  in  his  reply,  have 
not  hesitated  to  talk  of  the  influence  of 
diet  and  medicines  in  calculous  dis¬ 
orders,  and  of  the  importance  of  ex¬ 
amining  the  urine  for  albumen  in  dis¬ 
eases  of  the  kidney.  Medical  men 
who  devote  themselves  to  science  and 
(medical)  literature,  often  confine  them¬ 
selves  to  special  branches,  and  are  thus 
withdrawndrom  practice;  but  they  are 
not  the  less  useful  in  aiding  the  strug¬ 
gles  of  the  “  practical”  men,  by  demon¬ 
strating  the  principles  upon  which  dis¬ 
eases  should  be  treated.  Practice, 
without  the  aid  of  scientific  theory,  is 
mere  groping  in  the  dark.  No  man 
ever  made  a  good  or  safe  practitioner, 
who  despised  scientific  research  ;  and 
the  medical  works  and  periodicals  of 
the  present  day  demonstrate  its  im¬ 
portance  to  the  progress  of  medicine.* 


*  The  Lectures  of  Baron  Liebig1  upon  the  most 
recondite  parts  of  chemical  science  in  relation  to 
Organic  Chemistry,  were  published  a  few  years 
since  in  the  Lancet.  We  have  only  just  com¬ 
pleted  in  the  pages  of  the  Medical  Gazette,  a 
valuable  course  of  lectures  recently  delivered  by 
Dr.  Golding  Bird,  on  the  Influence  of  Researches 
inOrganic  Chemistry  on  Therapeutics,  especially 
In  relation  to  the  depuration  of  the  blood  ;  and  a 
series  of  lectures  on  the  application  of  the  science 
of  chemistry,  to  the  discovery,  treatment,  and 
cure  of  disease,  by  Dr.  Garrod,  is  now  in  course 
of  publication,  in  our  contemporary,  the  Lan¬ 
cet.  This  diffusion  of  science  is  intended  to  im¬ 
prove  practitioners,  and  not  to  lower  them  as  a 
class.  In  fact,  we  would  as  soon  subscribe 
to  Ledru  Rollin’s  revolutionary  doctrine,  that  the 
less  a  man  is  educated,  the  better  is  he  qualified 
to  exercise  political  rights,  as  to  the  suggestion 
that  an  acquaintance  with  literature  and  science 
tends  to  create  a  bad  class  of  practitioners. 


Well  may  Dr.  Hawkins  say  in  rela¬ 
tion  to  the  parliamentary  question  put 
to  him :  — 

“Tales  cum  fuerint  viri,  qui  studiis  libe- 
ralibus,  redditi  essent  aptiores  Medicinse, 
per  mihi  mirura  videtur,  hisce  temporibus, 
esse  aliquos,  qui  titterarum  et  scientiae 
studia  Medicis  indici,  saltern  ex  auctoritate, 
nolint :  iramo,  nonnullos,  qui  studia  Medi¬ 
cis,  obfutura,  atque  ad  medendum  irnpedi- 
mento  fore  contendant. 

“  Quid?  impedientne Medicos humanitatis 
studia  ?  O  !  stultos  Linacros  et  Caios  ! 
O  !  amentein  Harveium  !  Quam  nullius 
consilii  fuerunt  Sydenhamus,  Boerhaavius, 
Hallerus,  Meadus,  Heberdeni,  Halfordus ! 
Qui,  tanti  cum  fuerint,  docti ;  credo,  majo- 
res  fuissent  indocti.  O  !  obtrectatores,  in- 
vidum  genus !  Nempe,  cum  viderint  sibi 
doctrinam  esse  nullam,  quam  vellent,  veluti 
vulpes  in  fabula  (namque,  in  re  anili,  anilem 
fabulam  mihi  proferre  liceat)  quam  vellent, 
veluti  vulpes  mutila,  docti  ornnes  doctrinam 
suam  abscidant  atque  deponant ! 

“  Vel  si  non  sint  maligni,  si  non  sint 
“  animi  sub  vulpe  latentes,”  at  certe  nes- 
ciunt  quantum  doctrina  vim  promoveat  in- 
sitam.”  (p.  22.) 

The  quackery  of  St.  John  Long, 
although  it  has  now  died  off,  is  not 
allowed  to  pass  without  comment. 

“  Interdum  quoque  fieri  potest  ut  prosint 
linimenta  acriora  et  exulcerantia  ;  at  iis  nullo 
discrimine  servato,  abuti,  ferreum  est ; 
sicut,  hercle,  nimis  aspere  traetavit  multos, 
nuper,  faraosus  quidam  ;  de  corio  alieno  qui 
lusit  miserabiliter.”*  (p.  25.) 

*  As  we  are  dealing  classically  with  this  noto¬ 
rious  quack,  we  shall  here  quote  a  few  stanzas 
from  a  burlesque  epitaph  on  one  of  his  patients, 
whose  death  brought  him  into  great  notoriety. 
Of  the  patient  it  says — 

Quas  causa  mortis 
Infelix  Virgo 
Aqua  Fortis 
Urens  a  tergo. 

And  of  the  rise  and  progress  of  the  practitioner 
himself,  who  is  reported  to  have  been  originally 
a  needy  Irish  sign-painter 
Quis  fuit  ille 
Johannes  praefatus  ? 

O’Driscoll  Billy 
Olim  nuncupatus. 

Medicus?  nequaquam, 

Sed  pictor  signorum 
In  Tipperaria 
Inops  bonorum' 

Nunc  dives  auri 
Sedet  sublimis 
In  curru,  celebratus 
Prosa  atque  rhymis. 

Qua;  tantae  famas 
Fuit  origo, 

Venter  solutus 
Marchionis  de  Sligo. 

Num  particeps  alter 
Dementiae  vestrae, 
lino  sane  fuit 
Dominus  lngestrie. 


34.2 


POPLITEAL  ANEURISM  MISTAKEN  FOR  AN  ABSCESS. 


In  concluding  the  oration,  Dr.  Haw¬ 
kins  alludes  with  good  classical  effect 
and  powerful  irony  to  the  medical 
heresies  of  the  present  day- — the  cold- 
water  cure,  the  wet  sheet  (involucra 
madida)  homoeopathy,  mesmerism,  &c. 
Of  homoeopathy  he  says — 

“  Prae  cseteris,  autem,  isti  mihi  videntur 
versuti,  qui,  ‘  similia  similibus  curari,’ 
jactitant,  idque,  portionibus  perexiguis,  vel, 
si  Diis  placet,  perquam  minutissimis.  Mira- 
bile  dictu  est,  at  creditur.  Interea  isti  secure 
nihil  agunt,  Naturae  committentes  omnia; 
et  disetse  tenui,  in  qua,  mirum  est,  prorois- 
soribus  istis,  quam  dicto  audientes  sint 
hiantes  aegri.  Quid ,  si  majus  quiddam  ali- 
quando  lenient  isti  ?  Quid,  si  remediis  vel 
periculosissimis  aliquando  non  dubitent  uti  ? 
Sed  clanculum.  Nam  cum  similes,  plerum- 
que,  inter  se  videantur  istorum  pilules,  at 
visu  tantum,  non  re,  sunt  similes.  Sint 
igitur  pilulse  illse  lenes  et  innociue;  acres  hse, 
seu  modo  non  mortiferae  :  devorentur  hae  : 
si  quid  male  cesserit,  examinentur  illse  :  in- 
veneris  quid  ?  nil  nisi  pulverem,  et  saccharum 
lactis.  Ergo,  quodcunque  fiat  de  aegrotis, 
isti  impune  abeunt.”  (p.  25.) 

This  passage.it  will  be  seen,  refers  to 
the  shameful  fraud  on  the  part  of  one 
of  these  homoeopathic  quacks,  which 
we  had  occasion  to  expose  about  a 
year  since,  in  which  a  strong  dose  of 
morphia  was  given  alternately  with  a 
dose  of  sugar  of  milk,*  and  the  patient 
nearly  lost  her  life  ! 

We  have  devoted  some  space  to  this 
oration,  as  the  majority  of  our  readers 
may  not  have  had  the  opportunity  of 
hearing  it  delivered,  and  the  publica¬ 
tion  now  before  us  may  not  fall  into 
their  hands.  They  will  perceive  from 
the  quotations  we  have  made,  that  it  is 
not  a  dry  classical  production,  but  that 
it  contains  some  useful  hints  and  sug¬ 
gestions  in  reference  to  passing  events. 
The  composition  of  the  oration  reflects 
great  credit  upon  Dr.  Hawkins  as  a 
scholar  and  a  physician. 


J^tdJtcal  ©rials  ants  Inquests. 


ACTION  FOR  MALAPRAXIS.  POPLITEAL 
ANEURISM  MISTAKEN  FOR  AN  ABSCESS. 
VERDICT  AGAINST  THE  PRACTITIONER. 

John  O’ Brien  v.  Thomas  Ambrose,  M.D. 

Counsellor  Synan  opened  the  pleadings. 
It  was  an  action  on  the  case,  brought  against 


the  defendant  for  want  of  skill  as  a  surgeon 
in  his  treatment  of  the  plaintiff.  The  decla¬ 
ration  contained  three  counts,  and  damages 
were  laid  at  ,£J2,000. 

Mr.  Henn,  Q.C.,  stated  the  case.  He  said 
he  appeared  for  the  plaintiff,  who  appealed 
to  the  jury  for  a  certain  amount  of  damages 
as  remuneration  for  a  very  grievous  injury 
he  had  sustained,  as  alleged,  in  consequence 
of  unskilful  treatment  of  him  by  the  defend¬ 
ant.  The  plaintiff  was  a  young  man,  (aged 
about  3G  years),  and  some  time  since  had 
been  in  comfortable  circumstances,  but  lat¬ 
terly  he  had  been  much  reduced  in  life,  owing 
to  the  injuries  he  had  received  at  the  hands 
of  the  defendant,  Dr.  Ambrose.  O’Brien 
was  a  farmer  residing  at  Carna,  about  twenty- 
five  miles  from  this  city,  and  had  a  wife  and 
three  children.  In  August,  1846,  a  small 
swelling  made  its  appearance  just  under  the 
knee-joint  of  O’Brien’s  leg,  which  increased 
by  degrees,  and  as  it  became  more  trouble¬ 
some,  induced  him  to  proceed  to  Rathkeaie, 
where  he  showed  it  to  an  apothecary  named 
O’Hanlon,  who  gave  him  some  ointment  to 
apply  to  the  swelling,  and  also  a  lotion.  He 
did  apply  it,  but  without  effect,  and  the 
swelling  became  worse.  In  November  he 
sent  to  Newcastle  for  Dr.  Ambrose,  the  de¬ 
fendant  in  this  action,  in  order  that  he  should 
afford  his  professional  advice  and  assistance. 
His  lordship  w-ould  tell  the  jury  that  any 
person  professing  to  be  a  surgeon  or  phy¬ 
sician  was  bound  to  bring  proper  skill  to 
bear  in  the  discharge  of  his  duty,  and  any 
person  not  so  qualified  is  liable  to  an  action 
of  damages  should  the  patient  under  treat¬ 
ment  be  injured  in  consequence  of  his  want 
of  skill.  Dr.  Ambrose  proceeded  to  the 
house  of  the  plaintiff,  where  he  saw  the  poor 
man,  and  at  first,  owing  to  some  extraordi¬ 
nary  skill  peculiar  to  the  doctor,  he  pro¬ 
nounced  the  swelling  “  a  blast,”  the  medical 
meaning  of  which  he  (Mr.  H.)  knew  nothing 
about.  Previous  to  Dr.  Ambrose’s  visit, 
the  brother  of  the  plaintiff  had  frequently 
felt  the  swelling  and  it  yielded  when  pressed. 
The  doctor  reccommended  leeches  and  wrote 
a  prescription,  which  was  sent  to  Mr. 
O’Hanlon,  the  Rathbone  apothecary,  and 
the  remedies  specified  were  applied,  but 
without  any  beneficial  effect.  It  was  plain 
Dr.  Ambrose  mistook  the  ailment  of  the 
patient,  and  treated  it  as  an  abscess.  It  ac¬ 
cordingly  got  worse,  and  on  the  9th  of  De¬ 
cember  the  doctor  paid  a  second  visit,  when 
he  found  his  patient  in  a  more  unfavourable 
state,  and  was  evidently  still  of  opinion  that 
the  ailment  was  an  abscess.  The  fact  was 
that  the  ailment  was  aneurism — that  is,  an 
enlargement  of  the  artery — a  most  dangerous 
thing,  and  the  jury  would  hear  from  the 
medical  men  to  be  examined  how  aneurism 
ought  to  be  treated  by  a  surgeon — that  treat¬ 
ment  which  would  effect  a  cure  in  one  case, 


*  See  vol.  xl.  p.  294. 


343 


MR.  A.  S  TAYLOR  ON  GAS  EXPLOSIONS  IN  HOUSES. 


might  cause  the  loss  of  life  in  another.  Mr. 
Henn  then  explained  that  Dr.  Ambrose 
punctured  the  artery  with  a  lancet,  and  in¬ 
stead  of  matter  issuing  from  it,  pure  blood 
spouted  out.  This,  counsel  attributed  to 
the  unskilfulness  of  Dr.  Ambrose,  who  used 
water,  bandages,  &c.,  to  stop  the  bleeding, 
and  on  the  same  night  O’Brien  was  brought 
into  the  County  Infirmary,  where,  on  a  con¬ 
sultation  of  doctors,  it  was  deemed  necessary 
to  cut  off  the  leg  in  order  to  save  the  plain¬ 
tiff’s  life,  and  that  amputation  accordingly 
took  place,  else  the  patient  would  have  bled 
to  death. 

Kennedy  O’Brien,  Pat.  O’Brien,  William 
Bradish,  Thomas  O’Brien,  and  Patrick 
O’Neill,  relatives  of  the  plaintiff,  were  then 
examined,  and  deposed  to  the  fact  of  Dr. 
Ambrose’s  having  attended  the  patient,  pre¬ 
scribed  for  him,  and  ultimately  lanced  the 
tumor,  from  which  blood  flowed  profusely. 

Mr.  Philip  O’Hanlon,  of  Rathkeale, 
apothecary,  proved  that  he  supplied  leeches, 
ointment,  & c.,  as  prescribed  by  Dr.  Am¬ 
brose  for  the  patient’s  use. 

Dr.  Robert  R.  Gelston  was  then  called, 
but  on  being  handed  the  book  refused  to  be 
sworn  until  paid  three  guineas  a  day  for  his 
attendance,  which  plaintiff’s  solicitor  refused, 
owing  to  his  client’s  poverty. 

Dr.  John  Wilkinson  and  Dr.  Parker 
(resident  medical  attendants  of  the  County 
Infirmary),  also  refused  to  give  evidence 
unless  .paid  a  like  sum. 

After  some  discussion  it  was  ruled  by  the 
Court  that  two  guineas  a  day  should  be  paid 
to  such  of  the  profession  as  were  examined. 

Dr.  Gelston  was  then  sworn,  and  deposed 
to  the  admission  of  the  patient  into  the 
County  Infirmary  on  the  10th  Dec.,  and  the 
condition  in  which  he  was — that  the  man 
was  in  such  a  dangerous  state  that  he,  Dr. 
Gelston,  Dr.  Wilkinson,  and  Dr.  Russell 
held  an  immediate  consultation,  and  decided 
on  amputation  as  the  only  means  of  saving 
the  man’s  life,  and  accordingly  the  limb 
was  cut  off  instanter.  The  doctor  under¬ 
went  a  lengthened  examination,  and  gave 
his  testimony  in  so  distinct  and  lucid  a 
manner  that  every  person  in  court  felt  grati¬ 
fied  at  his  interesting  detail  of  the  appearance 
and  treatment  of  aneurism,  the  skill  and 
judgment  to  be  exercised  in  such  cases  by  a 
medical  man,  and  other  explanations,  which 
proved  the  familiar  knowledge  and  experience 
of  his  scientific  medical  and  surgical  qualifi¬ 
cations.  He  admitted  that  want  of  skill  in 
the  defendant  must  have  led  him  to  treat  the 
patient  as  described  by  Mr.  Henn. 

Dr.  John  Wilkinson  was  also  produced, 
and  gave  similar  testimony  regarding  the 
unskilful  treatment  of  the  patient. 

Mr.  Coppinger,  in  addressing  the  jury, 
ably  vindicated  the  character  of  the  defend¬ 
ant,  and  referred  to  published  medical  reports 


with  the  view  of  showing  that  most  eminent 
practitioners  and  medical  men  had  been  mis¬ 
taken  as  to  appearances,  and  therefore,  that 
unless  the  jury  believed  that  in  this  case  a 
want  of  skill  was  apparent,  they  were  bound 
to  return  a  verdict  in  favour  of  the  defend¬ 
ant.  The  learned  counsel  complimented 
Dr.  Gelston  for  the  exceedingly  satisfactory 
and  gentlemanly  manner  in  which  he  gave 
his  testimony,  observing  that  he  had  seldom 
met  with  a  medical  witness  who  displayed 
more  skill,  judgment,  and  general  talent  in 
his  profession. 

The  judge  then  charged  the  jury,  who  re¬ 
tired  for  half  an  hour,  and  brought  in  a 
verdict  for  the  plaintiff  of  ,£100  damages. — 
Dublin  Medical  Press. 


CToiTT^ponticncc, 


ON  GAS  EXPLOSIONS  IN  HOUSES. - CAUSE 

OF  THE  EXPLOSION,  AND  SUGGESTIONS 

FOR  ITS  PREVENTION.  BY  ALFRED  S. 

TAYLOR,  F.R.S.,  LECTURER  ON  CHEMIS¬ 
TRY  IN  GUY’S  HOSPITAL. 

While  much  has  been  said  and  written  on 
the  subject  of  explosions  in  mines,  but  little 
attention  has  been  paid  to  the  danger  which 
may  arise,  through  accident  or  from  careless¬ 
ness,  by  the  use  of  coal-gas  for  the  purpose 
of  lighting  houses.  Explosions  have  occa¬ 
sionally  taken  place,  but  these  have  been,  for 
the  most  part,  slight,  and  productive  of  no 
danger  to  life,  and  of  but  little  damage  to 
property.  The  explosion  which  recently 
occurred  in  Albany  Street  was  perhaps  one 
of  the  most  formidable  and  disastrous  in  its 
effects  of  any  that  have  been  recorded  since 
coal-gas  was  used  for  the  purpose  of  arti¬ 
ficial  lighting. 

Popular  errors. — There  is  unfortunately 
much  popular  ignorance  on  the  subject. 
Many  persons  cannot  realize  the  fact  that 
they  are  deriving  light  from  the  combustion 
of  fire-damp  ;  and  although  the  journals  not 
unfrequently  contain  accounts  of  the  most 
fearful  accidents  occurring  in  coal-mines, 
the  public  are  unwilling  to  believe  that  they 
are  exposed  to  any  similar  risk  by  the  intro¬ 
duction  of  gas  into  houses ;  yet,  as  the  re¬ 
cent  deplorable  occurrence  testifies,  accidents 
of  a  most  alarming  kind  may  occur,  unless 
great  precaution  be  used.  We  have  heard 
it,  indeed,  gravely  questioned  by  well- 
informed  persons  whether  coal-gas  could 
produce,  by  its  explosion,  such  an  amount 
of  destruction  as  was  caused  on  this  occa¬ 
sion — and  gun-cotton  and  gunpowder  have, 
been  appealed  to  as  the  more  probable 
sources  of  the  accident.  Such  an  opinion 
only  tends  to  increase  the  liability  to  acci- 


344 


Mil.  A.  S.  TAYLOR  ON  GAS  EXPLOSIONS  IN  HOUSES. 


dents,  by  diverting  attention  from  the  real 
cause.  Gun-cotton  and  gunpowder  act 
only  by  producing  gaseous  matter ;  and 
when  compared  with  an  explosive  mixture 
of  gas,  their  effects  are,  cateris  paribus , 
far  less  sudden  and  tremendous.  The  entire 
destruction  of  a  vast  coal-mine,  with  the  lives 
of  one  hundred  persons,  by  a  single  explo¬ 
sion  of  fire-damp,  should  at  least  teach  those 
who  are  willing  to  fly  to  any  explanation 
rather  than  the  true  one,  that  the  explosive 
force  of  a  mixture  of  gas  with  air,  when 
ignited,  is  quite  adequate  to  explain  the 
occurrence  of  any  amount  of  destruction. 
When  they  are  told  that  there  is,  chemically 
speaking,  no  difference  between  the  fire¬ 
damp  of  mines  and  that  mixture  which  is 
speedily  made  by  allowing  unburnt  gas  to 
escape  into  a  shop  or  room  through  a  jet,  a 
damaged  pipe,  or  a  defective  gas- meter,  they 
may  then  be  led  to  perceive  their  mistake. 
To  those  who  know  and  have  experienced, 
even  on  a  small  scale,  the  effects  produced 
by  the  ignition  of  a  mixture  of  hydrogen  and 
oxygen,  or  of  coal-gas  and  oxygen,  it  is 
unnecessary  to  say  a  word  on  so  simple  a 
matter. 

Composition. — The  coal-gas  supplied  to 
houses  is  of  very  variable  composition  :  it 
consists  of  a  number  of  inflammable  gases 
and  vapours,  all  of  which,  when  mixed  with 
a  certain  proportion  of  air,  are  liable  to 
explode  with  tremendous  force.  The 
common  purified  coal-gas  is  composed  of 
light  carburetted  hydrogen,  olefiant  gas, 
carbonic  oxide,  hydrogen,  nitrogen,  the 
vapours  of  naphtha,  and  bisnlp'nuret  of  car¬ 
bon.*  In  the  process  of  purification  by 
lime,  the  gas  loses  in  great  part,  but  not 
entirely,  the  sulphuretted  hydrogen  and  car¬ 
bonic  acid  which  enter  into  its  composition 
as  it  first  escapes  from  the  retort  during 
distillation. 

A  pound  of  coal  will  give  four  and  a  half 
cubic  feet.  The  composition  of  the  product 
when  fit  for  use  varies  according  to  the 
period  at  which  the  gas  is  collected. 


*  The  smell  of  coal-gas  is  owing  to  the  pre¬ 
sence  of  these  vapours  and  of  some  sulphuretted 
hydrogen.  The  light  carhuretted  hydrogen,  ole¬ 
fiant  gas,  and  hydrogen,  when  pure,  are  free 
from  any  odour.  Gas  cannot  be  deprived  entirely 
of  sulphuretted  hydrogen  without  losing  much 
of  its  illuminating  power ;  and  there  is  no  pro¬ 
cess  known  by  which  it  can  be  entirely  freed 
from  the  vapour  of  bisulphuret  of  carbon.  It  is 
owing  to  the  presence  of  these  bodies  that  coal- 
gas,  while  burning,  produces  sulphurous  acid, 
which  is  not  only  offensive  to  respire,  but  very 
injurious  to  furniture.  The  library  at  the 
Athenaeum  Club  was  some  years  since  extensively 
damaged  by  the  sulphurous  (becoming  sulphuric) 
acid  evolved  from  the  gas-burners.  In  conse¬ 
quence  of  this,  Mr.  Faraday  suggested  an  ingeni¬ 
ous  plan  of  burning  gas  and  at  the  same  time 
carrying  oil’ the  products  of  combustion  by  means 
of  a  tube. 


At  the  After  After 
beginning.  5  hours.  10  hours. 


Light  carbd.  hyd. 

.  82-5 

56* 

20- 

Olefiant  gas  .  .  . 

.  13* 

7* 

o- 

Hydrogen  .  *  .  . 

.  0* 

21*3 

G0» 

Carbonic  oxide  . 

.  3*2 

11* 

10’ 

Nitrogen  .... 

.  1-3 

4-7 

10* 

100* 

100- 

100- 

Spec.  gr. .  . 

.  0*65 

0-5 

0-34 

The  amount  of  hydrogen  goes  on  increas¬ 
ing  in  proportion  to  the  duration  of  the 
process,  and  the.  explosive  power  of  the  gas 
thereby  becomes  increased.*  It  is  also 
worthy  of  remark,  that  the  gas,  even  in  the 
beginning,  is  but  little  more  than  half  as 
heavy  as  the  atmosphere.  It  is,  therefore, 
very  light,  and  in  all  cases  tends  to  ascend 
in  an  apartment — a  fact  easily  demonstrated 
by  experiment.  This  ascensional  power  is 
greatest  in  that  gas  which  is  collected  after 
a  ten  hours’  distillation. 

Explosive  proportions. — It  has  been  al¬ 
ready  observed,  that  the  whole  of  the  gases 
of  which  coal-gas  consists,  with  the  excep¬ 
tion  of  nitrogen,  are  highly  explosive  when 
mixed  in  certain  proportions  with  atmo¬ 
spheric  air.  The  vapours  of  naphtha  and 
bisulphuret  of  carbon  are  also  explosive 
under  these  circumstances  ;  and  when  the 
coal-gas  ascends  through  a  stratum  of  air  in 
a  closed  apartment,  this  explosive  mixture 
becomes  speedily  formed.  In  a.  well-closed 
room,  if  not  of  very  large  size,  every  por¬ 
tion  of  air  would,  in  the  course  of  a  short 
time,  become  explosive  by  admixture  with 
the  light  coal-gas.  Owing  to  a  peculiar 
law  which  regulates  the  diffusion  of  gases, 
they  tend,  notwithstanding  the  greatest 
differences  in  their  specific  gravities,  to 
mingle  uniformly  in  all  proportions.  This 
is  proved,  with  respect  to  coal-gas,  by  the 
smell  being  equally  perceptible  in  every  part 
of  the  room. 

The  exact  proportion  of  air  required  to 
produce  the  greatest  amount  of  explosion 
has  not  been  accurately  determined.  It  is 
customary  to  refer  to  the  experiments  of  Sir 
H.  Davy  on  light  carburetted  hydrogen; 
but  it  is  obvious,  from  the  very  variable 
proportion  of  this  compound  in  coal-gas, 
and  the  presence  of  other  inflammable  gases 
and  vapours,  that  the  results  obtained  by 
this  excellent  chemist  cannot  be  strictly 
applied  to  mixtures  of  coal-gas  and  air. 
They  are,  however,  probably  sufficiently 
near  the  truth  for  all  practical  purposes.  If 


*  According  to  an  analysis,  made  by  M. 
Tourdes,  of  coal-gas  which  had  occasioned  the 
deaths  of  four  persons  at  Strasburg,  it  consisted, 
in  100  parts,  of  31  hydrogen,  225  light  carbu¬ 
retted  hydrogen,  21  carbonic  oxide,  14  nitrogen, 
and  6  of  olefiant  gas,  with  some  carbonic  acid. 


ME.  A.  S.  TAYLOR  ON  GAS  EXPLOSIONS  IN  HOUSES. 


345 


the  gas  be  in  too  large  or  in  too  small  a 
proportion,  there  will  be  no  explosion.  Sir 
H.  Davy  found  that,  when  one  volume  of 
gas  was  thoroughly  mixed  with  one ,  two ,  or 
three  volumes  of  air,  the  mixture  did  not 
explode,  but  was  merely  burnt  or  consumed. 
When  the  gas  formed  from  one-fifteenth  to 
one-thirtieth  part  of  the  mixture  with  air,  it 
did  not  explode,  but  the  candle  burnt  with 
an  increased  flame.  The  explosive  propor¬ 
tions  are  those  in  which  the  gas  forms  from 
one-sixth  to  one-fourteenth  part  of  the 
mixture,  and  the  greatest  explosive  power 
was  manifested  when  one  volume  of  gas  was 
mixed  with  seven  or  eight  volumes  of  air. 
In  the  coal-gas  examined  by  M.  Tourdes,  it 
was  found  that,  in  order  to  render  it  explo¬ 
sive,  it  was  necessary  to  mix  it  with  eleven 
volumes  of  air. 

Conditions  which  modify  the  explosive 
force. — In  the  exertion  of  this  explosive 
force,  much  depends  on  the  completeness 
with  which  the  gases  are  mixed,  and  this 
must  be  regulated  by  the  time  during  which 
they  have  been  in  contact.  I  have  safely 
ignited  a  mixture  of  fifty  cubic  inches  of 
oxygen  and  olefiant  gas  in  a  glass  vessel 
when  the  mixture  had  not  been  made,  for 
more  than  a  few  minutes ;  but  in  one  ex¬ 
periment  in  which  the  gases  had  been  in 
contact  for  several  hours,  a  large  glass 
vessel  which  contained  one  hundred  cubic 
inches,  was,  on  the  approach  of  a  lighted 
candle,  shattered  to  dust.  The  largest  piece 
of  glass  which  could  be  found  after  the 
explosion  did  not  measure  more  than  a 
quarter  of  an  inch. 

The  explosive  power  of  coal-gas  derived 
from  a  distillation  of  some  hours’  duration 
becomes  greatly  increased  by  reason  of  the 
free  hydrogen  which  it  contains.  In  gas 
collected  after  ten  hours,  the  proportion  of 
hydrogen  amounts,  according  to  Mitscher- 
lich,  to  no  less  than  sixty  per  cent.  The 
dangerously-explosive  properties  of  this 
kind  of  coal-gas  (chiefly  used  in  aerostation) 
may  be  estimated  from  the  fact  discovered 
by  Davy,  that  fifty  cubic  inches  of  coal-gas 
at  its  maximum  of  explosive  power  (i.  e. 
eight  volumes  of  air  to  one  of  gas),  did  not 
produce  so  loud  a  report  as  five  cubic  inches 
of  a  mixture  formed  of  two  parts  of  atmo¬ 
spheric  air  and  one  of  hydrogen.  It  was 
also  discovered  by  Davy  that  the  presence 
of  carbonic  acid  and  nitrogen  in  an  explosive 
mixture  of  light  carburetted  hydrogen  and 
air  tended  to  diminish  the  force  of  the  ex¬ 
plosion.  In  the  mixtures  which  are  liable 
to  occur  accidentally  in  houses,  this  coun¬ 
teracting  effect  is  not  likely  to  operate  to 
any  material  extent. 

Degree  of  heat  required  for  explosion. — 
Sir  H.  Davy  found  that  an  iron  rod,  at  the 
highest  degree  of  red  heat,  did  not  inflame 
explosive  mixtures  of  fire-damp  and  air,  but 


flame  kindled  it  directly.  With  respect  to 
the  coal-gas  of  shops,  I  have  repeatedly  as¬ 
certained  by  experiment,  that  the  dull  red 
heat  of  paper,  saturated  in  nitre  and  ignited, 
will  not  inflame  or  explode  it.  A  poker  or 
bar  of  iron  heated  to  moderate  redness,  in¬ 
flames  it  immediately.*  This  difference  may 
be  probably  owing  to  the  presence  of  hydro¬ 
gen,  olefiant  gas,  and  the  vapours  of  naphtha 
and  bisulphuret  of  carbon,  all  of  which  are 
kindled  by  a  degree  of  red  heat  which  would 
not  kindle  the  mixture  of  fire-damp  and  air 
in  coal  mines.  Accidents  in  houses  are 
generally  occasioned  by  the  flame  of  a 
candle. 

Cause  of  the  explosion. — It  may  be  ob¬ 
served  that  the  cause  of  the  explosion  is  the 
sudden  concussion  of  the  air.  If  any  of 
these  explosive  mixtures  be  ignited  by  the 
aid  of  the  electric  spark  in  vacuo ,  in  glass 
vessels  of  great  strength,  a  bright  flash  of 
light  is  observed  to  pervade  the  whole  of  the 
vessel ;  but  there  is  no  report,  or  only  a 
very  slight  sound,  at  the  moment  of  the  dis¬ 
charge.  It  is  well  known  to  chemists,  that 
water  and  carbonic  acid  are  the  chief  pro¬ 
ducts — the  carbon  and  hydrogen  of  the  gas 
and  inflammable  vapours  suddenly  and  in¬ 
stantaneously  combine  with  the  oxygen  of 
the  air,  and  the  nitrogen  is  at  the  same  time 
set  free.  It  is  the  sudden  expansion  of  the 
mixture,  during  this  chemical  change,  which 
produces  that  terrific  vibration  of  the  air 
indicated  by  the  report. f  Thus,  if  a  soap- 
bubble,  filled  with  the  mixture  of  gas  and 
air,  be  exploded  while  floating  in  the  air, 
the  force  of  expansion  will  blow  out  a 
candle  at  some  distance  from  it.  If  the 
mixture  be  exploded  in  a  bottle  loosely 
corked  (a  dangerous  experiment),  the  cork 
is  always  blown  out.J  This  silent  expan¬ 
sion  of  the  gases  at  the  time  of  combination 
can  be  easily  witnessed  and  measured  in 
strong  glass  tubes,  graduated  for  the  purpose. 
Experiments  on  the  degree  of  expansion 
during  the  explosion,  can  only  be  performed 


*  This  experiment  also  serves  to  illustrate  the 
extraordinary  lightness  of  coal-gas,  especially 
after  it  has  stood  some  little  time.  The  glass 
jar  containing  the  gas  should  be  opened  with  its 
mouth  downwards,  and  a  piece  of  dry  nitre 
paper  ignited  should  be  gradually  raised  in  it. 
The  thick  smoke  floats  at  the  lowest  level  of  the 
jar,  and  does  not  rise  into  the  upper  part  of  the 
vessel,  which  is  rilled  with  the  light  coal-gas. 

f  This  experiment  may  be  safely  performed  by 
forcing  from  a  bladder  fifty  or  one  hundred  cubic 
inches  of  the  explosive  compound  into  a  wide 
basin,  containing  a  mixture  of  soap  and  water. 
The  vessel  should  be  filled  to  the  rim  with  the 
soapy  liquid:  any  portion  unprotected  by  the 
water  is  liable  to  be  blown  off  and  give  rise  to  an 
accident. 

t  In  the  delivery  of  chemical  lectures,  these 
accidents  are  liable  to  occur.  I  have  known  a 
cork  and  glass  tube  blown  in  this  way  to  a  height 
of  fifteen  feet,  by  the  ignition  of  a  few  cubic 
inches  of  an  explosive  mixture  contained  in  a 
bottle. 

I ' 


346 


MR.  A.  S.  TAYLOR  ON  GAS  EXPLOSIONS  IN  HOUSES. 


on  a  small  scale;  and  it  has  been  found 
that  in  a  small  tube  the  volume  is,  at  the 
moment  of  greatest  expansion,  tripled. 
There  can  be  no  doubt  that  when  some  hun¬ 
dreds  of  cubic  feet  are  kindled,  the  expan¬ 
sion  is  much  greater  than  this. 

The  late  accident. — From  what  I  have 
been  able  to  ascertain  by  inquiry  of  a  sur¬ 
veyor  who  knew  the  house,  the  room  in 
which  the  explosion  occurred  had  a  capacity 
of  1,620  cubic  feet.  If  the  coal-gas  were 
entirely  light  carburetted  hydrogen,  the 
quantity  required  to  give  this  volume  of  air 
its  maximum  explosive  force,  would  be  from 
about  100  to  200  cubic  feet.  The  mixed 
nature  of  coal-gas  renders  it  impossible  to 
say  what  number  of  cubic  feet  must  have 
escaped  in  order  to  render  the  air  of  such  an 
apartment  explosive.  If  the  apartment  were 
of  less  dimensions,  or  only  a  part  of  the  air 
in  the  room  was  rendered  explosive,  then 
the  escape  of  a  smaller  quantity  of  gas  would 
have  explained  the  result.  If  the  coal-gas 
contained  much  hydrogen,  a  much  smaller 
quantity  of  it  escaping  under  water  pressure, 
which  is  generally  kept  on  during  the  night, 
would  equally  account  for  the  accident ; 
since  the  explosive  force  of  such  a  mixture 
has  been  proved  to  be  ten  tinfes  as  great  as 
that  of  coal-gas  and  air.  How,  or  in  what 
way,  the  coal-gas  escaped  into  the  apart¬ 
ment,  it  is  here  unnecessary  to  inquire.  The 
ignition  of  from  500  to  1,000  cubic  feet  of  a 
mixture  of  this  kind,  would  fully  and  satis¬ 
factorily  account  for  the  extensive  destruc¬ 
tion  caused  on  this  occasion.  This  will  be 
fully  understood  by  those  who  have  wit¬ 
nessed  the  explosive  power  of  100  cubic 
inches  of  the  mixed  gases. 

Test  of  the  presence  of  such  dangerous 
mixtures. — The  smell  of  coal-gas  is  an  ex¬ 
cellent  test  of  its  presence.  It  may  be  per¬ 
ceived  when  the  gas  is  mixed  with  air  in  far 
less  than  an  explosive  proportion.  The 
smell  has  been  found  to  be  very  perceptible, 
when  the  gas  formed  only  the  1  -  150th  part 
of  the  mixture,  and  it  was  still  strong  when 
dilated  with  500  volumes  of  air.  When  in 
an  explosive  proportion,  the  odour  is  ex¬ 
ceedingly  powerful :  there  is,  therefore,  fair 
warning  of  the  possible  occurrence  of  danger. 
The  presence  of  any  odour  indicates  a  leakage, 
which  is  always  liable  to  increase  when  the 
pressure  is  put  on  at  night,  and  the  gas  is 
not  burning.  It  is  proper  to  remark,  that 
less  than  an  explosive  proportion  may  act  as 
a  poison,  if  it  be  respired  for  some  hours. 
There  are  reports  of  six  deaths  on  record, 
where  persons  have  been  thus  killed  by 
sleeping  in  rooms  near  to  which  there 
was  a  leakage  of  gas.  M.  Tourdes  found 
that  an  atmosphere  containing  one -thirtieth, 
or  even  one-fiftieth  part  of  coal-gas,  seri¬ 
ously  affected  animals.  It  cannot  be  too 
strongly  impressed  upon  the  minds  of  those 


who  use  gas  in  dwelling-houses,  that  where 
a  smell  is  perceptible,  the  defect  should  be 
immediately  found  out  and  remedied.  When 
the  leakage  is  comparatively  slight,  it  may 
endanger  the  lives  of  those  who  sleep  in  or 
near  the  spot ;  and  when  it  has  reached  a 
higher  point,  it  may  lead  to  a  serious  acci¬ 
dent  by  explosion. 

Prevention  of  accidents. — The  observance 
of  a  few  simple  rules  would  suffice  to  prevent 
accidents.  1.  The  gas  should  be  commanded 
by  two  well  fitted  stop-cocks ,  one  at  the 
main,  and  another  at  the  burner.  2.  No 
smell  of  gas  should  be  perceptible  in  the 
room  after  it  has  been  turned  off.  Any 
escape  of  gas  will  easily  be  detected  by  the 
smell  if  the  room  be  closed  for  a  short  time. 
This  should  not  be  suffered  to  continue,  as 
it  is  a  clear  proof  of  some  defect.  Gas  will 
escape  through  the  minutest  apertures  or 
chinks.  3.  The  free  access  of  air  to  the 
room,  by  leaving  the  door  open.  It  would 
be  proper,  if  possible,  to  leave  a  portion  of 
the  window  down,  or  to  have  one  of  the 
upper  panes  of  glass  removed,  and  a  pane  of 
perforated  zinc  substituted.  A  hole  in  the 
shutter  mightallow  of  the  communication  with 
the  outer  air.  The  free  ventilation  of  a  room 
in  which  gas  has  been  burning,  is  advisable 
under  all  circumstances,  as  it  tends  to  re¬ 
move  the  air  vitiated  by  combustion.  In 
the  event  of  any  leakage,  it  will,  by  leading 
to  the  extensive  detection  of  the  gas,  tend  to 
prevent  the  formation  of  an  explosive  mix¬ 
ture.  If  it  be  inconvenient  to  procure 
ventilation  by  the  door  or  window,  an  aper¬ 
ture  made  into  the  chimney  near  the  ceiling, 
and  protected  by  a  closed  valvular  plate, 
which  would  admit  of  being  drawn  down 
when  the  gas  is  turned  off,  would  tend  to 
prevent  a  dangerous  accumulation.  The 
light  gas  would  find  its  way  into  the  chimney, 
and  its  escape  would  be  aided  if  the  inner 
door  of  the  apartment  was  left  open.  4. 
When  a  smell  is  perceived,  although  slight, 
in  or  near  a  room  supplied  with  gas,  it 
would  always  be  a  safe  precaution  to  ex¬ 
tinguish  any  light,  and  open  the  doors  and 
windows  for  a  short  time  before  venturing 
near  the  spot  with  a  lighted  candle. 

It  will  be  seen,  therefore,  that  the  great 
principle  of  safety,  is  to  have  a  free  ventila¬ 
tion,  especially  at  the  upper  part  of  every 
room  which  is  supplied  with  gas.  If,  in  a 
small  room,  there  be  a  leakage,  which  is 
neglected,  and  the  doors  and  windows  be 
completely  closed  for  two  or  three  hours,  it 
is  certain  that  there  will  be  formed  a  most 
dangerous  explosive  mixture,  which  only  re¬ 
quires  the  approach  of  a  lighted  candle  to 
produce  such  a  fearful  accident  as  that  which 
has  been  lately  witnessed.  It  is  the  illustra¬ 
tion  of  the  fire-damp  in  mines  on  a  small 
scale,  with  the  difference,  that  while  the 
miner  cannot  prevent  the  accumulation  of 


THE  UPTON-ON-SEVERN  UNION  AND  POOR-LAW  MEDICAL  RELIEF.  347 


the  gas  from  the  coal  strata,  and  he  cannot 
secure  a  perfect  ventilation,  the  gas-burner 
has  it  in  his  power  to  adopt  both  of  these 
precautions.  In  most  shops,  there  is  tole¬ 
rably  free  ventilation  :  hence,  accidents  from 
coal-gas  are  by  no  means  common. 

Since  these  remarks  were  written,  an  in¬ 
quest  has  been  held,  and  Dr.  Arnott  was 
called  upon  to  give  evidence  respecting  the 
cause  of  the  explosion  in  Albany  Street.  I 
am  glad  to  find  myself  supported  in  these 
views  by  so  competent  an  authority  as  Dr. 
Arnott. 


THE  UPTON-ON-SEVERN  UNION  AND  POOR- 
LAW  MEDICAL  RELIEF. 

To  the  Medical  Profession. 

Gentlemen, — The  thanks  of  the  late  Me¬ 
dical  Officers  of  the  Upton-on-Severn  Union 
are  due  to  you  as  a  body,  for  the  sympathy 
with  which  our  address  of  July  6th  has  been 
received  by  you  ;  and  the  almost  unlooked- 
for  support  and  encouragement  which  have 
met  us  in  all  quarters  ;  for  the  generous  and 
manly  spirit  with  which  our  cause  has  been 
advocated  by  the  xMedical  Journals ;  and  for 
the  courage  and  magnanimity  with  which 
the  profession,  more  especially  in  our  own 
county,  has  put  jtself  forward  to  make  com¬ 
mon  cause  with  us. 

The  general  testimony  we  have  thus  re¬ 
ceived  shall  unite  us  to  increased  exertion, 
to  unflinching  perseverance,  in  a  cause  sanc¬ 
tioned  by  every  principle  of  truth  and  equity — 
a  cause  to  which  we  are  happy  to  find  all  the 
intelligence  of  our  own  county  is  rapidly  giv¬ 
ing  in  its  adherence,  and  in  which,  though 
no  longer  personally  and  pecuniarily  in¬ 
terested,  a  sense  of  principle  will  urge  us 
forward  to  overthrow  the  bulwarks  reared  by 
vulgar  cunning  and  callous  hypocrisy.  Yet 
a  little  longer — let  us  hold  together  yet  a 
while,  and  this  event  must  occur ;  no  other 
result  can  seriously  be  contemplated. 

It  now  becomes  our  duty,  as  briefly  as 
possible,  consistently  with  making  ourselves 
properly  understood,  to  continue  our  narra¬ 
tive  of  the  proceedings  in  this  Union;  and 
although  we  are  unable  to  state  that  our 
hopes  and  predictions  have  been  fulfilled  to 
the  very  letter ;  although  we  have  been  met 
by  treachery  almost  in  our  own  camp  ;  al¬ 
though  the  search  through  the  lanes  and 
alleys  of  the  profession  has  been  attended 
with  more  success  than  that  of  its  highways, — 
we  yet  feel  that  we  have  ample  room  for 
congratulation  on  the  healthy  spirit  pervad¬ 
ing  the  profession  in  general ;  and  that  by 
any  less  sanguine  than  ourselves,  our  hitherto 
partial  success  will  be  deemed  a  most  unex¬ 
pected  triumph.  Of  the  facts  which  we 
have  to  lay  before  you,  some  will  elicit  your 
approbation,  others  your  regret :  some  there 


are,  which,  if  they  fail  to  raise  your  astonish¬ 
ment,  will,  we  are  assured,  excite  your  con¬ 
tempt  and  indignation.  Had  our  proposi¬ 
tions  met  at  first  with  the  fullest  success, 
our  general  cause  could  not  have  been  put 
forth  in  the  same  glowing  light,  nor  the 
same  extensive  moral  results  have  been 
obtained,  as  must  now  inevitably  be  the 
case.  It  will  be  in  your  remembrance 
that  at  the  meeting  of  the  Board  of  Guar¬ 
dians,  on  July  20th,  the  districts  of  this 
Union  were  altered  and  consolidated  ;  re¬ 
duced  in  number  from  seven  to  five  ;  and 
that  advertisements  were  issued  to  the  pro¬ 
fession  for  tenders  :  we  briefly  recapitulate 
the  names,  extent,  population,  and  salary  of 
these  districts. 


No.  of 

District.  Name.  Population.  Acres.  Salary. 


1  or  Upton 

2  or  Workhouse 

3  or  Eldersfield 

4  or  Kempsey 

5  or  Powick 


6,312 

18,020 

i?83 

20 

3,409 

16,040 

70 

2,203 

7,840 

40 

1,598 

5,430 

20 

The  tenders  for  these  districts  were  to  be 
sent  in  to  the  Board  at  their  meeting,  on 
August  3rd,  that  being  the  day  on  which  our 
resignations  took  effect.  We  also  beg  you 
to  carry  in  your  mind,  that  an  Assistant- 
Commissioner,  Mr.  Greaves,  was  present  at 
the  meeting  of  July  20th,  and  that,  to  the 
best  of  our  knowledge,  the  question  was 
asked  by  him,  whether  the  Beard  were  of 
opinion  they  could  procure  fresh  officers  of 
equal  professional  standing  and  respectability 
with  those  whose  resignations  had  been  ten¬ 
dered  ;  that  he  was  met  by  an  unhesitating 
affirmative  ;  and  that  on  this  understanding, 
the  arrangements  of  the  Board  (two  of  the 
districts  being,  as  you  observe,  over  the  legal 
acreage)  received  the  provisional  sanction  of 
the  Poor-Law  Board.  On  the  3d  of  Au¬ 
gust,  then,  two  tenders  were  presented  to 
the  Board  :  one  for  the  1st  and  2nd  districts, 
the  other  for  the  3rd  district.  For  the  4th 
and  5th  districts  no  tenders  appeared.  A 
gentleman  named  Shevvard  was  placed  in 
nomination  for  the  1st  and  2nd  districts; 
but  no  application,  personal  or  written, 
having  been  made  by  him,  we  are  unwilling 
to  make  him  a  third  in  so  unenviable  a  cate¬ 
gory  ;  we  will  rather  presume  that  he  was 
nominated  without  his  authority.*  Acting 
under  the  advice  of  our  friends,  and  to  take 
from  our  opponents  the  paltry  excuse  of  our 
not  tendering,  we  also  sent  in  a  joint  tender 
on  the  same  occasion.  The  following  is  a 
copy,  and  it  will  be  observed  that  we  ap¬ 
portioned  the  salaries  in  exact  accordance 
with  our  previous  resolutions  and  application 
to  the  Committee  :  — 

*  This,  we  are  informed,  is  strictly  correct : 
Mr.  Sheward  did  not  apply  for  any  one  of  the 
districts,  and  he  was  nominated  without  his 
being  a  party  to,  or  concurring  in  such  a  step. 


348  THE  UPTON-ON-SEVERN  UNION  AND  POOR-LAW  MEDICAL  RELIEF. 


:  »  '  -  ' — — 

To  the  Chairman  and  Board  of  Guardians 
of  the  Upton-on- Severn  Union . 

Gentlemen, 

We,  the  undersigned,  beg  to  offer  you  our 
services  as  Medical  Officers  to  this  Union, 
for  the  Districts  and  at  the  salaries  specified 
below*. 

We  remain,  gentlemen, 

Your  obedient  servants, 

H.  S.  Trash — Joseph  Meears — 
Chas.  Braddon — W.  T.  White 
— C.  E.  Prior. 

At  a 

No.  salary  of 

2.  Workhouse  .  .  .  £35  H.  S.  Trash. 

5.  Powick  District  .  27  J.  Meears. 

1.  Upton  District  .  .120  C.  Braddon. 

4.  Kempsey  District  .  54  W.T.  White. 

3.  Eldersfield  District  90  C.  E.  Prior. 

Although  several  ex  officio  Guardians 
were  at  the  Board  prepared  to  support  our 
tender,  it  was  laid  aside,  and  treated  with 
contempt  ;  the  Board  resolving,  that,  as  it 
was  not  in  accordance  with  the  terms  of  the 
advertisement,  it  could  not  be  entertained. 
The  tenders  of  the  two  other  parties  were 
accepted.  The  tender  of  Mr.  Henry  Brun- 
ning  Marsh,  who  offered  himself  for  the  1st 
and  2d  Districts,  was  accepted,  and  the 
tender  of  Mr.  John  Nelson  Thomas  for  the 
3d  District  was  also  accepted.  The  4th 
District  was  also  placed  under  Mr.  Marsh’s 
charge  (thus  making  an  extent  of  26,000 
acres  under  one  practitioner).  The  care  of 
the  sick  poor  in  the  5th  District  was  con¬ 
fided  to  Mr.  William  Corner  West,  who 
volunteered  his  services  thus  to  assist  his 
brethren  !  and  to  relieve  the  Board  from  a 
difficulty  which  would  otherwise  have  been 
insurmountable.  These  appointments  have 
not  yet  received  the  sanction  of  the  Poor 
Law  Board  ;  nor  will  they,  under  any  cir¬ 
cumstances,  be  sanctioned  for  more  than 
twelve  months.  This  we  have  from  the 
Poor  Law  Board  itself. 

And  now,  gentlemen,  a  word  as  to 
“  equal  standing  and  respectability.”  The 
medical  men  who  have  just  resigned  their 
offices  are  men  of  unblemished  character,  of 
unsullied  reputation  :  they  have  discharged 
their  several  duties  carefully,  faithfully,  con¬ 
scientiously  ;  and  can  refer  with  pride  and 
satisfaction  to  the  estimation  in  which  they 
are  held  in  their  different  localities. 

The  newly-elected  officer  of  the  1st  and 
2d  Districts,  and  temporary  holder  of  the 
4th,  Mr.  Marsh,  resigned  a  medical  district 
in  this  Union  in  the  month  of  November, 
1844,  upon  an  investigation  into  an  alleged 
charge  of  neglect  made  against  him  as  to  the 
death  of  a  pauper,  conducted  by  this  Board 
of  Guardians  in  the  presence  of  an  Assistant 
Poor  Law  Commissioner.  On  this  occasion 
the  Board  decided  that  a  case  of  gx*oss 


neglect  had  been  made  out.  He  was  sub¬ 
sequently  elected,  in  the  autumn  of  1846, 
to  a  small  district  in  this  Union  for  a  pro¬ 
bationary  term  of  six  months.  He  was  re¬ 
elected  in  May  1847,  for  another  proba¬ 
tionary  term  of  twelve  months,  at  the 
expiration  of  which  period  he  was  out-voted 
by  the  Board,  and  another  medical  officer 
appointed  in  his  room  ;  and  yet  the  constant 
practice  in  this  Union  for  a  period  of  years 
has  been  to  make  the  appointments  of  Me¬ 
dical  Officers  permanent. 

We  leave  you,  gentlemen,  to  draw  your 
own  inferences  from  these  facts.  And  now 
for  Mr.  John  Nelson  Thomas,  the  Medical 
Officer  (!)  of  the  3d  District.  Mr.  Thomas 
does  not  possess  the  College  Diploma  ;  con¬ 
sequently  he  is  not  duly  qualified  as  a  Poor 
Law  Medical  Officer.  Mr.  Thomas,  in  the 
summer  of  1843,  perceived  it  to  be  to  his 
advantage  to  resign  his  appointment  as  a 
Medical  Officer  in  this  Union,  in  conse¬ 
quence  of  the  occurrence  of  certain  un¬ 
pleasant  circumstances,  which  are  recorded 
in  the  minute-book  of  the  Upton  Board  of 
Guardians.  Mr.  Thomas  was  not  dismissed 
— he  only  resigned  his  appointment ;  and 
so,  by  the  way,  did  Mr.  Marsh. 

Thirdly,  as  to  the  5th  District,  Mr.  Wm. 
Corner  West,  of  Great  Malvern,  like  Mr. 
Nelson  Thomas,  is  but  half  qualified, 
having  only  the  Diploma  of  the  College 
(at  least,  so  Churchill’s  Directory  affirms). 
Mr.  West  was  a  man  whom  we  had 
always  recognised  and  treated  as  a  brother 
officer,  on  whose  support  and  assistance  we 
had  fully  relied.  As  surgeon  to  the  Malvern 
Dispensary,  Mr.  West  has  the  charge  of  the 
poor  of  Malvern  and  two  adjacent  parishes 
in  this  Union — the  Guardians  being  sub¬ 
scribers  to  the  Dispensary,  and  such  being 
found  the  best  method  of  managing  that  dis¬ 
trict.  Although  Mr.  West,  therefore,  was 
not  a  regular  officer  of  the  Union,  yet  it  was 
judged  courteous  to  invite  him  by  circular 
to  our  first  meeting.  An  answer  was  received 
from  Mr.  West,  expressing  the  warmest 
concurrence  in  our  objects,  and  authorizing 
us  to  attach  his  name  to  our  resolutions. 
Accordingly,  Mr.  West’s  name  was  attached 
to  them,  and  forwarded,  with  our  own  signa¬ 
tures,  to  the  Board  of  Guardians.  In  sub¬ 
sequent  letters  Mr.  West  retracted  this  per¬ 
mission,  on  the  plea  that  he  had  understood 
our  resolutions  to  be  for  the  Poor  Law  Board, 
not  for  the  Board  of  Guardians,  with  whose 
arrangements,  not  being  a  regular  officer,  he 
did  not  consider  himself  privileged  to  inter¬ 
fere  ; — but  all  the  letters  breathed  a  spirit  of 
encouragement  and  sympathy,  although  the 
writer  appeared  scarcely  sanguine  of  success. 
Let  the  profession,  then,  picture  to  itself 
our  astonishment  at  hearing  that  Mr.  West 
had  volunteered  his  services  for  the  Powick 
District. 


UPTON-ON- SEVERN  UNION.  THE  ASIATIC  CHOLERA. 


349 


Such,  gentlemen,  are  the  facts  of  this  most 
glaring  case,  and  thus  far  have  they  gone. 
Have  they  given  you  no  surprise?  are  the 
proceedings  of  Boards  of  Guardians  else¬ 
where  guided  by  the  same  principles  ?  and 
are  the  interests  of  the  poor  always,  think 
you,  the  first  object  of  their  solicitude  ?  We 
have  received  a  reply  to  the  statement  which 
we  forwarded  to  the  Poor-law  Board, through 
the  official  reserve  and  brevity  of  which  we 
flatter  ourselves  we  can  detect  somewhat  of 
a  favourable  spirit.  We  have  also  submitted 
to  their  consideration  the  same  facts  we  now 
lay  before  you  ;  and  we  have  every  hope, 
from  the  well-known  good  feeling  and  recti¬ 
tude  of  Mr.  Buller  and  his  colleagues. 

We  hesitate  not  to  avow  our  pride  in  hav¬ 
ing  struck  the  first  blow  in  so  good  a  cause. 
Let  us  all  join  heart  and  hand  to  follow  it 
up.  The  Poor-law  Board  have  told  us  that 
— “  It  does  not  appear  to  them  that  the 
total  amount  of  medical  salaries  in  this 
Union,  as  measured  by  the  population  and 
area,  is  unusually  low  when  compared  with 
other  similarly  situated  agricultural  Unions.” 
Be  it  so  :  we  are  grateful  for  the  statement 
of  this  fact — so  much  the  better  for  our  pur¬ 
pose — so  much  the  more  reason  for  an  im¬ 
mediate  adoption  of  our  line  of  conduct  in 
other  Unions.  Let  a  similar  course  to  ours 
be  pursued  but  in  two  or  three  instances,  it 
scarcely  needs  more,  and  we  venture  to  pre¬ 
dict  that  the  days  of  poor-law  tyranny  over 
our  profession  are  numbered  ;  and  that  the 
whole  iniquitous  system  will  speedily  sink 
before  the  current  of  public  reprobation. 
We  complain  not  of  any  peculiar  hardship  ; 
nor  do  we  wish  to  convey  the  impression 
that  there  has  been  anything  in  the  circum¬ 
stances  of  the  ex-officers  of  this  Union  to 
justify  the  step  they  have  taken  more  than  in 
hundreds  of  similar  instances  throughout  the 
country  ;  yet  let  it  not  be  supposed  that  we 
are  possessed,  in  the  slightest  degree  more 
than  our  compeers,  of  an  immunity  from 
what  is  generally  feared  as  the  consequence 
of  such  a  proceeding.  No,  gentlemen,  we 
contend  for  a  principle  more  than  for  par¬ 
ticular  interests  ;  and  are  fully  aware  of  the 
nature  of  our  undertaking  :  we  know  that  as 
a  body  we  must  bear  the  full  tide  of  paro¬ 
chial  wrath,  and  official  abuse, — we  have 
been  charged  with  using  a  threat,  where  we 
only  intimidated  an  alternative — as  indivi¬ 
duals,  the  busy  tongue  of  slander  will  not  be 
wanting  to  defame  the  purity  of  our  inten¬ 
tions,  nor  the  voice  of  prudential  counsel  to 
undermine  our  resolution.  Aided  and  en¬ 
couraged  by  you,  we  pass  over  and  despise 
all  these  minor  troubles. 

Now  let  our  examples  be  followed  firmly 
quietly,  in  a  gentlemanly,  but  decided  spirit. 
M  e  frankly  avow  that  in  measures  of  this 
sort,  we  have  more  confidence  than  all  the 
societies,  institutes,  and  conventions,  whi  h 


decorate  our  profession.  The  slang  of  the 
day  has  been  brought  to  bear  upon  us, — we 
have  had  the  free-trade  jargon  of  “  competi¬ 
tion,” —  of  “young  men  glad  to  come  for¬ 
ward,” —  of  a  “  profession  overstocked,” — 
of  “  lots  of  doctors  in  the  market,”  &c., 
applied  to  our  case, — we  have  stood  the 
brunt  of  it,  and  you  see  the  result,  how 
paltry,  how  miserable  !  You  have  yet  to 
witness  the  ignominious  failure  of  our  oppo¬ 
nents. 

Within  a  fortnight  we  hope  to  read  in  the 
Medical  Journals,  that  our  example  has  been 
followed,  that  others,  without  any  more  delay 
or  temporizing,  have  resolved  on  the  down- 
fal  of  the  present  abominable  system  of  the 
Poor-Law  Medical  Relief. 

We  remain,  gentlemen, 

Your  faithful  friends 

and  servants, 
Chas.  Buaddon, 

William  Todd  White. 

The  deputation  of  the  late  Medical  Officers  of 
the  Upton-on-Severn  Union. 

Upton-on-Severn,  August  15,  1848. 


iMctucal  Intdltcjence. 


THE  ASIATIC  CHOLERA. 

The  cholera  was  very  mild  in  Constanti¬ 
nople.  It  has  manifested  itself  at  Adrianople, 
and  with  much  severity.  It  was  declining 
in  some  parts  of  Russia,  and  the  Russian  phy¬ 
sicians  had  declared  that  its  ravages  had  been 
principally  owing  to  the  inordinate  abuse  of 
spirituous  liquors  by  the  people. 

CHOLERA  IN  EGYPT. 

By  letters  from  Alexandria,  dated  August 
1st,  it  appears  that  the  cholera  has  broken 
out  throughout  all  Egypt,  with  more  or  less 
intensity.  It  made  its  appearance  about  the 
middle  of  last  month  in  a  town  of  the  Delta, 
called  Tantah,  where  an  immense  number  of 
people,  amounting  to  about  165,000,  were 
assembled  in  pilgrimage  from  all  parts  of 
Egypt  and  Syria  to  celebrate  the  festival  of 
a  Mahomedan  saint.  In  Cairo,  during  the 
last  week,  there  have  been  about  300  cases 
daily;  here,  about  120  ;  in  most  of  the  vil¬ 
lages  on  the  Nile  there  are  daily  cases  :  and 
it  is  much  feared  that  the  number  will  ma¬ 
terially  increase  during  the  present  month 
of  Ramadan,  which  began  yesterday,  when 
the  natives  fast  all  day,  and  commit  excesses 
during  the  night.  Before  the  people  dis¬ 
persed  at  Tantah,  it  is  said  that  there  must 
have  been  upwards  of  3,000  deaths  from  this 
disease. 

UNIVERSITY  OF  LONDON. - FIRST  EXAMI¬ 

NATION  FOR  THE  DEGREE  OF  BACHELOR 

OF  MEDICINE. 

First  division. — William  Ayre,  London 
Hospital ;  E.  Enfield  Barron,  Guy’s  Hospi- 


350 


CASE  OF  ALLEGED  RAPE 


tal ;  J.  Syer  Bristowe,  St.  Thomas’s  Hospi¬ 
tal  ;  E.  W.  A.  Day,  Queen’s  College,  Bir¬ 
mingham  ;  Robert  Growse,  Guy’s  Hospital; 
W.  M.  G.  Hewitt,  University  College  ; 
Edward  Jackson,  University  College;  J. 
Henry  Lakin,  King’s  College ;  R.  Benson 
Lewis,  Leeds  College  of  Medicine;  Edmund 
Manley,  Royal  Manchester  School  of  Medi¬ 
cine  ;  J.  Arthur  Payne,  King’s  College  ; 
James  Rigby,  University  College  ;  William 
Ryan,  Middlesex  and  Jervis-street  Hospital; 
H.  Hyde  Salter,  King’s  College ;  S.  J.  A. 
Salter,  King’s  College;  C.  J.  Shearman, 
University  College  ;  W.  H.  Thornton,  Royal 
Manchester  School  of  Medicine;  John 
Wood,  King’s  College. 

Second  division. — G.  H.  Bailey,  Univer¬ 
sity  College;  A.  H.  Hassall,  Royal  College 
of  Surgeons  in  Ireland  ;  Thomas  Jeston, 
King’s  College;  H.  Smyth,  Locock,  St. 
Thomas’s  Hospital;  R.  Deverell  Pyper, 
Middlesex  Hospital  ;  J.  R.  Reynolds,  Uni¬ 
versity  College  ;  Francis  Sibson,  University 
of  Edinburgh ;  Henry  Welsh,  King’s  Col¬ 
lege  ;  John  Wilkins,  King’s  College. 


^elections  from  journals. 


FORENSIC  MEDICINE. 

A  CASE  OF  ALLEGED  RAPE,  TRIED  IN  THE 
ST.  LOUIS  CRIMINAL  COURT.  BY  CHARLES 
W.  STEVENS,  M.D. 

A  young  man,  by  the  name  of  M‘Comas, 
was  charged  with  an  attempt  to  violate  the 
person  of  Mary  Young,  a  child  about  nine 
jmars  of  age.  The  testimony  went  to  show, 
that  the  prisoner,  at  two  different  times,  had 
taken  the  girl  upon  his  lap  and  raised  her 
clothing.  At  one  time  this  occurred  in 
M'Comas’s  private  room,  and  again  when 
they  were  riding  in  a  buggy.  In  both  in¬ 
stances  the  girl  sat  sideways  upon  his  lap. 
The  mother  discovered  stains  upon  the 
drawers  of  the  child,  resembling  those  made 
by  seminal  fluid.  She  charged  the  daughter 
with  having  permitted  some  man  to  meddle 
with  her.  When  threatened  with  chastise¬ 
ment,  she  gavethe  name  of  M'Comas.  The 
mother  examined  the  private  parts,  and 
found  them  inflamed,  and  discharging  mat¬ 
ter,  the  discharge  still  existing  [a  period  of 
several  weeks].  A  respectable  medical  gen¬ 
tleman  of  the  city  wTas  called  to  the  case 
immediately  after  the  disease  was  discovered 
by  the  mother.  He  examined  the  stains 
upon  the  clothing  ;  thought  they  might  have 
been  produced  by  seminal  fluid ;  was  not 
certain  that  such  was  the  case ;  stains  re¬ 
sembling  them  might  be  caused  by  other 


discharges ;  young  girls  were  subject  to  dis¬ 
eases  in  which  there  were  discharges  from 
the  genital  organs ;  found  the  nympbse  and 
orifice  of  the  vagina  in  a  state  of  inflamma¬ 
tion. 

I  was  called  to  visit  the  girl  about  eight 
days  after  the  gentleman  above  referred  to. 
I  did  not  see  the  clothing  or  the  stains  exa¬ 
mined  by  the  other  physician  ;  found  the 
labia,  nymphse,  and  orifice  of  the  vagina 
inflamed,  accompanied  by  a  muco-purulent 
discharge.  Visited  her  again  a  few  days 
after  ;  found  the  parts  still  inflamed,  and  the 
discharge  more  abundant,  and  mixed  with 
blood.  Saw  her  again  five  weeks  after  my 
first  visit;  the  inflammation  had  nearly 
subsided,  but  the  discharge  was  still  consi¬ 
derable,  and  somewhat  bloody  ;  Jound  the 
hymen  uninjured.  The  physician  regularly 
employed  by  the  prisoner,  testified  that  he 
had  not  been  called  upon  to  prescribe  for 
gonorrhoea.  In  the  above,  all  the  promi¬ 
nent  or  essential  points  of  the  testimony 
relating  to  the  facts  of  the  case,  are  fairly 
stated.  The  prisoner  was  sentenced  to  three 
years’  confinement  in  the  Penitentiary. 

Now,  whether  justice  has  been  done  to  the 
prisoner  in  this  instance  I  am  unable  posi¬ 
tively  to  say ;  but  I  was  forcibly  impressed 
with  the  truth  of  Sir  Matthew  Hale’s  re¬ 
mark  upon  this  crime,  when  he  says,  “  It  is 
an  accusation  easy  to  be  made,  and  harder 
to  be  proved,  but  harder  to  be  defended  by 
the  party  accused,  though  innocent.”  Tay¬ 
lor,  in  his  work  on  Medical  Jurisprudence, 
says,  “That  for  one  real  case  of  rape  there 
are  ten  pretended  cases.”  Our  works  on 
legal  medicine  abound  with  reports  of  cases, 
where  persons  have  been  unable  to  defend 
themselves  against  these  charges,  and  have 
suffered,  not  only  in  the  loss  of  reputation, 
but  by  imprisonment,  and  the  severest 
penalties  in  the  power  of  the  law  to  inflict ; 
and  yet,  after-developments  or  disclosures 
have  shown  them  to  be  innocent. 

The  case  of  M‘Comas  was  one  in  which 
but  little  positive  testimony  was  adduced. 
It  was  one  of  those  perplexing  cases  in  which 
nearly  all  the  witnesses,  especially  the  medi¬ 
cal  witnesses,  expressed  their  opinion  with 
the  greatest  caution  and  reserve  ;  and  this  of 
necessity,  because  unable  to  arrive  at  defi¬ 
nite  conclusions  upon  the  subject.  A  pro¬ 
minent  purpose  on  the  part  of  the  prosecu¬ 
tion,  after  failing  by  positive  testimony  to 
prove  connection  or  an  attempt  at  the  same, 
seemed  to  be,  to  convince  the  jury  that  the 
girl  was  affected  with  gonorrhoea  ;  and  it  was 
upon  this  point  the  case  hinged,  as  must 
have  been  apparent  to  all  who  attended  the 
trial.  In  fact,  I  was  so  informed  by  one  of 
the  jurors  after  the  decision.  If  it  had  been 
fully  established  that  Mary  Young  was 
affected  with  this  disease,  the  jury  would 


NEW  MODE  OF  RECLAIMING  HABITUAL  BRANDY  DRINKERS.  351 


certainly  have  had  better  reason  to  conclude 
that  the  prisoner  communicated  the  disease 
to  her.  The  jury  did  not  convict  M'Comas 
because  stains  were  found  upon  the  drawers 
resembling  those  made  by  seminal  fluid,  for 
the  child  had  at  this  time  a  discharge  from 
the  vagina  that  fully  accounted  for  the  stains  ; 
they  did  not  find  him  guilty  alone  upon  the 
testimony  of  the  child,  for  she  stated  that 
she  sat  upon  his  lap  sideways,  and  in  no 
other  manner.  The  jury  must  have  reasoned 
in  this  way  : — The  girl  sat  upon  the  lap  of 
M'Comas  ;  she  afterwards  was  attacked  with 
gonorrhoea  :  therefore,  he  attempted  to  com¬ 
mit  a  rape  upon  her,  and  the  charge  is  sus¬ 
tained. — Now,  leaving  out  of  view  the  fate 
of  the  prisoner,  as  well  as  the  justice  or  in¬ 
justice  of  the  verdict,  let  us  ask  the  ques¬ 
tion, — Can  any  physician,  in  a  case  like  this, 
guided  by  the  best  lights  in  the  profession, 
determine  with  such  certainty  as  to  enable 
him  to  testify  in  a  court  of  justice,  whether 
the  disease  be  gonorrhoea ,  or  vaginal  catarrh 
of  some  writers,  or  the  muco-purulent  dis¬ 
charge  which  young  girls  are  subject  to  from 
a  variety  of  causes  ? — Missouri  Medical  and 
Surgical  Journal ,  and  British  American 
Journal ,  May  1848. 

A  NEW  MODE  OF  RECLAIMING  HABITUAL 
BRANDY  DRINKERS. 

BY  DR.  SCHREIBER. 

This  plan  consists  in  confining  the  person 
treated  to  one  room,  and  giving  him  brandy 
in  all  his  drink,  whether  water  or  coffee,  and 
mixing  brandy  in  small  quantities  with  all 
his  food.  139  soldiers  were  treated  by  Dr. 
Ritzous,  at  Stockholm,  under  this  system. 
During  the  first  few  days,  from  five  to  seven, 
this  new  regimen  pleased  the  patients  much. 
They  were  in  a  state  of  continual  joyous  in¬ 
toxication.  The  pulse  became  full  and 
slow  ?  the  tongue  red  and  moist.  All 
complained  of  a  sense  of  burning  in  the  re¬ 
gion  ot  the  stomach.  The  stools  were  re¬ 
gular  ;  the  urine  red  and  scanty ;  the  skin 
moist.  The  pupils  were  neither  contracted 
nor  dilated.  About  the  end  of  the  fifth  or 
seventh  day,  the  excitement  of  intoxication 
ceased  ;  the  patient  came  to  himself,  but  was 
languid  and  silent.  The  sensation  of  burning 
in  the  stomach  became  more  acute,  and  was 
accompanied  by  inextinguishable  thirst.  The 
tongue  became  yellow  about  the  edges;  the 
stomach  could  take  neither  food  nor  drink, 
but  they  were  immediately  rejected  by  vomit¬ 
ing.  The  greater  number  gave  up  eating. 
The  pu:se  was  small,  weak,  and  trembling. 
At  the  end  of  from  two  to  four  days,  this 
state  disappeared  in  its  turn,  and  the  patient 
recommenced  eating  and  drinking.  Some 
were  again  attacked  with  intoxication  during 
six  or  eight  days ;  and  when  they  came  to 


their  reason,  they  always  preserved  an  in¬ 
vincible  repugnance  for  food  and  drink 
mingled  with  brandy.  In  six  of  the  men, 
slight  delirium,  which  disappeared  of  itself, 
remained  after  the  end  of  the  treatment. 

All  the  persons  thus  treated  were  care¬ 
fully  examined  by  medical  men  :  it  was  con¬ 
sidered  important  to  direct  attention  to  the 
thoracic  and  abdominal  organs,  and  to  in¬ 
quire  if  there  existed  no  disposition  to  apo¬ 
plexy  and  cerebral  congestion. 

The  duration  of  the  treatment  varied  from 
six  to  twelve  days  ;  for  some  it  required 
twenty  days,  including  the  time  required  for 
the  treatment  of  the  convalescence.  This 
consisted  in  a  new  regimen — substituted  for 
that  with  brandy,  which  had  produced  such 
an  aversion  that  even  its  odour  excited 
nausea.  At  first,  pure  water  was  given  in 
small  quantities,  then  milk,  or  gruel,  and,  by 
and  by,  other  kinds  of  food  were  also  given, 
but  always  in  small  quantity. 

The  treatment  was  suspended  in  seven 
individuals  :  in  two  owing  to  convulsions  j 
in  three  from  the  vomiting  of  blood  ;  in  one 
from  haemoptysis  ;  and  in  another  owing  to 
a  blow  received  by  the  patient  on  the  head. 

No  other  disagreeable  results  followed  the 
treatment:  indeed,  those  submitted  to  it 
appeared  to  enjoy  better  health  than  they 
had  previously.  One  only  was  attacked  by 
melancholy,  and  cured  by  laxatives. 

One  man  was  obliged  to  suspend  the 
treatment  on  the  sixth  day,  he  being  then 
threatened  with  cerebral  congestion  and 
symptoms  of  irritation  in  the  abdominal 
organs.  He  was  cured  by  cold  applications 
to  the  head,  and  purgation  with  castor  oil. 
When  he  recovered,  he  had  completely  lost 
his  taste  for  brandy. 

Of  the  whole  garrison,  139  men  were 
treated  on  this  plan  of  Schreiber — 128  were 
completely  reclaimed  from  drunkenness,  4 
relapsed,  and  7  were  obliged  to  suspend 
the  treatment.  The  greater  number  were 
from  20  to  25  years  of  age. 

In  this  mode  of  treatment,  strict  surveil¬ 
lance  on  the  part  of  a  medical  man  is  neces¬ 
sary.  Results  so  satisfactory  as  those  just 
recorded  cannot  be  always  expected :  re¬ 
lapses  may  take  place  after  apparently  the 
most  complete  recovery;  but  it  is  not  less 
certain  that  this  plan  of  treating  so  widely- 
spread  and  ignoble  a  vice  merits  all  the 
attention  of  the  physician. — L’  Union  Medi¬ 
cate.  2 

***  There  is  another  point  which  it  may 
be  as  well  to  consider  in  adopting  this  sin¬ 
gular  method  of  treating  drunkenness,  viz. 
whether,  if  death  should  ensue  from  it,  the 
practitioner  might  not  have  to  answer  a 
charge  of  poisoning  by  alcohol. 


352  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY,  ETC 


BIRTHS  &  DEATHS  in  the  Metropolis 


The  following  is  a  selection  of  the  numbers  of 
Deaths  from  the  most  important  special  causes: 


During  the  week  ending  Saturday,  Aug.  19 

Births 


Males 
Females. . 


668 

619 

1288 


Deaths. 
Males ....  506 
Females..  513 


1019 


Av.  of  5  Sum. 
Males ....  495 
Females..  477 

972 


(34  in  number;  —  Registrars ’  Districts,  129. 
Population,  in  1841,  1,915,104.) 

West— Kensington;  Chelsea;  St.  George, 
Hanover  Square;  Westminster;  St.  Martin 
in  the  Fields;  St.  James  ..  (Pop.  301,326)  145 
North  — St.  Marylebone  ;  St.  Pancras  ; 
Islington  ;  Hackney . (Pop.  366,303)  192 

Central— St.  Giles  and  St.  George;  Strand; 
Holborn;  Clerkenwell ;  St.  Luke;  East 
London  ;  West  London ;  the  City  of 
London  . (Pop.  374,759)  188 

East— Shoreditch ;  Bethnal  Green  ;  White¬ 
chapel;  St.  George  in  the  East;  Stepney ; 
Poplar . (Pop.  393,247)  208 

South  — St.  Saviour;  St.  Olave  ;  Ber¬ 
mondsey  ;  St.  George,  Southwark  ; 
Newington;  Lambeth;  Wandsworth  and 


Causes  of  Death. 

All  Causes . 

Specified  Causes . 

1.  ^3/7«ofic(orEpidemic,Endemic. 

Contagious)  Diseases . . 
Sporadic  Diseases,  viz. — 


tain  seat  . . 
Irain,  Spinal 
and  Senses 


Respiration . 

5.  Heart  and  Bloodvessels _ 

6.  Stomach,  Liver,  and  oth 

Organs  of  Digestion  . 

7.  Diseases  of  the  Kidneys,  &c. 

8.  Childbirth,  Diseases  of  t! 

Uterus,  &c . 

9.  Rhematism,  Diseases  of  tl 
Bones,  Joints,  &c . 

10.  Skin,  Cellular  Tissue,  &c . 

11.  Old  Age . 

12.  Violence,  Privation,  Cold,  and 


479,469)  286 

. .  1019 

Av.  of 

5  Sum. 

1019 

972 

999 

968 

384 

257 

35 

45 

109 

120 

80 

80 

28 

28 

75 

79 

11 

8 

1  5 

10 

5 

7 

0 

1 

29 

1  * 

50 

1  27 

8 

Small-pox  .  32 

Measles  .  9 

Scarlatina  . 115 

Hooping-cough..  18 

Diarrhoea  .  81 

Cholera  .  17 

Typhus  .  61 

Dropsy .  15 

Sudden  deaths  . .  5 

Hydrocephalus..  27 
Apoplexy .  21 


J  Paralysis .  20 

|  Convulsions  ....  35 

Bronchitis .  22 

Pneumonia .  34 

Phthisis . 107 

Dis.  of  Lungs,  &c.  12 

Teething .  16 

Dis.  Stomach,  &c.  5 
Dis.  of  Liver,  &c.  10 

Childbirth .  3 

Dis.ofUterus,&c.  2 


Remarks. — The  total  number  of  deaths  was 
47  above  the  weekly  summer  average. 


METEOROLOGICAL  SUMMARY. 

Mean  Height  of  Barometer .  2975 

“  “  Thermometer1  .  59‘ 

Self-registering  do.b - max.  91’  min.  38’8 

“  in  the  Thames  water  —  63-  —  61* 

a  From  12  observations  daily.  b  Sun. 

Rain,  in  inches,  0-91 :  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological. — The  mean  temperature  of  the 
week  was  2’6°  below  the  mean  of  the  month. 


BOOKS  received  during  THE  WEEK. 

The  Hand  plirenologically  considered. 

The  Vegetarian  Advocate,  late  Truth-tester, 
No.  1. 

Continental  Travel:  with  an  Appendix  on  the 
Influence  of  Climate,  &c.  By  Edwin  Lee,  Esq. 
Comptes-rendus,  Nos.  5,  6,  Juillet  31  &  Aoflt  7. 
Casper’s  Wochenschrift,  29.  Juli. 


NOTICES  to  CORRESPONDENTS. 

R.  R. — Dr.  West’s  Lectures  are  now  completed, 
and  they  will  shortly  be  published  in  a  dis¬ 
tinct  volume.  Dr.  Watson’s  Course,  as  pub¬ 
lished  in  this  journal,  consists  of  88  Lectures. 
They  will  be  found  in  Vol.  27  to  Vol.  30  inclu¬ 
sive. 

I)r.  Snow’s  paper,  in  continuation,  has  been 

TGCGi  VG(1. 

C.  A. — A  note  wrill  be  sent,  and  the  papers  re¬ 
turned. 

Received.— Beta. 


THE  GEBJE51AX*  IHBEX. 

We  have  to  announce  to  onr  Subscribers  that  a  General 
Index  to  the  jirst  40  Volumes  of  the  London  Medical  Gazette 
will,  it  is  calculated,  form  a  large  Yolume  of  about  700  pages. 
The  cost  of  the  Index  Yolume,  respecting  which  many  inquiries 
have  been  made,  will  be  Twenty-four  Shillings ;  and  it  is  proposed 
to  commence  it  so  soon  as  the  Names  of  Five  Hundred  Subscribers 
have  been  obtained. — The  printers,  Messrs.  M  ilson  and  OgilVY, 
57,  Skinner  Street,  will  receive  the  Names  of  Subscribers. 


ftotftion  iHttfical  <£5a|fftf. 


Sefturcs. 


COURSE  OF  SURGERY, 
Delivered  in  the  years  1846  and  1847, 

By  Bransby  B.  Cooper,  F.R.S. 

Surgeon,  and  Lecturer  on  Surgery  at  Guy’s 
Hospital. 


Lecture  XXXYI. 

surgery  of  regtons — continued. 
Continuation  of  abdominal  region — epigas¬ 
tric  region — abscess  of  liver — distension 
of  gall-bladder.  Scirrhusof  the  pylorus 

—  case.  Aneurismal  tumors  —  hyper¬ 
trophy  of  the  spleen — case.  Adhesions 

between  duodenum  and  liver.  Umbilical 
region — urinary  discharge  from  umbili¬ 
cus — case — umbilical  tumors.  Obstruc¬ 

tion  in  the  intestines — its  causes — surgi¬ 
cal  operation  for  relief  of — question  as  to 
its  admissibility .  Abscess  in  the  lumbar 
region  —  case.  Hypogastric  region  — 
surgical  importance — disease  of  the  sig¬ 
moid  flexion  of  the  colon.  Inguinal  ca¬ 
nals — their  liability  to  morbid  changes — 
arrest  in  descent  of  testicle — anomalous 
symptoms — cases.  Varicocele —  treat¬ 

ment.  Hydrocele  of  spermatic  cord — 
difficulties  in  diagnosis  —  treatment. 
External  iliac  artery  tied  in  this  region. 
Pubic  region  —  removal  of  diseased, 
ovaria — greater  and  minor  operations — 
comparative  danger — puncturing  urinary 
bladder.  High  operation  for  stone. 

I  have  hitherto,  gentlemen,  directed  your 
attention  to  the  pathological  considerations 
resulting  from  lesions  occurring  from  without 
to  within — that  is,  from  the  parietes  towards 
the  cpity  of  the  abdomen  ;  but  there  are 
many  diseases  which  take  their  rise  within 
the  cavity  itself :  these  sometimes  require 
surgical  as  well  as  medical  treatment ;  and 
you  will  find  that  in  them,  as  well  as  in  cases 
of  injury  from  external  violence,  the  strict 
observance  of  the  system  of  regional  division 
will  afford  very  great  facility  in  forming  your 
diagnosis. 

In  the  epigastric  region,  for  instance,  tu¬ 
mors  are  often  formed,  the  true  character  of 
which  must  be  judged  of  rather  by  the  dis¬ 
turbance  they  cause  in  the  I  unctions  of  the 
important  organs  contained  in  this  part,  than 
by  the  physical  constitution  of  the  tumor 
itself.  A  fluctuating  tumor  may,  for 
example,  present  itself  in  the  right  hypo¬ 
chondriac  region  concomitantly  with  great 
disturbance  to  the  functions  of  the  liver  ;  and 
in  such  a  case  it  would  be  almost  impossible, 
without  strictly  investigating  the  history  of 

xlii.— 1083.  Sept.  1,  1848. 


353 


the  complaint  from  the  very  first  symptom, 
to  distinguish  a  distended  gall-bladder  from 
an  abscess  in  the  liver.  If,  under  these  cir¬ 
cumstances,  a  mistake  should  be  made,  and 
the  gall-bladder  be  punctured  instead  of  an 
abscess,  there  would  be  great  risk  of  extrava¬ 
sation  of  bile  into  the  peritoneal  cavity, 
which  would  be  certain  destruction  to  the 
life  of  the  patient. 

It  is  not  my  province  to  detail  to  you, 
gentlemen,  the  symptoms  in  cases  of  this 
kind  ;  but  I  feel  it  right  to  warn  you  against 
surgical  interference  in  them,  as  it  may  lead 
to  the  most  unfortunate  results.  Another 
description  of  tumor  is  sometimes  formed  in 
this  locality,— it  is  situated  just  at  the  junc¬ 
tion  of  the  scrobiculis  cordis  with  the  right 
hypochondriac  region,  and  can  generally  only 
be  felt  by  pressing  the  finger  upon  it  with 
some  force,  the  pain  being  at  the  same  time 
greatly  aggravated  by  the  pressure.  This 
tumor  is  usually  attended  by  vomiting, 
which  takes  place  an  hour  or  two  after  eat¬ 
ing,  and  is  sometimes  accompanied  by 
pyrosis. 

The  patient  is  generally  past  middle  life 
when  the  disease  manifests  itself,  and  he 
complains  more  of  emaciation  than  of  posi¬ 
tive  suffering  :  this  is  scirrhus  of  the  pylo¬ 
rus — an  affection  which  invariably  proves 
fatal.  On  the  day  of  the  coronation  of 
George  IV.  Sir  Astley  Cooper  and  myself 
were  in  the  house  of  a  lady  to  witness  the  pro¬ 
cession,  and  while  standing  at  the  window, she 
cursorily  mentioned  to  Sir  Astley  that  she 
always  broughtherfood  off  her  stomachabout 
an  hour  and  a  half  after  she  had  eaten.  Sir 
Astley  requested  her  to  allow  him  to  ex¬ 
amine  her,  and,  when  after  being  absent  a 
few  minutes,  he  returned  to  me,  he  said, 
“  Mrs.  C.  will  not  be  alive  this  day  three 
months. ”  Before  that  period  had  elapsed, 
she  was  dead.  Such  a  case,  you  will  imagine, 
could  not  come  frequently  under  the  notice 
of  the  surgeon,  but  at  the  same  time  it  is 
quite  necessary  that  you  should  know  some¬ 
thing  of  the  physical  characters  of  the  dis¬ 
ease,  in  order  that  you  may,  from  the  recital 
of  certain  symptoms,  be  able  to  perform, 
those  examinations  upon  which  your  diag¬ 
nosis  is  to  be  founded. 

Aneurismal  tumors  are  not  unfrequent  in 
the  epigastric  region,  and  they  may  so  far 
interfere  with  the  functions  of  the  stomach 
as  to  induce  the  supposition  that  that  organ 
was  the  subject  of  disease.  Its  disorder  is, 
however,  only  secondary,  proceeding  from 
the  existence  of  the  tumor  :  hence  it  becomes 
of  the  highest  importance  to  make  the  most 
minute  and  careful  examination,  when 
such  anomalous  symptoms  present  them¬ 
selves.  In  the  left  hypochondriac  region,  a 
large  tumor,  resulting  from  hypertrophy  of 
the  spleen,  sometimes  presents  itself  :  this 
is  a  condition  which  often  follows  protracted 


,354  ANEURISMAL  TUMORS - HYPERTROPHY  OF  THE  SPLEEN. 


intermittent  fever,  and  it  interferes  materially 
■with  the  functions  of  both  the  stomach  and 
liver:  this  is  not  to  be  wondered  at,  when 
we  consider  that  the  spleen,  stomach,  and 
liver,  all  derive  their  blood  from  the  same 
branch  of  the  aorta.  Cases  have  occurred 
in  which  the  spleen  has  become  separated 
from  its  attachment  to  the  diaphragm  and 
stomach,  and  even  descended  as  low  as  the 
left  iliac  region.  The  late  Dr.  Babington 
has  described  a  case  of  this  kind,  which  oc¬ 
curred  in  his  practice.  Enlargement  of  the 
spleen  is  not,  however,  so  frequent  a  disease 
as  is  supposed,  and  encysted  tumors  of  the 
ovaria  are  sometimes  mistaken  for  it.  I  re¬ 
member  being  once  present  in  consultation 
with  Sir  Astley  Cooper  and  Sir  Charles 
Clarke,  on  a  case  of  ovarian  dropsy, 
wherein,  after  I  had  drawn  off  the  fluid, 
Sir  Astley  Cooper  directed  our  attention  to 
a  large  tumor,  which  was  particularly  dis¬ 
tinguishable  from  the  flaccid  state  of  the  ab¬ 
dominal  parietes.  Sir  Astley  remarked, 
that  he  had  never  before  seen  the  spleen  so 
completely  retain  its  form  under  such  a  great 
increase  of  size.  Sir  Chas.  Clarke  replied, 
that  he  did  not  believe  it  to  be  the  spleen,  as 
he  had  never  known  that  viscus  to  be  en¬ 
larged  in  ovarian  dropsy.  About  six  weeks 
after,  the  patient  died,  and  a  post-mortem 
examination  shewed  Sir  Charles  Clarke’s 
opinion  to  be  correct,  as  the  tumor  consisted 
of  an  abnormal  growth  from  the  diseased 
ovarium.  I  mention  this  case,  gentlemen,  as 
I  consider  it  illustrative  of  a  very  important 
fact  connected  with  the  pathology  of  ovarian 
disease. 

In  obstinate  cases  of  jaundice,  deeply- 
seated  tumors  are  sometimes  formed  in  the 
epigastrium,  generally  in  the  neighbourhood 
of  the  junction  of  the  cartilages  of  the 
seventh  and  eighth  ribs.  The  tumors  are 
not  unfrequently  the  result  of  adhesion  be¬ 
tween  the  duodenum,  the  liver,  and  Glisson’s 
capsule,  interfering  with  the  passage  of  the 
bile  from  the  liver  to  the  duodenum.  When 
the  patient  presents  a  greenish-coloured  com¬ 
plexion,  I  always  suspect  that  the  pancreas 
is  involved  in  the  disease,  and  then  examine 
this  region  with  great  care,  to  ascertain  if 
there  be  any  perceptible  enlargement  of  that 
organ. 

In  infancy  it  is  not  uncommon  for  a  uri¬ 
nary  discharge  to  take  place  from  the  um¬ 
bilicus,  in  consequence  of  the  open  state  of 
the  urachus  :  in  such  a  case  you  should  first 
ascertain  that  there  is  no  obstruction  to  the 
passage  of  the  urine  through  its  natural 
canal,  and  if  that  should  be  the  case,  as  fre¬ 
quently  happens  from  congenital  phymosis, 
the  cause  of  the  obstruction  should  be  re¬ 
moved,  and  then,  upon  gentle  pressure  being 
applied  to  the  umbilicus,  the  urachus  gene¬ 
rally  closes,  although  there  have  been  in¬ 


stances  in  which  the  defect  was  never  re¬ 
medied. 

Some  years  ago  I  admitted  a  patient  into 
Guy’s  Hospital  who  had  been  for  many 
years  suffering  from  stricture  of  the  urethra ; 
and  in  consequence  of  frequent  attacks  of 
retention  of  urine,  his  bladder  had  become 
so  much  enlarged  as  to  rise  into  the  umbili¬ 
cal  region.  From  the  history  of  the  case,  it 
appeared  that  during  one  of  these  attacks  he 
was  seized  with  peritonitis,  which  required 
the  adoption  of  prompt  antiphlogistic  means 
to  subdue  it ;  and  external  inflammation 
around  the  umbilicus,  with  a  deep-seated 
pain  in  the  bladder,  then  supervened.  In 
a  few  days  a  small  abscess  burst  in  the  um¬ 
bilicus,  and  urinous  discharge  followed  ;  in¬ 
deed,  when  he  was  admitted  into  the  hospi¬ 
tal,  he  passed  as  much  urine  by  the  umbi¬ 
licus  as  by  the  natural  passage. 

The  plan  I  adopted  for  his  relief  was  to 
fasten  an  elastic  gum  catheter  in  the  bladder, 
for  the  purpose  of  keeping  the  urine  con¬ 
stantly  flowing,  and  preventing  any  accumu¬ 
lation  in  the  bladder ;  but,  as  the  constant 
pressure  of  the  instrument  caused  great  pain 
and  irritation,  I  changed  my  plan,  and  or¬ 
dered  his  urine  to  be  drawn  off  four  times  a 
day  :  he  soon  became  expert  enough  to  do 
this  himself ;  when,  unfortunately,  the  ca¬ 
theter  one  day  broke  during  its  withdrawal,, 
and  a  third  of  its  length  was  left  within  the 
bladder.  Afresh  train  of  symptoms  resulted 
from  the  presence  of  this  foreign  substance 
and  after  trying,  unsuccessfully,  every  means 
I  could  think  of  for  its  removal,  I  was 
obliged  to  perform  an  operation  similar  to 
that  of  lithotomy  :  the  patient  readily  re¬ 
covered  ;  and  I  then  redirected  my  attention 
to  the  original  complaint,  which  remained 
unrelieved.  I  resumed  the  plan  of  frequently 
drawing  off  the  water,  and  proposed  to  en¬ 
deavour  to  close  the  opening  by  a  plastic 
operation  :  this  was  consented  to,  and  I 
performed  it  by  paring  the  edges  of  the  fis¬ 
tula,  and  drawing  over  a  portion  of  the 
neighbouring  skin,  which  was  accurately 
adapted,  and  firmly  secured  by  suture: 
peritoneal  inflammation  set  in,  however,  and 
the  patient  died.  This  case  is  not  only  re¬ 
markable  from  the  discharge  of  urine  through 
the  umbilicus  taking  place  without  any  con¬ 
genital  malformation,  but  it  is  also  important 
from  the  circumstance  of  peritoneal  inflam¬ 
mation  following  the  operation  itself,  or 
arising  from  the  irritative  influence  of  the 
sutures  :  at  the  same  time,  it  is  clear  that 
the  constitution  of  the  patient  had  not  been 
much  deteriorated  by  the  original  disease,  as 
the  operation  of  removing  the  catheter  from 
the  bladder  was  sustained  with  so  little  dis¬ 
turbance  to  the  general  health. 

Tumors  sometimes  form  in  the  region  of 
the  umbilicus,  from  protrusion  of  viscera ; 


TUMORS  IN  THE  UMBILICUS 


355 


these  tumors  constitute  what  are  termed  um¬ 
bilical  hernise.  A  general  distension,  with 
a  fixed  pain  in  the  umbilical  or  lumbar  re¬ 
gions,  may,  however,  result  from  some  ob¬ 
struction  within  the  intestinal  canal ;  such  a 
condition  produces  constipation  and  sick¬ 
ness,  and  it  is  only  from  the  local  tender¬ 
ness,  and  the  history  of  the  case  from  its 
commencement,  that  the  exact  seat  of  the 
disease  can  be  ascertained :  if  vomiting  be 
the  prominent  feature,  the  obstruction  may 
be  referred  to  the  small  intestines  ;  if  con¬ 
stipation  and  tympanitis,  with  slight  vomit¬ 
ing,  only  be  present,  the  obstruction  is,  in 
all  probability,  in  the  large  intestine :  in 
either  case,  if  the  symptoms  do  not  yield  to 
the  prescribed  remedies,  it  becomes  a  ques¬ 
tion  whether  abdominal  exploration  is  not 
•justifiable.  It  sometimes  happens  that 
the  small  intestines  become  strangulated 
by  a  band  of  lymph  thrown  out  from  the 
mesentery,  or  by  a  portion  of  one  intestine 
.passing  under  a  band  of  adherent  matter 
-connecting  two  other  portions  to  each  other  : 
nothing  but  the  liberation  of  this  constric¬ 
tion  can  restore  the  patient  to  health ;  but 
it  is  doubtful  whether  any  operation  is  ad¬ 
missible,  as  it  is  impossible  to  tell  the  exact 
point  at  which  the  obstruction  exists  ;  still, 
as  the  exploration  offers  the  only  chance  of 
relief,  we  ought  perhaps  to  be  careful  how 
we  hesitate  to  make  the  attempt.  The  ob¬ 
struction  may  also  occur  from  intus-suscep- 
tion  of  a  portion  of  intestine  ;  if  the  opera¬ 
tion  of  exploration  were  resorted  to  in  this 
defect,  there  would  not  only  be  the  difficulty 
of  discovering  the  point  at  which  it  existed, 
but  there  is  great  doubt  whether,  in  such  a 
protracted  case,  the  parts,  when  restored  to 
their  normal  form,  would  be  competent  to 
perform  their  natural  functions.  Even  if 
£be  operation  should  be  determined  on,  the 
greatest  difficulty  appears  to  me  to  lie  in 
deciding  as  to  the  proper  moment  at  which 
it  may-  be  performed  with  least  risk  ;  for, 
although  little  chance  of  a  successful  re¬ 
sult  exists  if  it  be  delayed  until  the  last 
moment,  yet  no  one  would  venture  upon 
it  while  there  remained  the  slightest  pro¬ 
bability  that  nature  might  herself  effect  the 
removal  of  the  obstruction.  When,  from  pro¬ 
tracted  constipation,  produced  by  obstruc¬ 
tion  in  the  large  intestine,  the  ascending  or 
descending  colon  becomes  distended,  the 
situation  of  the  obstruction  may  be  generally 
discovered  by  the  peculiar  dull  sound  given 
upon  percussion ;  the  dulness  being  below  if 
the  obstruction  be  in  the  ascending  colon, 
and  above  if  on  the  descending.  In  cases 
in  which  the  constipation  is  insuperable, 
the  colon  should  be  opened,  and  its  con 
tents  evacuated  by  establishing  an  artifi¬ 
cial  anus  in  the  loins.  This  operation  is 
performed  by  making  an  incision,  about 
three  inches  in  length,  between  the  last  rib 


and  the  ileum,  and  about  two  and  a  half 
inches  from  the  spinous  processes  of  the 
lumbar  vertebrae :  this  incision  is  to  cut 
through  the  skin  and  mass  of  lumbar  mus¬ 
cles,  so  as  to  expose  the  quadratus  lumborum 
muscle,  which  is  next  to  be  divided,  when 
the  internal  layer  of  the  fascia  lumborum 
will  be  exposed,  and  that  being  cut  through, 
the  colon,  uncovered  by  peritoneum,  would 
present  itself  to  view  :  the  intestine  may 
now  be  easily  opened,  when  its  contents  will 
be  evacuated. 

Some  surgeons  have  maintained  that  this 
operation  is  inadmissible,  owing  to  the  diffi¬ 
culty  of  its  performance  without  injury  to 
the  peritoneum  ;  but  I  am  disposed  to  be¬ 
lieve  that  this  danger  is  much  exaggerated, 
and  that  if  the  part  of  the  intestine  exposed 
be  the  exact  seat  of  obstruction,  and  that 
the  intestine  is  distended  to  its  utmost,  it 
may  be  easily  opened  without  risk  of  wound¬ 
ing  the  peritoneum,  as,  in  the  natural 
condition,  the  posterior  fifth  of  the  descend¬ 
ing  colon,  from  the  termination  of  the  arch 
to  the  crest  of  the  ileutn,  is  naturally  un¬ 
covered  by  peritoneum,  and,  when  ab¬ 
normally  distended,  a  much  larger  surface 
is  left  exposed.  My  colleague,  Mr.  Hilton, 
has  performed  this  operation  upon  subjects 
who  have  died  of  insuperable  constipation, 
in  consequence  of  obstruction  of  the  lower 
portion  of  the  colon,  and  found  no  difficulty 
whatever  in  opening  the  colon  between  the 
last  rib  and  the  ileum,  even  without 
experiencing  any  obstacle  in  avoiding 
the  peritoneum.  M.  Amussat  recom¬ 
mends  a  crucial  incision,  so  as  to  secure 
sufficient  room  for  a  more  complete  in¬ 
spection  of  the  bowel ;  but  such  a  precau¬ 
tion  seems  scarcely  necessary,  and,  at  all 
events,  should  not,  I  think,  be  l’esorted  to 
unless  it  appears  requisite  as  the  operation, 
advances.  It  has  also  been  said  that  there 
is  some  difficulty  in  recognising  the  bowel 
even  when  it  is  really  exposed  ;  but  I  cannot 
understand  how  such  a  difficulty  can  occur  ; 
for  in  the  space  between  the  last  rib  and  the 
ileum,  and  anterior  to  the  quadratus  lum¬ 
borum  muscle,  nothing  but  colon  can  pre¬ 
sent  itself  to  view,  and  it  may  be  easily 
recognised  by  the  band  of  longitudinal  fibres 
which  are  exposed.  Some  caution  is  neces¬ 
sary  in  the  division  of  the  quadratus  lum¬ 
borum  itself,  which  should  be  carefully  dis¬ 
sected  through  almost  fibre  by  fibre,  to 
avoid  the  possibility  of  dividing  the  anterior 
layer  of  the  fascia  lumborum,  which  should 
not  be  cut  through  until  it  is  perfectly  ex¬ 
posed  by  the  removal  of  the  muscle  or  the 
fascia  constituting  the  precise  boundary  to  the 
cavity  of  the  abdomen,  so  that  it  furnishes 
an  infallible  means  of  recognising  the  precise- 
point  to  which  the  operation  has  advan.^d  $ 
and,  upon  laying  it  open,  nothing  hui  coloiqp 
can  be  spen,  pmlgssj  ipdep<I,  tjie  fchjney 


356  THE  HYPOGASTRIC  REGION — ITS  SURGICAL  IMPORTANCE. 


occupied  the  space,  which  could  only  be  the 
result  of  disease  in  that  viscus.  M.  Baudens 
considers  that  he  has  arrived  at  a  certain 
mode  of  distinguishing  the  colon  from  the 
kidney  when  a  doubt  arises,  his  plan  being 
the  introduction  of  a  very  small  trocar  or 
canula,  which,  if  penetrating  the  colon, 
would  lead  to  the  escape  of  gas,  and  the 
soiling  of  the  instrument  with  faeces  ;  while, 
if  the  kidney  were  punctured,  blood,  per¬ 
haps  mixed  with  urine,  would  flow  from  the 
canula.  The  treatment  of  the  artificial  apus 
is  the  same  in  this  as  in  other  cases  in  which 
it  may  be  be  formed. 

As  the  obstruction  in  the  colon  usually 
results  from  malignant  disease,  the  opera¬ 
tion  can  only  act  as  a  palliative  ;  but  the 
prolongation  of  life  even  for  a  few  months 
would  be  a  sufficient  boon  to  warrant  its 
being  undertaken.  Abscesses  in  the  loins 
may  sometimes  require  to  be  opened  in  this 
region  :  they  may  be  produced  by  disease  of 
the  spine,  and  then  constitute  what  are 
termed  lumbar  abscess,  or  they  may  arise 
from  the  kidneys.  I  once  saw  Sir  Astley 
Cooper  open  an  abscess  in  the  loins,  and 
remove  from  it  a  urinary  calculus,  which, 
from  the  history  of  the  case,  had  no  doubt 
passed  from  the  kidney  or  ureter  by  the 
process  of  ulceration,  the  stone  acting  as  an 
extraneous  body  in  the  surrounding  tissues. 

The  hypogastric  region. — This  is  perhaps 
more  frequently  the  subject  of  surgical  ope¬ 
rations  than  any  other  region  of  the  abdo¬ 
men  :  it  contains  the  ileum,  which  intestine, 
owring  to  its  slight  attachment  by  means  of 
the  mesentery,  as  well  as  from  the  existence 
of  the  natural  outlets  through  the  parietes  of 
this  portion  of  the  abdomen,  is  very  subject 
to  protrusion  :  it  also  contains  the  termina¬ 
tion  of  the  ileum,  with  its  somewhat  com¬ 
plicated  apparatus  in  the  right  iliac  region, 
and  the  termination  of  the  sigmoid  flexion  of 
the  colon  in  the  rectum,  on  the  left  iliac 
region,  in  both  which  localities  these  viscera 
often  become  the  seat  of  disease.  The 
urinary  bladder  and  part  of  the  internal 
organs  of  generation  occupy  the  pubic  re¬ 
gion,  and  these  often  require  surgical  opera¬ 
tions  for  the  relief  of  the  diseases  to  which 
they  are  subject.  The  lesions  which  so 
frequently  occur  at  the  termination  of  the 
ileum  in  the  caecum,  in  consequence  of  the 
disorganization  cf  the  ilio-colic  valve,  often 
lead  to  an  affection  termed  “  ileus,”  which 
requires  similar  treatment  to  that  described 
as  necessary  in  protracted  constipation  from 
disease  in  other  parts  of  the  colon.  This 
is,  however,  more  dangerous,  as  the  small 
intestines  are  implicated.  The  disease  may 
be  distinguished,  from  the  circumstance  of 
the  pain  being  constantly  referred  to  one 
spot  in  the  right  iliac  fossa,  where  a  fulness 
may  generally  be  felt. 

Although  but  little  is  known  of  the 


natural  function  of  the  vermiform  process 
of  the  csecum,  it  is  proved  beyond  question 
that  any  alteration  in  its  organization  pro¬ 
duces  great  disturbance  throughout  the 
whole  length  of  the  colon.  The  intrusion 
of  foreign  bodies, — its  adhesion  by  any 
process  of  inflammation, — its  protrusion 
from  its  natural  cavity,  so  as  to  form  a 
hernial  tumor, — all  produce  very  urgent 
symptoms,  of  which  the  immediate  cause  is, 
however,  discovered  with  great  difficulty,  as 
the  symptoms  are  all  referrible  to  the  altered 
action  of  the  colon,  in  which  disease  from 
any  other  cause  would  produce  a  like  effect. 

In  the  left  iliac  fossa,  a  tumor  of  consi¬ 
derable  size  is  sometimes  formed  by  an 
accumulation  of  faeces  in  the  sigmoid  flexion 
of  the  colon.  This  accumulation  is  usually 
attended  by  pain,  and  by  enlargement  of  the 
veins  in  the  left  lower  extremity,  in  conse¬ 
quence  of  the  pressure  of  the  sigmoid 
flexure  of  the  colon  on  the  left  iliac  vein. 
In  such  cases,  copious  enemata  are  indicated, 
for  the  purpose  of  softening  the  indurated 
faeces,  and  castor  oil  may  be  prescribed  as 
the  best  purgative  for  emptying  this  portion 
of  the  intestines. 

Malignant  disease  often  attacks  the  colon 
at  the  point  of  its  termination  in  the  rectum. 
This  may  produce  so  determined  an  ob¬ 
struction  to  the  passage  of  the  ejesta,  as  to 
lead  to  the  necessity  for  opening  the  colon 
as  already  described. 

The  inguinal  canals  situate  in  this  region, 
and  which  contain  the  spermatic  cord  in  the 
male,  and  the  round  ligament  of  the  uterus 
in  the  female,  are  very  liable  to  abnormal 
changes,  which  require  some  acumen  on  the 
part  of  the  surgeon  to  ascertain  their  exact 
character.  The  most  frequent  of  these 
changes  consists  in  the  swelling  produced  by 
the  protrusion  of  an  intestine  ;  but  a  swelling 
may  also  occur  here  from  the  presence  of  a 
testicle  not  descended  into  the  scrotum, 
from  a  varicose  state  of  the  spermatic  veins, 
or  from  a  hydrocele  of  the  spermatic  cord  : 
each  of  these  cases  would  require  totally 
different  treatment,  and,  therefore,  it  be¬ 
comes  highly  necessary  to  diagnose  them 
correctly.  When  the  tumor  is  suspected  to 
arise  from  the  presence  of  a  testicle  in  the 
inguinal  canal,  its  absence  from  the  scrotum 
would  be  strongly  corroborative  of  the  accu¬ 
racy  of  the  supposition,  and  further  proof 
may  be  obtained  by  pressing  the  tumor, 
when,  if  a  sensation  be  felt  similar  to  that 
experienced  in  compressing  a  testicle  in  its 
normal  situation,  there  can  be  but  little  doubt 
of  the  true  character  of  the  swelling.  In  young 
people  the  most  anomalous  symptoms  some¬ 
times  arise  in  cases  of  non-descended  testicle. 
A  youth,  the  son  of  Colonel  R.,  was  brought 
to  me  suffering  from  symptoms  similar  to 
those  in  case  of  calculus  passing  along  the 
ureter.  I  prescribed  the  warm-bath  with  calo- 


PUBIC  REGION — REMOVAL  OF  DISEASED  OVARIA 


357 


mel  and  opium,  but  without  success.  I  then 
made  an  examination  of  his  abdomen,  and 
discovered  the  left  testicle  situated  within 
the  inguinal  canal,  close  to  the  external  ab¬ 
dominal  ring.  I  at  once  perceived  that  this 
condition  of  the  testicle  was  the  probable 
cause  of  the  constitutional  irritation,  and 
considered,  that  if  1  could  contrive  by  any 
means  to  ensure  its  descent,  I  should  be 
able  to  afford  immediate  relief  to  the  patient. 
For  this  purpose  I  had  an  instrument  con¬ 
structed  by  Mr.  Bigg  by  which  I  was  en¬ 
abled  to  keep  the  scrotum  elongated,  so  as 
to  produce  a  constant  tension  of  the  guber- 
naculum,  and  establish  a  tendency  to  draw 
the  testicle  downwards.  At  the  same  time 
I  placed  a  weak  truss  on  the  inguinal  canal 
above  the  testicle  ;  and  this  produced  a  good 
effect  in  two  ways,  preventing  the  descent 
of  the  intestine  into  the  inguinal  canal,  and 
also  pressing  the  testicle  downwards  towards 
its  normal  situation  :  this  plan  of  treatment 
proved,  indeed,  perfectly  successful,  and,  in 
the  course  of  a  fortnight,  the  testicle  had 
completely  descended,  and  the  patient  was 
entirely  relieved  from  the  symptoms  which 
had  previously  caused  him  so  much  distress. 

I  have  since  had  a  similar  ease  in  Guy’s 
Hospital,  the  result  being  equally  successful. 
In  that  instance,  however,  I  did  not  make 
use  of  any  mechanical  contrivance  to  keep 
the  gubernaculum  on  the  stretch,  but  drew 
and  kept  the  scrotum  down  to  the  thigh  by 
pieces  of  adhesive  plaister  only. 

A  varicose  state  of  the  veins  of  the  sper¬ 
matic  cord  within  the  inguinal  canal  pro¬ 
duces  many  physical  sign3  that  closely  re¬ 
semble  hernia  :  such,  for  example,  as  the 
facility  with  which  the  tumor  seems  to  recede 
into  the  abdomen  under  pressure ;  its 
diminution  in  size  when  the  patient  is  in  the 
recumbent  posture,  and  its  propulsion  on 
coughing  and  sneezing.  The  perfect  absence, 
however,  of  any  derangement  of  the  bowels, 
would  excite  a  doubt  as  to  such  being  a  her¬ 
nial  swelling,  and  the  diagnosis  may  readily 
be  determined  by  maintaining  pressure  on 
the  internal  ring.  After  the  tumor  has  been 
reduced,  if  it  be  hernia,  it  cannot  return,  but, 
if  varicocele,  as  the  pressure  prevents  the  re¬ 
turn  of  blood,  the  tumor  soon  reappears,  its 
size  increasing  according  to  the  firmness  of 
the  pressure,  and  the  length  of  time  it  is  kept 
up.  Hydrocele  of  the  spermatic  cord  within 
the  inguinal  canal  forms  a  tumor  which  may 
be  very  easily  mistaken  for  an  irreducible 
hernia.  I  have  known  surgeons  of  great  ex¬ 
perience  to  fall  into  this  error;  and,  indeed, 
unless  the  tumor  be  transparent,  it  is  only 
by  negative  indications  that  the  two  can  be 
distinguished  from  each  other  ;  the  absence 
of  any  functional  derangement  in  the  bowels, 
and  want  of  continuity  with  the  internal 
ring,  (it  being,  indeed,  perfectly  circum¬ 
scribed  and  isolated),  form  its  principal  dis¬ 


tinctive  characters.  Before,  however,  any 
curative  means  be  adopted,  it  would  be  a 
safe  course  to  explore  for  fluid  with  a  fine 
grooved  needle  :  if  it  be  proved  to  be  hydro¬ 
cele,  it  may  be  cured  by  introducing  a  seton 
of  one  thin  thread  of  silk,  or  by  that  which 
I  consider  a  safer  plan,  merely  laying  open 
the  sac,  evacuating  the  fluid,  and  applying 
the  pressure  of  a  slight  truss,  to  prevent  its 
accumulation. 

In  cases  of  wounds  or  aneurism  the  ex¬ 
ternal  iliac  artery  is  tied  in  this  region  :  it  is 
also  in  the  pubic  portion  of  the  hypogastric 
region  that  the  incision  is  made  for  the  re¬ 
moval  of  diseased  ovaria — an  operation 
which  of  late  years  has  come  much  into 
vogue.  Some  surgeons  recommend,  indeed, 
that  the  incision  should  reach  in  the  course 
of  the  linea  alba  nearly  from  the  ensiform 
cartilage  of  the  sternum  to  the  pubes.  I 
have  once  performed  this  operation,  and, 
although  no  untoward  circumstances  oc¬ 
curred  during  the  operation  itself,  the  pa¬ 
tient  sunk  in  a  few  days,  never  having,  in¬ 
deed,  rallied  from  the  depressing  influence 
apparently  induced  by  laying  open  the  epi¬ 
gastrium.  I  have  always  attributed  the 
dangerous  effects  to  the  exposure  of  this  re¬ 
gion,  as  during  the  whole  period  of  her 
suffering  the  patient  always  referred  the 
sensation  of  pain  and  sinking  to  it. 

“  The  minor  operation,”  in  which  the  dis¬ 
eased  ovarium  is  exposed  by  making  an  open¬ 
ing  of  threee  or  four  inches  in  length  be¬ 
tween  the  pubes  and  umbilicus,  is  in  my 
opinion  by  far  the  more  admissible.  I 
have  seen  it  performed  twice,  with  complete 
success,  by  Dr.  Frederick  Bird,  and  have  no 
doubt  that,  in  well-chosen  eases,  it  would 
often  prove  successful.  As  to  the  operation 
itself,  it  requires  but  little  manual  dexterity 
or  anatomical  knowledge,  but  in  the  pre¬ 
paration  of  the  patient,  and  after  treatment, 
the  greatest  judgment  is  requisite.  The 
chief  danger  does  not,  however,  appear  to 
arise  from  peritonitis  ;  for  either  the  perito¬ 
neum  has  undergone  such  change  from  the 
effect  of  the  disease,  or  the  impression  made 
by  the  operation  on  the  vital  powers  is  too 
severe  to  admit  of  the  usual  inflammatory 
action  supervening ;  and  in  unsuccessful 
cases,  the  patient  seems  to  sink  from  exti’eme 
prostration,  rather  than  from  increased 
arterial  action.  With  respect  to  this  opera¬ 
tion,  however,  we  are  not  yet  in  possession 
of  sufficient  data  as  to  the  result  of  those 
already  performed,  to  be  enabled  to  judge  of 
the  propriety  of  its  adoption. 

In  the  pubic  region,  the  urinary  bladder 
is  sometimes  punctured  with  a  trocar,  and  it 
is  in  this  locality  also  that  the  high  opera¬ 
tion  for  the  stone  is  performed.  These 
operations  will,  however,  be  descrioed,  when 
I  speak  of  the  region  of  the  perineum,  and 
of  the  urinary  and  genital  organs. 


8.58 


COLLECTION  OF  FACTS  ILLUSTRATIVE  OF 


Original  Communications. 


A  COLLECTION  OF  FACTS  ILLUSTRATIVE  OF 
THE 

MORBID  CONDITIONS  OF  THE 
PULMONARY  ARTERY. 

AS  BEARING  UPON  THE  TREATMENT  OF 
CARDIAC  AND  PULMONARY  DISEASES. 

By  Norman  Chevers,  M.D. 
Assistant -Surgeon,  Bengal  Array. 

[Continued  from  p.  278.] 


obstruction  to  the  pulmonary  artery 

consequent  upon  external  compres¬ 
sion. 

Like  the  aorta,  the  pulmonary  artery  and 
its  branches  are  occasionally  found  passing 
through  large  malignant  tumors  without 
having  the  slightest  appearance  of  having 
Been  injuriously  compressed  by  the  surround¬ 
ing  growth.*  Still  the  calibre  of  this  vessel 
is  liable  to  be  seriously  encroached  upon  by 
various  morbid  growths,  and  accumulations 
in  the  neighbourhood  of  the  heart — such  as 
pericardial  deposits,  large  fluid  effusions  into 
the  thoracic  cavities,  aneurism  of  the  aorta, 
&c.  The  following  cases  afford  interesting 
examples  of  these  rare  forms  of  obstruc¬ 
tion  : — 

An  instance  is  recorded  in  the  Dublin 
Journal  for  May,  1841,  in  which  extensive 
and  thoracic  effusion,  the  result  of  double 
pleurisy  suddenly  supervening  upon  chro¬ 
nic  bronchitis,  produced  so  much  com¬ 
pression  of  the  heart  as  to  render  it  pro¬ 
bable  that  death  had  resulted  from  complete 
■flattening  of  the  right  ventricle.  For  eighteen 
liours  previously  to  the  unfortunate  patient’s 
death  he  suffered  from  frightful  dyspnoea. 
The  state  of  the  pulmonary  valves  is  unfor¬ 
tunately  not  described. 

Compression  of  the  hose  of  the  right  ven¬ 
tricle  and  origin  of  the  pulmonary  artery 
by  an  aneurism  of  the  ascending  aorta. — 
About  eleven  years  since,  I  watched  the  case 
of  a  middle-aged  man,  who  was  admitted  to 
Guy’s  Hospital,  with  a  pulsating  aneurismal 
swelling  upon  the  left  side  of  the  sternum. 
He  suffered  from  haemoptysis  and  extreme 
dyspnoea,  and  died  in  about  a  week  after 
bis  admission.  Upon  examination,  a  large 
aneurismal  pouch  was  found  arising  from 
one  of  the  sinuses  of  Morgagni,  and  pressing 
forwards  the  base  of  the  ventricular  septum 

*  Dr.  Sims  relates  a  case  in  which  the  right 
division  of  the  artery  passed  through  a  malig¬ 
nant  tumor,  and  was  much  dilated,  but  retained 
its  texture.  Medico-Chirurgical  Transactions, 
vol.  xviii.  p.  290. 


in  such  a  manner  as  to  place  it  completely 
in  contact  with  the  outer  wall  of  the  right 
ventricle  :  in  this  way  the  orifice  of  the  pul¬ 
monary  artery  had  become  nearly  flattened. 
Anteriorly  this  was  completely  the  case  ;  the 
left  pulmonary  sygmoid  valve  had  become 
adherent  by  a  fibrinous  clot  to  the  most  pro¬ 
jecting  part  of  the  tumor.  At  the  parts 
where  the  compression  must  have  been 
greatest,  and  where  the  surfaces  must  have 
been  placed  completely  in  contact  with  each 
other,  the  endocardium  was  deeply  reddened, 
and,  in  parts,  coated  with  fibrinous  coagula. 
The  heart  is  preserved  in  the  pathological 
collection  at  Guy’s,  (numbered  147825). 

The  two  following  interesting  parallel 
instances  have  been  recorded  by  Dr.  Elliot- 
son  : — 

Owen  S.,  setat.  39,  had  been  ill  five  years. 
When  admitted,  he  had  ascites,  anasarcaof  the 
legs,  a  quick  and  rapid  pulse,  dyspnoea  and 
palpitation,  but  could  lie  doivn.  The  palpi¬ 
tation  and  dyspnoea  had  lasted  a  year.  The 
jugulars  and  other  veins  of  the  neck  were 
distended  to  a  great  degree.  On  applying 
the  stethoscope  to  the  right  side  of  the  heart, 
or  upon  the  sternum,  a  whizzing  sound 
(bruit  de  soufflet )  was  heard,  and  it  was  as¬ 
certained,  by  feeling  the  pulse,  that  this 
sound  was  synchronous  with  the  contraction 
of  the  ventricles.  The  principal  post-mor¬ 
tem  appearances  were  as  follow  : — The,  peri¬ 
cardium  was  adherent  to  the  heart,  and  con¬ 
tained  some  portions  of  cartilage  :  there  was 
a  cartilaginous  body  in  the  substance  of  the 
wall  of  the  right  ventricle,  where  the  pulmo¬ 
nary  artery  leaves  it,  and  the  artery  was  con¬ 
tracted  in  size  to  that  of  the  brachial,  there, 
and  for  some  inches  beyond. 

A  man,  setat.  60,  who  had  been  out  of 
health  some  months,  suffered  from  orthop- 
noea,  anasarca  of  the  arms,  thighs,  and  legs, 
considerably  increased  action  of  the  carotids 
and  radials,  and  distension  of  the  veins  of  the 
neck,  with  tenderness  of  the  epigastrium.  A 
loud  and  distinct  bruit  de  soufflet  was  heard 
at  the  upper  part  of  the  sternum,  at  the 
moment  when  the  ventricles  contracted,  prov¬ 
ing  that  the  obstruction  must  be  at  the  outlet 
of  one  of  those  cavities,  while  the  situa¬ 
tion  in  which  the  noise  was  heard,  and 
the  distension  of  the  veins  pointed  out 
the  right  as  the  one  implicated.  The 
only  material  differences  between  these  two 
cases  were,  the  circumstance  that  in  the 
former  the  patient  could  lie  down,  while  in 
the  latter  he  could  not,  and  the  increased 
action  of  the  carotid  and  radial  arteries  in  the 
latter.  On  examination,  the  pericardium 
was  found  adherent  to  the  surface  of  the 
heart  in  every  part ;  the  heart  itself  was 
enlarged  to  twice  its  natural  size,  and  its 
substance  was  very  much  softened,  and  .so 
changed  in  texture  as  almost  to  have  lost  its 
fibrous  appearance,  A  part  of  this  change 


THE  MORBID  CONDITIONS  OF  THE  PULMONARY  ARTERY.  359 


might  be  owing  to  the  decomposed  state  of 
the  body,  but  certainly  not  all  of  it.  The 
walls  of  the  cavities  were  thickened,  but  not 
in  proportion  to  the  increase  in  size  of  the 
whole  heart;  the  cavities  themselves,  and 
especially  those  on  the  right  side,  being 
much  dilated.  At  the  origin  of  the  pulmo¬ 
nary  artery ,  a  fibro-cartilaginous  structure, 
as  large  as  a  small  egg,  was  found  almost 
surrounding  the  artery,  which  was  so  much 
diminished  in  calibre  that  it  would  scarcely 
admit  the  little  finger  ;  beyond,  the  artery 
retained  its  usual  size.  There  was  also  found 
to  be  a  large  aneurism  of  the  aorta,  which 
had  burst.* 

Obliteration  of  the  right  pulmonary 
branch  by  an  aortic  aneurism. — The  col¬ 
lection  at  Fort  Pitt  contains  a  preparation 
taken  from  the  body  of  a  corporal,  about 
33,  who  died  of  phthisis  pulmonalis, 
in  which  the  right  branch  Of  the  pul¬ 
monary  artery  is  completely  closed  at  its 
origin  by  the  pressure  of  a  small  aneurism 
arising  from  the  concavity  of  the  aorta,  near 
its  base.  The  closure  .was  permanent  from 
adhesion.  The  inner  coat  of  the  pulmonary 
artery  contiguous,  had  lost  its  natural 
smoothness.  This  disease  of  the  vessels  was 
never  suspected  during  life,  the  symptoms 
being  only  those  of  ordinary  phthisisf. 

Congenital  narrowness  of  the  pulmonary 
artery. — Dr.  Barlow  has  described  a  highly 
interesting  class  of  cases  of  young  patients 
who  have  suffered  from  birth  from  an  im¬ 
perfectly  developed  condition  of  the  respira¬ 
tory  apparatus,  the  thorax  being  more  or  less 
narrow  or  deformed,  the  trachea  small,  and 
the  lungs  ill  expanded,  who,  at  or  about  the 
period  of  puberty,  are  liable  to  become  the 
subjects  of  grave  cardiac  symptoms ;  and 
eventually  to  die  from  the  effects  of  obstruc¬ 
tion  to  the  circulation.  In  such  cases  it  is 
generally  found  that  the  left  cavities  of  the 
heart  and  aorta  are  either  normal  in  size  or 
below  the  natural  capacity. %  The  right  cavi¬ 
ties  are  more  or  less  dilated  and  hypertro¬ 
phied,  while  the  pulmonary  artery  remains 
small,  and,  what  is  very  remarkable,  has 
occasionally  been  found  by  Dr.  Barlow  to 
be  really  below  its  usual  standard  capacity. 
This  obtains  so  long  as  the  vessel  remains 
healthy. 

I  have  myself  observed  a  fewr  instances 
in  which  the  right  ventricle  had  become 
hypertrophied  in  consequence  of  the  long 
obstruction,  and  in  which  the  pulmonary 
artery  remained  small,  independently  of  any 


*  Medical  Gazette,  vol.  x.  p.  221. 
t  Third  Fasciculus  of  Anatomical  Drawings 
selected  from  the  Collection  of  Morbid  Anatomy 
in  the  Army  Medical  Museum  at  Chatham. 
Plate  vi. 

t  In  some  cases  the  left  auricle  and  ventricle 
are  dilated,  while  the  aorta  remains  small,  al¬ 
though  free  from  any  traces  of  organic  disease. 


apparent  organic  fault  in  its  texture  ;*  but 
it  is,  undoubtedly,  far  more  usual  to  find 
this  vessel  more  or  less  dilated,  in  cases 
where  the  circulation  through  the  lungs  has 
been  long  and  severely  impeded. 

The  tissues  of  the  pulmonary  artery,  being 
naturally  far  more  extensible  than  are  those  of 
the  aorta,  probably  do  not  undergo  precisely 
the  same  changes  of  dilatation,  &c.,  coinci- 
dently  with  the  occurrence  of  hypertrophy  of 
the  right  ventricle,  as  do  the  structures  of 
the  aorta  under  parallel  circumstances.  The 
right  ventricle  appears  to  be  capable  of 
becoming  hypertrophied  before  the  pulmo¬ 
nary  artery  has  undergone  any  remarkable 
or  proportionate  dilatation  ;  and  this  may 
be  especially  the  case  in  those  instances 
where  (as  Dr.  Barlow  argues)  the  vessel  is 
small  from  originally  faulty  development. 
Should  the  patient’s  muscular  system  be 
weak  (as  usually  happens  in  this  class  of 
instances),  it  is  probable  that  the  ventricle 
will  also  become  dilated  before  a  similar 
change  occurs  in  the  artery  :  the  muscular 
tissue  of  the  former  depending  more  for  its 
tone  upon  nervous  influence  than  does  the 
elastic  fibrous  structure  of  the  other.  The 
presence  also  of  a  freely  acting  safety  valve 
on  the  right  side  of  the  heart,  and  a  healthy 
condition  of  the  abdominal  vessels,  will,  at 
the  commencement  of  these  cases,  have  con¬ 
siderable  influence  in  relieving  the  pulmonary 
artery ;  while,  on  the  contrary,  a  close 
tricuspid,  and  obstructed  abdominal  circu¬ 
lation,  would  tend  greatly  to  hasten  its  dila¬ 
tation.  It  must  also  be  borne  in  mind,  that 
in  cases  of  this  description  death  is  not 
generally  to  be  ascribed  to  the  mere  obstruc¬ 
tion  produced  by  the  imperfect  development 
of  the  pulmonary  apparatus,  but  that  it  is 
usually  caused  by  the  superaddition  of  a 
certain  amount  of  inflammatory  or  other  dis¬ 
ease  in  the  originally  defective  lungs,  which 
hastens  on  the  fatal  result  long  before  the 
heart  and  its  appendages  have  undergone 
those  changes  which  they  would  ultimately 
have  presented  had  life  been  considerably 
prolonged. 

It  is  therefore  not  to  be  considered  that 
the  instances  in  question  by  any  means  dis¬ 
prove  the  generally  prevailing  rule,  that 
obstruction  to  the  pulmonary  circulation  has 
uniformly  a  tendency  to  produce  dilatation 
of  the  afferent  vessel  of  the  lungs.  And  it 
is  of  course  almost  unnecessary  to  add  that 
they  do  not  in  the  slightest  degree  prove  that 
pulmonary  obstruction  can,  under  any  cir- 


*  This  has  not  merely  occurred  in  very  young- 
individuals  ;  in  the  case  of  the  middle-aged  man, 
the  state  of  whose  lungs  I  have  described  in  the 
chapter  on  pulmonary  apoplexy,  the  orifice  of  the 
pulmonary  artery  was  nearly  of  the  ordinary 
capacity,  although  some  of  its  branches  were 
greatly  obstructed  by  old  coagula.  The  heart 
was  hypertrophied,  and  the  aorta  somewhat 
dilated. 


860 


COLLECTION  OF  FACTS  ILLUSTRATIVE  OF 


cumstances,  have  a  tendency  to  produce 
a  diminution  in  the  capacity  of  this  artery. 

Dr.  Barlow  has  also  shewn  that  a  con¬ 
dition  of  parts  similar  to  that  described  in 
the  above  class  of  cases  may  result  from  the 
occurrence  of  adhesion  of  the  pericardium  at 
a  period  of  life  when  the  development  of 
the  thoracic  organs  is  still  incomplete.* * * §  I 
have  also  brought  forward  a  series  of  instances 
which  illustrate  the  fact,  that  complete  ad¬ 
hesion  of  the  pericardium,  occurring  in  adult 
life,  has  a  tendency  to  produce  diminution 
in  the  size  of  the  heart  and  its  vessels  in  all 
cases  where  there  is  no  valvular  disease,  and 
the  pulmonary  and  systemic  circulations 
remain  tolerably  free.f 

All  morbid  anatomists  are  now  acquainted 
with  the  fact,  that  in  the  majority  of  cases 
of  pulmonary  consumption  the  cavities  of 
the  heart  are  found  considerably  below  the 
ordinary  standard  capacity ;  and  that  the 
pulmonary  artery  and  aorta  usually,  to  a 
greater  or  less  degree,  partake  in  this  change. 

Pathologists  are  indebted  to  Dr.  P.  M. 
Latham  for  an  explanation  of  the  remarkable 
and  important  principle  upon  which  this 
adaptation  is  effected. %  It  is  observable 
that  in  the  larger  proportion  of  cases  of 
phthisis,  even  long  after  nearly  the  entire 
structure  of  both  Jungs  has  been  rendered 
irrespirable  by  solid  deposits  and  purulent 
excavations,  there  is  usually,  while  the  pa¬ 
tient  remains  unexcited  and  at  rest,  an 
almost  entire  absence  of  severe  dyspnoea. 
This  often  continues  even  up  to  the  period 
of  dissolution  :  the  patient  dying  from  hse- 
morrhage,  exhaustion,  cerebral  complication, 
— or,  in  fact,  from  almost  any  other  cause 
than  mere  suffocation.  This  is  shewn  to 
depend  upon  the  very  small  quantity  of 
blood  which  is  propelled,  at  each  systole  of 
the  contracted  right  ventricle,  through  the 
pulmonary  vessels,  as  well  as  to  the  rapidity 
of  its  transit  through  the  narrowed  cavities 
of  the  heart.  The  colliquative  sweats  and 
diarrhoea,  which  are  such  frequent  attendants 
of  the  later  stages  of  this  disease,  are  there¬ 
fore  not  to  be  regarded  either  as  processes 
which  are  wholly  injurious  to  the  system,  or 
as  altogether  dangerous  symptoms  which  it 
is  absolutely  necessary  to  repel  by  vigorous 
treatment  :  they  must,  on  the  contrary,  be 
viewed  as  the  principal  means  which  nature 
adopts  to  relieve  the  heart  and  lungs  from  a 
large  proportion  of  the  circulating  fluid — a 
relief  which  the  latter  organs  require,  not 
only  in  consequence  of  the  great  diminution 
of  their  aerating  surfaces,  but  also  on  ac¬ 
count  of  the  impaired  action  of  the  bronchial 
exhalents  which  is  usual  in  this  disease. § 

*  Guy’s  Hospital  Reports,  vol.  v.,  New  Series. 

f  Guy’s  Hospital  Reports,  vol.  i.,  New  Series. 

t  See  Lectures  on  Diseases  of  the  Heart,  Med. 
Gaz.,  vol.  iii. 

§  It  has  been  observed  by  one  of  our  leading 


It  is  doubtless  owing  to  a  similar  dimi¬ 
nution  in  the  bulk  of  the  circulating  fluid 
that  the  circulation  through  the  lungs  is 
usually  so  free  in  cases  of  malignant  disease 
of  those  viscera.  Large  masses  of  softening 
cancerous  deposit  are  occasionally  found 
occupying  very  extensive  portions  of  the 
pulmonary  structure  in  the  bodies  of  patients 
who  have  scarcely  been  at  all  subject  to 
dyspnoea,  and  even  in  cases  where  no  symp¬ 
tom  has  occurred  to  lead  to  the  recognition 
of  the  disease  during  life.  In  such  cases  as 
these  the  heart  ana  its  vessels  have  usually 
been  observed  to  have  adapted  themselves  to 
the  diminished  volume  of  the  blood. 

Narrowing  of  branches  of  the  ■pulmonary 
artery  in  the  vicinity  of  phthisical  cavities . 
— In  'extensive  tubercular  degeneration  of 
the  lung,  even  after  softening  and  suppura¬ 
tion  have  commenced,  it  is  often  singular  to 
observe  branches  of  the  pulmonary  artery,  of 
various  diameters,  passing  through  the  ap¬ 
parently  disorganised  iung,  their  interiors 
remaining  entirely  free  from  the  slightest 
discolouration  or  deposit,  although  the  canals 
have  evidently  been  in  some,  degree  en¬ 
croached  upon  by  the  surrounding  effused 
matters.  In  more  advanced  stages  of  dis¬ 
ease,  however,  when  phthisical  excavations 
have  become  completely  formed,  complete 
obliteration  of  the  arterial  tracts,  which  are 
thus  left  in  a  state  of  isolation,  generally 
occurs,  while  those  portions  of  the  closed 
arteries  which  intervene  between  the  point 
of  occlusion  and  the  nearest  pervious  branch 
undergo  a  remarkable  degree  of  contraction, 
which  leaves  them  in  the  condition  of  very 
narrow  conical  cul-de-sacs.  This  latter 
change  has  been  very  accurately  described 
by  Dr.  Bailie,  who  remarks,  that  when 
blood-vessels  are  traced  into  abscesses  of  the 
lungs,  he  has  found  them  very  much  con¬ 
tracted  just  before  they  reach  the  abscess, 
so  that  the  opening  of  their  extremites  has 
been  closed  up  entirely.  On  such  occasions 
it  will  require  a  probe  to  be  pushed  with  a 
good  deal  of  force,  in  order  to  open  again 


pathologists  that  he  regards  a  small  heart  as  a 
bad  coincidence  in  the  case  of  tuberculous  dis¬ 
ease,  adding,  that  he  would  rather  have  a  large 
heart  than  a  small  one  in  connexion  with  phthisis. 
—[Clinical  Remarks  on  a  case  of  Tabes  Mesen- 
terica,  by  Dr.  C.  J.  B.  Williams:  Med.  Gaz., 
vol.  xviii.,  p.  1490.]— I  cannot  but  venture  to 
prefer  the  doctrine  of  Latham  to  that  of  this  high 
authority.  It  will,  1  believe,  be  usually  observed 
that  in  cases  of  phthisis  where  the  heart  is  large 
the  respiration  has  been  proportionably  difficult, 
the  pulse  comparatively  slow,  and  the  patients 
to  a  greater  or  less  degree  subject  to  that  de¬ 
pression  of  spirits  irom  which  the  rapidity  of 
the  circulation  in  phthisis  usually  renders  the 
victims  of  this  hopeless  malady  so  providentially 
free.  The  condition  of  the  phthisical  heart  can¬ 
not  be  regarded  as  one  of  atrophy :  all  its  cavities 
are  usually  small  and  well  contracted;  and  the 
muscular  tissue  of  its  walls  is  firm,  and  well 
adapted  to  maintain  short  and  rapid  propulsive 
movements. 


THE  MORBID  CONDITIONS  OF  THE  PULMONARY  ARTERY. 


361 


their  extremities.  In  these  contracted 
vessels,  he  adds,  the  blood  is  coagulated  as 
it  is  under  similar  circumstances  in  other 
parts  of  the  body.  This  change  of  the 
blood-vessels  he  regarded  as  designed  to 
prevent  the  occurrence  of  large  haemor¬ 
rhages,  which  would  certainly  prove  almost 
immediately  fatal. 

My  own  observation  has  led  me  to  be¬ 
lieve,  with  Cruveilhier,  that  the  obliterated 
trunks  of  pulmonary  vessels  much  more 
frequently  form  the  principal  substance  of 
the  bands  which  traverse  the  cavities  of 
many  phthisical  excavations  than  the  state¬ 
ments  of  Laennec  and  Andral  would  lead  us 
to  suppose.  While  the  excavations  are  of 
moderate  size,  the  obliterated  arteries  are 
usually  seen  passing  across  the  cavities,  in 
the  form  of  greyish  cords,  covered  externally 
with  a  coating  of  pus,  fibrine,  and  particles 
of  tubercular  matter,  and  presenting,  on 
transverse  section,  a  close  grained  coagulum, 
having  the  appearance  of  soddened  glue, 
perfectly  identified  with  their  degenerated 
tissues,  and  completely  occluding  their 
canals.  These  obliterated  vessels  are  easily 
broken  across,  their  structures  having  lost 
their  tenacity  ;  and,  as  the  cavities  increase 
in  size,  the  isolated  portions  appear  to  be¬ 
come  removed  by  sloughing,  leaving  only 
rounded  extremities,  which  form  slight  ele¬ 
vations  on  the  sides  of  the  vomicae. 

It  appears  that  in  the  generality  of  chronic 
phthisical  excavations,  the  portions  of  ves¬ 
sels  which  pass  across  the  cavities  become 
perfectly  obliterated.  It  is  in  the  last  de¬ 
gree  improbable  that  any  artery  which  has 
long  remained  in  this  manner  completely 
isolated  should  ever  remain  sufficiently  per¬ 
vious  to  become  either  the  seat  of  aneurism 
or  the  source  of  haemorrhage.  So  far  as  I 
have  observed,  or  can  learn,  these  accidents 
are  only  liable  to  occur  in  vessels  which  are 
situated  upon  the  walls  of  cavities,  and 
which  are  not  completely  isolated.  Still,  it 
is  not  improbable  that,  where  the  excava¬ 
tion  is  very  rapidly  formed,  a  considerable 
tract  of  artery  may  become  detached  before 
the  process  of  obliteration  has  been  com¬ 
pleted,  and  may  then  either  suffer  perfora¬ 
tion  or  be  actually  separated  during  a  violent 
paroxysm  of  coughing,  as  is  described  to 
have  been  the  case  in  a  somewhat  marvel¬ 
lous  case  described  in  the  Ephemerides  Nat. 
Cur. 

[To  be  continued.] 


apothecaries’  hall. 

Names  of  gentlemen  who  passed  their  exa¬ 
mination  in  the  science  and  practice  of  medi¬ 
cine,  and  received  certificates  to  practise,  on 
Thursday,  August  24, 1848  : — William  John 
Player,  Swansea — William  Richard  Hilton, 
Whitehaven,  Cumberland. 


OBSERVATIONS  ON  THE 

TREATMENT  OF  HEMORRHOIDAL 
TUMORS, 

CONNECTED  WITH  RELAXATION  OF  THE 
MUCOUS  MEMBRANE  OF  THE  RECTUM. 

By  Henry  Lee,  Esa.,  F.R.C.S. 
Assistant-Surgeon  to  King’s  College  Hospital. 

[Continued  from  page  245.] 

In  the  application  of  nitric  acid  to  he¬ 
morrhoidal  tumors,  the  degree  of  irri¬ 
tation  experienced  will  often  depend 
upon  the  extent  of  surface  involved  in 
the  operation.  When,  therefore,  a  con¬ 
siderable  amount  of  the  mucous  mem¬ 
brane  descends  with  the  tumors,  it  is 
desirable  to  select  certain  portions  of 
it,  to  which  the  application  of  the  acid 
should  be  confined.  The  effect  of  the 
acid  may  be  regulated  either  by  apply¬ 
ing  very  small  quantities  of  it  at  a  time, 
or  by  shielding  the  surrounding  surface 
by  a  paste  made  of  chalk  and  water. 

Every  portion  of  mucous  membrane 
to  which  the  acid  extends  should  be 
as  completely  deprived  of  vitality  as 
possible,  since  the  degree  of  pain  ex¬ 
perienced  will  necessarily  depend  upon 
the  remaining  sensibility  in  the  parts. 

Unless  these  conditions  are  observed, 
the  application  of  nitric  acid,  or  of  any 
other  caustic,  to  the  mucous  membrane 
of  the  rectum,  may  prove  as  serious  an 
operation  as  that  for  which  it  is  in¬ 
tended  as  a  substitute. 

Case  Y. — Wm.  Perry,  ast.  33,  was 
admitted  into  St.  George’s  Hospital  on 
the  1st  of  September,  1847.  He  had 
suffered  much  from  the  usual  symptoms 
of  piles  for  twelve  years ;  and  his  health 
had  become  seriously  impaired  by 
repeated  and  copious  loss  of  blood 
from  the  rectum.  When  he  strained 
at  stool,  a  cluster  of  piles  presented 
themselves,  which,  together  with  a 
considerable  portion  of  mucous  mem¬ 
brane,  formed  a  mass  the  size  of  half 
an  orange.  A  fortnight  after  his  ad¬ 
mission  (the  bowels  having  been  pre¬ 
viously  opened  by  some  mild  laxative 
medicine)  the  strong  nitric  acid  was 
applied  to  the  tumors,  and  allowed  to 
extend  over  nearly  the  whole  of  the 
protruded  parts.  He  experienced  con¬ 
siderable  pain  at  the  time  of  the  opera¬ 
tion  ;  and  a  few  hours  afterwards  had 
a  slight  rigor.  The  night  following  he 


362  MR.  LEE  ON  THE  TREATMENT  OF  HEMORRHOIDAL  TUMORS. 


was  kept  awake  by  pain  in  the  rectum, 
which  he  also  experienced  occasionally 
during  the  next  day.  On  the  third 
day  his  symptoms  were  relieved  ;  but 
he  still  found  that  the  tumors  descended 
every  time  that  he  went  to  the  water- 
closet,  and  caused  him  considerable  in¬ 
convenience  till  they  were  returned  to 
their  natural  situation. 

On  the  2d  of  October  the  applica¬ 
tion  of  nitric  acid  was  repeated  more 
carefully.  On  the  19th  of  the  same 
month,  his  symptoms  had  entirely  dis¬ 
appeared.  There  was  now  no  descent 
of  the  bowel ;  he  felt  himself  entirely 
free  from  pain  ;  and  the  hemorrhage 
from  the  bowels  had  ceased.  This  pa¬ 
tient  was  again  seen  on  the  22d  of 
February,  1848.  He  then  stated  that, 
from  the  time  of  leaving  the  hospital, 
he  had  continued  well  and  free  from 
pain,  but  that  a  few  days  previously  he 
had  again  experienced  a  slight  dis¬ 
charge  of  blood  from  the  bowel. 

I  can  have  no  hesitation  in  attribut¬ 
ing  the  pain  and  irritation  experienced 
in  this  case,  after  the  application  of  the 
nitric  acid,  to  the  conditions  above 
mentioned  not  having  been  regarded. 
Having  witnessed  this  operation,  now, 
in  a  considerable  number  of  cases,  I 
have  never  known  similar  inconveni¬ 
ences  to  arise  when  the  acid  has  been 
confined  to  a  small  portion  only  of  the 
mucous  membrane,  and  applied  so  as 
completely  to  destroy  its  sensibility. 

The  following  case  will  show  what  a 
comparatively  trifling  operation  this 

mav  become  under  favourable  circum- 

•/ 

stances : — 

Case  VI.— Captain  H.  was  seen  on 
the  6th  of  March,  1848.  He  had  suf¬ 
fered  from  piles  for  several  years,  and 
had  at  different  periods  lost  a  large 
quantity  of  blood.  Upon  examination, 
findingtwo  large  internal  haemorrhoids, 

I  applied  the  strong  nitric  acid,  so  as 
to  completely  destroy  the  mucous 
membrane  covering  them,  taking  care 
that  the  acid  extended  to  no  other  part. 
This  gentleman  experienced  only  a 
slight  uncomfortable  feeling  in  the 
lower  part  of  his  abdomen  during  the 
operation,  and  this  almost  immediately 
subsided.  I  requested  that  he  would 
lie  upon  the  sofa  for  the  remainder  of 
the  afternoon,  but  calling  upon  him 
again  in  the  course  of  a  few  hours,  I 
was  surprised  to  find  that  he  had  gone 
out  for  his  accustomed  walk.  The 


operation  in  no  way  interfered  with 
the  pursuit  of  his  usual  occupations. 

The  nitric  acid  in  such  cases  should 
be  the  strongest  that  can  be  procured  : 
that  which  is  usually  kept  by  chemists 
under  the  name  of  the  strong  nitric 
acid  does  not  effectually  destroy  the 
surface  to  which  it  is  applied  ;  and 
when  used  it  therefore  produces  more 
pain  than  the  strongest  acid,  and 
cannot  be  so  certainly  relied  upon  to 
accomplish  the  intended  purpose. 

The  most  convenient  way,  perhaps, 
of  applying  nitric  acid  to  htemorrhoi- 
dal  tumors,  so  as  to  insure  the  success 
of  the  operation,  is  to  encircle  the  base 
of  the  tumors  to  be  removed  with  any 
instrument  which  will  at  the  same  time 
hold  them  in  their  situation  and  make 
sufficient  pressure  to  prevent  the 
divided  vessels  from  bleeding;  any 
portions  of  the  haemorrhoidal  tumors, 
or  of  the  mucous  membrane,  may  then 
be  removed  with  a  pair  of  curved  scis¬ 
sors,  and  the  cut  surfaces  immediately 
wiped  dry  and  touched  with  the  acid. 
If  this  is  done  before  any  bleeding  has 
taken  place  the  blood  in  the  vessels 
will  be  coagulated,  and  the  vessels  per¬ 
manently  sealed.  Care  must  be  taken, 
however,  in  performing  this  operation 
that  the  pressure  completely  commands 
the  haemorrhage,  for  if  any  blood 
escapes  from  the  surface  it  will  be¬ 
come  mixed  with  the  acid,  and  prevent 
it  from  effectually  acting  upon  the  sur¬ 
face  to  which  it  is  applied.  The  in¬ 
strument  which  is  best  adapted  for 
restraining  the  haemorrhage  under 
these  cirumstances  bonsists  of  two 
parallel  curved  plates  of  steel,  with 
their  internal  edges  slightly  indented, 
so  as  to  fit  each  other  when  they  are 
brought  together;  these  two  plates  are 
connected  at  each  end  by  a  small 
cross  bar,  to  which  a  screw  is  adapted 
so  as  to  produce  the  exact  degree  of 
pressure  required.  When  the  tumor 
to  be  removed  projects  sufficiently,  a 
common  Indian-rubber  ring  applied 
round  its  base  will  frequently  answer 
every  purpose.* 

There  is  a  considerable  class  of 
cases  which  generally  pass  under  the 
common  name  of  “  piles,”  but  which 
differ  in  their  mode  of  origin  from  those 
which  have  been  before  considered. 
In  the  cases  to  which  I  now  allude  the 

*  If  an  Indian-rubber  ring  is  used  it  should  be 
cut  off  (not  pulled  off  over  the  tumor)  when  the 
operation  is  concluded. 


MR.  LEE  ON  THE  TREATMENT  OF  HEMORRHOIDAL  TUMORS.  368 


inconvenience  experienced  does  not,  in 
the  tirst  instance,  arise  from  the  exist¬ 
ence  of  hsemorrhoidal  tumors,  nor 
from  any  inflammatory  affection  of  the 
parts,  but  from  portions  of  the  relaxed 
mucous  membrane  becoming  inverted 
and  griped  by  the  muscular  fibres  si¬ 
tuated  at  the  lower  part  of  the  rectum. 
The  following  case  is  mentioned  by 
Mr.  Abernethy : — 

Case  VII. — A  medical  man  having 
dined  out  was  seized  with  some  distur¬ 
bance  in  his  bowels,  which  caused  him 
to  get  up  during  the  night.  He  re¬ 
turned  to  bed,  but  could  not  rest.  He 
experienced  great  pain  and  irritation 
about  the  pelvis,  and  was  unable  to 
attend  to  his  practice  the  next  day. 
When  Mr.  Abernethy  saw  him  he  had 
no  less  than  thirty  or  forty  scarifi¬ 
cations  upon  his  nates,  from  cupping- 
glasses  which  had  been  applied  in  the 
hope  of  procuring  some  relief.  Mr. 
Abernethy,  suspecting  that  a  small 
plait  of  bowel  had  descended,  and  was 
griped  by  the  sphincter  muscle  of  the 
bowel,  examined  the  parts,  and  found 
a  small  protrusion  :  this  he  returned  to 
its  natural  position,  and  immediately 
relieved  the  patient. 

The  insensibility  of  the  mucous 
membrane  in  this  complaint  frequently 
causes  the  symptoms  to  be  referred  to 
the  neighbouring  parts,  and  therefore 
it  is,  I  believe,  that  this  disease  often 
exists  without  being  recognised.  A 
patient  will  often  complain  of  a  dull 
pain  over  the  sacrum,  or  a  heaving 
aching  pain  in  the  perineum,  which 
neither  he  nor  his  surgeon  can  satis¬ 
factorily  account  for.  In  the  course  of 
time  some  other  symptom  presents 
itself,  which  draws  attention  to  the 
rectum,  and  the  usual  remedies  for  piles 
are  administered  :  laxatives,  mercury 
in  different  forms,  and  sometimes  local 
depletion,  are  had  recourse  to,  without, 
of  course,  any  ultimate  benefit  as  long 
as  the  disease  depends  upon  a  mecha¬ 
nical  cause. 

Permanent  relief  in  such  cases  can 
only  be  sought  by  means  of  such  re¬ 
medies  as  tend  to  brace  the  mucous 
membrane  of  the  bowel.  The  simplest 
as  well  as  the  most  efficacious  method 
of  accomplishing  this  is  to  remove  one 
or  two  small  longitudinal  folds  of  the 
mucous  membrane ; — when  any  portion 
ot  the  lining  of  the  bowel  can  be  forced 
down  this  may  be  easily  accomplished, 
in  the  same  way  as  recommended  for 


the  removal  of  hsemorrhoidal  tumors 
It  is  not  necessary  to  remove  the  pre¬ 
cise  portion  of  membrane  which  has 
become  inverted  ;  the  destruction  of 
any  portion  will,  after  the  wound  is 
healed,  have  the  effect  of  bracing  the 
remainder.  In  this,  as  in  the  operation 
for  hsemorrhoidal  tumors,  it  is  the  pro¬ 
cess  of  cicatrization  which  cures  the 
disease. 

When  an  operation  cannot  be  had 
recourse  to,  other  means  may  be  tried 
in  order  to  give  tone  to  the  bowel : 
among  the  first  of  these  may  be  men¬ 
tioned  frequent  ablution  with  cold 
water.  Different  kinds  of  ointment 
may  also  be  used  for  the  same  purpose. 
The  following  I  have  known  attended 
with  considerable  benefit:—]^  Pulv. 
Hydr.  Nitr.  Oxyd.  ^iij. ;  Pulv.  Capsici* 
gr.  v.;  Ung.  Cetacei,  5j.  M. 

But  in  cases  where  the  mucous  mem¬ 
brane  of  the  rectum  has  acquired  an 
habitual  disposition  to  “  bag,”  it  fre¬ 
quently  happens  that  no  local  appli¬ 
cation  will  afford  permanent  relief. 
The  loose  folds  of  membrane  (which 
may  or  may  not  be  connected  with 
hsemorrhoidal  tumors)  will  descend 
again  and  again,  and  sometimes  keep- 
up  irritation  in  the  part  for  several 
years.  An  effectual  remedy  may  some¬ 
times  be  found  under  such  circum¬ 
stances  by  affording  local  support  to 
the  relaxed  membrane.  The  disease 
being  of  a  mechanical  nature  may  be 
relieved  by  mechanical  means.  A  va¬ 
riety  of  instruments  have  at  different 
times  been  invented  in  order  to  accom¬ 
plish  this  object.  Those  of  the  sim¬ 
plest  construction  have  consisted  of 
a  stem  three  quarters  of  an  inch  in 
length,  with  a  cross-bar  at  one  extre¬ 
mity  to  prevent  the  instrument  from 
passing  into  the  rectum,  and  a  bulb  at 
the  opposite  end  to  retain  it  in  its  po¬ 
sition  when  introduced.  In  the  ad¬ 
vanced  periods  of  the  disease,  where 
the  muscular  rings  at  the  lower  part 
of  the  bowel  have  become  inverted 
from  above  downwards,  and  some  of 
them  protruded  together  with  the  re¬ 
laxed  membrane,  the  instruments  above 
mentioned  have  occasionally  been  of 
essential  service.  But  in  the  earlier 
stages  of  this  complaint  they  have  fre¬ 
quently  been  attended  with  more  irri¬ 
tation  than  the  disease  which  they 
were  intended  to  alleviate. 

In  the  former  part  of  this  paper  it 
has  been  stated  that  the  lower  extre- 


364  MR.  LEE  ON  THE  TREATMENT  OF  HEMORRHOIDAL  TUMORS. 


mity  of  the  bowel  in  its  healthy  con¬ 
dition  is  surrounded  by  muscular 
fibres  for  an  inch  and  a  half  or  two 
inches;  and  unless  the  stem  of  the  in¬ 
strument  is  made  of  sufficient  length 
to  allow  the  bulb  to  rest  above  the 
fibres  of  the  levator  ani,  they  will 
be  continually  acting  upon  it  and 
pressing  it  against  the  posterior  part 
of  the  prostate  gland.  The  instru¬ 
ment  should,  therefore,  be  at  feast 
two  inches  and  a  half  in  length, 
and  should  have  a  gentle  curve 
backwards,  so  as  to  adapt  it  to  the 
shape  of  the  rectum.*  An  instru¬ 
ment  of  this  kind,  when  properly 
adapted,  will  not  unfrequently  be  the 
means  of  keeping  the  relaxed  mem¬ 
brane  in  its  place,  and  of  preventing 
all  the  inconveniences  arising  from  its 
descent. 

Case  VIII. — A  chemist  in  a  country 
town  had  been  subject  for  twenty  years 
to  a  relaxed  condition  of  the  mucous 
membrane  of  the  bowel,  and  had  suf¬ 
fered  at  different  times  much  pain  and 
inconvenience  in  consequence.  Having 
no  difficulty  in  procuring  medicines, 
and  having  naturally  great  faith  in 
their  efficacy,  he  had  tried  every  re¬ 
medy  that  he  could  think  of; — he  had 
used  purgatives,  mercurials,  ointments 
of  various  kinds,  leeches,  &c. ;  and  oc¬ 
casionally  not  without  some  apparent 
temporary  advantage.  Each  year,  how¬ 
ever,  he  underwent  the  same  suffering 
and  inconvenience,  and  submitted  to 
much  the  same  routine  method  of  treat¬ 
ment.  In  the  year  1839,  having  seen 
this  patient  several  times,  and  finding 
nothing  like  inflammation  about  the 
rectum,  I  at  length  suggested  that  he 
should  wear  an  instrument  such  as  I 
have  above  described,  to  keep  the  re¬ 
laxed  mucous  membrane  in  its  natural 
situation.  The  symptoms  from  which 
this  patient  had  so  long  suffered  were 
now  immediately  relieved.  He  has 
worn  the  instrument  up  to  the  present 
time,  and  has  had  no  farther  occasion 
for  the  medicines  which  he  wms  for¬ 
merly  in  the  habit  of  using. 

Case  IX.— Mr.  C.  had  suffered  from 
relaxation  of  the  mucous  membrane 
of  the  rectum  for  five  or  six  years.  After 
W'alking  he  found  that  he  experienced 
a  very  disagreeable  sensation  about  the 
pelvis,  accompanied  by  a  slight  pro¬ 
trusion  from  the  bow^el,  and  that  if  he 

*  Instruments  of  this  kind  are  kept  by  Messrs. 
Savigny  and  Co.,  St.  James’s  Street. 


allowed  the  -protrusion  to  remain, 
some  inflammation  of  the  parts  fol¬ 
lowed.  This  gentleman  wTas  treated  in 
the  same  way  as  the  patient  in  the 
last  case  mentioned.  At  the  expira¬ 
tion  of  a  week  he  informed  me  that  he 
had  felt  none  of  his  former  incon¬ 
venience  since  he  had  worn  the  instru¬ 
ment. 

Such  instances  might  easily  be  multi¬ 
plied,  but  as  they  all  more  or  less  re¬ 
semble  each  other  in  their  history  and 
result,  any  farther  details  wrould  be 
unnecessary.  They  almost  alw-ays 
present  themselves  in  languid  constitu¬ 
tions,  where  there  is  little  or  no  ten¬ 
dency  to  inflammatory  action,  and 
should  be  carefully  distinguished  from 
cases  of  piles  occurring  in  plethoric 
subjects,  from  which  they  differ  no  less 
in  their  constitutional  mode  of  origin 
than  in  their  method  of  treatment. 

13,  Dover  Street,  Aug.  1848. 


ON  THE 

BLOOD-VESSELS  OF  THE  NERVES 
OF  THE  HEART. 

By  Joseph  Swan,  F.R.C.S.  &c. 


The  superficial  blood-vessels  placed 
just  underneath  the  pericardium,  and 
the  interspersed  fat,  have  not  been 
noticed,  especially  with  respect  to  their 
very  interesting  arrangement  in  rela¬ 
tion  to  the  nerves. 

Many  years  ago,  I  injected  with 
quicksilver  numerous  transparent  ves¬ 
sels  running  in  lines  on  the  surface  of 
the  heart  of  a  calf  a  few  days  old ;  and 
lately  I  have  examined  the  nerves 
of  the  heart  of  the  ox,  which  weighed 
rather  more  than  five  pounds  and 
a  half,  and  as  the  auricles  wrere  quite 
open,  it  wras  drained  of  nearly  all 
its  blood.  On  the  surface  the  nu¬ 
merous  nerves  were  plainly  seen  like 
t  w  hite  lines  as  far  as  the  fat  was 
absent;  on  the  surface  of  these  w’hite 
lines  there  was  a  transparent  fainter 
line,  which  T  believed  to  be  a  ves¬ 
sel,  but  from  its  emptiness  I  could 
not  well  determine  its  nature :  on 
removing  the  pericardium  and  ex¬ 
posing  some  of  those  white  lines,  I 
found  them  as  flat  as  the  retina;  but 
on  tracing  them  upwards  they  became 
less  broad,  and  appeared  much  smaller, 
especially  near  their  connections  with 


MR.  SWAN  ON  THE  BLOOD-VESSELS  OF  THE  NERVES  OF  THE  HEART.  365 


the  trunk  or  plexus  from  which  they 
proceeded.  On  tracing  one  of  these 
lines  upwards  from  the  apex,  I  did  not 
find  it  a  single  chord;  but  when  it 
advanced  more  to  the  base  of  the  heart, 
it  divided  and  sent  one  of  its  portions 
deep,  some  part  of  which  appeared  to 
communicate  with  a  deep  artery  and 
another  part  to  rise  to  the  surface 
amongst  the  fat,  which,  from  the  ulti¬ 
mate  transparency  and  situation,  I 
believed  to  be  composed  either  of  veins 
or  absorbents.  As  I  felt  dissatisfied 
about  the  nature  of  the  white  lines  on 
the  preceding  heart,  I  procured  another 
as  large,  but  had  a  portion  of  each 
lung  left  attached  to  it,  by  wffiich 
means  the  blood  was  kept  in  the 
vessels:  on  examining  the  surface  I 
saw  the  coronary  arteries  and  veins, 
and  the  white  lines  crossing  them 
obliquely,  as  described  by  Scarpa;  but 
they  were  accompanied  by  vessels  of 
the  size  of  thick  hairs,  filled  with  blood, 
one  on  each  side;  although  these 
appeared  as  veins,  I  believe  there  is 
also  an  artery  and  absorbent.  The 
whole  surface  of  the  heart  was  covered 
with  similar  vessels  filled  with  blood. 

The  trunks  of  the  cardiac  nerves  of 
the  ox  are  very  small  in  proportion  to 
the  weight  of  the  parts  they  supply  ; 
their  branches  also  appear  remarkably 
small  before  they  are  joined  by  their 
respective  arteries,  and,  in  fact,  their 
continuations  in  the  white  lines  on  the 
surface  of  the  heart,  do  not  contain 
near  the  quantity  of  nervous  matter 
represented  by  some  anatomists. 

The  arteries  of  the  nerves  are  of 

large  size  in  proportion  to  the  quantity 

of  nervous  matter  the  nerves  contain. 

Some  branches  of  the  nerves  travel  a 

considerable  distance  obliquely  before 

they  accompany  or  embrace  an  artery  ; 

previously,  some  of  these  nerves  have 

not  anv  visible  arterv.  In  some  in- 
*  * 

stances,  a  larger  nerve  joins  a  propor¬ 
tionate  artery,  and  both  divide  equally, 
being  continued  as  the  separate  white 
lines  or  nerves  on  the  suface  of  the 
heart.  The  artery  of  a  nerve,  in  des¬ 
cending,  forms  some  transverse  con¬ 
nections  with  that  of  contiguous  ones, 
and  with  several  subjacent  arteries.  I 
have  not  succeeded  in  filling  with  in¬ 
jection  the  arteries  throughout  the 
nerves;  nevertheless,  it  may  be  fairly 
concluded  that  the  arteries  are  con¬ 
tinued  to  the  termination  of  the  nerves, 
as  vessels  can  be  discovered  on  them 


for  some  days,  especially  after  the 
heart  has  been  immersed  in  water  ;  and 
as  the  lateral  veins  can  be  distinctly 
traced,  filled  with  blood,  to  the  end  of 
every  nerve  on  the  surface  of  the 
heart ;  and  they  are  purposely  arranged 
at  the  side  of  the  nerve  for  returning 
its  blood. 

The  lateral  vessels  on  each  side  of 
the  nerve  are  the  veins,  which  have 
numerous  transverse  branches  for  com¬ 
municating  with  those  of  the  adjoining 
nerves.  They  empty  themselves  into 
large  venous  trunks  at  different  places. 

1  have  injected  several  of  these  lateral 
vessels,  and  their  transverse  branches, 
with  quicksilver.  There  is  some  diffi¬ 
culty  in  injecting  them  as  well  as  the 
arteries,  as  all  the  muscular  branches 
require  to  be  filled  before  the  injection 
passes  freely  into  them. 

In  the  moist  state  the  artery  may 
continue  distinctly  visible  for  some 
days,  whilst  the  veins  become  empty 
and  disappear.  In  the  dried  state, 
on  the  contrary,  the  arteries  gene¬ 
rally  disappear,  although  in  some  in¬ 
stances  a  central  mark  may  be  ob¬ 
served  ;  but  the  veins  remain  appa¬ 
rent  from  the  contained  blood,  and 
form,  as  it  were,  a  distinct  skeleton  of 
the  nerve. 

In  the  moist  state  the  empty  veins 
appear  as  part  of  the  nerve ;  and  their 
transverse  branches,  by  joining  toge¬ 
ther  the  adjacent  nerves,  may  be  easily 
mistaken  for  nervous  connections  or 
communications. 

As  the  artery  and  veins  form  part  of 
the  bulk  of  the  nerve,  they  may  add 
more  or  less  to  its  size,  according  to 
the  nature  of  the  fluid  in  which  the 
organ  is  preserved  ;  also  according  to 
the  manner  in  which  they  are  observed: 
so  that  they  may  appear  larger  by  im¬ 
bibition  whilst  contained  in  the  fluid, 
and  smaller  bv  their  emptiness  when 
exposed  to  the  air.  As  putrefaction 
has  advanced  the  nerves  have  appeared 
smaller  ;  whilst  marks,  as  of  carbona¬ 
ceous  matter,  have  been  found  about 
them,  and  were  probably  derived  from 
the  veins. 

The  uses  of  these  vessels  are  for  sup¬ 
plying  the  nerves  with  blood,  and 
allowing  an  easy  return  of  it  during 
the  action  of  the  heart.  The  uses  of 
the  other  parts  of  the  superficial  plexus 
placed  just  underneath  the  pericar¬ 
dium,  are  for  supplying  the  fat,  the 
pericardium  and  the  secretions. 


366  mr.  fraser’s  description  of  a  piece  of  mechanism. 


There  is  an  especial  analogy  of  ar¬ 
rangement,  and  not  improbably  of  some 
functional  power,  between  the  ciliary 
nerves  and  arteries,  independently  of 
the  retina,  and  those  of  the  heart. 
Both  are  affected  in  a  somewhat  similar 
manner  in  the  passions :  from  sympathy 
with  other  organs,  and  from  a  deficiency 
of  blood.  The  small  arteries  for  the 
nerves  may  be  influenced  momentarily 
•with  the  nerves  from  mental  emotion 
or  bodily  disorder:  the  vital  stimulus 
their  blood  affords  may  be  thus  with¬ 
held  from  the  nerves,  and  fainting,  or 
instant  death,  be  produced,  especially 
when  the  heart  has  been  impoverished 
by  the  diminution  of  the  calibre  or  ac¬ 
tivity  of  the  coronary  arteries,  through 
the  ossification  or  thickening  of  their 
coats. 


Plan  of  the  Vessels  of  the  Nerves  of  the 
Heart. 


1,  1,  1. 

2,  2,  2,  2,  2. 


Artery  running  down  the  nerve. 

Vein  placed  on  each  side  of 
the  nerve. 


3,  3,  3,  3.  Transverse  veins  forming  com¬ 
munications  between  the 
lateral  veins  of  adjoining 
nerves. 

A,  4,  4.  Cardiac  nerves. 


DESCRIPTION  OF  A 

PIECE  OF  MECHANISM, 

ON  THE 

SUPPOSED  PRINCIPLE  OF  MUSCU¬ 
LAR  ACTION. 

Read,  and  Model  exhibited,  before  the 
Medico-Chirurgical  Society,  Aberdeen, 
July  6,  1848. 

By  W.  Fraser,  Esq.,  M.R.C.S.E. 


Having  several  years  ago  had  an  op¬ 
portunity  of  seeing  a  number  of  elec¬ 
tro-motive  machines  of  various  con¬ 
structions,  I  was  much  struck  by  ob¬ 
serving  the  extreme  weakness  of  the 
power  rendered  available  for  practical 
purposes  by  the  different  mechanical 
arrangements  employed,  compared  with 
the  tremendous  force  actually  exerted, 
under  certain  circumstances,  by  the 
moving  power  made  use  of.  An  electro¬ 
magnet,  which  would,  within  its  proper 
sphere  of  power,  attract  to  itself,  and 
retain  suspended,  a  weight  of  many 
tons,  could  not  be  made  by  any  of  the 
arrangements  I  saw  employed,  to  per¬ 
form  the  twentieth  part  of  the  labour 
of  one  horse. 

I  shall  not  occupy  your  time  by  de¬ 
scribing  what  those  arrangements 
wrere,  as  most  of  you  have  seen  them 
as  well  as  myself,  but  come  at  once  to 
the  description  of  one  upon  an  entirely 
new  principle,  which  I  have  carried 
into  effect  with  the  happiest  result,  and 
of  which  the  idea  was  suggested  by 
the  mode  in  which  the  muscular  force 
appears  to  be  exerted  in  that  micro¬ 
cosm  or  little  world, — our  own  body, 
the  proper  study  of  which  I  believe 
to  be  capable  of  affording  the  key  to 
many  hitherto  unsolved  problems  in 
various  departments  of  science. 

It  has  for  some  time  been  a  current 
belief  in  physiology,  that  the  contrac¬ 
tion  of  muscles  is  produced  by  the 
mutual  attraction  of  minute  cells  or 
globules,  arranged  in  parallel  lines,  of 
which  the  ultimate  fibrils  of  the  mus¬ 
cular  tissue  consist.  The  stimulus 
that  excites  this  attraction,  is  the  vital 
electricity,  or  the  nervous  or  bio-gal¬ 
vanic  current,  transmitted  by  the 
nerves,  and  brought  to  bear  upon  the 
muscular  globules  by  means  of  the 
ultimate  nervous  filaments,  which  in- 
terlaceamong  them,  and  form  a  network 
of  anastomoses,  so  as  to  complete  the 
circle  or  current  of  nervous  influence, 
of  which  the  fountain,  or,  at  all  events, 


ON  THE  SUPPOSED  PRINCIPLE  OF  MUSCULAR  ACTION. 


867 


the  prime-motor,  is  the  brain  or  spinal 
marrow.  The  aggregate  of  these 
minute  movements  gives  the  extent  of 
contraction  of  the  entire  muscle;  the 
combined  force  of  these  molecular  at¬ 
tractions,  its  full  power  or  strength. 

The  following  extracts  and  tigures 
from  Dr.  Carpenter’s  “  Manual  of 
Physiology,”  will  place  the  subject 
more  clearly  before  us  : — • 

At  p.  200,  he  says,  “When  the 
fibrillee  are  separately  examined  under 
a  high  magnifying  power,  they 
are  seen  to  present  a  cylindrical 
or  slightly  beaded  form,  and  to 
be  made  up  of  a  linear  aggregation  of 
distinct  cells.  We  observe  the  same 
alternation  of  light  and  dark  spaces  as 
when  the  fibril lae  are  united  into  fibres 
or  into  small  bundles ;  but  it  may  be 
distinctly  seen,  that  each  light  space  is 
divided  by  a  transverse  line,  and  that 
there  is  a  pellucid  border  at  the  sides  of 
the  dark  spaces  as  well  as  between 
their  contiguous  extremities. 

“  This  pellucid  border  seems  to  be  the 
cell-wall:  the  dark  space  enclosed  by 
it  (which  is  usually  bright  in  the  cen¬ 
tre),  being  the  cavity  of  the  cell,  which 
is  usually  filled  with  a  highly  refract¬ 
ing  substance.  When  the  fibril  is  in  a 
state  of  relaxation  as  seen  at  a,  the 
diameter  of  the  cells  is  greatest  in  the 
longitudinal  direction;  but  when  it  is 
contracted,  the  fibril  increase#  in  dia¬ 
meter  as  it  diminishes  in  length, — so 
that  the  transverse  diameter  of  each 
cell  becomes  equal  to  the  longitudinal 

ce 


diameter  as  seen  at  b,  or  even  exceeds 

it. 

“The  diameter  of  the  ultimate 


fibrillse  will  of  course  be  subject  to 
variations  in  accordance  with  the  con¬ 
tracted  or  relaxed  condition  ;  but  it 
seems  to  be  otherwise  tolerably  uni¬ 
form  in  different  animals,  being  for  the 
most  part  about  T10, 000th  of  an  inch. 
The  average  distance  of  the  strife,  too, 
is  nearly  uniform — about  1-10, 000th 
of  an  inch  in  different  animals,  though 
considerable  variations  present  them¬ 
selves  in  every  individual,  and  in  diffe¬ 
rent  parts  of  the  same  muscle.” 

On  the  subject  of  the  arrangement 
of  the  nerves  and  tendons  in  connec¬ 
tion  with  muscles,  the  same  authority 
says,  p.  203,  “  The  muscles  of  animal 
life  are,  of  all  animal  tissues  except  the 
skin,  the  most  copiously  supplied  with 
nerves.  These,  like  the  blood-vessels, 
lie  on  the  outside  of  the  myolemma  of 
each  fibre,  and  their  influence  must 
consequently  be  exerted  through  it. 


ultimate  fibres  or  tubes  cannot  be  said 
to  terminate  anywhere  in  the  muscular 
substance  ;  for,  after  issuing  from  the 
trunks,  they  form  a  series  of  loops, 
which  either  return  to  the  same  trunk 
or  join  an  adjacent,  one.  The  occa¬ 
sional  appearance  of  the  termination 
of  a  nervous  fibril  is  caused  by  its 
dipping  down  between  the  muscular 
fibres,  to  pass  towards  another  stra¬ 
tum. 

“  Every  muscular  fibre,  of  the  striated/ 
kind  at  least,  is  attached  at  its  extremi¬ 
ties  to  fibrous  tissue,  through  the  me¬ 
dium  of  which  it  exerts  its  contractile 
power  on  the  hone  or  other  substance 
which  it  is  destined  to  move.  Thus 
the  whole  muscle  is  penetrated  by 
minute  fasciculi  of  tendinous  fibres, 
and  these  collect  at  its  extremities  into 
a  tendon.” 

Of  the  anatomical  arrangement  now 


368  me.  fraser’s  description  of  a  piece  of  mechanism, 

*"•* — !l  r "  ''  -  1  1  1  '  .  ■  ■ . Tfc 


ON  THE  SUPPOSED  PRINCIPLE  OF  MUSCULAR  ACTION. 


369 


described,  the  electro-motive  machine 
I  have  constructed  is  as  close  an  imi¬ 
tation  as  possible  :  it  consists  of  a 
number  of  electro-magnets  opposed 
endwise  to  one  another,  arranged  in 
parallel  lines,  and  connected  together 
by  fastenings  in  such  a  way  that,  when 
made  to  act  simultaneously,  their 
united  force  can  be  brought  to  bear 
upon  one  point. 

The  annexed  figures  will  give  an 
idea  of  the  apparatus  both  in  a  state 
of  repose  and  of  action,  or,  to  speak 
analogically,  in  the  opposite  states  of 
relaxation  and  contraction. 

Fig.  1  represents  a  series  of  eight 
rectangular  prisms  of  soft  iron,  one 
and  one-eighth  of  an  inch  long,  by  a 
quarter  of  an  inch  square,  placed 
endwise,  at  the  distance  of  one-twelfth 
of  an  inch  from  one  another.  Fig.  2 
shews  the  same  in  close  contact.  Figs. 

3  and  4  represent  the  prisms  in  the 
same  relative  position,  but  armed  with 
a  continuous  covered  copper  wire,  and 
connected  together  in  such  a  manner 
as  to  admit  of  free  motion  within  a 
limited  extent.  Each  prism  has  co¬ 
vered  wire,  about  l-20th  of  an  inch 
thick,  wrapped  round  it  closely  and 
regularly,  in  three  layers,  and,  before 
being  carried  to  the  next  prism  or 
magnet,  the  wire  is  extended  out  for 
about  an  inch  and  a  half  at  right 
angles  to  the  prism,  and  bent  back 
again  at  an  acute  angle,  by  which 
means  the  resistance  it  offers  to  the 
motion  of  the  magnets  is  almost  en¬ 
tirely  overcome. 

The  prisms  or  magnets,  with  their 
opposite  poles  opposed  to  each  other, 
are  connected  together  bv  ligaments  of 
catgut,  the  length  of  which  can  be  so 
graduated,  by  twisting  them  by  means 
of  a  small  pin  (which  can  be  fixed  by 
having  its  end  inserted  among  the 
wire),  that  any  distance  that  may  be 
necessary  can  be  assigned  as  the  limit, 
of  motion  to  the  magnets.  It  is  pro¬ 
per  to  mention  that  the  prisms  are  all 
bound  together  by  two  bands  of  vul¬ 
canized  Indian  rubber,  in  close  con¬ 
tact  with  their  opposite  sides,  and 
sufficiently  on  the  stretch  to  overcome 
entirely  the  weight  with  which,  when 
hanging  perpendicularly,  one  part  of 
the  apparatus  would  bear  upon  the 
other. 

The  advantage  of  the  arrangement 
now  described  is,  that  as  the  same 
current  of  galvanism  is  equally  efficient 
in  rendering  many  prisms  magnetic  as 


one,  and  as  the  motions  produced  by 
the  magnetic  influence  are,  by  the  way 
in  which  the  prisms  are  in  the  appa¬ 
ratus  connected  together,  communi¬ 
cated  from  the  one  to  the  other,  and 
all  accumulated  or  brought  to  bear  at 
the  end  of  the  series,  the  amount  of 
power  gained  is  just  the  attractive 
power  of  one  prism  multiplied  by  the 
number  in  the  series,  deducting,  of 
course,  the  resistance  to  be  overcome 
by  moving  the  additional  number  of 
magnets.* 

Supposing  one  electro-magnet  to  be 
capable  of  raising  three  pounds  one- 
twelfth  of  an  inch,  by  combining  96 
of  them  into  one  chain  or  series,  in  the 
way  shewn  in  the  model,  there  would 
be  attained  a  power  of  raising  three 
pounds  a  distance  of  of  an  inch,  or 
eight  inches  ;  but  allowing  the  addi¬ 
tional  magnets  and  their  appendages  to 
weigh  one  pound,  and  to  be  provided 
with  no  counterbalancing  arrangement, 
then  it  is  evident  that  the  actual  power 
attained  would  be  only  that  of  raising 
two  pounds  a  height  of  eight  inches. 
But,  by  combining  100  such  columns, 
each  containing  96  magnets,  there 
would  be  attained  a  power  of  raising 
200  pounds  eight  inches,  or  100  pounds 
sixteen  inches,  or  fifty  pounds  thirty- 
two  inches,  &c.  according  to  the 
manner  in  which  the  combination  was 
made. 

Figures  5  and  6  shew  how  the  chains 
Fig.  5. 


*  The  apparatus  above  described,  which  weighs 
five  and  a  half  ounces,  with  the  aid  of  a  moderate 
battery  lifts  a  pound  and  a  half  a  distance  of 
nearly  half  an  inch.  Its  action  is  almost  instan¬ 
taneous  ;  and  the  shock  with  which  it  becomes 
rigid  or  relaxed,  as  the  stimulus  is  applied  or 
withdrawn,  reminds  one  very  forcibly  of  the 
spasmodic  action  of  a  muscle. 


370 


mr.  fraser’s  description  of  a  piece  of  mechanism. 


Fig.  6. 


of  magnets  might  be  combined  into  a 
compound  machine  :  one  end  of  them 
being  attached  to  the  fixed  beam  a , 
near  which  the  battery  (in  this  in¬ 
stance  a  Smee’s  of  six  jars)  is  placed, 
their  other  extremities  being  fixed  to 
the  moveable  beam  b,  from  which 
any  motion  required  could  be  easily 
taken.  In  fig.  5  the  magnetsare  in  a 
relaxed  state,  their  connection  with 
the  battery  being  broken;  while  in 
fig.  6  they  are  in  a  state  of  contrac¬ 
tion,  the  circuit  of  wire  which  connects 
them  with  the  battery  being  complete. 

By  combining  a  number  of  such 
frames  together,  all  connected  by  the 
same  wire,  and  by  augmenting  the 
strength  of  the  battery,  any  degree  of 
power  might  be  obtained,  and,  as  in 
the  steam-engine,  the  apparatus  might 
be  easily  made  self-governing  in  its 
action,  by  having  a  small  cup  of  mer¬ 
cury  with  which  one  of  the  wires  was 
connected,  placed,  say  at  c,  fig.  5 :  the 
other  end  of  the  wire  could  be  made 
alternately  to  dip  into  it  and  emerge 
from  it,  by  means  of  a  pendulum,  so 
as  to  break  and  restore  the  connection, 
and  thus  keep  the  machine  going  with 
any  degree  of  frequency  that  might  be 
required. 

Various  expedients  might  be  em¬ 
ployed  to  neutralize  or  counterbalance 
the  weight  of  the  apparatus,  if  the 
power  to  be  thus  gained  were  thought 
a  sufficient  object.  Thus,  the  magnets, 
supposing  them  to  hang  perpendicu¬ 
larly,  might  be  articulated  together  by 
elastic  ligaments  (as  in  the  model  on 
the  table)  strong  enough  to  overcome 
their  weight,  and  no  more ;  or  they 


might,  if  placed  horizontally,  be  pro¬ 
vided  with  small  w’heels,  and  made  to 
move  in  a  sort  of  railway. 

Upon  the  whole,  it  is  evident  that 
the  power  of  such  an  apparatus  would 
depend  upon  the  perfection  of  it's 
mechanism,  and  upon  the  fidelity  with 
which  it  could  be  made  to  imitate  the 
model  which  Almighty  Wisdom  has 
presented  to  us  in  the  muscular  struc¬ 
ture  and  action.  And,  as  the  force  of 
the  attraction  of  electro  magnets  in¬ 
creases  prodigiously  as  their  distance 
diminishes,  (inversely  as  the  square  of 
the  distance?)  it  follows  that  the  smaller 
and  more  numerous  the  component 
magnets  of  the  machine  could  be 
made,  the  greater  would  be  the  power 
attained.  But  in  this  respect,  it  is  not 
to  be  expected  that  human  ingenuity 
could  ever  be  able  to  reach,  by  many 
hundred,  I  might  say  thousand,  de¬ 
grees,  the  minuteness  of  the  muscular 
tissue.  Yet  even  if  the  motive  power 
attained  were  only  a  five-hundredth 
part  of  that  which  muscle  can  be  made 
to  exert,  in  proportion  to  the  weight  of 
the  apparatus,  this  would  be  a  very 
great  advance  upon  the  results  that 
have  hitherto  been  arrived  at  in  this 
department. 

Though,  undoubtedly, it.  will  be  long 
before  qlectricity  be  brought  to  super¬ 
sede,  or  even  to  compete  with,  steam 
as  a  source  of  mechanical  power,  yet 
such  a  result  need  not  be  looked  upon 
as  chimerical,  after  the  extraordinary 
properties  it  has  been  discovered  to  be 
possessed  of,  and  the  wonders  we  have 
seen  effected  by  it,  within  the  last  few 
years. 

Another  necessary  step  towards  this 
consummation,  besides  the  perfecting 
of  the  mechanical  arrangement,  would 
be  the  discovery  of  a  cheap  source  of 
galvanism  ;  one  whose  price  uTould  not 
exceed  that  of  the  fuel  employed  in  the 
production  of  steam.  But  that  the 
very  same  source  from  which  steam  is 
obtained  may  be  made  available  for  the 
generation  of  electricity,  is  proved  by 
recent  experiments;  though  whether 
in  a  form  suitable  as  a  source  of  elec- 
trO-motive  power,  yet  remains  to  be 
ascertained. 


BURIAL-CLUB  MURDERS - ENCOURAGEMENT  OF  SECRET  POISONING.  371 


MEDICAL  GAZETTE. 


FRIDAY,  SEPTEMBER  1,  1848. 


A  trial  which  has  recently  taken 
place  at  Chelmsford  has  brought  to 
light  a  secret  system  of  murder  by 
poison  which  rivals  that  of  the  Thugs 
in  India,  and  which  we  fear  is  much 
more  widely  spread  over  England  than 
the  public  are  inclined  to  believe.  We 
know  of  no  better  name  to  give  to 
this  form  of  Thuggee  than  that  of 
Burial-club  murder;  and  it  is  with 
regret  we  must  acknowledge  that  our 
legislators  are  either  unwilling  or 
unable  to  adopt  measures  for  the  pre¬ 
vention  of  this  horrible  crime.  It 
is  the  boast  of  our  laws  that  human 
life  is  more  valuable  in  England  than 
in  any  other  civilized  state  ;  .and  w*e 
admit  that  this  statement  is  true,  so 
far  as  open  attempts  at  assassination 
are  concerned.  These  laws,  however, 
are  not  only  inadequate  to  suppress 
murder  by  poison,  but  in  various  ways 
they  actually  aid  its  secret  and  suc¬ 
cessful  perpetration.  Thus,  in  the 
first  place,  no  check  is  placed  on  the 
sale  of  arsenic :  any  country  grocer  is 
allowed  to  sell  it,  and  any  child  to  buy 
it.  So  that  the  common  pretence  is 
set  forth  by  the  purchaser,  that  he  or 
she  is  desirous  of  destroying  a  few  rats 
or  mice,  this  deadly  instrument  of 
death  is  at  all  times,  and  in  all  places, 
to  be  obtained  at  a  very  cheap  rate. 
When  the  purpose  is  answered,  and 
the  unfortunate  individual  has  been 
sent  quietly  out  of  the  world  by  a 
sudden  attack  of  “  bowel  complaint,” 
the  defective  state  of  the  Registration 
Act  supplies  a  means  of  lawfully  con¬ 
cealing  the  crime.  A  plausible  story, 
accompanied  by  the  statement  of  a 
person  present  at  the  death,  will  gene¬ 
rally  ensure  registration  of  the  cause 


under  the  head  of  cholera  or  summer 
diarrhoea !  Much  care  is  taken  to 
avoid  any  inquiries  on  the  part  of  the 
coroner  or  his  officers,  and  the  crime  is 
concealed  by  the  grave.  Not  content 
with  supplying  the  means  of  murder 
and  a  legal  method  of  silencing  the 
inquiries  of  gossiping  neighbours,  the 
law,  by  the  toleration  of  burial-clubs, 
actually  supplies  a  ready  and  sufficient 
motive.  Our  readers  must  be  fully 
aware  that  within  the  last  few  years  we 
have  had  in  various  parts  of  England 
numerous  proofs  of  the  perpetration  of 
crimes,  the  existence  of  which  could 
hardly  have  been  credited.  Parents  have 
poisoned  their  children,  and  children 
their  aged  parents,  for  the  sake  of 
ridding  themselves  of  an  incumbrance, 
and  of  procuring  a  few  pounds  by  their 
deaths  under  the  name  of  burial-money ! 

The  case  of  the  woman  May ,  lately 
tried  and  executed  at  Chelmsford,  is  a 
fair  type  of  this  species  of  crime, 
carried  to  its  maximum  of  cruelty  and 
atrocity,  and  concealed  by  a  degree  of 
cunning  which,  but  for  the  avaricious 
desire  of  clutching  the  price  of  blood 
before  the  body  of  her  murdered  bro¬ 
ther  was  barely  cold,  would  have  com¬ 
pletely  succeeded  in  preventing  all 
inquiry.  Having  entered  her  name  in 
a  Burial-club,  and  made  the  deceased 
her  nominee ,  with  a  statement  that  he 
was  a  very  healthy  man,  and  much 
younger  than  he  really  was,  she  ad¬ 
ministered  to  him,  about  a  month 
afterwards,  a  dose  of  arsenic,  which 
she  had  procured  on  the  usual  plea  that 
her  cottage  was  very  much  infested 
with  rats.  The  poison  had  its  usual 
effects :  the  death  was  entered  by  the 
registrar  under  the  questionable  de¬ 
signation  of  “  decline,”  and  the  man 
was  buried.  In  consequence  of  her 
having  claimed  the  death-money  some¬ 
what  early,  and  her  accounts  respect¬ 
ing  the  illness  of  the  deceased  having 
varied,  the  body  was  exhumed  three 


ENCOURAGEMENT  OF  SECRET  POISONING. 


372  BURIAL-CLUB  MURDERS — 

weeks  after  burial ;  and  it  was  then 
proved  that  the  deceased  had  died 
from  the  effects  of  arsenic.  Circum¬ 
stantial  evidence  brought  the  crime 
clearly  home  to  the  prisoner,  and  led 
to  her  conviction.  In  the  course  of 
this  inquiry  it  was  rendered  highly 
probable  that,  some  years  previously, 
she  had  poisoned  a  former  husband 
and  many  of  her  children  !  The 
sum  to  which  she  was  entitled  under 
the  Burial-club  rules  was  about  nine 
pounds.  Her  counsel,  in  his  defence, 
very  ingeniously  contended  that  the 
smallness  of  the  sum  could  not  be 
taken  as  a  sufficient  motive!  Unfor¬ 
tunately,  however,  experience  is  very 
much  against  this  standard  of  inno¬ 
cence.  A  much  smaller  sum  has  been 
known  to  tempt  criminals  to  the  per¬ 
petration  of  murder;  and  this  leads  us 
to  consider  whether  these  country 
death-clubs  should  not  be  either  en¬ 
tirely  suppressed,  or  placed  under  very 
strictrules, in  order  to  prevent  them  from 
becoming  actual  incentives  to  crime. 

We  have  now  before  us  the  “  Fades 
and  Regulations  of  the  New  Society, 
for  rendering  mutual  assistance  in  cases 
of  mortality,  held  at  the  Privateer  Inn, 
Harwich.”  This  was  the  club  selected 
by  Mrs.  May,  because  being  rather  re¬ 
mote  from  the  village  where  she  resided, 
it  might  prevent  any  strict  inquiries 
being  made  respecting  her  nominee,  or 
a  suspicion  of  the  plans  which  she  had 
then  in  contemplation  respecting  him. 
The  deceased  appears  to  have  been 
marked  out  as  a  sheep  is  by  a  butcher, 
and  his  value  as  a  pecuniary  invest¬ 
ment  accurately  calculated.  It  requires 
no  great  amount  of  capital  to  become  a 
member  of  one  of  these  clubs  for  the 
better  encouragement  of  secret  poison¬ 
ing.  Rule  I.  runs  as  follows  : — 

“  Every  person  becoming  a  Member 
of  this  Society,  shall,  at  the  time  of 
entrance,  pay  the  sum  of  one  shilling , 
for  the  purpose  of  purchasing  books, 
&c.,  for  the  use  of  the  society,  and 


threepence  for  the  rules  and  regula¬ 
tions,  and  appoint  a  nominee.” 

In  addition  to  this  shilling-invest¬ 
ment,  the  moderate  sum  of  fourpence 
per  quarter  is  paid  ;  and  at  the  death 
of  any  one  member  or  nominee,  there 
is  an  additional  charge  of  sixpence. 
The  extra  sum  thus  collected,  forms 
the  premium  to  be  paid  within  three 
days  of  the  death  of  either  member  or 
nominee.  On  the  whole,  it  will  be 
perceived  that,  excluding  the  risk  of  a 
conviction  for  murder,  this  is  really  a 
cheap  investment,  especially  when  it  is 
known  that  the  money  is  only  nomi¬ 
nally  for  the  death  :  it  may  be  expended 
in  any  way  that  the  member  pleases  ! 
To  keep  up,  however,  some  show  of 
consistency,  the  club  requires  that 
whatever  may  be  the  amount  col¬ 
lected,  the  deceased  must  be  buried 
decently.  In  the  case  to  which  we 
have  alluded,  the  criminal  had  so  laid 
her  plans  as  to  obtain  the  whole  pre¬ 
mium  as  profit ;  for  it  appears  that  she 
had  lost  no  time  in  causing  her  brother 
to  be  buried  at  the  expense  of  the 
parish.  Thus,  then,  in  a  club  of  this 
kind,  there  is,  for  a  few  shillings,  a 
chance  of  getting  nine  or  ten  pounds — - 
the  cost  of  the  arsenic  required  to  create 
a  claim,  being  too  small  to  be  taken 
into  consideration.  These  clubs  for 
affording  members  assistance  in  cases 
of  mortality,  whether  from  poison  or 
otherwise,  are,  we  believe,  very  nume¬ 
rous  in  the  provinces;  and,  although  it 
is  obvious  from  their  regulations  that 
they  give  to  one  person  a  direct  interest 
in  the  death  of  another,  they  appear  to 
multiply  without  the  slightest  check  or 
control.  As  in  the  Derby  or  other 
sweeps,  their  head- quarters  are  at  pub¬ 
lic-houses,  and  anybody  is  at  liberty 
to  make  a  small  investment,  and  specu¬ 
late  on  the  death  of  a  neighbour.  We 
must  confess  our  surprise,  that  with  the 
revelations  of  the  secret  murders  by 
poison,  which  have  had  their  origin  in 


BURIAL-CLUB  MURDERS - THE  SALE  OF  ARSENIC. 


373 


these  low  associations,  the  Government 
has  not  interfered;  but,  as  with  the 
sale  of  arsenic,  the  figure  of  mor¬ 
tality  from  the  prevalence  of  these 
clubs,  has  probably  not  yet  become 
sufficiently  high.  It  will  require  a 
greater  accumulation  of  these  atrocities 
to  induce  our  legislators  to  interfere 
with  that  liberty  which  appears  to  be 
the  exclusive  privilege  of  a  Briton — 
namely,  of  poisoning  himself  or  his 
neighbour,  at  the  cheapest  possible 
rate,  and  without  let  or  hindrance. 

If  wTe  wish  to  extirpate  this  species 
of  Thuggism  in  the  provinces,  these 
Death  -  clubs  must  be  immediately 
looked  to.  There  is  one  provision 
in  their  rules  well  calculated  to  en¬ 
courage  murder.  The  name  of  a  per¬ 
son  may  be  entered  as  a  nominee  by 
a  member,  while  the  said  nominee  is 
kept  in  entire  ignorance  of  the  arrange¬ 
ment.  Thus  it  is  not  necessary  to  in¬ 
form  him  that  the  sooner  he  dies,  the 
sooner  will  the  member  be  entitled  to  a 
respectable  premium  to  provide  him 
with  a  coffin,  while  the  difference  will 
go  into  the  said  member’s  pocket !  In 
the  Chelmsford  case,  the  unfortunate 
deceased  was  kept  in  complete  igno¬ 
rance  that  tw7o  or  three  shillings  had 
been  paid  upon  his  life,  or  he  might 
have  removed  from  a  locality  where 
such  a  dangerous  interest  in  his  death 
had  been  created  without  his  know¬ 
ledge  or  consent.  The  person  whom  it 
is  intended  to  poison,  has,  therefore,  no 
reason  to  suspect  that  he  is  a  marked 
man,  and  that  his  murderer  is  only 
waiting  for  a  convenient  opportunity 
to  remove  him  without  exciting  the  re¬ 
marks  of  neighbours.  Such  a  rule  as  this 
is  obviously  a  direct  encouragement  to 
murder.  If  these  death-clubs  be  not 
wholly  suppressed  as  dangerous  to 
society,  there  should  be  at  least  a  strict 
regulation,  that  the  nominee  must,  in 
all  cases,  be  a  party  to  the  contract, 
and  be  made  fully  aware  that  seme 


person,  who  might  have  no  great  affec¬ 
tion  for  him  during  life,  was  very 
desirous  of  making  a  little  profit 
out  of  him  at  his  death.  This  would 
be  only  starting  fairly,  so  that  the  two 
might  know  the  interest  which  each 
would  have  in  the  other’s  death.  As 
it  is,  the  poisoning  is  all  on  one  side : 
the  mortality  club  gives  the  member 
fair  encouragement  to  get  rid  of  the 
nominee  in  a  quiet  way.  We  believe 
that  the  records  of  our  criminal  courts 
would  enable  us  to  make  out  a  long 
list  of  such  cases. 

As  to  the  sale  of  arsenic ,  we  think 
that,  wdthout  interfering  to  an  incon¬ 
venient  extent  with  the  liberty  of  the 
subject,  it  would  be  a  wise  rule  not  to 
allow  it  to  be  sold  except  under  the 
signature  of  a  licensed  medical  practi¬ 
tioner.  If  wTanted  for  a  lawful  pur¬ 
pose,  the  signature  of  a  medical  man 
would  never  be  withheld.  It  is  true, 
this  would  not  guard  against  forgery ; 
but  most  of  those  who  wanted  arsenic 
for  unlawful  purposes,  would  not  easily 
succeed  in  forging  a  name  ;  and  if  they 
required  another  to  aid  them  in  this,  it 
would  be  equal  to  declaring  their  cri¬ 
minal  intention.  Certificates  of  this 
kind  might  be  made  available  only  for 
the  day  on  which  they  are  signed,  and 
within  a  certain  district.  This  plan 
would  not,  of  course,  entirely  suppress 
the  sale  of  arsenic,  but  it  would  have 
the  effect  of  checking  it ;  and  we  are 
certain  that  it  would  annually  cut  off 
from  some  hundreds  of  criminals  the 
means  of  carrying  out  their  diabolical 
intentions.  It  would  have  the  effect, 
too,  of  supplying  that  evidence  which 
is  now  so  frequently  wanting  in  crimi¬ 
nal  cases,  namely,  of  the  purchase  of 
poison.  These  are  surely  advantages 
sufficient  to  outweigh  the  slight  incon¬ 
venience  to  which  some  glass-blowers, 
shot-makers,  and  farmers,  would  be 
subjected  in  procuring  a  medical  order 
for  arsenic.  The  druggist  or  grocer 


374 


ERMAN’S  TRAVELS  IN  SIBERIA. 


who  dispensed  the  poison  might  always 
retain  the  document  as  evidence ;  and 
this  would  operate  much  more  power¬ 
fully  in  arresting  the  arm  of  the  mur¬ 
derer,  than  the  present  loose  practice 
of  requiring  the  attendance  of  a  wit¬ 
ness. 

With  respect  to  the  registration  of 
deaths,  more  care  is  demanded.  No 
deaths  should  be  entered  except  upon 
the  certificates  of  licensed  medical 
practitioners.  No  cause  of  death  should 
be  taken  from  the  statement  of  non- 
medical  persons  without  some  inquiry 
amongtheneighbours.  Unless  these  pre¬ 
cautions  are  observed,  the  Registration 
Act  furnishes  a  ready  method  of  con¬ 
cealing  crimes;  for  the  fact  of  burial, 
under  a  registrar’s  certificate,  might  be 
taken  as  sufficient,  in  many  cases,  to 
silence  inquiry.  Judging  from  the  ex¬ 
humations  which  so  frequently  take 
place  many  months  after  interment, 
and  from  the  discovery  of  arsenic  in 
the  exhumed  bodies,  there  is  great 
reason  to  believe  that  hundreds  are 
yearly  carried  out  of  the  world  by  poi¬ 
son,  whose  deaths  have  swelled  the 
lists  of  cholera,  diarrhoea,  &c. !  Some 
of  the  Eastern  Counties,  especially 
that  of  Essex,  have  acquired  a  fatal 
notoriety  in  this  respect;  but  wre  do 
not  believe  that  the  crime  of  secret 
poisoning  is  more  common  there  than 
in  other  agricultural  districts  where 
access  to  arsenic  is  just  as  easy. 
The  apparent  frequency  of  murder 
by  poison  in  Essex,  is,  we  believe, 
due  to  the  fact,  that  the  coroners  and 
magistrates  of  that  county  exert  them¬ 
selves  to  the  utmost  in  endeavouring 
to  suppress  this  detestable  crime,  and 
they  spare  no  efforts  to  bring  the  cri¬ 
minals  to  justice.  We  could  name  a 
county,  not  far  distant  from  the  metro¬ 
polis,  where  an  entirely  different  course 
is  pursued.  Cases  of  poisoning  in  that 
county  are  seldom  heard  of.  Is  it  that 
they  are  so  much  less  frequent  than 


elsewhere,  or  that,  for  the  sake  of 
avoiding  expense,  the  investigations 
are  slurred  over,  and  the  deaths  by 
poison  are  entered  in  the  registration- 
books  as  cholera  or  diarrhoea  ?  From 
some  facts  which  have  come  to  our 
knowledge,  we  are  inclined  to  adopt 
the  latter  conclusion.  These  facts  de¬ 
mand  the  earnest  and  immediate  atten¬ 
tion  of  Government. 


IftcbtefoS. 


Travels  in  Siberia ;  including  Excur¬ 
sions  Noi  thwards  down  the  Obi  to 
the  Polar  Circle,  and  Southwards  to 
the  Chinese  f  rontier.  By  Adolph 
Erman.  Translated  from  the  Ger¬ 
man,  by  W.  D.  Cooley.  2  vols.  8vo. 
pp.  495  53G.  London :  Longmans, 
1848. 

From  the  title  it  would  appear  that  a 
notice  of  this  work  was  hardly  adapted 
to  the  pages  of  a  medical  periodical, 
yet  when  we  state  that  the  author  is 
one  of  the  Humboldt  school,  able  and 
ready  to  bring  scientific  knowledge  to 
bear  upon  topographical  observations, 
it  may  be  inferred  that  in  the  volumes 
before  us  we  have  notan  ordinary  book 
of  travels.  The  name  of  M.  Erman 
has  been  long  known  to  men  of  science 
in  this  country.  In  1844  he  received 
one  of  the  medals  of  our  Royal  Geo¬ 
graphical  Society,  and  his  remarkable 
discoveries  connected  with  the  frozen 
soil  of  Siberia,  have  deservedly  won  for 
him  a  European  reputation.  As  we 
have  just  stated,  this  is  no  ordinary 
book  of  travels :  it  is  a  most  interesting 
philosophical  survey  of  the  coldestquar- 
ter  of  the  globe.  The  botanist,  the  mine¬ 
ralogist,  the  geologist,  the  chemist,  and 
the  ethnologist,  will  here  find  a  record 
of  valuable  facts  in  their  respective 
sciences,  collected  by  one  whose  mind 
was  well  able  to  perceive  their  recipro¬ 
cal  relations,  and  to  arrange  them  in  a 
form  which  would  be  most  acceptable 
to  educated  men  of  all  professions.  In 
describing  the  gold  and  platinum  mines 
of  the  Uralian  chain,  or  in  calculating 
the  muscular  strength  of  an  Ostyak  or 
Samoyede  by  the  initial  velocity  im¬ 
parted  to  an  arrow,  the  author  is  equally 
at  home;  and  in  no  part  of  the  work 
do  we  discover  that  admixture  of 


ERMAN’s  TRAVELS  IN  SIBERIA. 


375 


pseudo-science  or  pedantry  which  da¬ 
mages  the  works  of  some  other  travel¬ 
lers,  who  have  been  desirous  of  passing 
for  learned  men.  The  digressions  in 
which  M.  Erman  indulges  flow  sponta¬ 
neously  from  the  philosophical  habit 
which  he  had  evidently  acquired  before 
setting  out  on  his  journey— -of  contem¬ 
plating  all  objects  and  events  in  every 
possible  aspect. 

The  discovery  of  platinum  in  Siberia 
is  wrell  known  to  be  of  comparatively 
recent  origin.  At  Kushva,  M.  Erman 
made  an  acquaintance  with  the  dis¬ 
coverer,  M.  Voiko  u,  and  he  gives  the 
following  account  of  the  distribution  of 
gold  and  platinum  in  the  district : — 

“  Gold  and  platinum  in  these  districts  lie 
in  beds  of  pebbles,  partly  at  the  bottom  of 
the  valleys  that  cross  the  course  of  the  Tura, 
and  partly  diffused  more  widely  through  the 
plains  on  either  side  of  this  river  ;  the  metals 
lying  among  the  detritus  of  the  hornblend 
and  feldspath,  collected  between  the  transi¬ 
tion  limestone  rocks  which  bound  the  valleys. 
There  would  appear  to  be  no  difficulty,  at 
first,  as  to  the  source  of  their  production,  as 
they  are  scattered  over  the  slopes  of  the 
Ural,  east  and  west;  still  the  unaccountable 
peculiarity  was  found  to  prevail  there,  that 
the  quantity  of  gold  in  the  undisturbed  veins 
of  quartz  was  much  less  than  in  the  sedimen¬ 
tary  beds,  and  that  it  was  likewise  different 
in  its  form  and  condition,  being  in  crystal¬ 
line  scales  in  the  former,  and  in  roundish 
grains  in  the  latter.  It  cannot,  therefore, 
proceed  from  veins  like  the  present,  of  which 
the  beds  on  the  east  of  the  hills,  in  the  district 
of  Kushva,  are  formed  ;  but  the  whole  sub¬ 
stance  of  the  rocks  through  which  these 
veins  penetrate  must  be  impregnated  with 
the  metal.  It  was  in  a  bed  of  worn  fragr- 
ments  of  greenstone  and  limestone,  washed 
by  the  river  Iss  into  the  lower  valleys,  after 
the  bursting  of  a  dam  formed  across  it,  not 
many  years  since,  by  a  landslip,  that  pla¬ 
tinum,  sand,  and  iron,  mixed  with  titanium, 
were  first  found.”  (Yol.  i.  p.  250). 

It  is  a  remarkable  fact,  that  while 
nations,  deemed  little  above  savages, 
have  been  in  the  habit  of  treating 
idiots  with  kindness  and  a  respect 
almost  amounting  to  veneration,  we, 
until  nowq  have  allowed  these  unfor¬ 
tunate  beings  to  remain  as  neglected 
and  despised  outcasts.  It  was  only  a 
few  weeks  since  that  we  announced  in 
the  pages  of  this  journal  a  plan,  for  the 
first  time  suggested  in  this  country,  of 
erecting  an  asylum  for  idiots.  It  is 
true  that  in  less  favoured  countries 
than  our  own,  this  kindness  towards 


idiots  has  probably  been  based  on 
superstition. 

“  The  superstitious  feelings  of  the  Russians 
are  strikingly  evinced  in  the  veneration  with 
which  the  Blazhennie  (from  blayo,  favour, 
blessing,  Russ.),  or  blessed  people,  as  they 
term  them,  are  treated.  They  are  nothing 
better  than  idiots  to  whom  they  apply  this 
name — whose  mental  condition  is  believed  to 
be  a  peculiar  endowment,  and  indicative  of 
supernatural  possession  or  divine  transport ; 
and  communities  here  consider  themselves 
as  much  favoured  by  the  presence  of  a  blaz¬ 
hennie,  as  the  Swiss  do  with  the  Cretins.  All 
their  casual  expressions  are  looked  upon  as 
oracular ;  and  they  are  often  invited  to  great 
distances  by  those  who  have  the  means  to 
pay  for  their  unconscious  vaticinations. 
Religious  establishments  are  the  foremost  in 
their  anxiety  to  attach  them  to  their  body, 
by  which  they  derive  considerable  profit.  It 
is  not  very  long  since  there  was  an  instance 
of  a  female  convict  obtaining  a  remission  of 
her  sentence,  in  consequence  of  some  ex¬ 
pressions  of  fatuous  half-meaning  that 
escaped  her ;  and  she  was  upon  the  point  of 
entering  upon  a  new  career  as  prophetess, 
but  for  the  jealousy  of  some  priests,  by 
whom  she  was  convicted  of  premeditation. 
She  was  ultimately  condemned  to  complete 
the  full  term  of  her  exile.”  (Vol.  i.  p.  273). 

The  intensity  of  the  cold  in  a  Siberian 
atmosphere,  and  the  ease  with  which 
it  is  borne  by  the  inhabitants,  without 
injury  to  health,  excites  the  surprise  of 
those  who  have  been  accustomed  to 
temperate  climates.  The  most  intense 
cold  prevails  when  there  is  the  least 
light,  i.  e.  when  the  days  are  only  a 
few  hours  long.  Hence  the  windows 
of  the  dwelling  consist  of  small  holes 
in  the  eastern  wall,  and  these  are 
actually  glazed  with  flakes  of  ice  a 
foot  thick.  The  fire  within  causes  the 
ice-window  to  melt  on  the  inside,  and 
it  thus  becomes  as  smooth  and  polished 
as  a  mirror,  while  the  crevices  are 
completely  closed  by  the  refreezing  of 
the  melted  ice.  The  quantity  of  light 
which  penetrates  is  small;  but  the 
Siberian,  at  this  season  of  the  year, 
sacrifices  light  for  warmth.  We  are 
elsewhere  informed  by  the  author  that 
some  of  his  Samoyede  companions 
slept  comfortably  al  fresco  in  their  fur 
garments  and  skins,  although  the  snow 
beneath  them  had  a  temperature  of 
— 31°,  or  63°  below  the  freezing  point 
of  water!  (Vol.  ii.  p.  71). 

The  fact  that  a  temperature  at  or 
near  the  freezingpointprevails  through¬ 
out  the  year  at  a  few  feet  depth  in  the 


376 


ERMAN’S  TRAVELS  IN  SIBERIA. 


ground,  will  account  for  the  absence  of 
putrefaction,  and  the  perfect  preserva¬ 
tion  of  the  bodies  of  the  dead.  Erman 
mentions  a  remarkable  instance  of  this 
at  Beresou,  in  the  disinterment  of  the 
body  of  Prince  Menchikof,  the  minister 
of  Peter  I.,  ninety  two  years  after 
burial.  “The  coffin  was  found  to  be 
Embedded  in  frozen  soil,  and  its  con¬ 
tents  had  undergone  so  little  change, 
that  pieces  of  the  clothing  in  which 
the  body  was  wrapped  were  sent  to  the 
descendants  of  the  deceased  ;  and  even 
the  eyebrows,  heart,  and  other  parts  of 
the  corpse,  were  added  to  these  relics.” 
(p.  462).  A  wooden  church,  which  the 
exiled  minister  erected  on  the  spot 
with  his  own  hands,  has  long  since 
fallen  to  decay. 

The  author  describes  a  curious  fea¬ 
ture  in  the  habits  of  the  rein-deer, 
which  we  have  never  before  met  with 
in  the  accounts  published  of  this 
animal  by  writers  on  natural  his¬ 
tory  : — 

“  I  had  already  had  occasion  to  remark  at 
different  yurts,  the  remarkable  longing  which 
rein-deer  have  for  human  urine,  but  ]  have 
never  seen  it  exhibited  so  distinctly  and  de¬ 
cidedly  as  to-day  ;  for  in  order  to  gratify  this 
desire,  some  of  these  shy  animals  had  sponta¬ 
neously  come  close  to  the  tent,  and  as  soon  as 
any  one  went  out  to  make  water,  they  ran  up 
in  full  trot  to  catch  the  stream  in  the  air  with 
their  under- lip  protruded  ;  and  if  the  first 
were  driven  back,  then  others  hastened  for¬ 
wards,  and  kept  licking  with  avidity  the 
melted  snow.  It  is  manifest,  therefore,  that 
it  is  not  the  warmth  of  the  fluid,  but  its 
saltness,  which  awakens  this  desire,  as  we 
sometimes  observe  it  in  our  he-goats  ;  but  it 
exists  in  these  animals  in  so  extraordinary  a 
degree,  that  the  taming  of  the  rein-deer,  or 
the  power  of  habituating  them  to  their  mas¬ 
ters,  seems  to  depend  essentially  or  perhaps 
wholly  upon  it.  In  no  other  case  do  they 
lay  aside  their  natural  shyness  or  their  ap¬ 
parent  aversion  to  man  ;  for  they  will  not 
eat  from  the  hand,  however  good  the  fodder  ; 
and  if  fresh  moss  be  plucked  and  thrown  to 
them  on  the  snow,  they  only  smell  it,  and 
turn  away.”  (Vol.  ii.  p.  73.) 

At  Iviakhta  and  Maimachen,  M. 
Erman  came  in  contact  with  the 
Chinese.  The  former  is  the  frontier- 
town  of  Russia,  and  is  more  distant 
from  St.  Petersburgh  than  that  city  is 
from  the  centre  of  the  earth!*  'He 

*  At  Tarakanova,  which  is  80  versts  nearer  St. 
Petersburgh,  there  is  a  pillar  or  milestone  re 
cording  the  measured  distance  from  the  Russian 
capital -“To  St.  Petersburgh,  5963  versts  (3975 
English  miles).” 


ascertained  that  the  sea-slugs,  which  the 
Chinese  are  in  the  habit  of  eating  as 
great  delicacies,  are  nothing  more  than 
the  large  and  long  muscles  of  the 
Holothuria  fuliyinosa.  The  animal, 
in  the  dried  state,  is  only  seven  lines 
wide  and  two  inches  long;  but  when 
steeped  in  water  it  swells  to  double 
the  size.  When  boiled  for  some  time 
it  yields  a  well-flavoured  and  abundant 
jelly,  which  is,  however,  very  salt, 
most  probably  owing  to  the  saline 
matter  retained  in  its  body  in  the  pro¬ 
cess  of  drying.  The  jelly  is  coloured 
brown  also  by  the  pigment  of  the 
outer  skin.  The  muscular  substance  or 
meat  which  remains  after  extracting 
the  jelly,  is  tough,  and  tastes  not  un¬ 
like  veal. 

The  Chinese  physicians  of  Mai¬ 
machen  have  been  in  the  habit  of  em¬ 
ploying  acupuncturation  in  the  treat¬ 
ment  of  diseases :  and  they  appear  to 
have  adopted  this  practice  long  before 
it  was  known  in  Europe.  (Vol.  ii. 

p.  261). 

M.  Erman  states  that  the  goitre  is 
very  prevalent  in  Siberia.  He  met 
with  it  in  a  severe  form  in  the  valley  of 
the  Lena;  and  it  appears  that  one 
place,  Gorboosk,  actually  derives  its 
name  (Goitre-town)  from  the  frequency 
of  this  disease  among  the  inhabitants.* 
It  would  also  appear  from  statements 
made  in  other  parts  of  the  work,  that 
the  Siberians  are  subject  to  a  severe 
form  of  ophthalmia,  and  a  disease 
which  resembles,  from  the  description, 
elephantiasis.  The  practice  of  medi¬ 
cine  appears  to  be  at  a  very  low  ebb 
among  them  :  it  appears  to  exist  only 
in  an  empirical  form. 

Our  author  was  able  to  confirm  the 
accuracy  of  the  observation  which 
philosophers  have  recently  made  re¬ 
specting  the  connection  of  the  magnetic 
condition  of  a  locality  and  its  tempera¬ 
ture.  The  Siberian  magnetic  pole  is 
between  Irkutsk  and  Yakutsk,  and 
there  is  no  doubt  that  the  magnetic 
meridian  was  crossed  near  Parshinsk, 
in  longitude  112°.25  E.,  and  latitude 
82°.5  N.  Here  then  is  a  singular  addi¬ 
tion  to  our  knowledge  of  climate,  that 
the  greatest  intensity  of  cold  is  met  with 
at  the  magnetic  pole.  Yakutsk,  the 
capital  of  Eastern  Siberia,  lies  two 
degrees  farther  south  than  Drontheim. 
in  Norway,  and  about  the  same  dis- 


*  Gorboosk,  from  gorb,  a  knob  or  tumor. 


ERMAN’S  TRAVELS  IN  SIBERIA. 


377 


tance  more  south  than  Beresov  on  the 
Obi ;  yet  these  places  enjoy  an  incom¬ 
parably  milder  climate  than  that  of 
Yakutsk.  In  the  latter  place,  the  soil 
within  a  few  feet  from  the  surface,  is 
frozen  throughout  the  year  to  a  depth 
of  630  feet,  hence  the  only  supply  of 
water  is  from  the  river  in  summer,  and 
from  the  melted  snow  in  winter. 
Erman  remarks — 

“  The  inhabitants  of  the  Swiss  Alps  would 
not  unjustly  thinkthemselves  lost,  if  they  were 
compelled  to  live  at  the  height  of  10,000  feet 
or  2300  feet  above  the  Hospice  of  the  Great 
St.  Bernard,  and  thei'e  to  support  and  clothe 
themselves  by  keeping  cattle,  and  with 
the  productions  of  the  surrounding  moun¬ 
tains  ;  yet  they  would  there,  and  not  until 
they  arrived  at  that  height,  be  settled  on 
ground  having  the  same  temperature  which  I 
found  here  among  the  Yakuts,  who  are  rich 
in  cattle.  It  would  seem,  therefore,  as  if 
that  succeeded  in  Siberia  which  was  impos¬ 
sible  in  Europe,  if  we  did  not  take  into 
account  that  the  same  constant  temperature 
of  the  ground  may  be  made  up  at  different 
places  of  very  different  elements. ”  P.  368. 

It  would  appear  from  thermometrical 
observations  made  at  Yakutsk  by  two 
intelligent  inhabitants,  that  the  daily 
range  of  temperature  is  far  greater  than 
under  any  of  the  meridians  of  Europe. 
From  an  examination  of  these,  it  ap¬ 
pears  that  the  mean  temperature  of  the 
air  in  Yakutsk  is  1 8°*5.  A  degree  of 
cold  exceeding  5S°.5  takes  place  every 
year  between  the  17th  December  and 
the  18th  of  February;  and  most  fre¬ 
quently  in  the  first  three  weeks  of 
January.  We  need  hardly  inform  our 
readers,  that  at  this  temperature,  mer¬ 
cury  would  be  a  malleable  solid,  capa¬ 
ble  of  being  drawn  into  wire  or  rolled 
into  sheets,  and  actually  it  continues 
in  this  state  for  one-sixth  of  the  year. 
The  maximum  cold  observed  on  the 
habitable  globe,  was  recorded  here  on 
the  5th  January,  1829.  The  spirit 
thermometer  then  sunk  to  — 72°*4,  or 
104o,4  below  the  freezing  point  of 
water  !  Erman  and  his  translator  are 
mistaken  in  stating  that  the  lowest  de¬ 
gree  of  cold  yet  produced  bv  artificial 
means  was  no  more  than  — 87°.  Pro¬ 
fessor  Faraday  has  by  the  aid  of  solid 
carbonic  acid  and  ether  produced  a  cold 
=  — 166°,  or  nearly  200°  below  the 
freezing  point  of  water.  It  appears 
that  as  a  compensation  for  the  severity 
of  winter,  a  warm  but  short  summer 
succeeds  by  equable  and  rapid  transi¬ 


tions.  There  are  128  days  in  the  year 
without  frost,  and  during  the  summer 
months  the  thermometer  has  been 
known  to  rise  in  the  shade  as  high  as 
77°.  During  the  short  summer,  the 
ground  is  thawed  to  the' depth  of  three 
feet,  and  crops  of  wheat,  barley,  rye, 
potatoes,  turnips,  and  other  hardy 
vegetables,  are  obtained.  The  soil  is  in 
its  original  or  virgin  state,  and  is  ex- 
,  ceedingly  productive  without  the  aid 
of  guano,  or  the  numerous  artificial 
manures  to  the  use  of  which  we  are 
obliged  to  resort.  As  we  have  else¬ 
where  stated,  the  inhabitants  do  not 
appear  to  suffer  in  health  from  the 
severe  climate  in  which  they  live,  nor 
can  we  find  that  their  food  consists 
entirely  of  oil  or  other  highly  carbona¬ 
ceous  compounds,  which,  according  to 
Baron  Liebig’s  theory,  would  be  abso¬ 
lutely  necessary  to  prevent  their  bodies 
from  being  consumed  by  the  highly, 
condensed  oxygen,  which  it  is  supposed 
they  are  obliged  to  respire. 

Mr.  Cooley  gives  the  above  tempera¬ 
tures  in  Reaumur’s  degrees  as  in  the 
original :  we  have  rendered  them  into 
Fahrenheit’s  degrees,  in  order  to  make 
them  intelligible  to  English  readers,  it 
is  a  matter  of  regret  that  all  our  best 
translators  are  guilty  of  this  fault.  As 
English  books  are  written  for  English¬ 
men,  foreign  degrees  and  measurements, 
if  introduced  at  all,  should  always  be 
accompanied  in  brackets  by  the  corres¬ 
ponding  English  equivalents. 

Here  is  a  fact  interesting  to  meteoro- 
logists  regarding  snow  :  — 

“  I  had  begun  about  noon  to  measure 
solar  altitudes,  when  a  number  of  light 
clouds,  driven  fast  by  the  west  wind,  began 
to  form.  The  air  cooled  down  to  34°,  and 
snow  fell  for  sixteen  minutes ;  then  the 
clouds  dispersed  again,  and  the  evening  was 
clear,  with  increasing  cold.  I  have  never 
seen  snow  in  such  perfect  and  variously- 
formed  crystals  as  during  this  short  and 
sudden  storm.  Each  grain  fell  single,  and 
among  the  few  which  settled  on  my  instru¬ 
ments,  I  could  distinguish  six  different 
forms  :  doubtless  many  more  remained 
unobserved ;  for  my  attention  was  drawn 
in  the  meantime  to  a  more  wonderful  and 
quite  novel  phenomenon.  Many  of  the 
crystals  began  to  melt  the  instant  they 
touched  a  solid  body,  and  some,  as  it  seemed 
to  me,  melted  while  falling  through  the  air ; 
but  this  was  followed  by  a  new  congelation, 
the  grain  of  snow  assuming,  notits  previous 
form,  but  another  more  complex.  The 
most  complicated  forms,  indeed,  were  com- 


378 


MR.  PEARL  ON  THE  CAUSES  OF  GOUT. 


paratively  rare  ;  but  those  transformed 
under  our  eyes  were  so  predominant,  and 
presented  a  spectacle  so  full  of  motion,  that 
at  last  we  could  hardly  help  imagining  them 
to  be  endowed  with  life.  In  fact,  it  is  only 
in  the  case  of  living  beings  that  we  are 
accustomed  to  witness  such  mysterious 
changes,  without  inquiring  after  the  forces 
that  produce  them.”  (Vol.  ii.  p.  502). 

We  here  close  our  notice  of  a  highly 
interesting  work.  The  space  which 
we  could  assign  to  it  has  not  been 
sufficient  to  do  full  justice  to  the 
labours  either  of  author  or  translator; 
we  must  leave  this  to  our  literary  con¬ 
temporaries.  Still  our  readers  will  be 
able  10  form  an  opinion  of  the  contents 
of  these  volumes.  The  reputation  of 
Erman  as  a  scientific  observer,  renders 
it  unnecessary  for  us  to  say  more  than 
we  have  said  at  the  beginning  of  this 
notice  ;  and  it  is  only  doing  justice  to 
Mr.  Cooley  to  state,  that  the  translation 
is  extremely  well  executed. 


(JTciTtspcmfoence. 


ON  THE  CAUSES  OF  GOUT. 

Sir, — The  careful  reading  of  Mr.  White’s 
perspicuous  and  able  paper  on  gout,  in  the 
Gazeite  of  the  18th  inst.,  has  induced  me 
to  make  a  few  observations  on  one  cause  of 
gout  which  has  hitherto  not  been,  as  far  as 
I  know,  alluded  to  by  writers  on  that  dis¬ 
order  ;  and  I  trust  that  the  few  observations 
on  the  nature  of  a  disease  of  which  I  have 
had  great  practical  experience,  will  not  be 
deemed  presumptuous,  or  altogether  out  of 
place. 

I  take  the  tenor  of  Mr.  White’s  paper  is 
to  prove,  1st — That  the  cause  of  Gout  is  an 
animal  poison  in  the  blood,  transmitted  from 
parents  to  their  children,  or  generated  in 
those  in  whom  it  is  not  hereditary,  in  a  man¬ 
ner  which,  in  the  present  paper,  he  has  not 
pointed  out,  but  has  left  us  to  infer  it  to  be 
by  vitiated  secretions  produced  by  an  erro¬ 
neous  dietetic  system,  which  he  intends  to 
point  out  in  a  future  publication.  2nd — 
That  this  poison  is  formed  and  retained  in 
the  body  by  a  functional  disorder  of  the 
liver. 

All  the  symptoms  and  products  of  gout 
lead  to  the  conviction  that  its  cause  is  a 
specific  animal  poison,  cured  or  suspended 
by  a  specific  remedy  ;  and  that  paroxysm 
of  gout  is  a  discharge  of  the  morbid  products 
of  gout  through  the  kidneys,  liver,  and  skin, 
attended  with  more  or  less  fever  and  inflam¬ 
mation. 


That  the  gout  is  transmitted  from  the 
parents  to  their  offspring  is  a  fact  never  at¬ 
tempted  to  be  controverted ;  but  as  to 
the  manner  it  is  generated  where  not  so 
transmitted,  authors  have  differed  most 
widely,  and  given  a  variety  of  causes,  some 
of  which  are  of  the  most  opposite  nature  : 
but  most  are  agreed  that  intemperance  and 
indolence  are  its  main  producers.  The  gout 
so  frequently  attacks  the  most  active  and 
temperate  men,  that  I  feel  certain  these  two 
supposed  causes  are  much  overrated,  and 
that  intemperance  more  frequently  acts  in 
bringing  on  paroxysms  by  exciting  fever, 
where  the  gout  probably  had  been  long 
latent  in  the  system  :  and  there  is  no  fact 
better  established  than  that  intemperance 
has  much  decreased  of  late  years,  while  the 
proportion  of  the  populace  now  attacked 
with  gout  is  more  numerous  than  formerly. 
My  own  conviction  is  that  the  gout  is  some¬ 
times  communicated  from  one  individual  to 
another  ;  that  it  was  so  in  my  own  person, 
and  in  many  others  that  have  come  under 
my  own  observation.  If  the  cause  of  gout 
be  an  animal  poison,  and  I  think  there  can 
be  no  doubt  of  that  fact,  and  which  Mr. 
White  has,  in  his  paper,  pointed  out  in 
a  clearer  manner  than  has  hitherto  been 
done,  I  do  think  it  far  more  likely  to  be 
produced  by  long  attendance  on  those  suf¬ 
fering  from  this  malady,  whose  whole  secre¬ 
tions  are,  during  a  paroxysm,  greatlyimpreg- 
nated  with  the  morbid  products,  than  by 
diet.  1  had  a  most  painful  and  protracted 
attack  myself,  in  the  spring  of  1847,  which 
lasted  till  near  Midsummer ;  during  the 
sleepless  nights  that  it  occasioned,  I  thought 
of  every  possible  cause  that  could  have  pro¬ 
duced  it.  It  was  not  hereditary  in  me ;  I 
could  not  call  to  my  mind  one  relation  that 
had  ever  had  it  :  it  could  not  have  been  in¬ 
dolence  that  produced  if,  nor  intemperance, 
for  my  habits  are  temperate,  and  I  take  a  great 
deal  of  exercise  in  the  open  air ;  then  what 
could  have  been  the  cause  of  an  attack  that 
first  began  in  the  eyes  and  afterwards  per¬ 
vaded  the  whole  system,  almost  every  joint, 
the  skin,  and  even  the  pleura?  My  own 
reasoning  on  gout  led  me  to  the  same  con¬ 
clusion  as  Mr.  White,  that  it  was  an  animal 
poison,  and,  being  so,  it  might  be  also  com¬ 
municable,  and  that  I  had  derived  it  from 
some  one  of  the  numerous  patients  afflicted 
with  the  gout  that  I  had  attended  from  the 
autumn  of  1846  to  the  summer  of  1847. 

In  one  of  my  visits  to  a  gentleman  who 
suffered  from  repeated  attacks,  and  in  whose 
hot  room  I  remained  a  long  time  exposed 
to  the  effluvia  of  his  profuse  perspirations, 
and  also  to  the  evacuations  which  I  had  to 
examine,  I  shewed  him  my  gouty  hands,  and 
told  him  that  I  considered  I  had  caught 
the  gout  of  him,  or  some  one  else.  “  I  have 
thought  the  gout  was  catching  before,”  was 


MR.  PEARL  ON  THE  CAUSES  OF  GOUT. 


379 


his  reply  ;  “  I  inherited  the  gout  from  my 
parents :  father  and  mother,  brothers  and 
sisters,  all  had  gout,  but  none  of  my  late 
wife’s  relations.  She  became  gouty  after 
her  marriage,  and  it  in  a  great  measure  de¬ 
stroyed  her.  I  have  often  thought  she  re¬ 
ceived  it  from  me.” 

A  patient  of  mine,  now  in  business,  a 
very  gouty  man,  declares  that  none  of  his 
relations  are  so  afflicted,  and  that  he  became 
so  while  he  was  a  valet  to  a  gouty  gentle¬ 
man,  whose  chalk  stones  he  used  often  to 
remove,  as  well  as  bandage  his  legs,  and 
give  him  every  kind  of  attention  when 
helpless  from  the  disorder. 

There  is  now  living  in  Windsor  Forest  a 
former  valet  to  a  well-known  nobleman,  a 
personal  friend  to  the  three  last  kings,  who 
is  crippled  by  gout,  and  who  relates  that, 
when  he  first  entered  this  nobleman’s  ser¬ 
vice,  who  was  frequently  attacked  by  gout, 

he  was  thus  addressed  by  him  : — “  J - , 

have  you  ever  had  the  gout?”  “  No,  my 
Lord,”  was  the  reply.  “  Then  you  will 
have  it.  I  have  never  had  a  valet  that  did 
not  get  the  gout  before  he  left  me,”  was  the 
nobleman’s  rejoinder.  And  although  this 
man  was  of  an  excellent  constitution,  and 
not  hereditarily  tainted  by  gout,  lived  in  a 
most  temperate  and  careful  manner,  and  has 
been  all  his  life  one  of  more  than  common 
intelligence,  and  who  avoided  all  excesses, 
and  adopted  such  regimen  as  appeared  most 
likely  to  cause  exemption,  and  yet  got  the 
gout ;  and  how  is  this  to  be  explained — 
that  all  the  valets,  whose  service  compels 
them  to  keep  within  bounds,  should  be  so 
attacked,  whilst  the  others,  who  might,  with¬ 
out  much  restriction,  run  riot  in  strong 
potations,  escaped  ? 

It  would  appear  that  Mr.  White  is  rather 
premature  in  declaring  that  a  fit  of  the  gout 
is  only  a  manifestation  of  a  functional  dis¬ 
order  of  the  liver.  Without  doubt,  the  liver 
being  the  greatest  purifier  of  the  blood  of 
any  organ  in  the  body,  a  larger  portion  of 
morbid  matter  may  pass  through  it,  and 
then  be  discharged  in  the  bowels,  than  of 
any  other  single  organ  ;  but  a  perfect  re¬ 
moval  of  a  fit  of  the  gout  seldom  takes  place 
without  a  profuse  perspiration  ;  and  profuse 
perspirations  are  exceedingly  popular  as  a 
means  to  remove  the  gout.  That  the  gout 
cannot  be  removed  by  acting  on  the  liver 
merely,  or  without  colchicum,  can  be  ex¬ 
plained  by  two  cases  that  occurred  to  me 
recently.  One  gentleman  had  a  severe  fit 
of  the  gout  and  paralysis,  the  paralysis  ap¬ 
pearing  first,  but  coming  on  slowly,  his 
mouth  lastly  being  drawn  completely  on  one 
side,  and  his  speech  impaired.  I  recom¬ 
mended  this  gentleman  to  allow  the  gout  to 
take  its  course,  believing  it  to  be  the  best 
proceeding  to  take  in  reference  to  the  ap¬ 
parently  more  formidable  attack  of  paralysis. 


He  was  bled  and  cupped,  and  had  calomel 
and  saline  purgatives,  and  this  procedure  met 
with  the  approval  of  a  gentleman  of  eminence 
from  London,  who  strongly  recommended 
that  colchicum  should  not  be  administered. 
Notwithstanding  this  active  treatment,  and 
acting  on  the  secretions,  the  paralysis  got 
worse,  and  the  fever,  and  goutand  pains  in  the 
head  increased.  I  then  determined  to  give 
colchicum  in  as  strong  doses  as  the  patient 
could  bear, — as  the  gout  passed  away,  so  did 
the  paralysis,  and  the  pain  in  the  head.  He 
did  not  regain  the  power  of  closing  the  eye 
perfectly  for  some  time,  and  the  tears  ran 
down  the  cheek,  but  this  was  also  restored 
by  small  doses  of  colchicum  long  repeated. 

Another  gentleman  whom  I  saw  after¬ 
wards,  but  did  not  attend,  had  paralysis, 
was  gouty  ;  he  was  purged  with  calomel  and 
salines  for  a  long  time ;  starved  nearly,  and 
was  under  treatment  by  the  most  eminent 
men  in  London  for  months  :  his  voice  is  now 
defective,  and  is  unable  to  take  any  exercise. 

I  attribute  the  difference  in  the  above  cases, 
to  the  free  use  of  colchicum  in  the  former 
one,  administered  as  a  specific  for  the  gout, 
on  the  same  principle,  that  1  would  admi¬ 
nister  mercury  for  syphilis  ;  for  in  all  pro¬ 
bability,  the  causes  of  the  paralysis  in  these 
gentlemen,  was  a  thickening  of  the  membrane 
of  the  brain  similar  to  the  joints  by  a  depo¬ 
sition  of  gouty  matter, — as  paralysis  is 
sometimes  occasioned  by  disease  of  the 
cranium  in  syphilis ;  and  I  repeat,  that  no^ 
treatment,  however  calculated  to  increase 
secretions  of  the  liver,  could  have  benefitted 
these  two  gentlemen,  unless  it  was  combined, 
with  sufficient  quantities  of  the  specific,  cq/- 
chicum. 

As  regards  the  treatment  of  gout,  both  for 
its  prevention  and  cure,  it  appears  to  be  very 
simple.  A  fit  of  the  gout  is  to  be  cured  by 
colchicum  so  administered  as  to  injure  as 
slightly  as  possible  the  constitution. 

To  prevent  the  return  of  fits,  is  to  adopt 
the  most  sparing  regimen  :  a  fit  of  the 
gout  is  inflammation  of  a  specific  character. 
A  person  should  live  in  cool  rooms,  and  if  he 
drink  fermented  liquors  at  all,  they  ought  to 
be  weak  beer,  or  light  acid  wines, — to  eat 
sparingly  of  meat.  Fish  and  vegetables  well 
cooked,  and  fruit  ad  libitum.  I  think  that 
proscription  of  acids  and  vegetables,  and  the 
recommendation  of  mutton  chops,  and  weak 
brandy  and  water  for  diet,  to  be  founded  on 
erroneous  principles.  The  acidity  and 
eructations  are  not  produced  by  the  diet, 
but  by  the  acrimony  of  the  juices,  when  the 
fire,  as  I  may  so  term  it,  is  lighted  up  in  the 
system.  Many  gouty  people  by  abstinence, 
may  avoid  attacks  altogether, — all  may  dimi¬ 
nish  the  severity  of  the  fits.  But  there  are 
many  whose  occupations  require  the  body 
to  be  kept  up  in  high  condition,  (if  I  may 
use  such  a  term),  others  who  cannot  resist. 


380  ADDRESS  TO  THE  GRADUATES 


these  must  occasionally  suffer,  and  suffer 
severely.  As  regards  the  asthenic  species, 
or,  as  it  is  popularly  termed,  the  cold  gout, 
that  I  consider  to  be  an  exception  to  the 
rule,  and  to  be  left  to  the  sagacity  of  the 
medical  attendant,  but  it  ought  to  be  strictly 
considered  an  exception.  There  are  asthenic 
cases  of  small- pox  and  asthenic  cases  of 
measles,  and  it  has  been  the  making  the  ex¬ 
ception  the  rule  that  formerly  led  to  the 
heating  treatment  of  small-pox  and  measles, 
and  to  the  destruction  of  thousands  of  human 
lives. — I  am,  sir, 

Your  obedient  servant, 

G.  Pearl. 

Windsor,  August  24. 


JMducal  Intelligence. 


THE  CHOLERA. 

A  recent  letter  from  Aleppo  gives  a  fright¬ 
ful  account  of  the  ravages  of  the  cholera 
morbus  in  Asia  Minor.  The  number  of 
deaths  increased  daily  ;  and  between  the  17th 
and  19th  of  July,  nearly  1000  patients  suc¬ 
cumbed.  Belief  in  predestination  prevents 
the  Mahometan  part  of  the  population  from 
taking  any  precautions,  or  resorting  to  any 
remedies.  Since  the  15th  of  July,  the  ave¬ 
rage  diurnal  number  of  deaths  has  amounted 
to  140.  To  aggravate  the  evil,  there  are 
only  three  European  physicians  in  Aleppo, 
with  a  population  of  80,000. 

A  letter  from  Abo,  in  the  Grand  Duchy  of 
Finland,  dated  the  1st  inst.,  states  that  the 
cholera  had  appeared  in  that  town  for  the 
second  time  on  the  26th  of  July  ;  52  persons 
had  been  attacked,  of  whom  25  had  died, 
and  11  had  recovered.  Further  accounts 
state  that  that  fatal  malady  was  making 
great  ravages  in  Czernowitz,  in  Austrian 
Galicia.  The  inhabitants  were  quitting  the 
town  to  take  shelter  in  the  mountains. 

Russia. — The  Vienna  papers  of  the  17th 
and  18th,  received  this  morning,  state 
that  the  cholera  is  raging  in  the  interior  of 
the  empire,  and  that  the  disease  is  exceed¬ 
ingly  malignant  at  Riga,  where  as  many  as 
100  are  carried  off  daily,  out  of  a  popula¬ 
tion  of  from  40,000  to  50,000  inhabitants. 
It  is  remarkable  that  the  parents  of  the  pa¬ 
tients  who  have  recently  died  of  cholera 
were  carried  off  by  the  same  disease  in 
1832-33. 

king’s  college  hospital. 

The  Committee  of  Management  of  King’s 
College  Hospital  have  succeeded  in  purchas¬ 
ing  a  large  plot  of  ground,  on  which  they  pro¬ 
se  to  erect  a  new  hospital,  on  such  a  scale 
as  will  afford  ample  accommodation  for  the 


OF  THE  UNIVERSITY  OF  LONDON. 


suffering  poorof  the  densely  populated  district 
around  it.  The  ground  extends  from  Carey 
Street  to  Clement’s  Lane,  and  is  of  considera¬ 
ble  size.  This  is  a  very  important  acquisition, 
not  only  for  the  hospital,  which  now  occupies 
a  high  position  among  the  charitable  institu¬ 
tions  of  the  metropolis,  but  also  for  the 
neighbourhood,  which  cannot  fail  to  be 
greatly  improved  by  the  removal  of  the  old 
decaying  houses  now  standing  upon  the 
ground,  and  the  erection  of  a  handsome 
building  instead  of  them.  A  new  street  has 
been  long  talked  of  in  this  locality,  to  relieve 
the  overthronged  thoroughfare  of  the  Strand; 
and  we  cannot  help  thinking  that  the  Com¬ 
missioners  of  Metropolitan  Improvements, 
if  disposed  to  act  in  conjunction  with  the 
authorities  of  the  hospital,  might  find  their 
object  much  facilitated  by  this  new  acquisition 
on  the  part  of  the  committee. 

ADDRESS  TO  THE  GRADUATES  OF  THE 
UNIVERSITY  OF  LONDON. 

The  Committee  appointed  at  the  General 
Meeting  of  Graduates,  at  Freemasons’  Hall, 
on  the  8th  of  June  last,  desire  to  address 
their  constituents,  to  inform  them  of  their 
past  proceedings,  and  of  the  measures  in 
contemplation  for  securing  and  improving 
the  position  which  they  feei  that  they  have 
already  gained.* 

The  Resolutions  passed  at  that  Meeting 
pointed,  it  will  be  remembered,  to  the  orga¬ 
nization  of  the  Graduates  for  the  protection 
of  their  academical  and  general  interests — 
their  desire  to  act  in  harmony  with  the  views 
of  the  Senate — to  the  securing  for  the  Gra¬ 
duates  as  a  body  representation  in  the  Uni¬ 
versity  ;  and  until  this  could  be  effected,  an 
occasional  and  stated  communication  between 
the  Graduates  and  the  Senate. 

And  by  the  4th  Resolution  your  Commit¬ 
tee  was  appointed  “  to  draw  up  a  scheme 
for  the  organization  of  the  Graduates,  to  be 
submitted  to  a  future  General  Meeting,  to 
be  called  by  the  Committee  :  such  Commit¬ 
tee  to  have  authority  to  communicate  the 
Resolutions  now  agreed  upon  to  the  Senate, 
and  to  have  full  powers  to  act  generally  on 
behalf  of  the  Graduates,  until  such  General 
Meeting  of  the  Graduates  shall  be  held.” 

In  acting  upon  this  Resolution,  your 
Committee  consider  it  premature  to  draw 

*  It  will  not  be  amiss  to  state,  for  theinformation 
of  such  Graduates  as  may  not  have  become  ac¬ 
quainted  with  the  present  movement,  that  it  origi¬ 
nated  in  the  conviction  long  felt  among  the  Gra¬ 
duates,  both  that  the  Metropolitan  University  was 
deficient  in  that  widespread  influence  in  society 
which  the  liberal  views  of  its  founders  seemed  to 
promise,  and  that  the  value  of  their  own  degrees 
was  very  imperfectly  estimated  by  the  public. 
These  facts  were  felt  to  be  closely  connected  with 
the  absence  of  any  constitution  incorporating 
the  Graduates  as  part  of  the  University.  The 
movement  may  fairly  claim  to  be  of  public  in¬ 
terest,  no  less  than  of  private  benefit  to  the  Gra¬ 
duates  themselves. 


ADDRESS  TO  THE  GRADUATES  OF  THE  UNIVERSITY  OF  LONDON.  38] 


up  any  elaborate  scheme  of  organization  un¬ 
til  the  direction  in  which  it  would  be  most 
useful  should  be  better  ascertained.  If  the 
Senate — of  whose  views  your  Committee 
were  then  entirely  ignorant — should  be  pre¬ 
pared  for  the  immediate  admission  of  the 
Graduates  as  part  of  the  Body  Corporate  of 
the  University,  the  Graduates  would  become 
organised  by  the  arrangements  necessary  for 
that  measure.  If,  on  the  other  hand,  their 
claims  were  entirely  repudiated,  an  organi¬ 
zation  of  a  different  nature  would  have  to  be 
provided. 

Your  Committee,  therefore,  immediately 
placed  themselves  in  communication  with 
the  Senate,  and  having  satisfied  that  body 
that  they  were  representatives  of  the  general 
wishes  of  the  Graduates,  drew  their  attention 
to  the  appointment,  in  1840,  of  a  Committee 
of  the  whole  Senate,  to  consider  of  any  alte¬ 
rations  it  might  be  expedient  to  make  in  the 
Charter,  and  to  the  resolution  unanimously 
agreed  to  on  Mr.  Warburton’s  motion  by 
that  Committee,  “  That  as  soon  as  the  Gra¬ 
duates  of  three  years’  standing  shall  amount 
in  number  to  300,  it  will  be  expedient  to 
constitute  the  said  Graduates,  and  all  future 
Graduates  of  the  same  standing,  together 
with  the  persons  who  then  or  thenceforth 
shall  be  or  shall  have  been  Members  of  the 
Senate,  the  Electoral  Body  of  this  Univer¬ 
sity  and  desired  to  be  informed  whether 
it  was  in  contemplation  to  act  upon  this  Re¬ 
solution,  which  it  was  believed  would  take 
effect  on>  the  1st  of  December  next.  Your 
Committee  were  informed  in  reply,  that  the 
Resolution  was  no  longer  subsisting,  having 
been  subsequently  rejected;  and  that  the 
subject  had  not  since  been  mentioned  in  the 
Senate. 

Finding,  however,  that  the  Members  of 
the  Senate  were  fully  alive  to  the  extent  and 
serious  purpose  of  the  present  movement, 
your  Committee  persevered  in  pressing  the 
matter  on  their  attention,  and  the  Senate 
shortly  afterwards  consented  to  represent 
the  w  ishes  of  the  Graduates  to  the  Secretary 
of  State. 

The  Senate  have  also  agreed  to  communi¬ 
cate  to  your  Committee  such  of  their  mi¬ 
nutes  as  generally  affect  the  Graduates,  and  to 
receive  such  representations  as  your  Com¬ 
mittee  may  think  it  desirable  to  offer. 

Your  Committee  would  observe,  that  by 
this  Resolution,  and  the  fidelity  with  which 
it  has  been  acted  upon,  one  of  the  objects  of 
the  General  Meeting  is  already  realised  ;  a 
regular  communication  being  established 
between  the  Senate  and  the  Graduates. 
Tour  Committee  are  now  in  constant  inter¬ 
course  with  the  Senate,  and  are  also  exten¬ 
sively  acquainted  with  their  past  proceed¬ 
ings  ;  and  are  consequently  in  a  position  to 
invite  the  communications  of  Graduates  upon 
n>  matters  either  of  general  importance  or 


of  personal  interest ;  in  both  of  which  they 
have  reason  to  assure  themselves  their  re¬ 
presentations  will  have  weight. 

The  Earl  of  Burlington  having,  in  pur¬ 
suance  of  the  Resolution  of  the  Senate,  in¬ 
formed  Sir  George  Grey  of  the  wishes  of  the 
Graduates,  your  Committee  immediately 
obtained  his  consent  to  receive  a  Deputation, 
and  accordingly  Dr.  Storrar,  Professor  Mil¬ 
ler,  Dr.  Tyler  Smith,  Mr.  Quain,  Mr.  Jes- 
sel,  and  the  secretaries,  Dr.  Robert  Barnes 
and  Mr.  Foster,  waited  upon  Sir  George 
Grey,  at  the  Home-office,  on  the  28th  July 
ult. 

The  Deputation,  in  pursuance  of  the  in¬ 
structions  of  your  Committee,  represented  to 
Sir  George  Grey  the  circumstances  under 
which  this  movement  originated — the  strength 
of  the  feeling  among  the  Graduates,  as  evi¬ 
denced  by  two  crowded  meetings,  (the  latter 
attended  by  Graduates  from  distant  parts  of 
the  county,)  and  the  numerous  letters  of 
adhesion  then  and  since  received,  and  that 
consequently  your  Committee  ought  to  be 
regarded  as  representing  the  considerable 
majority  of  the  present  Graduates  of  the 
University.  They  then  represented  that  by 
the  present  constitution  of  the  University 
the  Senate  was  a  body  completely  isolated 
from  the  Graduates,  and  without  any  autho¬ 
rised  channel  of  communication  with  them, 
and  consisted  pi’ineipally  of  members  of 
other  Universities,  who  could  not  be  sup¬ 
posed  to  feel  that  peculiar  and  exclusive  in¬ 
terest  in  the  University  of  London  which 
must  be  necessarily  felt  by  its  Graduates  : 
that  at  present  (and  the  consciousness  of 
this  had  created  great  uneasiness)  the  Gra¬ 
duates  had  no  share  or  influence  whatever 
in  the  management  of  its  affairs,  but  as  soon 
as  they  had  received  their  degrees,  (perhaps 
by  the  post  or  a  messenger,)  they  had  no¬ 
thing  more  to  do  with  the  University:  and 
that  their  desire  was  to  be  made  a  part  of 
the  Corporate  Body  of  the  University  (being 
in  fact  the  parties  principally  interested  in 
its  welfare),  with  privileges  similar  to  those 
enjoyed  by  the  Graduates  of  Oxford,  Cam¬ 
bridge,  and  Durham  (in  accordance,  as  it  is 
understood,  with  a  promise  to  that  effect 
from  Government  at  the  foundation  of  the 
University),  and  subject  to  such  modifica¬ 
tions  as  the  peculiar  nature  and  objects  of 
this  University  might  render  proper. 

The  deputation  then  stated  that  the  Gra¬ 
duates  already  exceeded  400,  and  from  the 
number  of  the  Under-Graduates  it  was  pro¬ 
bable  that  before  the  necessary  arrangements 
could  be  completed,  they  would  fall  little 
short  of  1000  in  number,  and,  upon  these 
grounds,  strongly  submitted  that  the  time 
was  now  come  for  such  a  reconstruction  of 
the  University  as  would  admit  the  Graduates 
to  be  a  part  of  the  Corporate  Body,  agree¬ 
ably  to  the  original  intention  of  its  Founders ; 


382  ADDRESS  TO  THE  GRADUATES  OF  THE  UNIVERSITY  OF  LONDON. 


and  without  entering  upon  any  plan  or 
details  (which  appeared  premature),  re¬ 
quested  Sir  George  Grey,  if  he  acceded  to 
the  general  principle  of  the  above  repre¬ 
sentations,  to  remit  to  the  Senate  the  con¬ 
sideration  of  the  proper  measures  to  be 
adopted.  Your  Committee  then  proposed 
to  submit  to  the  Senate  such  a  measure  as 
should  satisfy  the  Graduates,  trusting  that 
in  the  result  a  constitution  might  be  framed 
which  should  meet  with  the  approval  of  Sir 
George  Grey,  and  be  acceptable  to  the 
present  Senate  and  the  Graduates  gene¬ 
rally. 

Although  your  Committee  are  necessarily 
anxious  not  to  construe  Sir  George  Grey’s 
reply  too  favourably,  they  believe  the  Gra¬ 
duates  may  rely  upon  his  favourable  con¬ 
sideration  of  their  wishes.  Sir  George  Grey 
was  understood  to  say  that  he  could  not 
answer  definitively  without  consulting  the 
Senate  ;  but  that  the  desire  of  the  Graduates 
was  very  natural  and  proper  ;  and  if  the 
Deputation  would  oblige  him  with  a  written 
statement  of  their  views,  it  should  have  his 
best  consideration.  Allusion  being  made  to 
a  rumour  that  it  was  in  contemplation  to  fill 
up  some  of  the  vacancies  in  the  Senate,  Sir 
George  Grey  spontaneously  assured  the  De¬ 
putation  that,  if  that  measure  were  resolved 
upon,  it  should  in  no  way  prejudice  the 
Graduates,  or  their  ulterior  object  of  obtain¬ 
ing  a  new  Charter. 

A  statement  to  the  effect  of  the  above 
representations  has  since  been  transmitted  to 
Sir  George  Grey,  and  its  receipt  officially 
acknowledged  by  Mr.  Waddington,  the 
Under-Secretary  for  the  Home  Depart¬ 
ment. 

In  the  present  state  of  public  business,  an 
early  reply  from  Sir  George  Grey  is  not 
expected.  Your  Committee  are  engaged 
meanwhile  in  the  difficult  and  delicate 
task  of  drawing  up  a  scheme  for  the  incor¬ 
poration  of  the  Graduates  in  the  University. 
For  the  purpose  of  giving  useful  expression 
and  efficiency  to  their  views,  three  plans 
appear  to  present  themselves  : — First :  A 
Convocation  of  Graduates,  as  at  Oxford, 
Cambridge,  and  Durham,  with  defined  and 
distinct  powers  of  their  own.  Second:  The 
plan  suggested  by  Mr.  Warburton  in  1840, 
to  vest  the  entire  administration  in  the 
Senate,  who  should  become  in  process  of 
time  the  representatives  of  the  Graduates  by 
periodical  retirement  of  a  proportion  of 
their  number,  and  election  of  new  Members 
by  the  Graduates.  Third  :  A  combination 
of  both  these  measures.  Whichever  of  these 
your  Committee  may  eventually  submit, 
they  will  be  guided  by  the  assurance  that 
the  Graduates  do  not  desire,  and  would  dis¬ 
approve  (were  it  attempted)  any  mere  trans¬ 
ference  to  themselves  of  the  powers  now 
enjoyed  by  the  Senate ;  but,  duly  regarding 


the  rightful  superiority  of  that  body,  to  in¬ 
troduce  themselves  as  a  new  power  into  the 
University,  and  to  effect  such  a  distribution 
of  its  labours  as  may  most  effectually  secure 
the  high  purpose  of  its  foundation. 

Addressing  themselves  to  the  Medical 
Graduates,  your  Committee  can  assure  them 
that  their  position  with  reference  to  the  pro¬ 
posed  Medical  Registration  Bill  has  engaged 
the  serious  attention  both  of  the  Senate  and 
of  your  Committee.  The  Senate  has  entered 
a  caveat  against  the  projected  new  Charter 
to  the  College  of  Physicians,  and  Dr.  Billing 
and  Dr.  Hodgkin  have  been  examined  as 
witnesses  on  their  behalf  before  the  Com¬ 
mittee  of  the  House  of  Commons.  Your 
Committee,  considering  that  the  Graduates 
ought  also  to  be  represented,  having  a  more 
immediate  interest  in  the  question,  made  the 
necessary  application,  and  Dr.  Storrar  and 
Dr.  Robert  Barnes,  M.B.,  were  accordingly 
examined  as  representatives  of  the  Gra¬ 
duates. 

Your  Committee  are  anxious  to  express 
the  sense  they  entertain  of  the  service  ren¬ 
dered  to  the  cause  of  the  University  and  of 
the  Graduates,  by  the  clear  demonstration 
submitted  by  Dr.  Billing  and  Dr.  Hodgkin 
of  the  superior  character  of  the  examinations 
for  its  degrees  in  Medicine. 

Dr.  Storrar  and  Dr.  Robert  Barnes  urged 
the  same  point,  contrasting  the  compre¬ 
hensive  examinations  of  the  University  of 
London,  conducted  under  the  sanction  and 
supervision  of  the  State,  with  the  imperfect 
examinations  instituted  by  the  irresponsible 
medical  corporations.  Having  established 
the  fact  that  the  examinations  of  the  Uni¬ 
versity  of  London  formed  a  guarantee  of 
fitness  to  practise,  whether  as  a  Physician  cr 
Surgeon,  at  least  as  efficient  as  that  afforded 
by  any  other  Institution,  a  formal  claim  was 
then  urged  that  the  Medical  Graduate  of  the 
Metropolitan  University  should  have  the 
right  to  practice  conferred  upon  him  in 
virtue  of  his  degree.  It  was  further  con¬ 
tended  that  he  should  be  uncontrolled  in 
this  right  by  the  superfluous  examinations 
or  imprimatur  of  the  Colleges  of  Physicians 
and  Surgeons,  and  untaxed  by  additional 
pecuniary  contributions  to  these  bodies — 
contributions  which  must  appear  in  the  light 
of  exactions,  as  no  equivalent  could  be  given 
in  return. 

The  leading  arguments  by  which  the 
foregoing  claim  was  supported  were  : — 

1st.  The  public  good  that  must  result 
from  the  stimulus  thus  imparted  to  the 
medical  corporations  to  maintain  a  high 
standard  of  requirements  from  candidates 
for  diplomas. 

2d.  The  peculiar  claim  which  the  Gra¬ 
duates  of  the  University  of  London  have 
upon  the  care  of  the  State,  which  had 
founded  the  University. 


ADDRESS  TO  THE  GRADUATES  OF  THE  UNIVERSITY  OF  LONDON.  383 


3d.  The  fact  that  in  three  several  Acts  of 
Parliament,  the  equivalency  of  the  degrees 
in  Laws  and  Arts  of  the  University  of 
London  with  those  of  Oxford  and  Cam¬ 
bridge  has  been  already  declared,  and  the 
consequent  justice  of  extending  the  like 
consideration  to  the  degrees  in  Medicine. 

Special  objections  were  also  taken  to 
certain  provisions  in  the  proposed  Medical 
Bill,  and  in  the  Charters  to  the  Colleges  of 
Physicians  and  General  Practitioners,  espe¬ 
cially  against  that  clause  which  would  admit 
as  Members  of  the  College  of  Physicians 
(the  proposed  qualification  to  practise  as 
Physician)  M.D.’s  of  Scotch  and  Foreign 
Universities,  while  it  would  exclude  M.B.’s 
of  the  University  of  London.  The  attention 
of  the  Registration  Committee  was  also 
directed  to  that  extraordinary  provision 
which  would  forbid  a  Graduate  in  Medicine 
from  using  his  academical  title,  unless  au¬ 
thorized  by  admission  as  Member  of  the 
College  of  Physicians. 

The  limits  of  this  Address  preclude  a  more 
detailed  statement  of  the  many  topics  ad¬ 
verted  to  in  this  evidence  ;  but  the  Com¬ 
mittee  cannot  forbear  expressing  the  con¬ 
viction  they  entertain,  that  the  representa¬ 
tions  urged  on  behalf  of  the  Medical  Gradu¬ 
ates  of  the  University  of  London,  will  be 
followed  by  the  most  weighty  and  beneficial 
effects.  It  cannot  fail  to  appear  that  an 
University  which,  from  its  constitution  and 
connection  with  the  State,  and  consequent 
freedom  from  all  selfish  influences,  is  so  emi¬ 
nently  calculated  to  advance  the  cause  of 
Medical  Science,  and  to  promote  the  inde¬ 
pendence  of  the  Profession,  should  assume  a 
correspondingly  high  position  in  any  settle¬ 
ment  of  Medical  affairs. 

Your  Committee  has  appointed  a  Medi¬ 
cal  suh-Committee  to  watch  the  progress  of 
the  Medical  Bill,  and  the  Charters  sought 
by  Medical  Corporations,  the  prosecution  of 
which  has  been  postponed  to  the  next  Ses¬ 
sion  of  Parliament;  and  the  Committee  in¬ 
vite  the  assistance  of  the  Graduates  generally 
in  furnishing  any  suggestions  or  information 
that  may  promote  the  object  of  their  labours. 

In  conclusion  :  although  the  position  now 
gained  is  but  a  step  towards  our  final  object, 
it  is  an  improvement  very  decided  upon  the 
condition  in  which  we  but  recently  found 
ourselves.  At  the  time  of  the  General 
Meeting,  an  immediate  application  to  the 
Government  for  a  new  Charter  was  certainly 
not  thought  of.  We  were  ignorant  of  the 
views  of  the  Senate  ;  our  own  were  ill- defined 
and  uncertain.  We  had  been  brought  to¬ 
gether  by  the  consciousness  of  a  common 
wrong — that  while  other  Graduates  held,  as 
such,  a  position  of  at  least  some  honour  and 
influence,  our  degrees  were  unrecognized 
even  by  our  own  University.  The  energy 
with  which  the  Graduates  have  taken  up  the 


matter,  has  effected  the  change.  The  Senate 
has  shown  its  sense  of  the  movement,  and  of 
the  consideration  due  to  our  wishes,  by  them¬ 
selves  communicating  to  the  Home  Secretary 
our  general  desire  to  be  represented  in  the 
University,  and  by  resolving  to  communicate 
with  your  Committee  in  all  matters  of  interest 
to  the  Graduates.  And  with  respect  to  our 
ultimate  views,  your  Committee  have  ac¬ 
quired,  in  drawing  up  a  scheme  for  incorpo¬ 
rating  the  Graduates  into  the  University, 
not  only  clearer,  but  larger  conceptions  of 
the  position  which  the  Graduates  may  most 
beneficially  hold.  These,  when  matured, 
they  will  submit  to  the  Graduates.  It  is 
not  improbable,  they  may  recommend  their 
constituents  to  seek  for  a  Charter,  embody¬ 
ing  them  in  a  Convocation  with  extensive 
Initiative,  as  well  as  Vetoist  powers,  and 
providing  for  them,  also,  Representatives  in 
the  Senate  itself,  Thus  the  Graduates  of 
the  University  of  London  will  be  raised  to  a 
position  not  inferior  to  that  anciently  held 
by  the  Graduates  of  Oxford  and  Cambridge  ; 
while  the  Metropolitan  seat  of  their  Univer¬ 
sity  ensures  an  advantage  denied  to  the  less 
fortunate  sites  of  the  older  Institutions, — 
that  the  permanent  residence  in  its  imme¬ 
diate  neighbourhood  of  the  large  majority  of 
its  Graduates  will  secure  alike  their  duties 
from  neglect  and  their  privileges  from  usur¬ 
pation. 

(Signed)  William  Arthur  Case,  M.A. ; 
Charles  James  Foster,  M.A.  LL.B. ; 
Nathaniel  Jennings,  M.A. ;  George 
Jessel,  M.A.  ;  William  Shaen,  M.A.  ; 
Thomas  Jacob  Freeth,  LL.D. ;  John 
Richard  Quain,  LL.B.  ;  Frederick 
John  Wood,  LL.B.  ;  P.  Edward 
Barnes,  B. A.  ;  Jos.  Gouge  Greenwood, 
B.A. ;  Charles  Wm.  Maugham,  B.A.  ; 
Timothy  Smith  Osier,  B.A.  ;  Wm. 
Willmer  Pocock,  B.A. ;  Wm.  Cald¬ 
well  Roscoe,  B.A.  ;  Edward  Ballard, 
M.D.  ;  Joseph  Hullett  Browne,  M.D. ; 
Stephen  J.  Goodfellow,  M.D. ;  Wm. 
Edward  Humble,  M.D.  ;  George  John¬ 
son,  M.D.  ;  Frederick  William  Mac¬ 
kenzie,  M.D. ;  Fredericke  R.  Manson, 
M.D.  ;  William  Allen  Miller,  M.D. 
F.R.S.  ;  Richard  Quain,  M.D.  ;  John 
Snow,  M.D.  ;  John  Storrar,  M.D.  ; 
Robert  Barnes,  M.B.  ;  Henry  Letheby 
M.B. ;  William  Tyler  Smith,  M.B. ; 
John  Birkbeck  Nevins,  M.D.,  Liver¬ 
pool  ;  John  Taylor,  M.D.,  Hudders¬ 
field  ;  Joseph  Carpenter  Bompas,  M.B., 
Bristol;  Edwin  Hearne,  M.B.,  South¬ 
ampton. 

Graduates’  Committee-Room, 

37,  Arundel-Street,  Strand. 

August  16th,  1848. 


384 


M.  ROUX  ON  AMPUTATION  AND  GENERAL  AND 


j&elecitcms  from  ^journal*. 


ON  AMPUTATION  AND  GENERAL  AND  LOCAL 

ETHERIZATION  IN  TRAUMATIC  TE¬ 
TANUS.  BY  M.  ROUX,  NAVAL  SURGEON 

IN  CHIEF  OF  CHERBURG,  CORRESPONDING 

MEMBER  OF  THE  NATIONAL  ACADEMY 

OF  MEDICINE. 

“  If  tetanus  be  caused  by  a  wound,  we  must 
not  hesitate  to  amputate  immediately. ” — 
Larrey ,  Chir.  Milit.,  t.  i.  p.  260. 

“  Experience  has  long  banished  from  my 
mind  all  doubt  as  to  the  alleged  efficacy  of 
amputation  in  these  cases.” — Dupuytren , 
Clin.  Chir.  t.  ii  609. 

I.  On  amputation  in  traumatic  tetanus. 

Struck  with  the  inefficiency  of  the  treat¬ 
ment  in  the  numerous  cases  of  traumatic 
tetanus  which  he  met  with  in  Egypt,  Larrey 
was  induced  to  combat  that  so  often  fatal 
disease  by  amputation. 

Velpeau,  Lisfrance,  Blizard  Curling,  and 
Others,  have  reproduced  this  idea  in  their 
writings;  while  on  the  other  hand,  Boyer, 
S.  Cooper,  Dupuytren,  Berard,  and  others, 
have  combated  it. 

Others — among  whom  is  M.  Baudens — 
consider  that  the  question,  still  undecided, 
can  only  be  settled  by  experience  and  a  just 
appreciation  of  the  facts. 

I  propose  to  examine  this  question  anew, 
both  in  a  theoretical  and  practical  point  of 
view. 

While  some  surgeons  have  advised  ampu¬ 
tation  in  all  cases  of  traumatic  tetanus, 
others,  and  these  comprise  a  great  majority, 
only  amputate  when  the  nature  of  the 
wound  itself  requires  the  loss  of  the  limb. 

The  partisans  of  amputation,  considering 
that  the  primary  cause  of  tetanus  resides  in 
that  part  of  the  peripheral  nervous  system 
directly  mod  tied  by  the  wound,  have  thought 
that  by  the  removal  of  the  cause  the  effect 
will  cease.  They  found  their  opinion  on 
the  gravity  of  the  disease — on  the  imminence 
of  the  danger  leaving  no  choice — and  on  the 
two  following  considerations  :  1.  The  wounds 
followed  by  tetanus  are  often  complicated  by 
the  laceration  of  nerves,  and  by  the  presence 
of  unrecognised  foreign  bodies — effects  which 
are  removed  by  amputation.  The  reality  of 
this  fact  has  often  been  demonstrated  by  the 
autopsy  :  of  this  Dupuytren  reports  a  re¬ 
markable  example.  1  have  noticed  two 
additional  cases,  under  the  care  of  M.  Lal- 
lemand,  at  Montpellier.  2.  Amputation 
being  inevitable,  owing  to  the  gravity  of  the 
lesion,  the  disturbance  which  it  excites  is  far 
from  inducing  the  same  danger  that  would 
exist  if  it  were  practised  after  the  cessation  of 
tetanus,  which  it  might  then  reproduce.  In 


addition,  the  patient  is  not  exposed  to  the 
other  results  of  severe  lesions.  Finally,  six 
ca-es  of  recovery  after  amputation  have  been 
recorded  by  French  surgeons  ;  and  out  of 
eleven  cases  reported  by  Mr.  Blizard  Curling, 
seven  recovered.  In  a  case  cited  by  Valen¬ 
tin,  tetanus,  following  an  injury  to  the  great 
toe,  which  disappeared  after  amputation, 
returned  before  cicatrization  was  complete. 

Many  surgeons  object  to  amputation  in 
traumatic  tetanus  for  the  following  reasons  : 
—  1,  Traumatic  tetanus  may  have  its  origin 
in  a  nerve  affected  by  a  lesion,  but  once  de¬ 
veloped  it  invades  and  exists  in  the  whole 
system ;  2,  Amputation,  often  itself  the 
cause  of  tetanus,  produces  disturbance 
capable  of  aggravating  the  disease  ;  3,  The 
annals  of  such  cases  attest  that  several  thera¬ 
peutical  agents  have  produced  more  cures 
than  have  been  obtained  by  amputation  ;  4, 
Finally,  amputation  is  far  from  always  cur¬ 
ing  traumatic  tetanus  :  Larrey,  Dupuytren, 
and  Cloquet,  have  cited  six  unsuccessful 
cases  ;  and  S.  Cooper  three.  According  to 
Sir  James  Macgregor,  the  English,  after  the 
battle  of  Toulouse,  made  many  unsuccessful 
attempts  to  cure  tetanus  by  amputation. 

The  solution  of  this  question  is  without 
doubt  one  of  the  most  difficult  in  surgery. 
In  my  opinion — 

1.  Amputation  is  not  usually  a  curative 
means  in  tetanus. 

2.  Amputation  will  most  probably  be  of 
service  when  tetanus  supervenes  on  irregular 
wounds,  complicated  with  undetected  fo¬ 
reign  bodies,  and  with  lacerations  of  nerves. 

II.  On  etherization  in  traumatic  tetanus. 

The  appreciation  of  the  modifications 
which  the  organization  presents  under  the 
influence  of  tetanus  and  of  etherization,  soon 
led  surgeons  to  oppose  those  agents  which 
produce  insensibility  and  muscular  relaxation 
to  a  disease  characterized  by  opposite  pheno¬ 
mena — exaltation  of  sensibility  and  muscular 
rigidity.  Recovery  from  idiopathic  tetanus 
has  already  resulted  from  the  use  of  the 
ether  or  chloroform  in  cases  treated  by  MM. 
Petit,  Mignot,  and  Ledru. 

Traumatic  tetanus,  more  unyielding  to 
treatment  than  traumatic,  has  already  yielded 
several  times  to  anaesthetic  agents,  since,  by 
these  means,  Pertusio  and  T.  Hopgood,  have 
obtained  successful  results.  But  at  other 
occasions  chloroform  and  ether  have  proved 
unserviceable,  as  in  the  cases  of  MM.  Vel¬ 
peau  and  Ivonneau  ;  indeed,  these  agents  ap¬ 
peared  to  aggravate  the  disease  in  the  case 
of  one  of  the  wounded  of  February,  cited  by 
M.  Robert,  and  in  another  case  communi¬ 
cated  by  M.  Roux. 

In  spite  of  the  want  of  uniformity  in 
the  results  obtained,  some  clinical  facts 
authorize  a  perseverance  in  the  plan  of  ether¬ 
izing  patients  affected  with  tetanus  from 


LOCAL  ETHERIZATION  IN  TRAUMATIC  TETANUS. 


385 


physical  causes,  and  of  submitting  them  to 
repeated  etherizations. 

In  applying  the  physiological  views  of  re¬ 
flex  movements  to  traumatic  tetanus,  I  think 
we  are  led,  not  only  to  etherize  the  whole 
system  through  pulmonary  inhalation,  but 
also  all  wounded  surfaces,  so  as  to  modify 
them  by  local  etherization  from  the  imme¬ 
diate  application  of  anaesthetic  vapours. 

If,  as  Muller,  (Marshall  Hall),  and  the 
most  eminent  physiologists  of  our  time,  con¬ 
sider,  the  theory  of  reflex  movements  is  ap¬ 
plicable  in  the  explanation  of  tetanic  con¬ 
tractions,  much  light  will  be  thrown  on  the 
pathology  and  therapeutics. 

“  When,”  says  Muller,  (Phys.  t.  i.  p. 
G09)  “  sensations  which  have  been  produced 
by  external  impressions  on  the  sensitive 
nerves,  determine  movements  in  other  parts, 
the  effect  is  never  the  result  of  reaction 
between  the  sensory  and  motor  fibres  of  a 
nerve  itself ;  but  it  depends  upon  this,  that 
the  sensorial  excitement  is  transmitted  to  the 
brain  and  spinal  marrow,  and  then  reacts  on 
the  motor  fibres. 

“  In  pathological  conditions,”  he  adds, 
*l  the  strong  local  excitement  of  a  sentient 
nerve,  may,  by  the  violence  of  the  stimulus 
transmitted  to  the  brain  and  spinal  marrow, 
produce  convulsions  and  rigors,  as  may  be 
seen  after  the  extraction  of  a  tooth.  It 
often  happens  that  the  local  irritation  of 
nerves  from  inflammation,  or  the  presence 
of  a  tumor,  will  produce  general  spasms, 
and  even  epilepsy. 

“  The  irritation  of  the  spinal  marrow,  oc¬ 
casioned  by  local  excitement,  may  be  so 
severe  where  there  is  an  extensive  injury,  as 
to  give  rise  to  continual  convulsions.  All 
violent  irritation  of  the  spinal  marrow,  is  a 
tetanus,  which,  may  have  been  excited  by 
narcotic  poisons,  or  by  some  immediate  and 
local  impression.  We  may  easily  understand 
on  these  principles,  the  manifestation  of 
traumatic  tetanus. 

In  this  form  of  tetanus  the  muscular  con¬ 
traction  may  be  caused  by  two  circum¬ 
stances — first,  by  an  injury  to  some  part  of 
the  sensory  nervous  system  ;  secondly,  by 
the  immediate  lesion  of  the  motor  nervous 
system. 

In  the  first  case,  the  lesion  may  exist  at  the 
extremity  of  one  or  more  sentient  nerves,  in 
the  course  of  those  nerves,  or  in  the  poste¬ 
rior  or  central  portion  of  the  spinal  marrow. 
The  impression  inflicted  on  the  sentient 
nerves  by  a  wound,  is  transmitted  to  the 
posterior  part  of  the  spinal  marrow,  which 
reacts  on  the  motor  portion  of  the  spinal 
marrow ;  and  hence  the  convulsions  and 
muscular  rigidity,  the  duration  of  which 
depends  on  the  permanence  and  extent  of 
the  exciting  cause.  Things  happen  nearly 
in  the  same  manner,  and  the  final  result  is 
the  same,  when  there  is  immediate  injury  to 


a  sentient  nerve,  or  to  the  sensitive  portion 
of  the  spinal  marrow. 

When,  on  the  other  hand,  the  lesion  ex¬ 
citing  the  tetanus  exists  in  the  motor  nervous 
system,  it  always  affects  the  anterior  layers  of 
the  spinal  marrow,  and  to  an  extent  in  re¬ 
lation  with  the  number  of  the  contracted 
muscles.  The  lesion  of  only  one  motor 
nerve,  will  only  excite  contractions  iu  the 
few  muscles  supplied  by  it.  When  a  lesion 
of  the  motor  porton  of  the  spinal  marrow 
excites  tetanus,  the  phenomena  are  not  ex¬ 
plained  by  the  law’s  which  regulate  the  reflex 
motions. 

The  primary  cause  of  traumatic  tetanus 
resides  in  the  wound  itself,  and  may  exist 
either  in  the  extremities  or  course  of  the 
sentient  nerves,  or  in  the  motor  portion  of 
the  spinal  marrow,  or  the  motor  nerves. 

Surgeons  have  acted  in  instinctive  accord¬ 
ance  with  these  principles  when  they  have 
successfully  treated  tetanus  by  such  means 
as  the  local  application  of  opium  and  mor¬ 
phia  ;  the  division  of  the  lacerated  nerves  ; 
the  extraction  of  foreign  bodies  which  had 
wounded  the  nerves  ;  the  division  of  ligatures 
which  compressed  them  ;  the  incision  of 
imperfect  cicatrices  ;  cauterization  ;  the  am¬ 
putation  of  the  limb,  and  other  modes  of 
procedure. 

To  the  list  of  successful  means,  I  propose 
to  add  the  direct  or  local  etherization  of  the 
wounded  surfaces.  By  this  direct  etheriza¬ 
tion  and  consequent  local  etherism,  I  hope 
to  isolate  the  affected  part  from  the  rest  of 
the  orgarflsm,  to  render  insensible  the 
wounded  sentient  nerves,  so  as  to  unfit  them 
for  transmitting  morbid  impressions,  and  to 
arrest  the  tetanus  by  preventing  the  reaction 
of  the  sentient  upon  the  motor  nervous 
system.  But  while  this  local  etherization, 
(which  I  accomplish  easily  by  means  of  my 
ether  apparatus),  ought  to  be  practised  on 
the  wounded  surfaces,  or  the  lacerated  sen¬ 
tient  and  motor  nerves,  the  anaesthetic 
vapours  ought  to  be  used  with  judgment,  so 
that  the  insensibility  may  be  excited  to  a 
proper  degree,  and  that  the  mobility  of  the 
part  may  not  be  permanently  abolished. 
These  precautions  will  be  superfluous,  when 
the  surface  of  an  amputated  stump,  or  of  the 
integument  denuded  by  a  burn  or  lacerated 
wound,  shall  be  subjected  to  etherization. 

M.  Lonyet  on  local  etherization. 

It  results  from  the  experiments  of  M. 
Longet,  “  that  a  mixed  nerve,  the  sciatic, 
for  instance,  exposed  in  a  part  of  its  course, 
and  submitted  to  the  action  of  the  vapour 
of  ether,  or  of  ether  itself,  becomes  insensi¬ 
ble,  though  still  excitable,  at  and  below  the 
etherized  point. 

“  In  the  first  degree  of  direct  etheriza¬ 
tion,  which  appears  at  the  end  of  half  a 
minute  in  dogs  and  rabbits,  the  nerve, 


386 


M.  ROUX  ON  AMPUTATION  AND  GENERAL  AND 


although  absolutely  insensible  at  the  points 
indicated,  still  has  the  power  to  excite 
voluntary  motion  in  the  muscles  which 
it  controls.  In  the  second  degree ,  which 
manifests  itself  after  an  immediate  etheriza¬ 
tion  somewhat  more  prolonged  (three  or 
four  minutes),  the  mixed  nerve  loses  the 
power  which  it  still  possessed  in  the  first 
degree :  it  is  still  insensible,  and  is  entirely 
dispossessed  of  the  faculty  of  exciting  volun¬ 
tary  motion,  though  its  excitability  still  re¬ 
mains.  Finally,  in  the  third  degree,  which 
may  be  observed  after  the  contact  of  the 
ether  with  the  nerve  of  from  twelve  to 
fifteen  minutes,  there  is  neither  sensibility 
nor  voluntary  motion  in  the  muscles  sup¬ 
plied  by  the  nerve,  nor  any  proof  of  excita¬ 
bility  in  the  nerve.” 

The  author  afterwards  makes  the  impor¬ 
tant  remark,  “  That  the  direct  etherization 
of  the  nervous  system  may  be  so  conducted 
as  to  produce  effects  sometimes  transient,  at 
others  lasting.  In  the  first  degree,  the 
anaesthesia  can  only  last  a  few  seconds  ;  in 
the  second,  the  sensory  and  motor  faculties 
sometimes  return  in  less  than  twelve  hours  ; 
finally,  in  the  third  degree,  the  prolonged 
contact  of  the  ether  may  alter  the  intimate 
composition  of  the  nervous  tissue,  the  facul¬ 
ties  of  which  can  only  be  restored  by  the 
regeneration  of  the  tissue  itself.” 

The  experiments  on  the  same  subject 
communicated  to  the  Academy  of  Sciences 
by  M.  Serres,  and  the  researches  by  MM. 
Pappeinheim  and  Good,  on  the  structure  of 
nerves  which  have  lost  their  function  under 
the  influence  of  ether,  shew  the  danger  of 
exposing  the  nerves  too  long  to  the  action  of 
ether. 

In  advising  direct  etherization  to  wounds, 
lacerated  nerves,  and  burns,  I  would  confine 
its  action  to  the  first  and  second  degrees 
pointed  out  by  M.  Longet.  It  is,  indeed, 
advisable  not  to  go  so  far  as  the  second 
degree  when  the  nerve  to  be  affected  is  very 
large.  In  such  a  case,  the  exposure  of  the 
wound  to  the  anaesthetic  vapours,  repeated 
at  short  intervals ,  would  offer  the  advan¬ 
tages  of  continuous  etherization  without  the 
dangers.  Local  etherization  may  be  pro¬ 
longed  without  danger  when  it  is  applied  to 
a  superficial  wound. 

In  proposing  direct  etherization  as  a  local 
treatment  of  traumatic  tetanus,  I  do  not 
conceal  from  myself  that  that  disease  soon 
embraces  the  whole  nervous  svstem,  and 
lessens  the  chance  of  success  by  attacking  it 
at  one  point  only.  Local  and  general 
etherization  ought  to  be  conjoined  in  such 
cases  with  the  other  successful  therapeutical 
agents. 

My  confidence  in  the  efficacy  of  the  means 
I  propose  is  not  founded  on  the  treatment 
of  any  case  of  tetanus ;  nevertheless,  experi¬ 


ments  which  I  will  relate  authorise  me  in 
concluding  that  it  is  rational,  when  we  em¬ 
ploy  general  etherization  in  traumatic  te¬ 
tanus,  to  conjoin  with  it  local  etherization. 

III.  On  amputation  and  etherism  in 
traumatic  tetanus. 

It  is  probable  that  the  opponents  of  am¬ 
putation  in  traumatic  tetanus,  even  when 
the  lesion  itself  calls  for  the  loss  of  the  limb, 
will  have  modified  their  opinion  since  the 
discovery  of  chloroform. 

Amputation  practised  during  etherization 
is  unaccompanied  by  any  shock  to  the 
system,  and  converts  the  complicated  lesion 
before  existing  into  a  simple  wound.  Be¬ 
sides  this,  etherism,  producing  phenomena 
the  opposite  of  those  of  tetanus,  opposes 
with  advantage  its  action  to  that  of  the 
disease. 

Everything  leads  to  the  belief  that  the 
truth  of  this  principle  will  be  acknowledged. 
In  traumatic  tetanus ,  where  the  injury  ne¬ 
cessitates  the  loss  of  the  limb ,  etherism 
ought  to  be  excited,  and  amputation  per¬ 
formed. 

In  a  case  where  tetanus  followed  an  in¬ 
jury  to  the  forefinger,  M.  Velpeau  employed 
repeated  etherization,  without  amputating. 
M.  Yoonneau  employed  chloroform  and 
ether,  without  amputation,  in  vain,  in  a  case 
of  tetanus  following  a  gun-shot  wound  of 
the  right  hand.  Both  these  patients  sank, 
in  spite  of  the  repeated  employment  of 
chloroform  and  ether. 

In  the  following  case  death  took  place, 
although  amputation  was  performed  and 
repeated  etherization  was  practised. 

Case. — Traumatic  tetanus — amputation  of 
the  leg  during  etherism — repeated  etheri¬ 
zation  during  four  days — death. 

9th  April,  1848.  Joachim  Gauthen,  a 
robust  man  of  nervous  temperament,  was 
admitted  into  the  Hospital  of  Marine,  at 
Cherbourg,  suffering  from  fracture  of  the 
fibula,  with  complete  dislocation,  outwards, 
of  the  ankle  joint.  There  was  a  small 
wound  over  the  inner  maleolus.  The  foot 
was  easily  replaced.  Next  morning  there 
was  neither  swelling  in  the  limb,  nor  general 
fever.  , 

On  the  12th,  heat,  redness,  and  swelling 
of  the  limb  came  on,  accompanied  by  fever. 
During  the  next  few  days  he  became  worse ; 
fetid  discharge  came  through  the  wound 
over  the  maleolus ;  and  the  parts  over  and 
within  the  articulation  began  to  slough. 

Incisions  were  made,  and  on  the  21st  the 
swelling  was  lessened,  but  the  general  condi¬ 
tion  of  the  patient  was  worse  :  the  foot  w'as 
displaced  ;  the  sloughing  was  extensive  ;  the 
joint  and  the  tibia  exposed  ;  the  foot  red  and 
oedematous.  In  addition,  he  spoke  and 
swallowed  with  difficulty  ;  and  trismus  was 
present. 


LOCAL  ETHERIZATION  IN  TRAUMATIC  TETANUS. 


387 


Amputation  was  now  indispensable,  and 
would  have  been  already  performed  but  for 
the  general  reaction,  and  the  great  swelling 
of  the  upper  part  of  the  leg.  The  immediate 
amputation  of  the  limb  was  decided  on,  the 
occurrence  of  tetanus  not  being  considered 
an  obstacle. 

In  five  minutes,  unconsciousness  was  pro¬ 
duced  by  chloroform.  The  inhalation  was 
continued  for  three  more  minutes,  until  the 
stiffening  of  the  limbs  gave  place  to  complete 
relaxation  ;  and  the  leg  was  amputated,  the 
patient  being  quite  unconscious.  The  chlo- 
roformization  was  repeated  several  times 
during  the  operation;  and  the  patient  was 
insensible  for  about  eighteen  minutes. 

After  the  operation,  the  trismus  was 
slightly  lessened  ;  but  the  jaws  could  only 
be  partially  opened.  The  patient  com¬ 
plained  of  violent  pain  in  the  stump.  In 
the  course  of  the  day  chloroform  was  ad¬ 
ministered  five  times.  Each  time  pain  was 
suspended  with  consciousness,  and  the  tris¬ 
mus  lessened  with  muscular  relaxation. 
But  these  effects  were  only  momentary. 

Next  day  the  pain  was  lessened,  but  the 
trismus  was  more  pronounced.  Poultices, 
with  laudanum,  were  applied  to  the  wound. 
Etherization  was  practised  six  times  in  the 
course  of  the  day.  The  effect  of  ether  on 
the  patient  did  not  differ  from  that  of  chlo¬ 
roform. 

On  the  23d,  opisthotonos  was  established  ; 
but  the  limbs  were  still  free,  except  during 
paroxysms.  Ether  was  given  once,  and 
chloroform  six  times  during  the  day.  The 
ether  excited  a  prolonged  rigor,  violent 
cough,  and  a  sense  of  suffocation.  The 
ether  was  consequently  exchanged  for  chlo¬ 
roform.  During  the  evening,  after  the  last 
inhalation,  the  bronchise  appeared  to  be 
filled  with  frothy  fluid. 

On  the  24th,  the  symptoms  were  not 
materially  modified.  Deglutition  was  more 
laborious,  and  was  always  accompanied  by 
cough  and  a  sense  of  suffocation,  as  if  each 
time  liquid  entered  the  air  passages.  The 
trismus  and  opisthotonos  were  complete  and 
unyielding.  He  inhaled  chloroform  thrice 
during  the  day.  The  difficulty  of  breathing 
increased,  and  he  became  gradually  worse. 
Deglutition  was  only  possible  during  the 
short  interval  of  muscular  relaxation  which 
followed  the  inhalation  of  chloroform. 

At  midnight  he  became  suddenly  worse : 
the  respiration  being  frequent  and  emba- 
rassed,  the  pulse  rapid,  and  anxiety  increased; 
convulsions  came  on  ;  intelligence,  hitherto 
scarcely  affected,  disappeared  ;  a  cold  sweat 
covered  the  body ;  and,  almost  without 
ag°ny»  he  died  at  1  a.m.,  on  the  25th. 

Autopsy  24  hours  after  death — Complete 
muscular  relaxation,  which  came  on  a  few 
hours  after  death. — The  brain  and  spinal 
marrow,  slightly  congested,  were  in  all  re¬ 


spects  normal.  Little  blood  in  the  cavities 
of  the  heart.  Lungs  engorged,  but  crepita¬ 
ting.  Mucous  membrane  of  the  air  pas¬ 
sages,  especially  in  the  minute  bronchi,  of 
an  ineffaceable  red.  Nothing  remarkable 
was  observed  elsewhere. 

In  this  case,  the  anaesthetic  inhalations 
were  only  followed  by  momentary  relief. 
The  etherism,  sometimes  exciting  cough 
and  sense  of  suffocation,  aggravated,  for  the 
time,  the  disease.  The  progress  of  the  dis¬ 
ease  was  not  modified  by  their  use,  since  he 
died  on  the  fifth  day  from  the  beginning  of 
the  attack ;  the  usual  period  at  which  the 
tetanic  die.  , 

In  reflecting  on  the  intense  pain  seated  in 
the  stump,  it  occurred  to  me,  that  direct 
etherization  of  the  wounded  surfaces  might 
remove  the  painful  impressions  which  were 
transmitted  to  the  nervous  centres,  and  cure 
the  tetanus  by  removing  the  reflex  action 
on  the  muscular  system.  It  seemed  to  me 
that  this  local  and  direct  etherization  of  the 
wounded  surfaces  would  affect  with  anaesthe¬ 
sia  the  extremities  of  the  sensitive  nerves  ; 
interrupt  the  connection  of  those  nervous 
extremities  with  their  centres ;  deprive  the 
nervous  system  of  its  painful  participation 
in  the  suffering  of  divided  parts ;  remove  the 
muscles  and  the  whole  organism  from  the  re¬ 
action  which  violent  irritation  in  the  incitor 
nerves  produces :  in  a  word,  isolate  the 
wound,  by  detaching  it,  so  to  speak,  from 
animal  life,  without  injuring  its  relations 
with  organic  life.  This  isolation,  it  ap¬ 
peared  to  me,  might  be  obtained  by  the 
direct  and  continuous  action  on  the  wound 
of  the  vapours  of  chloroform  or  ether,  with¬ 
out  having  to  fear  that  the  insensibility  in 
the  nerves  would  spread  beyond  the  points 
immediately  acted  on  by  the  anaesthetic 
v  apour,  that  there  would  be  danger  from  ab 
sorption,  or  that  the  stump,  deprived  of  the 
reaction  of  the  whole  economy,  might  want 
the  necessary  irritation  to  carry  it  through 
its  successive  stages  to  cicatrization  :  since 
these  vapours,  which  deprive  the  nerves  of 
their  functions,  excite  the  rest  of  the  tissues. 

Experiments,  with  regard  to  the  effect  of 
local  etherism  on  the  lower  animals  and  on 
man ;  but  these  are  neither  sufficiently 
numerous  nor  decisive  to  be  yet  brought 
forward.  2 


ON  THE  COMPOSITION  OF  THE  SPLENIC 
AND  PORTAL  BLOOD.  BY  M.  J.  BE'- 
CLARD. 

In  a  work  lately  presented  to  the  Parisian 
Academy  of  Sciences,  on  the  functions  of 
the  spleen  and  liver,  the  contents  of  which 
are  based  upon  the  results  of  comparative 
analyses  of  the  blood  of  the  splenic  and 
portal  veins,  M.  J.  Beclard  observes  that 
his  analyses  of  arterial  blood  confirm  the 


388  HINTS  TO  PRESCRIBERS  ON  THE  NECESSITY  OF  WRITING  THE 


opinion  generally  entertained,  that,  from 
whatever  part  of  the  arterial  system  it  is 
taken,  its  composition  is  invariably  the 
same.  Arterial  blood  comes  from  one  organ, 
viz.  the  lungs,  passes  through  one  organ, 
the  heart,  and  is  then  distributed  to  all 
parts  of  the  body.  Venous  blood,  on  the 
contrary,  is  derived  from  every  organ  of  the 
body  ;  consequently  has  sources  as  nume¬ 
rous  as  the  organs  themselves,  and  may  be 
supposed  to  present  certain  differences  in 
composition  from  whichever  organ  it  is  exa¬ 
mined.  With  regard  to  the  differences  be¬ 
tween  arterial  and  venous  blood  generally, 
M.  Bedard  states,  that,  having  in  a  series 
of  experiments  compared  the  blood  of  the 
carotid  artery  with  that  of  the  jugular  and 
crural  veins,  he  found  a  diminution  of  cor¬ 
puscles  and  a  slight  increase  of  fibrin  in  the 
venous  blood. 

The  spleen  resembles  a  gland  in  many 
respects,  but  differs  in  having  no  excretory 
duct :  hence  it  is  necessary  to  examine  the 
blood  for  an  explanation  of  its  use.  The 
results  of  thirty-two  experiments,  in  which 
blood  was  drawn  from  the  splenic  and  from 
the  jugular  veins  in  living  animals,  and  a 
comparative  analysis  made  of  the  fluid  from 
both  these  sources,  shewed  that  the  blood 
returning  from  the  spleen  invariably  contains 
fewer  corpuscles,  more  albumen,  and  rather 
more  fibrin,  than  the  blood  in  the  jugular 
vein  :  hence  the  opinion  that  the  spleen  is 
the  organ  for  the  formation  of  blood-cor¬ 
puscles  is  no  longer  tenable  :  it  seems  rather 
to  be  the  site  of  their  destruction. 

Since  the  trunk  of  the  portal  vein  is 
formed  by  the  junction  of  the  splenic  with 
the  superior  mesenteric,  it  appeared  to  M. 
Beclard  that,  to  obtain  a  correct  analysis  of 
the  portal  blood,  the  contents  of  the  superior 
mesenteric  should  be  examined  previous  to 
this  vein  being  joined  by  the  splenic ;  for 
the  blood  in  the  portal  vein  itself  will  be 
mingled  with  that  from  the  spleen.  From 
many  examinations  of  the  blood  of  the  su¬ 
perior  mesenteric,  he  finds  that,  as  a  rule, 
the  quantity  of  its  albumen  is  considerably 
increased  during  the  early  period  of  diges¬ 
tive  absorption,  while  in  the  latter  periods 
of  this  absorption  the  quantity  of  corpuscles 
is  greatly  increased.  He  did  not  find  that 
the  proportion  of  fatty  matter  was  ever 
greater  in  the  blood  of  the  superior  mesen¬ 
teric  vein  than  in  that  of  the  rest  of  the 
venous  system — an  observation  which  makes 
it  probable  that  nearly  all  the  fatty  matter 
removed  from  the  contents  of  the  intestinal 
canal  is  taken  up  by  the  lacteals,  and  very 
little,  if  any,  by  the  blood-vessels. —  Comptes 
Rendus ,  1848.  A 


HINTS  TO  PRESCRIBERS  ON  THE  NECESSITY 

OF  WRITING  THE  DIRECTIONS  FORTAKING 

MEDICINES,  IN  ENGLISH.  BY  M. DONOVAN, 

ESQ.  M.R.I.A. 

As  the  new  Dublin  Pharmacopoeia  is  to  be 
published  in  English,  its  appearance  will 
afford  a  proper  opportunity  for  introducing 
what  appears  to  me  a  very  necessary  reform 
in  the  prescriptions  of  medical  practitioners. 
The  subject  to  which  I  beg  attention  is  the 
custom  of  writing  in  the  Latin  language  the 
directions  for  taking  or  applying  the  medi¬ 
cines  prescribed .  What  is  the  use  of  this  ? — 
why  labour  to  conceal  from  the  patient  that 
which  is  written  for  no  other  purpose  than 
that  he  may  know  it  ? 

The  disadvantages  which  attend  the  prac¬ 
tice  are  numerous.  The  physician  may,  with 
great  ease,  write  a  direction  in  Latin  which 
it  is  very  difficult  to  convey  in  English,  or 
which  may  admit  of  several  interpretations; 
and  it  is  unfair  to  fix  on  the  apothecary  the 
responsibility  of  conveying,  in  the  brief  com¬ 
pass  of  a  label,  the  exact  intention  of  the 
physician,  in  a  language  which  the  latter  did 
not  use.  The  responsibility  of  giving  precise 
directions  for  the  use  of  a  medicine  ought 
surely  to  fall  on  its  prescriber. 

I  might  rely  on  the  obvious  truth  of  this 
observation  ;  yet  it  may  not  be  amiss  to  give 
a  few  instances  of  Latin  directions  of  com¬ 
mon  occurrence  in  prescriptions,  which  often 
lead  to  misconception,  and  which,  notwith¬ 
standing  their  apparently  trifling  import,  do 
occasionally  cause  great  embarrassment  to 
the  apothecary. 

One  of  the  common  nuisances  in  medical 
Latinity  is  the  expression  “pro  re  nata,” 
which  was  once  translated  by  a  pharmaceu¬ 
tical  savant ,  “  for  the  newlv-born  infant.” 
We  often  find  that  this  direction  is  given  for 
the  exhibition  of  a  medicine  of  no  definable 
power.  If  a  medicine  have  a  particular  and 
recognizable  effect,  such  as  an  aperient,  and 
is  directed  to  be  taken  “  pro  re  nata,”  the 
meaning  cannot  be  mistaken.  But  when  no 
well-marked  and  obvious  operation  can  be 
discovered,  which  can  be  expressed  as  a  title, 
written  at  the  head  of  the  lable,  according 
to  the  custom  of  apothecaries,  the  “  pro  re 
nata”  becomes  a  difficult  phrase  to  translate, 
or  to  be  understood  by  the  patient,  if  trans¬ 
lated.  Suppose  a  mixture  consisting  of 
several  nervous,  antispasmodic,  or  anodyne 
medicines,  is  directed  to  be  taken  “  pro  re 
nata,”  it  may  be  intended  for  many  con¬ 
ditions  or  emergencies,  not  one  of  which  the 
apothecary  has  been  made  acquainted  with. 
How,  then,  is  he  to  translate  the  direction  ? 
Several  modes  are  technically  made  use  of. 
One  is,  “  to  be  taken  occasionally.”  The 
patient,  little  the  wiser,  puzzles  himself  or 
the  apothecary  with  questions  about  the  in¬ 
terval  between  the  doses ;  and  he  comes  to 


DIRECTIONS  FOR  TAKING  MEDICINES  IN  ENGLISH. 


389 


the  conclusion  that  “  occasionally”  means 
nothing,  and  perhaps  he  is  not  far  from  the 
truth.  It  may  be  supposed  that  the  de¬ 
ficiency  has  been  supplied  by  the  prescriber 
in  a  private  direction  to  the  patient.  I  wish 
it  were  always  so  ;  all  then  would  be  right. 
Another  translation  often  used  is,  “  when 
necessary.”  The  patient  exclaims,  “  To  be 
sure  ! — medicine  is  never  taken  but  when  it 
is  necessary,  but  when  is  that  ?”  Unless 
previously  instructed,  he  is  no  judge  of  the 
intervals  of  pain,  sickness,  or  suffering,  at 
which  it  is  safe  to  take  his  dose.  A  third 
translation,  “  as  occasion  may  require,”  is 
liable  to  the  same  objection  :  neither  the 
apothecary  nor  the  patient  may  know  -what 
is  the  “  occasion”  meant.  The  blame  of  so 
vague  a  direction  is  sure  to  fall  upon  the 
apothecary  ;  and  hence  the  physician  is 
bound,  in  common  justice,  to  write  in 
English  the  exact  words  which  are  to  be 
copied  on  the  label :  the  intention  of  the 
prescriber  would  thus  be  better  fulfilled, 
and  the  apothecary  relieved  from  a  most  em¬ 
barrassing  responsibility. 

It  is  even  a  matter  of  some  doubt  if  the 
words  “pro  re  nata”  ought  to  bear  the  import 
in  which  prescribers  wish  them  to  be  under¬ 
stood.  Cicero  uses  them  in  the  sense  of 
“under  existing  circumstances.”  Neither 
Facciolati  nor  Ainsworth  give  the  modern 
acceptation  as  their  translation. 

If  prescribers  were  obliged  to  write  their 
directions  in  English,  they  would  soon  dis¬ 
cover  the  difficulties  under  which  they  place 
the  apothecary  by  the  use  of  Latin  words 
which  have  no  corresponding  English  words 
in  common  use.  Thus  applications  are 
directed  to  be  made  faucibus  internis. 
"What  is  to  be  written  on  the  label  ?  If 
the  apothecary  translate  the  words  by  the 
euphonic  terms  the  gorge,  or  the  weasand, 
the  patient  would  not  be  much  the  wiser. 
When  the  application  is  to  be  made  faucibus 
extends,  the  case  is  as  bad  ;  for  there  is  no 
English  word  to  express  these  parts  ac¬ 
curately  ;  neither  throat  nor  jaws  will  suf¬ 
fice.  Where  the  application  is  to  be  made 
thoraci,  it  may  mean  the  chest,  right  breast, 
sides,  or  part  of  the  back  :  which  of  these 
is  meant  ?  We  find  local  remedies  directed 
for  the  epigastric,  hypogastric,  umbilical, 
and  hypochondriac  regions  :  none  of  these 
parts  can  be  designated  in  the  compass  of  a 
label  with  anything  like  exactness.  I  have 
known  a  liniment  directed  to  be  applied 
regioni  laryngis,  and  was  much  puzzled  to 
contrive  a  label  that  would  express  the  part, 
unless  accompanied  by  a  dissertation  on  ani¬ 
mal  topography.  But  the  puzzle  was  much 
increased  in  another  case,  when  the  applica¬ 
tion  was  to  be  made  to  the  abdomen  of  a 
lady  :  the  “  lower  stomach,”  implying  the 
existence  of  a  second  one,  is  a  refinement 
which  borders  too  much  on  the  ridiculous. 

There  is  nothing  more  common,  in  pre¬ 


scriptions,  than  the  word  “  nocte,”  when  it 
is  intended  that  a  medicine  is  to  be  taken  or 
used  every  night.  Now,  nocte  (by  itself) 
does  not  necessarily  mean  every  night  :  if 
nocte  were  an  adverb,  as  mane  is,  or  may  be, 
then  it  would,  as  a  qualifier  of  the  action 
understood,  signify  every  night;  but  it  is  a 
substantive,  and  cannot  have  the  effect.  In 
this  uncertainty,  the  apothecary  is  bewil¬ 
dered  ;  and  is  doubtful  whether  he  should 
label  the  medicine  to  be  taken  “every  night,” 
or  “  this  night  he  knows  that  if  the  latter 
were  the  sense  intended,  it  should  have  been 
writren,  as  it  often  is,  hac  nocte ;  but  the 
question  with  him  is,  did  the  prescriber  enter 
into  these  minute  considerations  ?  It  would 
be  better  to  write  “  noctu”  when  every  night 
is  intended  ;  for  although  the  Roman  writers 
sometimes  used  the  word  to  express  a  par¬ 
ticular  night,  it  is  always  in  that  case  con¬ 
joined  wdth  a  hunting  expression,  and  without 
this  it  is  “  night  generally,”  or  “  every 
night.”  Thus,  Sallust  and  Cicero  say 
“  noctu  diuque.” 

An  analogous  error  occurs  in  the  use  of  the 
word  “  mane,”  which,  being  both  an  adverb 
and  a  substantive,  may  mean  either  “  every 
morning,”  or  less  properly,  “in  the  morn¬ 
ing:”  surely,  in  the  latter,  or  indeed  any 
case,  the  word  should  have  some  adjunct  to 
free  it  from  the  equivoque. 

But  one  of  the  worst  of  the  errors  of  this 
class  is  the  direction  frequently  given  for  a 
medicine  that  is  to  be  taken  every  night,  ex¬ 
pressed  in  the  prescription  by  “  hora  somni,’’ 
as  if  the  two  words  were  taken  adverbially. 
The  apothecary  has  a  right  to  interpret  the 
expression  literally,  to  be  taken  “  at  bed- 
|  time,”  meaning  for  that  night  only  ;  but  he 
is  not  warranted  in  directing  the  pill  to  be 
taken  at  “  bed-time  every  night,”  yet  that 
is  what  was  intended  by  the  prescriber. 

Much  inconvenience  often  arises  from 
measuring  medicines  by  spoon,  the  size  of 
which  varies  much,  according  to  the  fancy 
of  the  proprietors.  A  tablespoon,  in  a 
medical  sense,  is  the  measure  of  half  an 
ounce  ;  but  frequently  it  is  capable  of  con¬ 
taining  double  that  quantity.  The  same 
observation  applies  to  other  denominations  of 
spoons.  Aware  of  this  source  of  inaccuracy, 
some  physicians  direct  “  an  ounce,”  or  some 
aliquot  part  of  it,  to  be  taken  for  a  dose.  If 
such  a  direction  be  written  on  the  label, 
what  will  the  patient  think  of  the  common 
sense  of  the  apothecary  ? — and  if  it  be  not, 
what  will  the  prescriber  think  of  an  apothe¬ 
cary  who  had  directed  “  two  tablespoonfuls” 
of  a  medicine,  which  on  account  of  the  size 
of  the  spoon,  may  possibly  contain  double 
the  quantity  of  prussic  acid,  or  laudanum, 
or  black  drop,  that  was  intended  ?  How, 
then,  is  the  apothecary  to  act,  unless  he  sent 
the  patient  a  graduated  measure,  accompanied 
by  a  treatise  on  its  marks. 

Indeed  the  word  cochleare  is  altogether 


390  ON  WRITING  THE  DIRECTIONS  FOR  TAKING  MEDICINES  IN  ENGLISH. 


objectionable.  I  know  not  how  it  came  to 
be  used  as  the  measure  of  a  tablespoonful.* 
The  only  knowledge  we  possess  of  what  was 
the  measure  of  the  Roman  cochlear  is  derived 
from  Rhemius  Faunius,  who  informs  us  that 
cyathus  is  the  twelfth  part  of  a  sextarius  ; 
and  cochlear  or  cochleare  is  the  fourth  part 
of  a  cyathus.  I  have  shown  (Medical 
Press,  January  5th,  1848,  p.  9),  that  the 
Roman  sextarius  contained  8743  troy  grains, 
and  therefore  cochleare  must  be  equal  to 
0‘4  ounce,  or  about  half  the  measure  of 
many  modern  tablespoons.  Viewing  this 
measure,  then,  either  derivatively  or  practi¬ 
cally,  it  is  not  the  proper  representative  of  a 
tablespoonful  :  it  leads  to  uncertainty  in  a 
case  where  accurracy  is  so  necessary.  Beside 
all  this,  every  prescriber  does  not  bear  in 
mind  that  cochleare  is  a  generic  term  which 
requires  some  specific  adjunct  to  render  it  in¬ 
telligible.  I  have  known  cochleare  by  itself 
to  be  used  when  a  dessertspoonful  was  meant. 
Let  the  use  be  remembered  that  was  made 
of  the  omission  of  the  specific  designation 
during  the  investigation  of  Dr.  Cronin’s  case ! 
Some  sensible  physicians  direct  a  fourth  or 
sixth  part,  as  the  case  may  be,  to  be  taken 
at  the  proper  intervals  ;  this  removes  all 
ambiguity  .f 

The  word  “  urgente”  is  another  of  the 
puzzlers  which  often  occurs  in  prescriptions, 
and  which  cannot  always  be  translated  by  a 
manageable  word  on  a  label.  How  is 
“urgente  dolore’’  to  be  expressed?  “  when 
the  pain  is  distressing”  is  sometimes  written : 
is  pain  ever  agreeable,  or  otherwise  than 
distressing  ?  Others  write,  “  when  the  pain 
comes  on  but  the  pain  may  be  persistent, 
and  the  prescriber  may  have  meant  when  it 

*  I  hope  it  is  not  descending  too  minutely  into 
particulars,  which  some  may  deem  trivial  and 
out  of  place,  to  notice  the  spelling  of  this  word  in 
the  plural  number, — a  word  to  be  found  in  almost 
every  label  sent  from  an  apothecary’s  establish¬ 
ment,  and  often  the  cause  of  animadversion. 
Through  a  mistaken  refinement,  it  is  written  “  ta- 
blespoonsful”  by  persons  who  consider  “table¬ 
spoonfuls”  a  vulgarism.  I  believe  the  former  to 
be  erroneous,  and  the  latter  correct,  for  the  fol¬ 
lowing  reasons.  Although  one  of  the  institutions 
of  the  German  language,  it  is  foreign  to  English, 
and  looks  like  a  practical  bull,  to  insert  a  plural 
termination  in  the  middle  of  a  word.  We  have 
also  to  consider  that  when  two  tablespoonfuls  of 
a  medicine  are  to  be  swallowed,  we  do  not  make 
use  of  two  spoons,  but  one  only  :  why,  then,  give 
to  one  spoon  a  plural  termination  ?  The  expres¬ 
sion  in  question  is  not  to  be  considered  as  con¬ 
sisting  of  two  separate  words,  by  usage  written 
together — viz.,  spoons  full,  but  as  one  word  ;  in 
proof  of  which  I  adduce  the  fact  that  “  full,” 
drops  an  1,  and  therefore  cannot  be  the  adjective 
“  full,”  but  is  the  latter  member  of  a  dissyllable. 
How  ridiculous  would  it  be  to  say  that  a  person 
took  “two  mouthsful  of  anything;”  he  should 
first  have  two  mouths. 

t  It  is  to  be  hoped  that,  in  the  new  Pharmaco¬ 
poeia,  definitions  will  be  given  of  what  physicians 
ought  to  mean  when  they  write  tablespoon¬ 
ful,  dessert-spoonful,  wineglassful, — all  of  them 
measures  so  uncertain  and  so  differently  under- 
tood. 


becomes  very  great :  yet,  with  the  condition 
of  the  patient,  the  apothecary  is  supposed  to 
be  unacquainted. 

In  the  case  of  “  urgente  rigore,”  which  is 
sometimes  written,  a  new  difficulty  occurs. 
We  have  no  English  word  that  exactly  corre¬ 
sponds  with  the  medical  term  rigor:  shivering 
will  not  answer  in  all  cases ;  and  hence,  in 
medical  books,  the  Latin  word  itself  is 
always.used.  The  practitioner  relieves  him¬ 
self  easily  from  the  embarrassment  by  throw¬ 
ing  on  the  apothecary  the  difficulty  of  finding 
a  word  to  express  a  condition  of  the  body 
which  required  such  an  elaborate  description 
as  that  given  by  Celus  : — “  In  corporibus 
rigor  est,  cum  membrum  durescit,  torpetque 
velut  gelu  adstrictum,  et  sensum  amittit, 
et  corrumpitur.”  Ainsworth  translates  rigor 
by  a  great  stiff  cold,  hardness,  roughness, 
stiffness,  the  cold  of  an  ague  :  it  is  matter 
of  taste  which  the  apothecary,  ignorant  of 
the  symptoms,  shall  select. 

It  is  common  to  direct  a  dose  of  a  medi¬ 
cine  to  betaken  “pro  renata,  urgente tussi.” 
This  may  be  merely  a  thoughtless  pleonasm, 
meaning  that  the  medicine  is  to  be  taken 
“  when  necessary,  when  the  cough  is  trouble¬ 
some  or,  as  pro  re  nata  literally  means, 
“according  as  the  thing  happens  or  results,” 
the  interpretation  might  be  given  that  the 
dose  is  to  be  frequent  in  proportion  to  the 
violence  of  the  cough  ;  or  that  it  is  to  be 
taken  “  occasionally  while  the  cough  is 
urgent.”  How  is  the  apothecary  or  patient 
to  know  what  is  meant,  where  words  assume 
so  metaphysical  an  aspect  ?  Sometimes  the 
direction  is  that  the  medicine  is  to  be  taken 
“  subinde,  urgente  diarrhoea.”  Is  it  fair  to 
use  this  word  subinde,  on  the  meaning  of 
which  whole  dissertations  have  been  written, 
in  a  prescription  containing  most  probably 
laudanum  ?  And  if  to  this  difficulty  we  add 
that  of  finding  decent  language  in  a  very 
short  compass,  to  express  “urgente  diar¬ 
rhoea,”  it  will  be  seen  that  the  physician 
relieves  himself  of  some  difficulty  by  the  ex¬ 
pedient  of  throwing  it  on  the  apothecary, 
who  is  not  in  a  condition  to  resolve  it. 

I  could  give  many  other  instances,  but  the 
foregoing  may  suffice  :  they  offer  sufficient 
proofs  of  the  inconvenience  and  utter  inutility 
of  writing  directions  in  Latin,  and  it,  n  many 
cases,  none  of  the  best.  It  is  due  to  the  pa¬ 
tient,  as  well  as  to  the  apothecary,  that  the 
direction  should  be  in  plain  English  :  many 
an  error  would  thus  be  avoided  ;  and  many 
an  imputation  on  the  apothecary  spared. 
Several  physicians, excellentclassical  scholars, 
have  long  felt  the  prudence  of  dispensing  with 
the  mystery  of  a  Latin  direction,  and  have 
given  it  in  unmistakeable  English,  thus 
leaving  to  the  apothecary  the  simple  duty 
of  transcribing  it  on  his  label.  If  the  prac¬ 
tice  were  universally  adopted,  it  would  cer¬ 
tainly  convey  the  intentions  of  the  prescriber 


ON  THE  MANAGEMENT  OF  STILL-BORN  CHILDREN.  391 


with  more  precision,  because  more  directly 
to  the  patient ;  and  tend  to  remove  from  the 
public  mind  the  impression  that  physicians 
are  not  sufficiently  explicit  in  their  instruc¬ 
tions  for  the  exhibition  of  their  remedies. — 
Dublin  Medical  Press ,  Aug.  1848. 

*%*  There  is  much  truth  in  these  remarks. 
If  the  Latin  language  be  retained  for  medi¬ 
cines  there  can  be  no  good  reason  for 
employing  it  in  the  directions  :  while  there 
are  many  strong  reasons  against  its  use  for 
this  purpose.  Why  make  a  druggist  who 
may  have  no  knowledge  of  Latin  beyond  the 
Dames  of  medicines,  the  translator  of  our 
meaning  as  to  the  mode  in  which  a  medicine 
is  to  be  taken  ?  The  patient  must  have  the 
directions  sooner  or  later  in  English,  and 
who  is  so  qualified  to  write  them  as  the  pre- 
scriber  himself  ?  The  ambiguities  of  the 
Latin  language  and  the  ignorance  of  drug¬ 
gists,  have,  owing  to  the  present  practice, 
given  rise  to  numerous  deplorable  accidents. 
We  have  known  an  action  brought  upon  the 
real  meaning  of  the  words  “  si  opussit the 
physician  complaining  of  the  druggist  for 
having  put  a  wrong  meaning  to  his  words, 
when  there  was  not  the  least  necessity  for 
his  trusting  to  the  dispenser’s  knowledge  of 
the  classics. 


PARALYSIS  PRODUCED  BY  ARSENIC. 

Dr.  Clark  related  to  the  New  York 
Medical  and  Surgical  Society  the  case  of 
a  young  woman  who,  five  months  ago,  took 
arsenic  for  the  purpose  of  self-destruction. 
According  to  her  own  account,  she  purchased 
sixpence- worth,  amounting  to  three  table¬ 
spoonfuls,  all  of  which  she  took.  This  was 
■about  11  p.m.  Warm  water  was  given  her, 
and  vomiting  produced.  At  3  a.m.  she 
was  taken  to  the  New  York  Hospital,  where 
the  stomach-pump  was  used,  the  hydrated 
sesquioxide  of  iron  having  probably  been 
previously  administered.  She  had  afterwards 
some  fever,  but  gradually  became  better. 
Eight  days  after  taking  the  arsenic  she  was 
seized  with  severe  pains  in  the  upper  and 
lower  extremities.  The  parts  were  swollen, 
but  neither  red  nor  hot.  Three  days  after 
this  she  lost  almost  entirely  power  over  her 
extremities  ;  she  had  since  continued  bed¬ 
ridden,  and  is  now  at  Bellevue.  She  can 
move  her  arms  freely,  and  can  close  and 
open  her  hands,  but  with  no  force.  The  feet 
are  still  paralysed,  but  she  can  bend  the 
knees. — New  York  Annalist ,  and  Provincial 
Journal. 


ON  THE  MANAGEMENT  OF  STILL-BORN 
CHILDREN. 

The  management  of  suspended  animation  in 
newT-born  children  is  a  subject  so  well  un¬ 
derstood  ;  and  the  principles  upon  which  it 
should  be  conducted  are  now  so  clearly  re¬ 
cognised,  as  to  render  any  lengthened  obser¬ 
vations  thereon  wholly  unnecessary  in  a 
work  like  the  present.  The  following  short 
description,  therefore,  of  the  practice  of  the 
Hospital  in  this  class  of  cases  (  not  the  least 
important  or  interesting  to  the  accoucheur) 
is  purely  confined  to  practical  details,  espe¬ 
cially  such  as  relate  to  the  use  of  the  stetho¬ 
scope  and  of  artificial  respiration. 

When  a  child,  immediately  after  its  birth, 
exhibits  none  of  the  ordinary  signs  of  vitality, 
such  as  respiratory  efforts,  or  muscular  con¬ 
traction,  the  question  will  at  once  suggest 
itself,  does  life  yet  remain — is  there  still  a 
possibility  of  restoring  animation  ?  We 
hesitate  not  to  say  that  the  most  accurate 
information  upon  this  point  is  to  be  derived 
from  the  stethoscopic  examination  of  the 
heart,  for  we  have  seen  very  many  children 
resuscitated  with  whom  the  cardiac  pulsa¬ 
tions  as  detected  by  mediate  auscultation , 
had  been  the  only  proof  of  lingering  vitality. 
What  the  effect  of  such  evidence  should  be 
on  the  physician’s  conduct  we  need  not  at 
this  moment  stop  to  inquire  ;  but  it  would 
undoubtedly  prove  a  source  of  much  en¬ 
couragement  under  circumstances  otherwise 
apparently  hopeless,  and  at  a  time  wrhen  he 
must  be  oppressed  with  the  consciousness 
that  the  result  of  his  endeavours  is  awaited 
with  the  most  intense  anxiety  and  solicitude. 
We  have  seen  many  infants  restored  to  ani¬ 
mation  in  whom  respiration  was  for  a  long 
time  suspended,  yet  we  never  saw  a  single 
instance  where  the  slightest  symptoms  of 
vitality  could  be  produced  if  the  heart’s 
pulsations  had  ceased  to  be  audible  when  the 
child  was  born.  It  may  be  asserted,  without 
fear  of  contradiction,  that  had  the  stethoscope 
been  used,  no  such  accident  could  ever  have 
happened  as  a  doctor  ordering  an  infant  to 
be  removed  as  dead  which  afterwards  re¬ 
covered  without  any  assistance.  Let  it  not 
be  supposed,  from  the  preceding  observa¬ 
tions,  that  we  would  recommend  any  inno¬ 
vation  upon  the  rule  that  resuscitation  should 
always  be  attempted  in  the  absence  of  the 
signs  of  decomposition  ;  to  the  excellence  of 
this  precept  we  give  our  full  concurrence. 

Children  labouring  under  suspended  ani¬ 
mation  at  the  time  of  birth  are  found  to  pre¬ 
sent  very  different  external  appearances, 
which,  it  may  be  supposed,  are  regulated  by 
the  extent  and  kind  of  lesion  the  vital 
functions  have  sustained.  Now  we  think 
that,  setting  aside  physiological  considera¬ 
tions,  and  looking  solely  to  practice,  all  these 
cases  may  be  ccmvepieptly  arranged  in  two 


392 


ON  THE  MANAGEMENT  OF  STILL-BORN  CHILDREN. 


classes,  whose  characteristic  features  are 
drawn  from  the  general  condition  of  the 
infant.  In  the  one  case  the  child  is  pale  and 
perfectly  flaccid  ;  the  eyes  are  closed  ;  there 
is  complete  relaxation  of  all  the  muscles  ; 
great  flexibility  of  the  joints  ;  and  the  finger 
can  be  pressed  into  the  pharynx  without  any 
opposition  being  felt.  In  this  form,  which 
we  are  inclined  to  think  is,  perhaps,  the  more 
dangerous  of  the  two,  the  state  of  the  child 
closely  approximates  to  syncope,  as  there 
seems  to  be  a  failure  or  deficiency  of  the 
vital  principle. 

In  the  examples  of  the  second  class,  the 
outward  appearance  of  the  cbild  is  totally 
different,  and  would  seem  to  be  the  result  of 
great  cerebral  congestion  or  apoplexy.  The 
surface  of  the  body  is  apparently  swelled,  and 
of  a  red  or  livid  colour,  and  both  these 
characters  are  most  remarkable  in  the  face 
and  neck  ;  the  eyelids  are  generally  apart, 
and  the  eye- balls  prominent,  with  more  or 
less  injection  of  their  conjunctival  membrane. 
There  is  seldom  that  extreme  mobility  of  the 
limbs  and  flaccid  state  of  the  muscles  that 
we  see  in  the  former  class  of  cases.  This 
state  of  the  foetus  was  very  apt  to  occur 
where  the  umbilical  cord  had  tightly  encircled 
the  neck,  or  where  the  expulsion  of  the  body 
did  not  take  place  for  some  time  after  the 
head. 

Should  the  child  not  begin  to  breathe  im¬ 
mediately  after  its  birth,  sprinkling  the  chest 
and  face  with  cold  water  generally  proved  a 
most  efficient  means  of  stimulating  the  re¬ 
spiratory  muscles,  and  exciting  sensibility. 
This  is  a  measure,  however,  which  cannot 
be  persisted  in  after  the  first  or  second  trial, 
as  it  is  of  too  depressing  a  nature ;  on  this 
account,  also,  it  is  not  well  adapted  to  the 
cases  included  in  our  first  class.  It  was,  of 
course,  an  established  rule  not  to  sever  the 
connection  between  the  foetus  and  placenta 
as  long  as  the  pulsations  of  the  cord  con¬ 
tinued  distinct.  If  the  child  presented  an 
apoplectic  appearance,  some  blood  (3iij.  or 
5iv.)  was  allowed  to  flow  from  the  foetal  end 
of  the  funis  after  its  division.  This  simple 
mode  of  depletion  frequently  produced  the 
most  beneficial  effects,  relieving  the  oppressed 
state  of  the  nervous  system,  and  being 
speedily  followed  by  signs  of  increased  sensi¬ 
bility.  If  a  sufficient  quantity  of  blood 
could  not  be  procured  from  the  funis,  the 
application  of  a  leech  to  the  temple  was  fre¬ 
quently  attended  with  marked  advantage. 
When  the  cord  was  long  enough  to  admit  of 
it,  the  warm  bath  was  sometimes  employed 
before  cutting  it.  Smartly  slapping  the 
chest  or  buttocks  is  often  resorted  to  with 
advantage  in  mild  cases  where  the  suspension 
of  animation  is  only  partial  ;  but  it  will  not, 
we  think,  be  found  to  answer  any  good  pur¬ 
pose  if  the  infant  be  in  a  low  state  of  vitality. 
Ammonia  applied  to  the  nostrils  is  an  ex¬ 


cellent  restorative  if  there  be  any  attempts 
at  inspiration,  so  that  it  can  be  inhaled,  but 
otherwise  it  is  of  no  use.  These  efforts  of 
the  child  to  breathe  will  be  very  much 
assisted  by  compressing  the  epigastrium  and 
sides  of  the  chest  with  the  hands,  so  as  to 
empty  the  lungs  of  the  inspired  air  as 
effectually  as  possible.  In  the  first  instance, 
and  before  adopting  other  measures,  it  is  of 
importance  to  rid  the  mouth  of  any  mucus 
that  might  hinder  the  entrance  of  air  by  ob¬ 
structing  the  glottis.  For  this  purpose, 
Gardien  recommends  a  pledget  of  lint  dipped 
in  a  solution  of  common  salt  to  be  used. 
A  flexible  tube,  with  a  pump  attached  to  it, 
has  also  been  employed ;  but  we  give  the 
preference  to  the  finger  over  every  con¬ 
trivance. 

In  every  instance  where  the  process  of  re¬ 
spiration  was  slow  of  being  established,  or 
very  imperfect  after  two  or  more  trials  in 
the  above  restorative  measures,  artificial  re¬ 
spiration  was  commenced,  and  continued, 
with  intermissions ,  until  the  necessity  for 
its  further  employment  was  superseded  by 
the  natural  performance  of  the  function,  or 
until  the  gradual  failure  and  cessation  of  the 
heart’s  action  shewed  that  all  attempts  at 
recalling  the  vital  principle  might  be  relin¬ 
quished.  We  have  said  “with  intermis¬ 
sions,”  because  it  was  generally  thought 
advisable  to  suspend  the  process  for  a  moment 
or  two  at  intervals,  just  to  see  if  the  failure  of 
the  supply  of  air  to  the  lungs  would  stimu¬ 
late  the  child  to  make  an  effort  at  inspira¬ 
tion.  A  gum -elastic  male  catheter,  of  the 
full  size  (No.  9  or  10)  was  the  instrument 
used  on  all  occasions  for  inflating  the  lungs. 
The  child  was  placed  in  a  horizontal  posture, 
with  the  neck  considerably  extended,  and  the 
head  bent  rather  backwards ;  the  catheter 
was  passed  a  short  way  into  the  mouth,  and 
the  lips  and  nostrils  were  then  kept  closely 
compressed,  at  the  same  time  that  the  larynx 
was  gently  pressed  against  the  spine,  so  as  to 
favour  the  ingress  of  air  into  the  trachea,  and 
to  prevent  or  obstruct  its  transmission  down 
the  oesophagus.  Alternately  with  the  in¬ 
sufflation  of  the  lungs,  a  slight  degree  of 
pressure  was  made  on  the  epigastrium  and 
ribs,  with  a  view  to  assist  expiration.  There 
was  great  difficulty  with  some  children  in 
directing  the  current  of  air  down  the  trachea, 
and  keeping  it  from  distending  the  stomach. 
This  was  avoided  by  placing  a  hand  on  the 
praecordial  region,  and  altering  the  position 
of  the  head  and  larynx.  During  the  process 
of  inflation,  which  was  repeated  at  short 
intervals  in  imitation  of  natural  respiration, 
whenever  the  child  made  any  attempt  to 
breathe,  the  compression  was  instantly  re¬ 
moved  from  the  mouth  and  nose,  in  order  to 
give  every  facility  to  the  entrance  of  air.  It 
was  considered  a  point  of  importance,  in 
blowing  through  the  catheter,  to  do  so  in  the 


ON  THE  DIAGNOSIS  OF  ANEURISM  OF  THE  THORACIC  AORTA.  398 


manner  of  using  the  blow-pipe,  namely,  that 
the  efforts  should  be  made  by  the  mouth  and 
soft  palate,  and  not  by  the  chest ;  and  con¬ 
sequently,  that  the  air  should  come  from  the 
mouth,  and  not  from  the  lungs  of  the 
operator.  This  mode  of  inflating  the  lungs 
of  still-born  children  is,  we  conceive,  open 
to  fewer  objections  than  any  other.  In  the 
first  place,  the  degree  of  force  with  which 
the  air  is  propelled  can  be  carefully  regu¬ 
lated  :  secondly,  its  temperature  is  raised  be¬ 
fore  entering  the  chest  of  the  infant :  thirdly, 
in  quality  it  is  little,  if  at  all,  removed  from 
pure  atmospheric  air ;  and,  lastly,  no  injury 
can  possibly  be  inflicted  on  the  soft  parts 
within  the  mouth  of  the  child.  From  our 
experience  of  this  measure  we  must  speak  of 
its  utility  in  terms  of  the  strongest  com¬ 
mendation,  as  we  never  could  trace  any  evil 
effects  from  its  employment,  whilst  in  very 
many  instances  we  have  had  every  reason  to 
believe  that  the  child’s  life  was  preserved  by 
its  means. 

The  artificial  respiration  very  constantly 
accelerated  the  action  of  the  heart,  where 
this  was  at  all  pulsating  at  the  time  of  com¬ 
mencing  the  process  ;  but  we  never  observed 
that  it  restored  in  the  least  degree  the  cardiac 
movements  after  these  had  ceased  to  be  per¬ 
ceptible.  The  recovery  of  the  child  did  not, 
by  any  means,  follow  as  a  consequence  of 
this  improvement  in  the  heart’s  functions ; 
for,  on  many  occasions,  we  have  known  the 
pulse  to  double  its  rapidity  under  the  em¬ 
ployment  of  this  agent,  but  as  soon  as  its 
use  was  suspended,  the  velocity  of  the  circu¬ 
lation  would  quickly  diminish,  again  to  be¬ 
come  raised  on  inflating  the  lungs  ;  and  thus 
we  have  seen  matters  go  on  alternating  for 
two  hours  or  upwards,  and  yet  the  great 
object  of  our  exertions  not  be  ultimately 
attained. 

When,  however,  this  increased  frequency 
of  the  pulse  is  accompanied  by  other  indica¬ 
tions  of  vitality,  such  as  restoration  of  the 
natural  colour  to  the  surface,  the  efforts  at 
respiration  recurring  at  shorter  intervals  and 
with  more  strength,  signs  of  muscular  irrita¬ 
bility  in  the  limbs  and  face,  &c.,  we  may 
calculate,  with  tolerable  certainty,  upon  a 
successful  issue  to  the  case. 

The  artificial  process  was  generally  left  off 
as  soon  as  natural  respiration  was  at  all 
established,  or  at  least  sufficiently  so  to 
maintain  the  heart’s  function  in  that  state  of 
activity  to  which  it  had  been  raised  by  the 
temporary  expedient  of  inflating  the  lungs. 
As  resuscitation  can  seldom  be  considered 
complete  and  satisfactory  until  the  infant 
breathes  naturally,  or  cries  aloud,  it  was 
often  necessary  to  proceed  with  the  employ¬ 
ment  of  restorative  and  invigorating  remedies 
for  some  time  after  the  discontinuance  of 
artificial  respiration.  As  soon  as  the  child 
could  swallow,  small  quantities  of  white-wine 


whey  were  given  from  time  to  time  ;  or  if  it 
seemed  very  languid  and  feeble,  a  small 
enema  containing  a  few  drops  of  the  fetid  or 
aromatic  spirit  of  ammonia  was  administered. 
But  by  far  the  most  important  point  in  the 
management  of  these  weakly,  delicate  in¬ 
fants,  or  of  such  as  are  in  a  similar  condition 
from  having  been  born  prematurely,  is  to 
support  the  temperature  of  their  bodies  by 
artificial  means.  For  this  purpose  nothing 
answers  so  well  as  cotton  wadding,  being 
softer  and  warmer  than  flannel  or  any  of  the 
materials  ordinarily  used  in  the  clothing  of 
children. — Mi  Clintock  and  Hardy's  Prac¬ 
tical  Observations  (pp.  355 — 360). 


ON  THE  DIAGNOSIS  OF  ANEURISM  OF  THE 
THORACIC  AORTA.  BY  DR.  BELLING¬ 
HAM. 

The  difficulty  of  the  diagnosis  of  aneurism 
of  the  aorta  has  been  a  frequent  theme  of 
writers,  and  not  a  little  that  has  been  pub¬ 
lished  has  tended  rather  to  increase  than  to  di¬ 
minish  this  difficulty.  This  is  owing  partly 
to  writers  upon  thoracic  aneurism  taking  too 
limited  and  contracted  a  view  of  the  subject, 
as  if  one  symptom  or  one  set  of  symptoms 
belonged  exclusively  to  aneurism  in  this 
situation  :  and  partly  to  the  erroneous  views 
of  previous  authors,  which  have  been  adopted 
without  proof,  and  propagated  without  con¬ 
sideration  by  succeeding  writers  ; — such  as 
that  an  aneurism  of  this  artery  is  always  ac¬ 
companied  by  a  loud  single  bruit  de  soufflet, 
or  that  the  arbitrary  varieties  of  aneurism 
which  systematic  writers  have  made  are 
characterized  by  a  distinct  class  of  symp¬ 
toms.  The  fact  is,  that  bruit  de  soufflet,  in¬ 
stead  of  constituting  a  constant  auscultatory 
sign  of  aneurism  of  the  arch  of  the  aorta,  is 
never  heard  in  the  majority  of  cases  ;  and, 
instead  of  a  single  sound  being  characteristic 
of  aneurism  of  this  part  of  the  vessel,  a 
double  sound  is  the  rule,  and  a  single  sound 
the  exception  ;  while,  whether  the  aneuris- 
mal  sac  is  formed  by  all  the  coats  of  the 
artery,  or  by  the  external  alone,  after  the 
rupture  of  the  internal  and  middle,  will 
make  no  difference  in  the  symptoms.  The 
symptoms  of  aneurism  of  this  vessel  are  not 
the  result  of  the  changes  which  the  arterial 
tissues  undergo ;  but  they  are  the  result  of 
the  compression,  distension,  stretching,  and 
displacement  of  important  organs  or  parts, 
or  of  the  disturbance  of  function  of  vital 
organs  in  the  vicinity  of  the  aneurismal  sac ; 
and  the  growth  of  any  other  tumor  in  the 
same  situation  would  give  rise  to  pretty 
nearly  the  same  local  and  general  symptoms. 
— Dublin  Medical  Press. 


394  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY",  ETC. 


BIRTHS  &  DEATHS  in  the  Metropolis 
During  the  week  ending  Saturday ,  Aug.  26. 


Births. 
Males....  663 
females. .  662 


1325 


Deaths. 
Males....  486 
Females..  465 


951 


Av.  of  5  Sum. 
Males ....  495 
Females. .  477 


972 


(34  in  number;  —  Registrars'  Districts,  129. 
Population,  in  1841,  1,915,104.) 

West— Kensington;  Chelsea;  St.  George, 
Hanove  Square ;  Westminster;  St.  Martin 
in  the  Fields;  St.  James  ..  (Pop.  301,326)  155 
North  —  St.  Marylebone  ;  St.  Pancras  ; 
Islington  ;  Hackney . (Top.  366,303)  186 

Central — St. Giles  and  St.  George;  Strand; 
Holborn;  Clerk enwell ;  St.  Luke;  East 
London  ;  West  London  ;  the  City  of 
London  . (Pop.  374,759)  161 

East — Shoreditch  ;  Bethnal  Green  ;  White¬ 
chapel  ;  St.  George  in  the  East ;  Stepney  ; 
Poplar . (Pop.  393,247)  1 89 

South  —  St.  Saviour;  St.  Olave  ;  Ber¬ 
mondsey  ;  St.  George,  Southwark  ; 
Newington;  Lambeth  ;  "Wandsworth  and 
Clapham  ;  Camberwell ;  Rotherhithe  ; 
•Greenwich . (Pop.  479,469)  260 


The  following  is  a  selection  of  the  numbers  of 
Deaths  from  the  most  important  special  causes : 


Small-pox  .  32 

Measles  .  6 

Scarlatina  . 102 

Hooping-cough..  23 

Diarrhoea  .  63 

Cholera  .  7 

Typhus  .  87 

Dropsy .  14 

Sudden  deaths  . .  7 

Hydrocephalus..  17 
Apoplexy .  20 


Paralysis .  is 

Convulsions  ....  26 

Bronchitis .  30 

Pneumonia .  30 

Phthisis . 137 

Dis.  of  Lungs,  &c.  10 

Teething .  9 

Dis.  Stomach,  &c.  8 
Dis.  of  Liver,  &c.  5 

Childbirth .  4 

Dis.ofUterus.&c.  6 


Remarks.— The  total  number  of  deaths  was 
21  beloiv  the  weekly  summer  average. 


METEOROLOGICAL  SUMMARY. 


Mean  Height  of  Barometer .  29'68 

“  “  Thermometer1  .  57*7 

Self-registering  do.b - max.  887  min.  33*5 

“  in  the  Thames  water  —  62-6  —  59’8 


a  From  12  observations  daily.  b  Sun. 

Rain,  in  inches,  0-66:  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological. — The  mean  temperature  of  the 
week  was  about!  below  the  mean  of  the  month. 


Total 


951 


Causes  of  Death. 

.All  Causes . 

Specified  Causes . 

1 .  2h/OTO<ic(orEpidemic,Endemic, 
Contagious)  Diseases . . 
Sporadic  Diseases,  viz. — 

.2.  Dropsy,  Cancer,  &c.  of  uncer¬ 
tain  seat  . 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  . 

4.  Lungs  and  other  Organs  of 

Respiration . 

5.  Heart  and  Bloodvessels . 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion  . 

7.  Diseases  of  the  Kidneys,  &c... 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c . 

9.  Rhematism,  Diseases  of  the 
Bones,  Joints,  &c . 

10.  Skin,  Cellular  Tissue,  &c . 

11.  Old  Age . 

12.  Violence,  Privation,  Cold,  and 

Intemperance . 


1 

Av.  of 
5  Sum. 

951 

972 

943 

968 

363 

257 

47, 

45 

97 

120 

76 

80 

31 

28 

61 

79 

10 

8 

10 

10 

3 

7 

1 

1 

28 

50 

2D 

S 

BOOKS  received  during  THE  WEEK. 

System  der  Pliysiologie,  von  Carl  Gustav  Cams. 
5tes  Heft. 

Journal  de  Pharmacie  et  de  Chimie.  Aoftt  1848. 

Address  to  the  Graduates  of  the  University  of 
London. 

An  Inquiry  into  the  Proximate  Cause  of  Gout, 
and  its  rational  Treatment.  By  Anthony 
White,  M.B.  Src. 

Report  of  the  Council  of  the  National  Institute 
of  General  Practitioners  in  Medicine,  Surgery, 
and  Midwifery,  on  the  Present  State  of  the 
Medical  Reform  Question. 

The  British  American  Journal  of  Medical  and 
Physical  Science.  Edited  by  Archibald  Hall, 
M.D.  &c.  Montreal,  August  1848.  . 


NOTICES  to  CORRESPONDENTS. 

Received. — Mr.  J.  R.  Hancorn. — Mr.  Thomas 
Martin. 


Erratum. — In  our  last  No.  page  326,  col.  2, 
line  23,  from  the  top,  for  Sp.  Amm.  Avom. 
“  read  “  f5ij,” 


THE  GENERAL,  INDEX. 

We  have  to  announce  to  onr  Subscribers  that  a  General 
Index  to  the  first  40  Volumes  of  the  London  Medical  Gazette 
will,  it  is  calculated,  form  a  large  Yolume  of  about  700  pages. 
The  cost  of  the  Index  Yolume,  respecting  which  many  inquiries 
have  been  made,  will  be  Twenty-four  Shillings;  and  it  is  proposed 
to  commence  it  so  soon  as  the  Names  of  Five  Hundred  Subscribers 
have  been  obtained. — The  printers,  Messrs.  Wilson  and  Ogilvy, 
57,  Skinner  Street,  will  receive  the  Names  of  Subscribers. 


aontton  JMetsteal  <§a|£tie.  305 


lectures. 


CHEMISTRY  and  the  MICROSCOPE 

IN  RELATION  TO 

PRACTICAL  MEDICINE. 

By  George  E.  Day,  M.A.  &L.  M.  Cantab. 

Fellow  of  the  Royal  College  of  Physicians, 
Lecturer  on  Animal  Chemistry  and  Histology 
at  the  Middlesex  Hospital  School,  and  Phy¬ 
sician  to  the  Western  General  Dispensary. 


Lecture  IX. 

The  pabulum  of  the  blood — the  chyle — its 
physical,  chemical,  and  microscopical  cha¬ 
racters — the  lymph — its  physical,  che¬ 
mical,  and  microscopical  characters — 
identity  of  lymph  and  chyle  corpuscles — 
literature  of  the  subject — leading  divi¬ 
sions  in  the  consideration  of  the  blood — 
difference  between  living  and  coagulated 
blood  —  its  odour  —  temperature  —  spe¬ 
cific  gravity — mode  of  determining  its 
amount — its  microscopic  characters — • 
effect  of  different  reagents  on  the  red 
corpuscles. 

To  -day,  gentlemen,  we  proceed  to  the 
blood, — a  subject  of  such  vast  extent  in  its 
general  bearings,  that  I  hardly  know  where 
we  had  better  break  ground.  In  speaking 
of  the  blood,  I  shall  endeavour  to  confine 
myself  as  much  as  possible  to  points  of 
practical  utility  in  reference  to  the  science 
of  medicine,  and  shall  not  attempt  to  enter 
into  the  general  physiology  of  the  subject 
further  than  seems  absolutely  necessary.  As, 
however,  some  of  you  may  wish  to  enter 
more  at  length  into  certain  portions  of  the 
history  of  the  fluid,  I  have  noted  down,  and 
shall,  when  necessary,  refer  to,  the  works  and 
memoirs  in  which  you  will  find  most  of  the 
information  we  possess  regarding  it. 

I  have  invariably  assumed,  that  you  are 
well  acquainted  with  the  ordinary  principles 
of  physiology.  Let  me  call  your  attention 
for  a  few  minutes  to  the  consideration  of 
the  process  of  nutritive  absorption.  Animals 
for  the  most  part  derive  their  nourishment 
from  the  external  world  by  means  of  the 
lacteals  and  venous  system.  We  will  not 
stop  to  inquire  the  relative  parts  that  these 
two  systems  take  in  this  process,  as  we  have 
no  present  occasion  to  advert  to  venous  ab¬ 
sorption.  But  it  is  not  from  the  external 
world  alone  that  animals  derive  their 
nourishment.  During  the  continuous  de¬ 
composition  that  is  going  on  in  the  living 
body,  certain  materials  fit  for  nutrition  are 
continuously  liberated,  and  in  the  lymphatic 
system  we  find  an  especial  provision  for 
their  re-introduction  to  the  circulating  fluid. 

xlii.— 1084.  Sept.  8,  1848. 


I  propose  to  notice  the  fluids  of  the  lacteal 
and  lymphatic  systems — the  pabulum  of  the 
blood — before  proceeding  to  the  blood  itself. 

The  chyle ,  when  obtained  in  a  state  of 
purity — that  is  to  say,  when  taken  from  an 
animal  killed  while  the  process  of  digestion 
is  going  on,  is  an  opalescent,  somewhat  viscid 
fluid.  The  opalescent  or  milky  appearance 
is  more  marked  in  carnivorous  than  herbi¬ 
vorous  animals ;  and  in  the  latter  the  de¬ 
gree  of  turbidity  seems  in  some  degree  pro¬ 
portional  to  the  amount  of  fat  taken  in  the 
food.  It  has  been  stated  to  possess  a  seminal 
odour,  but  Gerlach,  who  has  carefully  ex¬ 
amined  this  fluid  in  dogs  and  rabbits,  ob¬ 
serves  that  it  is  devoid  of  odour,  and  that  it 
has  a  saline  and  slightly  sweet  taste.  He 
collected  the  chyle  from  the  vessels  of  the 
mesentery,  and  found  that  it  did  not  coagu¬ 
late,  that  it  was  generally  neutral,  but  occa¬ 
sionally  alkaline.  It  is  much  to  be  regretted 
that  he  did  not  obtain  a  sufficient  quantity 
for  analysis,  for  the  analyses  at  present  on 
record,  are  made  with  the  fluid  taken  from 
the  thoracic  duct,  which  is  a  mixture  of 
lymph  and  chyle. 

This  mixed  chyle  possesses  the  property 
of  slightly  coagulating,  and  usually  exhibits  a 
pink  tint.  While  the  former  contains  only 
albumen,  fat,  salts,  extractive  matters,  and 
water,  the  latter  contains  also  traces  of 
fibrine.* 

On  examining  fresh  chyle  obtained  by 
Gerlach’s  method,  we  may  easily  convince 
ourselves  that  its  opalescence  or  turbidity 
is  dependent  on  the  presence  of  minute  par¬ 
ticles  suspended  in  it,  which,  when  examined 
under  the  microscope,  present  a  lively  mole¬ 
cular  motion. 

These  particles  are  so  minute  as  to  pre¬ 
sent  no  definite  shape,  even  under  very 
high  powers. f  They  are  soluble  in  ether  ; 
and  hence,  on  the  addition  of  this  reagent, 
the  chyle  becomes  perfectly  clear.  Acetic 
acid,  very  carefully  added,  separates  a  few 
delicate  flocculi,  which  redissolve  in  a  slight 
excess  of  the  acid.  Hence  we  have  chemical 
evidence  that  the  particles  in  suspension 


*  As  a  general  rule,  I  have  endeavoured  to  ex¬ 
clude,  as  far  as  possible,  the  numerical  results  of 
analyses,  and  to  coniine  myself  to  the  legitimate 
conclusions  that  may  be  deduced  from  them. 
Those  who  wish  to  refer  to  the  recorded  analyses, 
will  find  them  in  the  English  translation  of 
Simon’s  “Animal  Chemistry;”  in  my  various 
“Reports,”  in  Ranking’s  “  Half-yearly  abstract 
of  the  Medical  Sciences and  in  Dr.  Garrod’s 
lectures  now  publishing  in  the.  “  Lancet.”  If  any 
of  the  readers  of  the  Medical  Gazette 
should  trace  a  peculiar  similarity  between  some 
of  my  lectures  and  those  of  Dr.  Garrod,  I  would 
venture  to  plead,  that  I  have  at  least  an  equal 
right  with  that  gentleman  to  make  use  of  my 
previous  labours. 

f  They  constitute  the  molecular  base  in  Mr. 
Gulliver’s  description.  See  his  “Observations 
on  the  Chyle,  &c.,”  in  his  additions  to  Gerber’s 
“  General  Anatomy.” 


396 


DR.  DAY  ON  CHEMISTRY  AND  THE  MICROSCOPE 


consist  of  fatty  matter  ;  and  further,  that 
the  chyle  contains  a  protein-compound  in 
solution. 

Fat,  however,  exist  in  the  chyle  as 
globules,  as  well  as  in  the  granular  form. 
It  is  not,  however,  so  abundant  as  is  gene¬ 
rally  supposed.  H.  Muller  frequently  ob¬ 
tained  chyle  without  any  fat-globules ;  and 
he  believes  that  in  the  more  minute  lacteals 
none  are  present.  Their  presence  and 
number  very  likely  depend,  as  I  have 
already  mentioned,  on  the  nature  of  the 
food — that  is  to  say,  on  the  proportion  of 
the  fat  to  the  protein-compounds. 

Elementary  granules  constitute  another 
and  a  very  important  element  of  the  chyle. 
They  may  be  distinguished  from  fat-globules 
by  their  small  size,  and  by  their  collecting  in 
groups  without  fusing  into  a  single 
particle. 

These  elementary  granules,  whether  oc¬ 
curring  in  the  chyle  or  elsewhere,  may  be 
regarded  as  representing  the  earliest  stage  of 
the  process  of  organization.  They  vary  in 
diameter  from  ^  to  yo^cnr  of  an  inch ; 
and  there  is  reason  to  believe  tly  they  con¬ 
sist  of  very  finely  comminuted  particles  of  fat 
invested  in  a  capsule  consisting  of  a  protein 
compound  ;  at  least,  we  can  artificially  give 
rise  to  a  very  similar  appearance,  by  mixing 
oil  with  an  albuminous  fluid,  when  the  latter 
forms  a  membrane  around  the  minute  vesi¬ 
cles  of  the  former.  (See  Lecture  VII.  p.  140). 
These  elementary  granules  exhibit  a  strong 
attraction  towards  one  another,  three  or 
more  of  them  forming  minute  aggregate 
masses,  and  being  apparently  held  together 
a  viscid  substance,  consisting  probably  of 
a  protein-compound. 

These  aggregate  masses  constitute  the 
chyle-corpuscles.  They  have  a  slightly 
granular  appearance,  an  indistinct  border, 
and  are  of  a  roundish  or  somewhat  elongated 
form,  wdth  more  or  less  distinct  lateral  pro¬ 
jections.  The  size  of  these  chyle  corpuscles 
varied  in  the  dogs  and  rabbits  examined  by 
Gerlach,  from  ^J^th  to  yy^th  of  an  inch, 
whilst  they  have  been  estimated  by  Valen¬ 
tine  at  about  °f  an  inch  in  the 

human  subject.  There  is  often  a  conside¬ 
rable  difference  in  the  size  of  these  bodies, 
even  in  the  same  animals.  The  smaller  ones 
are  usually  most  frequently  met  with  in  the 
lacteals  of  the  mesentery  lying  nearest  to 
the  intestine  ;  whilst  the  larger  ones  are  more 
numerous,  after  the  passage  of  the  chyle 
through  the  mesenteric  glands,  and  appear, 
then,  not  only  to  increase  in  number,  but 
also  in  regularity  of  form. 

On  adding  water  to  a  drop  of  chyle,  and 
examining  it  microscopically,  the  corpuscles 
appear  at  first  to  swell,  and  to  become 
rounded  in  form  ;  a  further  effect  of  this 
reagent  is  to  produce  among  the  greater 
number  a  separation  into  two  parts,  consist¬ 


ing  iu  most  cases  of  a  granular  roundish 
nucleus,  and  a  transparent  capsule. 

This  separation  into  the  nucleus  and  capsule 
is  not  produced  in  all  chyle-corpuscles  by 
the  action  of  water.  Indeed,  the  corpuscles 
of  chyle  which  have  not  passed  through  the 
mesenteric  glands  seldom  present  this  ap¬ 
pearance  to  the  full  degree. 

Acetic  acid  renders  the  chyle-corpuscles 
more  distinct,  and  their  outlines  sharper  ;  at 
the  same  time  it  gives  them  a  more  angular 
shape.  The  separate  granules  become  more 
obvious,  and  the  corpuscle  itself  smaller, 
and,  as  it  were,  shrunken. 

The  addition  of  dilute  caustic  potash  ren¬ 
ders  the  chyle-corpuscles  at  first  indistinct, 
and  finally  causes  their  complete  disappear¬ 
ance. 

The  best  microscopic  observers  agree  in 
regarding  the  chyle- corpuscles  as  cells  in 
the  act  of  development.  The  fluid  with  the 
finely  granular  precipitate  of  fat  is  the 
blastema,  from  which,  in  conformity  with 
the  ordinary  laws  of  cell-development,  ele¬ 
mentary  granules  are  formed,  which,  by 
their  union,  give  rise  to  the  aggregate 
masses  which  seem  in  this  case  to  contain 
the  nucleus  and  capsule  of  the  new  cell.  It 
is  difficult  to  make  out  the  exact  period  at 
which  the  cell-wall  is  formed;  but,  as  we 
meet  with  the  greatest  number  of  aggregate 
masses  devoid  of  a  cell-wall  in  the  chyle 
which  has  not  yet  passed  through  the  me¬ 
senteric  glands,  we  may  fairly  conceive  that 
these  glands  are  in  some  way  connected  with 
the  production  of  that  portion  of  the  cell. 
They  probably  act  by  affording  time  for  the 
elements  of  the  chyle  to  become  more  highly 
organized  and  further  developed ;  for  not 
only  have  all  the  corpuscles,  in  the  chyle  that 
has  passed  these  glands,  got  cell- walls,  but 
they  likewise  appear  more  numerous. 

We  proceed  to  a  closely  allied  fluid — the 
lymph.  Regarding  its  physical  properties, 
we  may  say  that  it  is  a  slightly  opalescent 
fluid,  having  a  faintly  yellow  tint.  Lymph 
taken  from  the  spleen  is  of  a  pale  pink 
colour,  but  this  is  owing  to  its  admixture 
with  red  blood-corpuscles. 

Fresh  lymph  is  devoid  of  odour,  and  is 
reported  to  have  a  faint  sickly  taste.  There 
are  some  things  in  animal  chemistry  it  is 
just  as  well  to  take  on  credit ;  and  tasting 
the  different  fluids  of  the  body  in  health  and 
disease  is  one  of  them. 

On  allowing  lymph  to  stand  for  ten 
minutes  or  a  quarter  of  an  hour,  it  separates 
into  a  soft  gelatinous  clot,  which  partially 
sinks,  and  a  slightly  yellow  supernatant  fluid. 

The  lymph  has  a  decidedly  alkaline  re¬ 
action.  The  following  are  the  principal 
points  in  which  it  differs  from  the  chyle : — 
It  contains  less  fat,  less  albumen,  and  more 
fibrin  :  indeed,  it  seems  very  doubtful  whe¬ 
ther  pure  chyle  contains  any  fibrin. 


IN  RELATION  TO  PRACTICAL  MEDICINE 


397 


With  regard  to  its  microscopic  elements, 
except  that  it  does  not  contain  the  finely 
granular  precipitate  and  the  fat-globules,  it 
presents  the  same  forms  as  the  chyle  ;  that 
is  to  say,  it  contains  elementary  granules, 
and  the  aggregate  masses  formed  by  their 
union,  and  corpuscles  precisely  identical 
with  those  which  I  have  described  as  sepa¬ 
rating,  under  the  influence  of  water,  into  a 
nucleus  and  a  capsule.  These  microscopic 
elements  are,  however,  less  abundant  in  the 
lymph  than  in  the  chyle. 

Water  and  all  other  reagents  seem  to 
react  in  precisely  the  same  manner  on  lymph 
and  chyle-corpuscles,  and  it  is  most  proba¬ 
ble  that  they  play  the  same  part  in  the 
animal  economy. 

I  have  entered  at  some  length  into  the 
consideration  of  these  fluids,  because  they 
have  an  important  bearing  on  the  produc¬ 
tion  of  the  blood.  For  analyses  of  the 
chyle  and  lymph,  and  for  further  informa¬ 
tion  regarding  them,  I  may  refer  you  to  the 
following  works  and  memoirs  :  — 

(1) .  Tiedemann  und  Gmelin,  die  Ver- 
dauung,  nach  Yersuchen. 

(2) .  Gulliver’s  Additions  to  the  transla¬ 
tion  of  Gerber’s  General  Anatomy. 

(3) .  Simon’s  Animal  Chemistry.  Yol.  1, 
pp.  350-359. 

(4) .  Nasse.  The  articles  “  Cbylus”  and 
4‘  Lymphe,”  in  Wagner’s  Handworterbuch 
der  Physiologie. 

(5) .  Herbst,  das  Lymphgefassystem  und 
seine  Verrichtung. 

(6) .  Valentin’s  Lehrbuch  der  Physiologie 
des  Menschen.  2nd  ed.  Vol.  1,  p. 
401,  &c. 

(7) .  H.  Muller,  Beitrage  zur  Morphologie 
des  Chylus  und  Eiters,  in  Henle  u.  Pfeufer’s 
Zeitschrift  fiir  rationelle  Medizin.  1845. 

(8) .  Gerlaeh,  Handbuch  der  allgemeinen 
und  speciellen  Gewebelehre  des  menschlichen 
Korpers,  pp.  20-28. 

From  these  prefatory  remarks  on  the 
•chyle  and  lymph,  we  proceed  to  the  con¬ 
sideration  of  the  blood. 

The  following  table  will  give  you  a  tolera¬ 
bly  clear  idea  of  the  plan  I  propose  to 
follow  in  the  consideration  of  this  fluid. 

We  shall  consider — 

I.  The  physical  and  microscopical  cha¬ 
racters  of  the  blood  previously  to  its 
coayulation. 

II.  The  process  of  coagulation,  and  its 
results. 

III.  The  chemical  composition  of  healthy 
.venous  blood. 

IV.  The  general  physiology  of  the  blood, 
* embracing  its  differences  in  different  vessels, 
the  changes  it  undergoes  in  respiration, 
and  its  general  metamorphoses. 

We  shall  treat  of  these  points  with  great 
brevity. 


Having  made  ourselves  well  acquainted 
with  the  characters  of  healthy  blood,  we 
shall  be  better  enabled  to  grapple  success¬ 
fully  with  the  greater  difficulties  presented 
by  the  study  of  the  blood  in  its  various 
morbid  conditions. 

I.  There  is  not  much  that  need  detain  us 
in  the  consideration  of  the  physical  and 
microscopical  characters  of  the  blood,  be¬ 
cause  your  attention  has  already  been  to  a 
certain  degree  directed  to  them  in  another 
course. 

The  blood,  while  moving  in  the  living 
body,  consists  of  a  nearly  colourless  fluid, 
in  which  blood-corpuscles  are  swimming; 
in  consequence,  however,  of  these  corpuscles 
being  too  minute  to  be  distinguished  by  the 
naked  eye,  it  appears  among  the  higher 
classes  of  animals  as  an  opaque  and  intensely 
red  homogeneous  fluid.  But  when  the 
blood  has  been  drawn  from  the  body,  and 
is  allowed  to  remain  at  rest,  a  spontaneous 
coagulation  takes  place,  and  the  blood  sepa¬ 
rates  into  the  clot  or  crassamentum,  and 
the  serum.  The  clot  is  composed  of  a  net¬ 
work  of  fibrin,  in  whose  meshes  the  cor¬ 
puscles  are  retained. 

Hence,  h  ing  blood  consists  of  corpus¬ 
cles  +  the  fffiid  in  which  they  swim,  and 
which  we  term  liquor  sanguinis  or  plasma ; 
while  coagulated  blood  consists  of  the  clot  + 
the  serum  in  which  it  swims.  The  following 
scheme  will,  perhaps,  render  this  statement 
clearer : — 


Living 

Blood 

Coagul. 

Blood 


Corpuscles 
Liquor  sang. 


Clot 


X 


Serum 


Corpuscles 

Fibrin 

Serum 

Corpuscles 

Fibrin 

Serum 


When  speaking  in  this  and  the  following 
lectures  of  the  blood,  I  wish  you  always  to 
understand  that  I  mean  venous  blood ;  un¬ 
less,  of  course,  I  specially  state  the  contrary. 

The  blood,  as  it  flows  from  the  body  dur¬ 
ing  the  operation  of  venesection,  may  be  de¬ 
scribed  as  a  somewhat  viscid  fluid  of  a  dark 
red  colour.  It  develops  a  peculiar  odour 
(the  aura  or  halitus  of  the  blood),  which 
you  will  have  no  difficulty  in  recognising 
after  having  once  observed  it,  but  which  it 
is  impossible  to  describe  satisfactorily.  It 
is  stronger  in  men  than  in  women,  and  in 
robust  than  in  weak  persons.  It  is  stated 
to  be  very  strong  in  the  blood  of  negroes, 
and  very  faint  in  that  of  eunuchs.  Barruel,  a 
French  chemist,  maintains  that  the  odour  is 
much  more  powerfully  evolved  on  the  addi¬ 
tion  of  sulphuric  acid ;  and  he  has  even, 
gone  so  far  as  to  assert  that  in  medico-legal 
cases  he  can  by  this  means  determine  the 
origin  of  a  spot  of  dried  blood — whether 
it  was  human  blood,  or  the  blood  of  a  beast, 
and,  indeed,  whether  it  arose  from  man,  WO* 


398 


DR.  DAY  ON  CHEMISTRY  AND  THE  MICROSCOPE. 


man,  or  child.  The  odour  developed  by 
sulphuric  acid  affords  a  fair  secondary  test, 
but  can  never  be  relied  on  as  our  sole  evi¬ 
dence.  The  acid  made  use  of  must  not  be 
very  strong  ;  it  probably  acts  by  combining 
with  soda  and  liberating  a  volatile  fatty  acid. 

The  temperature  of  the  blood  is  probably 
a  little  higher  than  that  of  any  of  the  solids 
of  the  body.  It  may  be  put  down  on  an 
average  at  about  99°  or  100°.  Simon  found 
that  blood  issuing  from  the  aorta  of  an  ox 
had  a  temperature  of  103°,  and  that  in  simi¬ 
lar  blood  from  a  pig  it  was  990,5.  The 
temperature  of  arterial  blood  is  usually 
nearly  2°  higher  than  that  of  venous  blood. 

The  specific  gravity  fluctuates  between 
1050  and  1059,  and  is  usually  higher  in  man 
than  in  woman  ;  in  fact,  we  may  say  that,  in 
a  state  of  health,  it  is  always  above  1053  in 
man,  while  in  woman  it  is  frequently  not 
above  1050. 

Its  quantity  in  the  adult  human  subject 
has  been  very  variously  estimated.  I  am 
inclined  to  think  that  it  generally  lies  be¬ 
tween  twenty-four  and  thirty  pounds.  Va¬ 
rious  means  have  been  adopted  to  determine 
this  question,  two  or  three  of  which  I  may 
mention  to  you.  Valentin  abstracted  a  cer¬ 
tain  quantity  of  blood  from  an  animal,  and 
ascertained  the  relative  proportion  of  water 
in  it.  He  then  injected  into  its  veins  a 
known  quantity  of  water,  and  again  abstract¬ 
ed  blood,  and  determined  the  relative  quan¬ 
tity  of  water  in  it.  By  comparing  the  pro¬ 
portion  of  water  contained  in  the  second  blood 
with  that  contained  in  the  first  blood,  he 
was  obviously  enabled  to  calculate  the  quan¬ 
tity  of  blood  with  which  the  water  that  he 
injected  must  have  mixed. 

Vogel  recommends  that  the  vessels  of  the 
dead  body  should  be  injected  with  pure 
water,  so  that  all  the  hsemato- globulin  may 
be  obtained,  from  which  the  total  amount  of 
blood  may  be  calculated  ;  and  Weisz  has  re¬ 
cently  suggested  that  the  iron  obtained  on 
the  incineration  of  the  body  might  serve  the 
same  purpose.  All  these  methods  are,  how¬ 
ever,  open  to  serious  objections. 

Of  the  microscopic  characters  of  the  blood 
I  need  say  little.  You  doubtless  recollect 
that  there  are  two  distinct  kinds  of  blood- 
corpuscles  swimming  in  the  liquor  sanguinis  : 
namely,  the  red  corpuscles,  and  the  white, 
colourless,  or  lymph  corpuscles.  The  for¬ 
mer,  when  viewed  under  the  microscope,  are 
seen  to  be  of  a  yellow  colour,  and  in  man, 
and  the  mammalia  (with  one  or  two  trilling 
exceptions)  of  a  circular  form, but  compressed 
laterally  so  as  to  present  a  discoid  appearance. 
The  latter  are  fewer  in  number,  and  if  the 
blood  that  is  being  examined  is  still  circulat¬ 
ing  in  the  vessels,  they  are  seen  close  to  the 
walls,  and  moving  forwards  with  much  less 
rapidity  then  the  central  current  of  the  so- 
called  red  corpuscles.  They  are  round,  of 


a  finely  granular  appearance,  and  are  gene¬ 
rally  rather  larger  than  the  red  corpuscles, 
from  which  they  may  be  distinguished  by 
their  want  of  colour,  their  almost  perfect 
sphericity,  and  their  granular  appearance. 

The  red  corpuscles  are  about  of  an 
inch  in  diameter.  They  consist  of  a  capsule 
or  cell-wall,  consisting  of  globulin  (see  Lec¬ 
ture  II.  p.  365),  and  fluid  contents  consist¬ 
ing  of  hsematin  and  globulin  in  a  state  of 
solution.  The  capsule  is  highly  elastic,  and 
in  this  respect  the  red  corpuscles  differ 
widely  from  the  colourless  ones,  which  do 
not  yield  to  pressure  without  bursting.  No 
nucleus  can  be  observed  in  human  blood- 
corpuscles. 

Much  stress  has  been  laid  on  alterations 
in  the  form  of  corpuscles  in  different  dis¬ 
eases  ;  but  as  these  differences  for  the  most 
part  depend  on  the  specific  gravity  of  the 
fluid  in  which  they  are  swimming,  in  accord¬ 
ance  with  the  laws  of  endosmosis  and  exos¬ 
mosis,  they  must  be  regarded  as  secondary  to 
the  altered  condition  of  the  surrounding 
liquid. 

I  shall  briefly  notice  the  action  of  certain 
reagents  on  the  blood-corpuscles.  Some  of 
these  reagents  act  simply  in  accordance  with 
physical  laws,  but  most  of  them  exert  a  che¬ 
mical  influence.  It  is  only  during  very  re¬ 
cent  times  that  the  effects  of  chemical  re¬ 
agents  on  microscopic  objects  have,  to  any 
extent,  been  observed.  It  is,  however,  a 
most  important  study.  It  is  the  most  subtle 
anatomy. 

The  effect  of  water  on  the  blood-corpus¬ 
cles  is  very  striking,  and  is  easily  seen  under 
the  miscroscope.  They  are  observed  almost 
instantaneously  to  swell ;  they  lose  their 
distinct  contour,  and  if  there  is  an  abundance 
of  water  they  altogether  disappear.  If,  how¬ 
ever,  the  blood-corpuscles  have  nuclei  of 
sufficient  magnitude  to  admit  of  examination 
(as  in  the  blood  of  fishes,  reptiles,  &c.),  these 
nuclei  will  be  seen  swimming  in  the  water 
after  the  disappearance  of  the  capsules. 

If,  upon  the  addition  of  water,  the  blood- 
corpuscles  have  swollen  to  such  a  degree  as 
to  be  imperceptible,  from  their  tenuity  and 
loss  of  colour,  under  the  microscope,  they 
may  be  restored  to  their  pristine  form  by 
the  addition  of  sugar,  of  common  salt,  of 
nitrate  of  potash,  or  nitrate  of  ammonia. 
Schultz  explains  this  phenomenon  by  suppos¬ 
ing  that  the  capsule  of  the  blood  corpuscle 
is  an  organic  structure,  which  is  stimulated 
to  contraction  by  the  above  solutions,  but 
which  is  relaxed  or  expanded  by  water ; 
there  is,  however,  no  necessity  for  hypothe¬ 
ses  of  this  kind,  as  the  phenomena  we  have 
described  can  be  sufficiently  accounted  for 
by  the  ordinary  laws  of  endosmosis:  for,  as 
a  general  rule,  the  corpuscles  are  seen  to 
swell  in  solutions  less  dense  then  the  serum, 
and  to  contract  in  those  of  greater  density. 


HERNIA  MAY  PROCEED  FROM  ANY  OF  THE  NATURAL  CAVITIES.  399 


In  examining  the  action  of  water,  and  in¬ 
deed  of  any  reagent,  on  the  blood-corpuscles, 
we  usually  find  that,  although  the  effect  on 
the  different  corpuscles  is  similar  in  kind,  it 
is  very  unequal  in  intensity.  This  difference 
is  probably  connected  with  the  different  ages 
of  the  corpuscles  acted  on.  We  shall  pro¬ 
ceed  with  this  subject  in  our  next  lecture. 


COURSE  OF  SURGERY, 
Delivered  in  the  years  1846  and  1847, 

By  Bransby  B.  Cooper,  F.R.S. 

Surgeon,  and  Lecturer  on  Surgery  at  Guy’s 
Hospital. 


Lecture  XXXVII. 

HERNIA. 

Definition. — Hernia  may  proceed  from  any 
of  the  natural  cavities — Hernia  of  the 
brain  —  of  the  lungs  —  Classification  — 
Case —  Diagnosis  —  Prognosis  —  Treat¬ 
ment — Abdominal  hernice — Classification 
— frequency  of  hernice — coverings  of  ab¬ 
dominal  hernia — Intrinsic  and  extrinsic 
Species  of  hernia — Inguinal — Varieties 
of  Femoral  hernia — Umbilical  hernia — 
Ventral  hernia — Obturator  hernia — Is- 
chiatic  hernia  —  Perineal  hernia —  Vaginal 
and  pudendal  hernice.  Contents  of  hernice 
— Diagnosis  from  symptoms — Hernia  of 
the  bladder.  Causes  of  hernia — predis¬ 
posing  and  exciting.  Form  of  a  hernial 
tumor.  Conditions  of  hernice — reduci¬ 
ble ,  irreducible ,  and  strangulated.  Re¬ 
ducible  hernia — Taxis — Treatment  — 
“  reduction  en  bloc  ” — operations — case. 
Irreducible  hernia — symptoms — obstruc¬ 
tion  of  a  hernia — treatment — operation. 
Conversion  of  irreducible  into  reducible 
hernia — case — mode  of  treatment  of  irre¬ 
ducible  hernia. 

The  protrusion  of  any  viscus  from  its  natu¬ 
ral  cavity  is  termed  a  hernia ;  and  as  the  hu¬ 
man  body  is  divided  into  three  distinct 
cavities, — that  of  the  cranium,  the  chest,  and 
the  abdomen, — each  of  which  contains  its  ap¬ 
propriate  viscera,  a  hernia  may  occur  in  con¬ 
nection  with  either  of  these  through  th:  escape 
of  any  portiou  of  the  organs  they  contain. 
Owing  to  the  solidity  and  continuity  of  the 
parietes  of  the  cranium,  protrusion  can, 
however,  only  occur  as  the  result  of  malfor¬ 
mation  or  fracture  of  those  bones  ;  the  pa¬ 
rietes  of  the  chest  also  consist,  in  a  great 
measure,  of  bone,  and  the  viscera  contained 
within  this  cavity  are  so  firmly  fixed  by  their 
investing  membranes,  that  they  are  but 
little  liable  to  protrusion  :  but  hernial  pro¬ 
trusions  of  the  viscera  of  the  chest  do  occa¬ 
sionally  happen,  and  M.  Morell-Lavallee 
has  written  an  excellent  monograph  upon 


this  subject.  He  has  divided  hernia  of  the 
lungs  into  four  classes,  viz.  congenital, 
traumatic,  consecutive,  and  spontaneous. 
Of  congenital  hernia  of  the  lungs  only 
one  case  is  recorded,  and  that  was  not  ob¬ 
served  until  after  death ;  it  was  discovered 
by  Cruveilhier  in  the  body  of  an  infant  who 
was  the  subject  of  spina  bifida.  Traumatic 
hernia  is  occasionally  met  with,  and  is 
produced  by  a  sword-thrust,  or  some 
similar  cause  ;  consecutive  hernia  follows  as 
the  result  of  rupture  of  a  portion  of  the 
parietes  of  the  thorax ;  and  spontaneous 
hernia  is  that  in  which  the  protrusion  occurs 
through  any  natural  outlet  from  the  thorax, 
but  is  most  frequently  met  with  in  the  in¬ 
tercostal  spaces,  where  it  is  indeed  always 
liable  to  be  produced  in  cases  of  abdominal 
weakness  of  the  parietes,  whether  that  be 
congenital  or  the  consequence  of  disease. 
M.  Morell-Lavallee  also  states  that  hernia 
of  the  lungs  may  take  place  in  subjects  in 
whom  local  debility  arises  from  some  cause. 
The  following  case  is  quoted  in  illustration : 
“An  officer  of  the  French  army  in  Spain, 
was  seized,  without  any  apparent  cause,  with 
a  violent  and  distressing  paroxysmal  cough, 
accompanied  by  pain  in  the  left  hypochon¬ 
driac  region.  In  the  course  of  a  few  days 
a  tumor,  as  large  as  an  egg,  appeared  at  the 
left  side  of  the  chest  :  the  tumor  was  in¬ 
creased  in  size  during  inspiration,  diminished 
during  expiration,  and  completely  disap¬ 
peared  under  pressure.  Rest,  regimen,  and 
the  application  of  a  compress,  so  far  over¬ 
came  the  affection  as  to  enable  him  to  return 
to  his  duties;  but  he  was  not  free  from  un¬ 
easiness  in  the  side,  and  was  obliged  to  sup¬ 
port  it  whenever  he  took  much  exercise.  The 
cough  returned  again  in  a  year  after  the  first 
attack,  and  the  tumor  appeared  this  time  on 
the  right  side  of  the  thorax.  These  tumors 
required,  during  coughing,  a  considerable 
pressure  ;  and  after  their  reduction  apertures 
could  be  felt,  which  seemed  to  result  from 
the  rupture  of  the  intercostal  muscles.”  A 
hernia  of  the  lungs  is  generally  formed  in 
the  anterior  part  of  the  chest,  and  is  some¬ 
times  of  very  considerable  size :  if  it  be 
slowly  formed,  it  obtains  a  covering  from 
the  pleura ;  and  even  should  the  protrusion 
take  place  suddenly,  it  often  afterwards  be¬ 
comes  enveloped  in  an  adventitious  serous 
membrane.  The  protruded  part  is  some¬ 
times  very  highly  congested,  so_  much  so, 
indeed,  as  to  give  rise  to  the  idea  that  it  has 
become  gangrenous,  inducing  its  removal 
instead  of  returning  it  into  its  proper  cavity. 
The  consecutive  hernia  usually  appears  gra¬ 
dually,  and  without  pain ;  but  the  sponta¬ 
neous  may  form  much  more  suddenly  and 
with  more  pain  at  first:  and  as  these  forms 
of  hernia  progress,  they  may  either  of  them 
give  rise  to  very  serious  suffering.  Sponta¬ 
neous  hernia  is  sometimes  very  small  at  first, 


400 


DIAGNOSIS  OF  THORACIC  HERNIA. 


but  its  size  increases,  particularly  during  a 
fit  of  coughing.  A  modification  of  this  her¬ 
nia  sometimes  exists,  which  is  termed  inter¬ 
mittent,  as  little  or  nothing  of  the  tumor  is 
perceptible,  except  during  forcible  expira¬ 
tion. 

The  diagnosis  in  thoracic  hernia  is  some¬ 
times  rather  difficult,  as  tumors  in  this  re¬ 
gion,  arising  from  other  causes,  may  readily 
be  mistaken  for  it.  A  patient  under  the 
care  of  Dr.  Hughes  in  Guy’s  Hospital,  who 
was  the  subject  of  a  pulmonary  affection, 
had  a  swelling  on  the  right  side  of  his  neck, 
which  distended  upon  coughing,  and  led  to 
the  supposition,  among  some  of  the  medical 
attendants  of  the  institution,  that  it  was  a 
hernia  of  the  apex  of  the  lung.  Although 
the  usual  crepitation  of  an  emphysematous 
tumor  was  but  very  indistinct,  if  at  all  ap¬ 
preciable,  Dr.  Hughes  himself  considered  it 
a  dilated  vein ;  by  another  it  was  thought 
to  be  chronic  abscess ;  I  myself  was  of  opi¬ 
nion  that  it  was  a  sero-cyst  or  hydrocele  of 
the  neck.  The  patient  died  of  phthisis  ;  and 
thus  an  opportunity  was  obtained  for  post¬ 
mortem  examination ;  when  it  was  found 
that  there  was  a  dilated  internal  jugular  vein, 
in  consequence  of  an  obstruction  to  the  re¬ 
turn  of  its  blood,  resulting  from  adhesions 
of  the  pleura,  which  interfered  with  the  pas¬ 
sage  of  the  reflux  blood  into  the  vena  inno- 
minata.  There  was  also  found  a  conside¬ 
rable  sized  cyst  connected  with  the  thyroid 
gland.  A  non-reducible  tumor  could  not, 
'however,  be  easily  mistaken  for  the  hernia, 
unless  it  were  placed  in  a  situation  in  which 
it  would  sink  during  inspiration,  as  in  the 


supra-clavicular  space,  in  which  case  error 
might  arise.  A  case  has  been  described  in 
v.  hich  an  abscess  appeared  between  the  false 
ribs  and  the  xyphoid  cartilage,  and  was  be¬ 
lieved  to  be  a  hernia  ;  but  the  fluctuation  and 
dulness  on  percussion  would  be  generally 
sufficient  to  distinguish  such  a  case. 

The  prognosis  in  this  description  of  her¬ 
nia  does  not  appear  to  be  very  unfavourable, 
judging  by  the  result  in  the  comparatively 
few  cases  that  are  known. 

The  treatment  of  consecutive  and  sponta¬ 
neous  hernia  is  very  simple  :  after  the  tumor 
has  been  reduced,  a  bandage,  with  a  com¬ 
press,  is  placed  firmly  over  it ;  and  in  this 
way  Velpean  has  effected  a  permanent  cure 
in  six  days. 

Notwithstanding  this  account  of  the  her- 
nise  to  which  the  viscera  of  the  chest  are 
liable,  it  is  to  the  protrusions  of  the  abdo¬ 
minal  viscera  that  surgical  aid  is  so  much, 
more  frequently  required,  and  they  therefore 
demand  our  more  particular  attention. 

Abdominal  hernise  are  very  frequent,  in 
consequence  of  the  number  of  natural  outlets 
or  perforations  for  the  transmission  of  blood¬ 
vessels  and  nerves.  The  species  to  which 
a  hernia  belongs  is  determined  by  the  parti¬ 
cular  region  in  which  the  viscus  makes  its 
escape.  Moreover,  there  are  many  peculia¬ 
rities  attendant  upon  this  condition  which 
render  necessary  the  subdivision  of  each 
species  into  varieties :  the  following  table, 
which  I  have  taken  from  my  friend  Mr. 
Teale’s  excellent  treatise  on  hernia,  exhibits, 
at  one  view,  a  very  convenient  and  correct 
classification  of  the  subject : — 


Genus.  Subgenera. 
^Cranial 


Species. 


Varieties. 


Thoracic 

Hernia  «{ 

Abdominal 


^Inguinal  .  . 

Femoral 
Umbilical 
Ventral 
Obturator 
Jschiatic 
Perineal 
Pudendal 
Vaginal 

^Diaphragmatic 


Oblique  Inguinal  Hernia 
Hernia  of  the  Tunica  Vaginalis 
Direct  Inguinal  Hernia 


I  have  already  stated  that  the  internal 
portion  of  the  walls  of  the  abdomen  is  formed 
by  the  internal  abdominal  fascia,  which  pro¬ 
longs  itself  with  every  structure  issuing, 
either  naturally  or  abnormally,  from  the 
cavity  ;  and  that  the  tendons  of  the  abdo¬ 
minal  muscles  are  furnished,  at  certain 
points,  with  apertures  to  permit  of  the  pas¬ 
sage  of  blood-vessels,  nerves,  absorbents, 
and  excretory  ducts  essential  to  the  organi¬ 
zation  and  functions  of  distant  parts.  These 
apertures  tend  to  diminish  the  power  of  re¬ 
sistance  which  the  walls  of  the  abdomen 


elsewhere  offer  to  the  escape  of  the  internal 
viscera. 

Besides  the  internal  fascia,  there  exists  a 
superficial  or  external  abdominal  fascia, 
composed  of  a  somewhat  elastic  tissue  ;  this 
structure  adds  to  the  strength  of  the  walls 
through  which  the  natural  outlets  pass,  and 
tends  to  preclude  the  liability  to  frequent 
hernia.  After  all,  however,  this  affection  is 
one  of  common  occurrence,  so  much  so  that 
statistical  information  shows  that  every 
tenth  person  is  subject  to  it  under  one  or 
other  of  its  varieties. 


THE  VARIOUS  SPECIES  OF  HERNIA 


401 


In  addition  to  the  two  fascia,  the  abdomen 
is  lined  by  peritoneum  ;  the  viscera  are  also 
covered  by  this  splanchnic  membrane  :  and 
therefore  it  may  be  said  that  every  hernia  is 
furnished  with  three  coverings  ;  and  although 
there  are  two  or  three  exceptions  with  re¬ 
spect  to  the  peritoneal  covering,  these  ex¬ 
ceptions  do  not  impoverish  the  general  fact. 
These  three  coverings  may  be  termed  the 
intrinsic  coverings  of  a  hernia ;  while 
others  which  differ  according  to  the  locality 
in  which  the  protrusion  occurs,  may  cor¬ 
rectly  be  styled  its  extrinsic  coverings. 

A  protruded  viscus  can  therefore  scarcely 
be  described  as  being  out  of  the  abdomen,  but 
that  that  cavity  itself  has  been  prolonged  be¬ 
yond  its  natural  limits  ;  a  condition  precisely 
similar  to  that  of  the  testicle  in  its  normal 
state,  which  brings  with  it,  in  its  descent 
from  the  abdomen  into  the  scrotum,  an  in¬ 
vestment  of  peritoneum,  covered  by  internal 
and  external  abdominal  fascia. 

The  various  species  of  hernia  derive  their 
names  from  the  natural  outlets  by  which 
they  issue  from  the  abdomen.  I  shall  men¬ 
tion  them  in  the  order  in  which  they  most 
frequently  occur. 

Inguinal  hernia  is  so  termed  from  the  re¬ 
gion  of  the  abdomen  at  which  the  protrusion 
takes  place,  viz.  through  the  opening  of  the 
internal  abdominal  fascia  into  the  inguinal 
canal;  through  the  same  space,  indeed,  by 
which  the  testicle  had  previously  descended 
from  the  lumbar  region  of  the  abdomen  into 
the  scrotum.  Inguinal  hernia  is  especially 
liable  to  varieties. 

Femoral  hernia. — A  protrusion  is  termed 
a  femoral  hernia  when  the  intestine  has  es¬ 
caped  from  the  abdomen  into  the  prolonga¬ 
tion  of  the  internal  abdominal  fascia  which 
covers  the  femoral  vessels,  and  constitutes 
what  is  termed  their  sheath.  The  protruded 
intestine  does  not,  however,  pass  down  either 
with  the  artery  or  vein,  but  quite  on  the 
inner  side  in  that  division  of  the  sheath 
which  encloses  the  absorbent  vessels. 

Umbilical  hernia. — This  is  a  protrusion 
at  the  navel,  which  outlet  is  differently  con¬ 
stituted  from  any  of  the  others  already  men¬ 
tioned  ;  for  although  soon  after  the  division 
of  the  umbilical  cord,  the  opening  is  closed 
by  cicatrization,  it  always  remains  a  weak 
point,  from  which  protrusion  is  liable  to 
occur  from  want  of  physical  power  in  the 
cicatrix  to  resist  the  pressure  from  within. 

Ventral  hernia. — This  distinguishing  term 
has  been  applied  to  protrusions  of  the  intes¬ 
tine  from  any  part  of  the  abdomen  where 
blood-vessels  pass  through  the  tendinous 
parietes,  particularly  in  the  course  of  the 
linea  alba  and  linea  semilunares ;  but  not 
through  the  muscular  parietes,  as  in  conse¬ 
quence  of  the  arrangement  of  the  fibres  of 
the  three  large  flat  muscles,  an  effective 
barrier  is  presented  to  protrusion  through 


them,  unless  from  some  abnormal  cause  their 
vital  contractile  power  becomes  diminished. 

Obturator  hernia. — In  this  hernia  the  in¬ 
testine  passes  through  the  opening  in  the 
ligament  of  the  obturator  foramen,  through 
which  the  obturator  vessels  and  nerves  are 
transmitted :  this  hernia  also  derives  a  co¬ 
vering  from  the  internal  abdominal  fascia. 

Ischiatic  hernia. — This  is  a  protrusion  of 
a  viscus  through  the  ischiatic  notch,  accom¬ 
panying  the  course  of  the  great  sciatic  nerve  ; 
but  from  the  depth  of  its  situation  it  can 
scarcely  happen  that  it  can  be  discovered 
during  life. 

Perineal  hernia  is  produced  by  the  escape 
of  intestine  through  the  lower  aperture  of 
the  pelvis  ;  it  occupies  the  space  between 
the  rectum  and  urinary  bladder,  and  some¬ 
times  forms  an  external  tumor  in  the  peri¬ 
neum. 

Vaginal  and  pudendal  hernice  must  be 
considered  as  modifications  of  peroneal  her¬ 
nia.  They  take  their  specific  name  accord¬ 
ing  as  they  encroach  most  upon  the  vagina 
or  pudendum. 

Diaphragmatic  hernice  are  usually  the 
result  either  of  malformation  or  laceration 
of  this  great  septum ;  in  either  of  those 
cases  the  protrusion  is  not  furnished  with  a 
peritoneal  sac  :  this  hernia  is  sometimes  pro¬ 
duced,  however,  by  the  yielding  of  the  natural 
openings  through  the  diaphragm,  and  it  is 
then  supplied  with  a  distinct  covering  of 
peritoneum. 

Contents  of  hernice. — Any  of  the  viscera 
contained  in  the  abdomen  may  become  the 
subject  of  hernia,  and  the  symptoms  vary 
according  to  the  function  of  the  displaced 
viscus  :  hence  in  forming  the  diagnosis  it  is 
of  great  importance  to  ascertain  what  pecu¬ 
liar  function  has  undergone  disturbance. 

In  consequence  of  the  looseness  of  the  at¬ 
tachment  of  the  jejunum  and  ilium  to  the- 
spine  by  means  of  the  mesentery,  those  vis¬ 
cera  are  particularly  liable  to  escape  from 
their  natural  cavity. 

Hernise  in  the  region  of  the  epigastrium 
usually  contain  the  transverse  arch  of  the 
colon ;  and  as  this  viscus  is  intimately  con¬ 
nected  with  the  stomach  through  the  medium 
of  the  omentum,  so  much  derangement  in 
the  functions  of  the  stomach  is  generally- 
produced,  as  to  have  led  to  the  belief  that 
that  organ  was  itself  protruded.  This  is, 
however,  of  very  rare  occurrence,  and  the 
only  displacement  to  which  the  stomach 
seems  to  be  liable  is  in  case  of  malfor¬ 
mation  of  the  diaphragm.  I  have  my¬ 
self  witnessed  a  case  of  this  diaphragmatic 
hernia,  in  a  child  who  had  died  of  re¬ 
mittent  fever,  with  some  anomalous  symp¬ 
toms  that  were  afterwards  accounted  for  in 
great  measure  by  the  abnormal  position  of 
the  stomach.  Many  years  since,  I  saw  a 
very  large  scrotal  hernia  in  a  patient  of  Mr. 


402 


HERNIA  OF  THE  URINARY  BLADDER. 


Dalrymple,  of  Norwich  :  strangulation  had 
occurred,  and  it  was  necessary  to  resort  to 
the  operation  :  the  patient,  however,  died, 
and  on  post-mortem  examination  it  was 
found  that  the  whole  length  ot  the  intestinal 
canal  was  contained  within  the  hernial  sac, 
and  even  the  pyloric  extremity  of  the  sto¬ 
mach  was  drawn  down  as  far  as  the  external 
abdominal  ring,  the  stomach  forming  a  con¬ 
tinuous  tube  extending  from  the  hypochon¬ 
driac  region,  across  the  abdomen  to  the 
right  side  of  the  pubic  region. 

The  ovaria,  fallopian  tubes,  and  even  the 
uterus,  sometimes  constitute  the  contents  of 
a  hernia,  giving  rise  to  symptoms  which 
rather  indicate  disturbance  in  the  functions 
of  the  procreative  organs,  than  in  those  of 
the  alimentary  canal.  Mr.  Teale  mentions 
a  case  of  a  young  female,  from  whom  the 
ovaria  were  removed  by  Mr.  Nourse,  of 
St.  Bartholomew’s  Hospital,  in  consequence 
of  their  protrusion  into  the  inguinal  canal, 
producing  so  much  inconvenience  as  to 
incapacitate  the  girl  for  her  ordinary  avoca¬ 
tions.  After  the  operation,  she  completely 
recovered  her  health,  but  ceased  to  men¬ 
struate,  although  that  function  of  the  uterus 
had  been  before  properly  performed. 

The  caecum  is  occasionally  the  subject  of 
hernia,  which  is  peculiar  on  account  of  the 
absence  of  a  peritoneal  sac. 

There  are  no  very  distinct  and  well- 
marked  symptoms  which  enable  the  surgeon 
to  ascertain  with  accuracy  the  exact  portion 
of  intestine  which  really  forms  a  hernia, — 
for  as  a  hernia  of  intestine  must  necessarily 
interfere  with  the  functions  of  the  bowels, 
the  symptoms  arising  from  such  obstruction 
are  very  similar,  whatever  may  be  the  portion 
of  intestine  protruded. 

About  a  year  ago,  I  performed  the  opera¬ 
tion  for  inguinal  hernia  on  the  right  side,  in 
a  patient  of  Mr.  Ward,  of  Watford.  On 
laying  open  the  internal  abdominal  fascia, 
(usually  termed  in  this  situation  the  fascia 
spermatica  interna),  I  immediately  exposed 
the  intestine,  uncovered  by  peritoneum,  and 
which,  from  its  broad  muscular  bands,  and 
the  presence  of  the  vermiform  process,  proved 
to  be  caecum.  As  soon  as  I  divided  the 
stricture,  the  patient  evacuated  the  bowTels 
per  atium  ;  this  I  considered  a  very 
favourable  symptom,  but  he  died  of  peri¬ 
tonitis  the  fifth  day  after  the  operation. 

It  may  be  supposed  that  hernia  of  the  cae¬ 
cum  could  only  occur  on  the  right  side; 
but  cases  are  recorded  in  which  it  has  passed 
over  so  as  to  constitute  a  hernial  protrusion 
on  the  left  side  of  the  body.  This  I  should, 
however,  imagine  could  only  happen  secon¬ 
darily,  the  viscus  being  drawn  over  by  an  ex¬ 
traordinary  protrusion  of  ileum  to  which  it 
is  attached  ;  indeed,  on  the  right  side,  the 
caecum  may  protrude  into  a  hernial  sac 
already  formed  by  the  ilium,  and  nothing 


but  the  great  size  of  the  tumor  could  lead 
to  the  supposition  that  such  a  condition  ex¬ 
isted. 

In  the  left  inguinal  region,  the  sigmoid 
flexion  cf  the  colon  sometimes  fills  the  her¬ 
nial  sac :  it  may  be  uncovered  by  perito¬ 
neum,  and  be  altogether  under  circumstances 
similar  to  those  which  relate  to  the  caecum. 
The  diagnosis  is  less  difficult  in  these  cases, 
if  none  of  the  small  intestines  be  affected, 
for  the  symptoms  indicate  obstruction  of  the 
large  intestines  alone,  and  are  unmarked  by 
urgent  or  stercoraceous  vomiting. 

Hernia  of  the  urinary  bladder  sometimes 
takes  place,  the  circumstances,  as  far  as  re¬ 
fer  to  its  coverings,  being  the  same  as  in 
hernia  of  the  caecum,  the  bladder  being  only 
partially  covered  by  peritoneum.  The 
symptoms  are,  however,  sufficiently  distinc¬ 
tive,  and  clearly  indicate  the  particular 
organ  protruded.  The  principal  predispos¬ 
ing  cause  of  this  hernia  is  abnormal  disten¬ 
sion  of  the  bladder  by  protracted  retention  of 
urine  :  it  remains,  when  emptied,  in  a 
flaccid  condition,  and  exceedingly  liable  to 
be  protruded  through  the  abdominal  rings, 
if  they  happen  to  be  at  all  enlarged.  Many 
cases  of  such  hernise  are  recorded,  and  even 
some  in  which  the  bladder  contained  urinary 
calculi,  that  were  safely  removed  by  the  ope¬ 
ration  of  laying  open  the  hernial  tumor. 
Some  years  ago,  I  saw  a  gentleman  at  the 
house  of  my  friend,  Mr.  Cooper,  of  Brent¬ 
ford,  who  was  the  subject  of  hernia  of  the 
bladder.  The  viscus  seemed  to  have  escaped 
as  a  direct  inguinal  hernia,  through  the  ex¬ 
ternal  abdominal  ring,  proceeding  down¬ 
wards,  partly  into  the  scrotum,  and  partly 
into  the  inguinal  canal.  This  gentleman 
could  only  empty  the  bladder  completely, 
by  raising  the  scrotum,  and  pressing  at  the 
same  time  both  the  scrotal  and  inguinal 
tumor.  In  this  case,  Mr.  Bigg  contrived  a 
suspensory  bandage,  capable  of  exerting 
pressure  upon  the  inguinal  region  :  this 
afforded  very  considerable  relief  to  the  in¬ 
convenience  and  annoyance  naturally  at¬ 
tached  to  such  a  condition. 

Sir  Astley  Cooper  has  also  described  the 
dissection  of  a  case  of  hernia,  in  which  the 
urinary  bladder  formed  part  of  the  contents 
of  a  hernial  sac,  intestine  and  omentum 
being  protruded  at  the  same  time  ;  the  blad¬ 
der  was,  however,  situated  behind  the  sac, 
being  merely  adherent  to,  and  not  within  it. 

An  important  symptom  of  hernia  of  the 
bladder  is  the  frequent  desire  to  make  water, 
from  the  patient  not  being  able  to  perfectly 
empty  the  organ.  It  may  be  supposed  that 
ventral  herniae  of  the  bladder  would  not  be 
very  unfrequent,  as  we  so  often  find  that  con¬ 
genital  defective  nutrition  produces  malfor¬ 
mation  of  the  anterior  parietes  of  the  abdo¬ 
men  in  the  pubic  region.  W7hen,  however, 
such  a  hernia  does  occur,  it  is  not  of  the 


CAUSES  AND  CONDITIONS  OF  HERNIA. 


403 


usual  character  of  ventral  hernia,  but  it 
is  found  that  the  anterior  surface  of  the 
bladder  is  equally  defective  with  the  parietes 
of  the  abdomen,  so  that  the  protrusion 
presents  the  mucous  surface  of  the  posterior 
wall  of  the  organ,  without  any  peritoneal 
covering.  I  have  seen  several  cases  of  this 
kind,  and  know  a  gentlemen,  now  living,  and 
upwards  of  forty  years  of  age,  who  is  the 
subject  of  this  malformation,  and  suffers, 
indeed,  little  more  than  the  inconvenience 
arising  from  the  constant  exudation  of  the 
urine. 

Hernise  not  only  derive  their  distinctive 
names  from  the  openings  through  which 
they  protrude,  but  also  from  the  name  of  the 
viscus  they  contain.  If,  for  instance,  the 
tumor  contain  intestine  alone,  it  is  termed 
an  enterocele  ;  if  omentum,  an  epiplocele  ; 
if  both  intestine  and  omentum,  an  entero- 
epiplocele ;  and  in  like  manner  if  a  tumor  be 
formed  by  the  protrusion  of  the  urinary 
bladder  or  uterus,  it  is  termed  respectively  a 
cystocele  or  metrocele. 

Causes  of  Hernia. — The  cause  of  a  hernia 
may  be  either  predisposing  or  exciting. 
The  weakness  of  the  parietes  of  the  ab¬ 
domen,  owing  to  the  number  of  outlets 
they  contain,  may  perhaps  be  looked  upon 
as  the  most  fruitful  source  of  the  protrusion 
of  abdominal  viscera,  and  any  influence 
which  tends  to  increase  abnormally  the  size 
of  these  openings,  must  increase  the  liability 
to  hernia.  Each  opening  appears  to  be 
furnished  at  its  external  circumference  with 
an  arrangement  of  muscular  fibre,  which, 
when  in  action,  resists  the  escape  of  the  in¬ 
closed  viscera.  Any  diminution  of  the  mus¬ 
cular  irritability,  will,  therefore,  diminish 
also  the  natural  resistance  at  these  points. 
This  is  proved  by  the  circumstance,  that 
hernia  is  seldom  produced  by  violent 
voluntary  muscular  exertion,  but,  on  the 
other  hand,  occurs  very  often  under  sud¬ 
den  exertion,  when  the  muscles  of  the 
abdomen  are  unprepared  to  maintain  the 
equilibium  of  resistance,  as  in  making  a 
strong  sudden  effort  to  recover  a  false  step, 
or  in  the  shock  communicated  to  the  body 
by  the  stumbltng  of  a  horse.  The  debili¬ 
tating  influence  of  long  illness  upon  the 
muscular  system  also  strongly  predisposes 
to  the  hernia,  and  persons  who  are  suddenly 
reduced  from  obesity  to  comparative  thin¬ 
ness  are  very  liable  to  this  affection,  from 
the  relaxed  condition  in  which  the  walls 
of  the  abdomen  are  left,  and  from  the 
absorption  of  the  fat  which  frequently  served 
to  partially  fill  up  the  openings.  A  similar 
condition  is  very  often  the  result  of  the 
evacuation  of  the  fluid  in  ascites.  Congenital 
defects  may  also  constitute  a  prominent  pre¬ 
disposing  cause  of  hernia,  and  this,  as  well 
as  the  other  causes  already  enumerated,  tends 
to  the  liability  to  protrusion  of  viscera,  on 


the  accession  of  any  exciting  cause,  whatever 
it  may  be. 

Exciting  causes  of  hernia.— One  ofthe  most 
frequent  of  these  is  cough  of  long  standing, 
which,  from  the  contractions  it  produces 
in  the  diaphragm,  gives  rise  to  a  con¬ 
tinued  pressure  of  the  viscera  downwards, 
tending  to  force  the  more  moveable  intestines 
through  the  enlarged  apertures  which  traverse 
the  already  weakened  walls  of  the  abdomen. 
Constipation  of  the  bowels,  and  permanent 
stricture  of  the  urethra,  in  both  of  which 
continued  muscular  exertion  is  required  in 
the  expulsion  of  the  excretions,  often  consti¬ 
tute  a  source  of  hernia,  and  mechanics  from 
wearing  belts,  and  females  from  the  pressure 
of  ill-shaped  and  excessively  tightened  stays, 
are  rendered  extremely  liable  to  visceral  protru¬ 
sions,  which  are  also  sometimes  produced  by 
blows  on  the  abdomen,  but,  in  that  case,  are 
generally  accompanied  by  laceration  either 
of  the  muscles  or  aponeuroses. 

As  the  tumor  which  constitutes  a  hernia 
necessarily  passes  through  a  constricted 
opening,  the  point  at  which  it  protrudes 
must  be  the  narrowest  portion  of  the  swell¬ 
ing,  and  is  technically  termed  the  neck  of 
the  hernia  :  this  constitutes  the  most  im¬ 
portant  part  of  the  tumor,  as  it  is  here  that 
the  chief  difficulty  is  experienced  in  return¬ 
ing  it  into  the  abdomen.  This  difficulty  is 
sometimes,  indeed,  found  to  be  insuperable  ; 
and  it  is  under  those  circumstances  that  a 
surgical  operation  becomes  necessary.  The 
central  portion  of  the  hernial  tumor  is 
termed  the  body,  and  its  free  extremity  the 
fundus.  This  division  may  appear  unim¬ 
portant,  but  by  directing  your  attention  to 
the  general  configuration  of  the  swelling, 
and  the  continuity  of  its  neck  with  the  in¬ 
terior  of  the  abdomen,  the  diagnostic  marks 
between  hernia  and  other  tumors  resembling 
it,  are  rendered  much  clearer  than  they 
would  otherwise  be  ;  and  this  arrangement 
will  also  be  found  convenient  in  referring  to 
the  tumor,  when  describing  the  manner  and 
direction  in  which  the  force  is  to  be  appiied 
in  its  reduction. 

Conditions  of  hernice. — A  hernial  tumor 
must  always  be  said  to  be  in  one  of  the  four 
following  conditions — viz.  reducible,  irredu¬ 
cible,  obstructed,  or  strangulated.  A  re¬ 
ducible  hernia  is  that  which  by  the  ap plica¬ 
tion  of  a  slight  force  may  be  returned  into 
the  cavity  of  the  abdomen.  The  force  em¬ 
ployed  in  effecting  this,  is  technically  termed 
taxis.  I  shall  not,  however,  further  desciibe 
this  at  present,  as  the  direction  in  which  the 
force  is  to  be  applied  differs  in  each  kind  of 
protrusion,  and  must,  therefore,  be  modified 
according  to  the  particular  direction  the 
viscus  has  taken.  As  a  general  rule,  it  may, 
however,  be  stated,  that  the  taxis  should  be 
applied  while  the  patient  is  in  the  recumbent 


404 


TREATMENT  OF  REDUCIBLE  HERNIA. 


position,  with  the  trunk  and  extremities 
elevated,  to  relax  the  abdominal  muscles. 

Treatment  of  reducible  hernia. — You 
will  generally  find,  gentlemen,  that  when 
called  to  a  case  of  hernia,  the  patient,  instead 
of  at  once  informing  you  of  the  existence  of 
a  tumor  either  in  the  abdomen  or  some 
other  region,  will  probably  complain  of  a 
sensation  of  tightness  in  the  scrobiculus 
cordis, — a  general  tenderness  over  the 
abdomen,  and  a  constipated  state  of  the 
bowels,  attended  by  more  or  less  nausea. 
These  symptoms  would  at  once  lead  you  to 
inquire  of  the  patient  if  a  tumor  existed  in 
the  abdomen  ;  and,  indeed,  you  should  ex¬ 
amine  yourself,  to  ascertain  whether  such  is 
the  case :  this  is  more  particularly  necessary 
with  females,  whose  natural  delicacy  would 
perhaps  render  them  unwilling  to  mention 
the  circumstance. 

If  it  be  ascertained  that  a  tumor  does 
exist,  and  that  it  be  tender  and  tense,  the 
taxis  should  not  be  immediately  applied, 
but  the  patient  should  be  placed  in  a  hot 
bath  (100°),  and  kept  under  its  influence 
until  a  slight  degree  of  faintness  is  pro¬ 
duced,  which,  if  he  be  of  a  full  plethoric 
habit,  may  be  maintained  by  abstracting  a 
small  quantity  of  blood  from  the  arm  ;  and, 
where  there  is  reason  to  suppose  that  the 
large  intestines  are  loaded,  an  enema  should 
also  be  administered. 

As  soon  as  the  patient  is  put  to  bed,  an 
attempt  should  be  made  to  reduce  the 
hernia  ;  and,  if  this  be  successful,  a  truss 
must  be  immediately  applied,  to  pre¬ 
vent  reprotrusion.  Should  the  hernia  not 
be  returnable  by  the  taxis,  it  becomes  a 
question  whether  the  operation  ought  to  be 
performed  immediately,  or  whether  the 
return  of  the  intestine  should  be  further 
attempted  by  other  means.  This  depends 
upon  the  urgency  of  the  symptoms,  and  the 
length  of  the  time  during  which  the  hernia 
has  been  protruded.  If  the  sickness  be  not 
violent,  and  the  tenderness  also  not  very 
great,  a  bladder  of  ice  may  be  applied  to 
the  tumor  :  this  tends  to  diminish  its  size, 
by  condensing  the  air  which  it  contains,  and 
by  checking  the  flow  of  blood  to  the  part ; 
and,  when  this  effect  appears  to  be  pro¬ 
duced,  the  taxis  must  again  be  applied,  and 
the  hernia  may  perhaps  now  be  returned 
into  the  cavity  from  whence  it  had  escaped. 
Supposing  the  attempt  to  be  successful,  pur¬ 
gative  medicines  should  not  be  immediately 
prescribed,  but  the  patient  allowed  to  re¬ 
main  in  a  state  of  perfect  quietude,  to  give 
time  for  the  protruded  intestine  to  recover 
from  the  abnormal  condition  in  which  it 
had  been  placed ;  and,  even  should  the 
patient  remain  several  days  without  eva¬ 
cuating  the  bowels,  unless  there  were  sick¬ 
ness,  1  should  not  consider  it  judicious  to 
e  re  with  the  operations  of  nature  by 


any  medical  treatment.  As  soon  as  the 
patient  has  had  a  motion  naturally,  he  may 
generally  be  considered  as  convalescent.  It 
must  not,  however,  be  taken  for  granted 
that  the  restoration  of  the  protruded  viscus 
to  its  natural  situation  will  invariably  re¬ 
lieve  the  symptoms ;  it  sometimes  hap¬ 
pens  that  the  hernial  sac  itself  is  returned 
with  its  contents.  This  is  termed  by  the 
French  “  reduction  en  bloc.”  The  symp¬ 
toms  may  in  that  case  all  continue ;  for,  in 
fact,  the  only  change  produced  is  the  con¬ 
version  of  an  external  into  an  internal 
hernia.  The  treatment,  under  these  cir¬ 
cumstances,  will  form  the  subject  of  our 
future  consideration. 

It  may  be  inferred,  from  what  I  have 
already  said,  that  the  reduction  of  a  hernia 
is  invariably  to  be  attempted.  This  is  not, 
however,  the  case  ;  for  if  the  swelling  be  of 
long  standing, —  if  the  urgent  symptoms 
should  have  subsided, — if  the  tumor  has 
become  suddenly  distended,  and  the  skin 
discoloured, — it  indicates  that  the  contents 
of  the  sac  have  undergone  such  changes  as 
to  be  beyond  restoration,  and  are  therefore 
unfitted  to  be  replaced  within  the  abdomen. 
In  this  case  the  hernial  sac  should  be  laid 
open,  the  stricture  divided,  and,  the  real 
condition  of  the  intestine  being  ascertained 
by  ocular  examination,  the  surgeon  is  enabled 
to  decide  whether  it  be  still  in  a  fit  state  to 
be  replaced  ;  and,  if  it  be  found  sphacelated, 
a  free  incision  should  be  made  into  it,  to 
produce  an  artificial  anus.  Many  instances 
are  on  record  in  which  the  patient  has  per¬ 
fectly  recovered  under  the  latter  mode  of 
treatment. 

When  it  is  considered  advisable  to  at¬ 
tempt  the  reduction  of  a  hernia,  and  it 
has  proved  successful,  a  truss  must  be  im¬ 
mediately  applied,  for  the  purpose  of  re¬ 
taining  the  returned  parts  within  their 
natural  cavity.  I  always  order  a  double 
truss  to  be  worn  even  where  the  rupture  is 
on  one  side  only  ;  for  the  equable  and  sym¬ 
metrical  pressure  is  more  agreeable  to  the 
patient,  and  it  also  prevents  the  tendency  to 
rupture  on  the  opposite  side,  often  induced 
by  wearing  a  single  truss.  Bandages  and 
compresses  are  sometimes  found  sufficient 
to  retain  the  hernia  without  the  use  of 
metallic  springs ;  but  they  are  generally 
employed  only  in  umbilical  and  ventral 
hernise.  All  mechanical  contrivances  may, 
indeed,  be  found  ineffectual  in  preventing 
the  reprotrusion  :  hence  various  operations 
have  been  devised  for  producing  “  the  ra¬ 
dical  cure”  of  reducible  hernia.  The  object, 
under  these  circumstances,  is  the  perma¬ 
nent  closing  of  the  aperture  through  which 
the  intestine  passes.  Most  of  the  proposed 
operations  are,  however,  in  my  opinion, 
unwarrantable,  from  the  great  danger  of 
peritonitis  :  and,  indeed,  I  consider  all  ope- 


SYMPTOMS  OF  IRREDUCIBLE  HERMA. 


405' 


rations  on  the  hernial  sac,  such  as  excision, 
cautery,  ligature,  and  so  forth,  as  extremely 
reprehensible. 

An  operation  has,  however,  been  recom¬ 
mended  by  M.  Gerdy,  which  I  have  once 
performed  on  a  patient  who  had  a  large 
scrotal  hernia,  the  descent  of  which  could 
not  be  prevented  by  any  kind  of  truss  that 
I  could  procure.  I  was  therefere  induced  to 
resort  to  this  operation,  because,  of  all 
those  proposed,  it  presented  least  liability 
to  inflammation  of  the  peritoneum.  The 
following  is  an  account  of  the  case  : — 

John  Hollman,  set.  22,  was  admitted 
into  Guy’s  Hospital,  1840,  being  the  sub¬ 
ject  of  a  large  reducible  inguinal  hernia 
on  the  aight  side  ;  and,  as  this  could  not 
be  retained  in  the  abdomen  by  any  truss, 
he  was  rendered  perfectly  incompetent  to 
follow  his  usual  avocations,  and  consented 
readily  to  the  operation  which  I  pro¬ 
posed.  Being  placed  on  his  back  on  a  table, 
with  his  chest  and  thighs  raised,  1  passed 
the  forefinger  of  my  left  hand  as  high  up  as 
I  could  through  the  external  ring  into  the 
inguinal  cannl,  pushing  before  it  a  portion 
of  the  integument  of  scrotum.  I  then  in¬ 
troduced  a  director,  along  which  I  passed  a 
needle  fixed  in  a  wooden  handle,  and  armed 
with  a  double  silk  ligature.  The  needle 
was  passed  to  the  very  extremity  of  the 
invaginated  skin,  and  was  pushed  through 
the  tendon  of  the  abdominal  oblique  muscle 
and  the  skin,  and  brought  out  an  inch  and 
a  half  above  Poupart’s  ligament.  One  end 
of  the  silk  was  then  retained  by  an  assistant, 
and  the  needle  drawn  back,  and  pushed 
through  a  second  time  in  exactly  the  same 
manner  as  at  first,  but  including  about  four 
lines  of  the  invaginated  integument.  The 
two  free  ends  were  then  tied  over  a  piece  of 
bougie  with  a  sufficient  degree  of  tension  to 
retain  the  intruded  portion  of  integument 
firmly  within  the  inguinal  canal.  A  piece 
of  lint  wrapped  around  a  director,  and 
dipped  into  Liq.  Ammon.,  was  passed  into 
the  “  cul  de  sac”  of  skin,  and  the  surface 
well  rubbed  with  it,  to  remove  the  cuticle 
and  promote  inflammation  in  the  cutis,  for 
the  purpose  of  obliterating  this  integumen¬ 
tary  canal,  and  forming  a  plug  sufficiently  firm 
to  prevent  the  future  descent  of  the  hernia. 
The  application  of  the  ammonia  produced 
intense  pain :  this  was,  however,  relieved 
by  opium.  Four  days  subsequently  to  the 
operation,  the  ligature  was  removed,  as 
purulent  discharge  was  freely  established. 
Pressure  was  kept  upon  the  part  by  com¬ 
presses,  to  promote  perfect  union,  and  in 
about  three  weeks  a  weak  truss  was  ap¬ 
plied  ;  but  he  still  remained  in  the  hospital 
another  fortnight,  after  which,  as  the  hernia 
did  not  descend,  he  left.  About  two  months 
after  he  had  returned  to  his  employment, 
which  was  of  a  violent  character,  the  hernia 
partially  descended ;  but,  by  the  use  of  a 


stronger  truss,  he  has  ever  since  been  able 
to  continue  at  work,  being,  however,  some¬ 
times  subject  to  a  slight  return  of  the  affec¬ 
tion  :  this  man  may  be  said  to  be  relieved, 
but  not  permanently  cured,  by  the  operation. 

Irreducible  hernia. — This  is  a  form  of 
hernia  in  which,  although  the  contents  can¬ 
not  be  returned  into  the  abdomen,  they  are 
not  subjected  to  sufficient  constriction  to 
render  them  incapable  of  performing  their 
natural  functions.  It  is  sometimes  termed 
incarcerated  hernia.  The  distinction  be¬ 
tween  the  two  is,  however,  perfectly  obvious  : 
in  one  case  the  contents  of  the  sac  are  only 
permanently  retained  in  it ;  in  the  other  the 
intestine  is  so  much  restricted  that  its  na¬ 
tural  functions  are  completely  impeded.  It 
rarely  happens  that  a  recent  hernia  becomes 
at  once  irreducible,  unless  it  be  immediately 
strangulated  ;  and  by  far  the  most  frequent 
cause  which  renders  a  hernia  irreducible  is 
the  employment  of  an  ill-fitting  truss,  which, 
admitting  of  the  descent  of  a  reducible 
hernia,  presses  upon  the  contents  of  the  sac, 
and  produces  thickening  of  the  parietes, 
and,  perhaps,  at  the  same  time,  adhesion 
between  the  intestine  and  the  interior  of 
the  sac.  Any  circumstance,  however,  which 
leads  to  inflammation  of  the  contents  of  a 
reducible  hernia  may  induce  a  liability  to 
incarceration.  No  very  urgent  symptoms 
necessarily  present  themselves  to  mark  the 
conversion  of  a  reducible  into  an  irreducible 
hernia :  the  functions  of  the  alimentary 
canal  may  still  be  duly  performed,  and  the 
patient  may  be  considered  perfectly  free 
from  danger ;  but  any  internal  functional 
derangement  or  slight  external  injury  would 
perhaps  suddenly  produce  the  most  urgent 
symptoms :  for  example,  undigested  matter 
of  any  kind  passing  into  an  incarcerated 
knuckle  of  intestine  is  retained  not  only  in 
consequence  of  the  form  of  the  protruded 
bowel,  but  also  from  the  diminution  of  its 
peristaltic  action  ;  and  thus  an  irreducible  is 
at  once  converted  into  an  obstructed  hernia. 

The  symptoms  arising  from  such  an  ob¬ 
struction  as  that  just  named  are  very  similar 
to  those  in  strangulated  hernia,  but  are  less 
urgent  in  their  character  ;  and  the  history  of 
the  case,  and  the  gradual  progress  of  the 
symptoms,  enable  the  surgeon  to  judge  be¬ 
tween  them. 

When  it  is  decided  that  the  case  is  one 
of  obstruction,  and  not  of  strangulation, 
copious  enemata  of  gruel  and  castor  oil 
should  be  administered,  and  purgatives  em¬ 
ployed  at  the  same  time.  These  means  are 
usually  found  sufficient ;  but  the  warm  bath, 
and  the  application  of  ice  to  the  tumor,  may 
in  some  instances  be  required.  If,  how¬ 
ever,  the  hernia  should  be  obstructed  by 
external  injury,  purgatives  ought  not  to  be 
prescribed  ;  but  leeches,  and  subsequently 
ice,  should  be  applied,  and  the  patient  kept 
in  perfect  rest,  as  any  attempt  to  produce 


406 


MR.  SIBSON  ON  THE  SIZE  AND  SITUATION  OF  THE 


evacuation  may  lead  to  lesion  of  the  injured 
intestine  ;  while,  if  nature  be  left  uninter¬ 
fered  with,  evacuation  will  take  place  as 
soon  as  the  bowel  is  sufficiently  restored  to 
render  it  capable  of  supporting  the  neces¬ 
sary  action. 

If  the  obstruction,  whatever  be  its 
cause,  cannot  be  overcome  by  the  means 
indicated,  there  remains  no  alternative  for 
the  surgeon  but  to  perform  an  operation 
similar  to  that  in  strangulated  hernia.  After 
the  obstruction  has  been  removed,  if  the 
hernia  still  remains  irreducible,  it  is  of 
great  importance  to  convert  it,  if  possible, 
into  the  reducible  form,  without  having 
recourse  to  a  surgical  operation.  The  mode 
of  effecting  this  is  well  illustrated  in  the 
following  case  : — 

A  young  farmer,  who  was  the  subject  of 
irreducible  hernia,  was  sent  to  me  by  Dr. 
Baddeley,  of  Chelmsford.  The  hernia  was 
of  two  years  standing,  and  so  anxious  w!as 
the  patient  to  obtain  relief,  that  he  was 
willing  to  submit  to  any  system  of  treat¬ 
ment  that  promised  to  afford  it.  I  pre¬ 
scribed,  in  the  first  instance,  purgatives,  to 
produce  complete  evacuation  of  the  bowels, 
and  ordered  him  to  remain  bed,  with  his 
shoulders  and  thighs  raised,  so  as  to  per¬ 
fectly  relax  the  abdominal  muscles.  A  low 
diet  was  strictly  enjoined,  and  a  grain  of 
blue  pill  and  a  quarter  of  a  grain  of  tar- 
tarized  antimony  given  twice  a  day,  with  the 
intention  of  stimulating  the  absorbents  to  the 
removal  of  the  fatty  matter  of  the  omentum. 
Ice  was  frequently  applied,  and  also  enemata, 
to  keep  the  intestines  perfectly  empty.  So 
anxious  was  the  patient  for  the  removal  of 
his  complaint,  that  he  submitted  to  all  these 
restrictions  during  the  space  of  five  weeks, 
but  in  that  time  no  favourable  change  had 
been  produced  beyond  a  slight  diminution  in 
the  size  of  the  tumor.  At  last,  quite  de¬ 
spondent  at  this  w'ant  of  success,  in  a  fit  of 
impatience  he  one  morning  jumped  out  of 
bed,  when,  to  his  great  surprise  and  joy, 
the  tumor  suddenly  disappeared.  He  im¬ 
mediately  applied  his  truss,  and  has  never 
experienced  the  least  return  of  the  protru¬ 
sion;  taking,  however,  the  precaution  of 
always  wearing  a  truss  even  in  bed. 

From  the  successful  result  of  the  treat¬ 
ment  in  this  case,  I  have  been  induced  to 
repeat  it  in  several  others,  both  in  public 
and  private  practice,  and  have  found  it  very 
successful.  If,  however,  your  efforts  should 
prove  abortive,  and  the  hernia  remain  irre¬ 
ducible,  an  apparatus  should  be  contrived  to 
support  the  tumor  and  defend  it  from  ex¬ 
ternal  injury  ;  and,  at  the  same  time,  the 
most  scrupulous  attention  must  be  paid  by 
the  patient  to  his  diet,  both  as  to  quality 
and  quantity  ;  for,  by  merely  a  slight  in¬ 
attention  to  the  rules  laid  down,  he  subjects 
himself  to  a  return  of  the  disorder,  and 
consequent  imminent  danger  to  his  life. 


©rtginal  (Sommumcationg. 


ON  THE 

SIZE  AND  SITUATION  OF  THE  IN¬ 
TERNAL  ORGANS  IN  VESICULAR 
EMPHYSEMA  AND  BRONCHITIS. 

By  Francis  Sibson,  Esq,. 

General  Hospital,  near  Nottingham. 

1.  Emphysema  and  Bronchitis  produc  e  r 
same  general  effect  on  the  size  and  situa¬ 
tion  of  the  lungs  and  heart.  2.  In  Em¬ 
physema  the  lungs  are  increased  in 
volume  to  an  extent  proportioned  to  the 
duration  of  the  disease.  3.  Indicated  in 
M.  Louis'  tables  of  the  extent  of  emphy¬ 
sema  in  different  cases.  4.  Case  of 
Wm.  Galloway  (see  engravings )  affected 
with  emphysema  and  heart  disease. 

5.  Enlargement  of  the  heart  usual  in  em¬ 
physema,  and  is  indicated  in  the  last 
stages  by  oedema  —  M.  Louis'  cases  of 
emphysema — J)r.  Boyd's,  Dr.  Clendin- 
ning's,  and  the  author's,  enumerating 
those  in  which  the  heart  was  enlarged. 
6.  The  heart  is  also  usually  voluminous  in 
bronchitis — Dr.  Boyd's  and  Dr.  Clen- 
dinning's  cases.  7.  Dilatation  and 
hypertrophy  of  the  right  side  of  the 
heart,  the  especial  result  of  emphysema 
and  bronchitis,  illustrated  by  the  author's 
and  the  observations  of  Dr.  Stokes,  Dr. 
Hodgkin,  and  Dr.  Hasse — Remarkable 
induration  of  the  walls  of  the  right 
ventricle  is  sometimes  observed.  8.  Only 
a  very  small  portion  of  the  heart  is  un¬ 
covered  by  the  voluminous  lungs  —  The 
lower  boundaries  of  the  lungs  are  lower, by 
an  inch  or  more,  than  in  health — The  ex¬ 
posed  portion  of  the  heart ,  and  the  heart's 
impulse,  are  immediately  behind,  below , 
and  to  the  left  of  the  xyphoid  cartilage — 
The  impulse  of  the  apex  is  not  felt 
between  the  ribs. 

9.  The  diaphragm  is  flattened  and  lowered 
in  emphysema.  10.  The  chest  is  ex¬ 
panded.  11.  The  liver  is  sometimes 
lessened  in  emphysema — sometimes,  espe¬ 
cially  when  complicated  with  other  dis¬ 
eases,  enlarged,  and  is  usually  enlarged 
in  bronchitis — Dr.  Boyd’s  cases. — In 
emphysema  the  liver  may  be  small,  and 
yet  its  lower  margin  may  be  unusually 
low,  the  viscus  being  much  displaced 
downwards  by  the  aescent  of  the  dia¬ 
phragm.  12.  Summary. 

I  am  induced  to  defer  the  description 
of  the  minute  changes  occurring  in 
the  lungs  in  bronchitis  and  emphy¬ 
sema  until  I  have  the  advantage  of 
seeing  a  paper  on  Emphysema,  by  that 
accurate  observer,  Mr.  Rainey,  which 
is  about  to  be  published  in  the  Medical 
and  Chirurgical  Transactions. 


INTERNAL  ORGANS  IN  VESICULAR  EMPHYSEME  AND  BRONCHITIS.  407 


2.  Myobject  in  this  paperis  to  describe 
the  position  of  the  internal  organs  in 
bronchitis  and  emphysema.  In  this 
point  of  view,  those  two  diseases  may 
be  considered  together,  as  they  both 
produce  the  same  general  effect  on  the 
lungs  and  heart. 

The  deviation  from  health  is  so  much 
more  marked  in  emphysema  than  in 
bronchitis,  that  I  shall  more  imme¬ 
diately  and  particularly  describe  the 
changes  in  the  position  of  the  internal 
organs  in  that  disease. 

The  essential  feature  in  emphysema 
is  the  general  and  permanent  enlarge¬ 
ment  of  the  lungs.  The  volume  of 
the  lungs  may  be  increased,  so  that 
they  occupy  more  space  than  can  be 
occupied  by  the  healthy  lungs  during 
the  deepest  possible  inspiration.  The 
lungs  are  permanently  enlarged  ;  there 
is  inability  on  the  part  of  the  patient 
to  expel  more  than  a  small  portion  of 
air  from  the  lungs.  In  extreme  cases, 
and  during  dyspnoea,  inspiration  is 
very  difficult,  but  the  expiration  is 
much  more  prolonged  and  difficult 
than  inspiration.  The  emphysema 
may  be  confined  to  any  part  of  a  lung, 
or  be  diffused  over  the  whole  of  one 
lung,  or  may  involve  both  lungs. 
Unless  under  special  circumstances, 
the  extent  of  the  disease  is  usually 
proportioned  to  its  duration. 

3.  This  is  well  shewn  in  the  two  fol¬ 
lowing  tables  of  cases  affected  with 
emphysema,  examined  after  death  by 
M.  Louis.  The  23  cases  in  the  first 
table  died  from  cholera  ;  the  19  in  the 
second  from  emphysema  or  some  other 
disease.  The  average  age  of  those  in 
the  first  was  50  ;  the  second,  60.  Those 
in  the  first  were  cut  off  in  an  earlier 


stage  of  the  disease  than  in  the  se¬ 
cond. 

23  cases  19  cases 
which  which 
died  did  not 

from  die  from 

cholera.  cholera. 

General  emphysema — 
in  both  lungs  ...  6  12 

left  lung  ....  3  2 

right  lung  ...  1  1 

of  left  upper  lobe  .  .  7  2 

right  upper  lobe  .  7  0 

left  lower  lobe  .  .  !  0 

right  lower  lobe  .  2  2 

middle  and  upper 

lobe  of  right  lung  3  0 

middle  part  of  right 

lung  ....  0  1 


Both  lungs  were  affected  throughout 
in  26  per  cent,  of  those  patients  af¬ 
fected  with  emphysema  and  dying 
from  cholera  who  were  on  the  average 
in  the  early  stage,  and  63  per  cent,  of 
those  cases  not  dying  from  cholera  who 
were  in  the  later  stages  of  emphy¬ 
sema. 

4.  In  W.  Galloway,  the  patient  from 
whom  the  engravings  which  illustrate 
this  paper  were  taken,  the  whole  of 
both  lungs  was  affected  with  emphy¬ 
sema,  but  the  disease  was  more  exten¬ 
sive  in  the  right  lung.  Before  death 
he  had  extensive  oedema.  Much  serous 
fluid  was  found  in  both  pleural  cavi¬ 
ties,  especially  the  right.  The  heart 
was  very  large,  the  ventricular  walls 
being  thick,  and  the  right  cavities  and 
pulmonary  artery  excessively  dilated. 
There  was  some  thickening  of  the 
margin  and  tendinous  cords  of  the 
mitral  valve.  Regurgitation  had  pro¬ 
bably  taken  place  during  life  both 
through  the  mitral  and  tricuspid  open¬ 
ings.  There  was  a  loud  systolic 
bellows  sound  below  and  to  the  left 
of  the  xyphoid  cartilage. 

5.  In  the  co-existence  of  oedema  and 
of  enlargement  and  disease  of  the  heart, 
Galloway’s  case  illustrates  thededuction 
of  M.  Louis,  that  in  all  those  persons 
dying  from  emphysema  who  had 
oedema  of  the  lower  extremities,  the 
volume  of  the  heart  was  materially  in¬ 
creased. 

Enlargement  of  the  heart  is  the  fre¬ 
quent,  though  not  invariable,  conco¬ 
mitant  of  emphysema,  as  M.  Louis 
observed  in 

Affected  Heart 
with  volumi- 

Emphy-  nous 
sema.  in. 

Cases  that  died  from  cho¬ 
lera  . 23  6 

Cases  that  did  not  die  from 
cholera  (the  most  ad¬ 
vanced  cases)  ....  19  10 

In  the  latter,  or  the  more  advanced 
class  of  cases,  the  heart  was  enlarged 
in  more  than  half;  in  the  less  ad¬ 
vanced  cases  it  was  only  enlarged  in. 
about  one-fourth,  — going  to  shew  that 
in  such  cases  the  enlargement  of  the 
heart  is  usually  consecutive  to,  and 
caused  by,  emphysema.  Sometimes, 
however,  emphysema  is  consecutive  to, 
and  caused  by,  heart  disease. 

That  accurate  observer,  Dr.  Boyd, 
in  the  statistical  reports  of  the  diseases 


408 


MR.  SIBSON  ON  THE  SIZE  AND  SITUATION  OF  THE 


Superficial  view. 


William  Galloway,  aged  43. — Emphysema,  bronchitis,  enlarged  heart,  right  cavities  dilated. 
Serum  in  both  pleura.  (Edema.  (Galloway  habitually  lay  on  the  right  side,  the  body 
consequently  twisted  to  the  right.) 

Weight  of  the  organs. —  Heart,  14^  oz. ;  right  lung,  23|  oz. ;  left  lung,  23  oz. ;  liver, 
40  oz. ;  right  kidney,  5  oz  ;  left  kidney,  5§  oz.  ;  spleen,  7  oz. 


and  weights  of  organs  of  persons  dying 
in  the  Marylebone  Infirmary,  gives  19 
cases  in  which  emphysema  existed  to 
a  greater  or  less  extent.  In  all  of 
these  cases  the  weight  of  the  heart  was 
greater  than  in  the  healthy  average 
(9  oz.  in  men  ;  8  in  women).  In  15  of 
the  cases  the  average  was  15^  oz.,  the 
lowest  being  12,  the  highest  22  (this 
case  was  complicated  with  pericarditis). 
In  two,  the  heart  was  stated  to  be 
large  ;  in  the  remaining  two,  one  heart 
weighed  9£  oz. ;  the  other,  10:  these 


were  from  females,  and  above  the  ave¬ 
rage  bv  from  1  to  2  oz. 

Dr.  Clendinning  gives  four  cases  of 
the  same  class  from  the  same  sources  : 
in  two  of  these  the  heart  was  much 
enlarged,  while  it  was  slightly  enlarged 
in  the  remaining  two. 

Of  ten  cases  observed  by  myself,  the 
heart  was  enlarged  in  eight,  and  of 
normal  size  in  twro.  One  of  these 
twTo  cases  died  from  a  compound  frac¬ 
ture  of  the  leg  ;  the  other,  a  man,  from 
pleuritis  and  other  affections,  the  re- 


INTERNAL  ORGANS  IN  VESICULAR  EMPHYSEMA  AND  BRONCHITIS.  409 


Deep  view. 


suit  of  an  injury  which  had  occasioned 
rupture  of  one  of  the  enlarged  lobules 
of  the  left  lung,  and  consequent  pneu¬ 
mothorax. 

6.  In  bronchitis, as  in  emphysema,  the 
lungs  are  voluminous,  and,  in  addition, 
in  the  majority  of  cases,  the  heart  is 
enlarged. 

Dr.  Boyd  gives  15  cases  of  bron¬ 
chitis,  in  all  of  which  the  heart  was 
enlarged.  In  ten  of  these  cases  in 
which  the  heart  was  weighed,  it 
averaged  14^  oz.  Nine  of  the  19  cases 
of  emphysema  given  above  were  com¬ 
plicated  with  bronchitis. 

Dr.  Clendinning  gives  7  cases  of 
chronic  bronchitis  :  of  these,  3  were 
rather  below  than  above  the  average 
weight  (two  of  these  bodies  were  much 


wasted  in  flesh);  and  in  4  it  was  above 
the  average  from  1^  to  2§  oz. 

We  may,  then,  consider  it  as  statisti¬ 
cally  proved,  that,  in  the  majority  of 
cases  of  emphysema  and  bronchitis, 
the  heart  is  abnormally  large. 

7.  In  Galloway,  and  in  Hudson,  af¬ 
fected  with  emphysema  ;  and  in  Wiber- 
ley  with  bronchitis,  (the  two  latter  are 
figured  in  my  paper  on  the  Situa¬ 
tion  of  Internal  Organs,  published 
in  the  Provincial  Medical  Trans¬ 
actions,  xii.  402,  429),  the  right 
ventricle  and  the  pulmonary  artery 
were  unusually  large.  In  Galloway, 
the  dilatation  of  the  right  cavities  was 
remarkably  great.  In  both  of  these 
cases  the  right  ventricle  almost  com¬ 
pletely  concealed  the  left,  a  mere  mar- 


410 


MR.  SIBSON  ON  THE  SIZE  AND  SITUATION  OF  THE 


gin  of  which  was  only  observable  to 
the  left  of  the  right.  Dr.  Stokes  speaks 
of  the  influence  of  this  disease,  at  page 
191  of  his  work,  on  Diseases  of  the 
Chest,  as  producing  an  accumulation  of 
blood  at  the  right  side  of  the  heart,  and 
consequent  disease  of  the  pulmonary 
or  right  cavities,  which  are  both  dilated 
and  hypertrophied. 

Dr.  Hodgkin,  in  his  Morbid  Anatomy, 
ii.  86,  observes  that  he  has  found 
several  of  the  best  marked  cases  of 
dilatation  and  thickening  of  the  right 
ventricle,  in  conjunction  with  emphy¬ 
sema,  which  appears  to  have  a  strong 
tendency  to  lead  to  diseases  of  the 
heart,  but  more  especially  of  the  right 
cavities. 

Dr.  Hasse,  too,  in  his  Pathological 
Anatomy,  p.  311,  places  hypertrophy 
and  dilatation  of  the  heart,  having  its 
seat  for  the  most  part  in  the  right  ven¬ 
tricle  and  auricle,  foremost  among  the 
secondary  changes  resulting  from  em¬ 
physema. 

In  two  cases  of  emphysema  in  which 
there  was  hypertrophy  and  dilatation 
of  the  right  ventricle,  the  walls  of  the 
ventricle  were  abnormally  hard  and 
firm,  standing  out  when  cut  into,  just 
as  if  they  had  been  previously  hardened 
in  alcohol. 

In  emphysema  and  bronchitis,  the 
resistance  to  the  circulation  through  , 
the  capillaries  of  the  lungs  causes  ac¬ 
cumulation  of  blood  in  the  right  cavity 
and  its  consequent  dilatation,  and  in¬ 
creased  force  in  its  walls  to  propel  the 
blood,  and  consequently  their  hyper¬ 
trophy. 

The  expansion  of  the  chest  itself 
tends  to  enlarge  the  cavities  of  the 

heart. 

8.  It  wdllbe  observed  that  in  Galloway, 
although  the  heart  is  so  materially  en¬ 
larged,  yet  that  only  a  very  small  por¬ 
tion  of  the  heart  is  uncovered  by  lung. 
The  heart  is, indeed,  much  enlarged,  but 
the  amplification  of  the  lungs  is  such, 
that  the  whole  heart  is  covered  by 
them,  except  a  small  portion  of  the  right 
ventricle. 

The  lower  margin  of  the  lungs,  and 
the  lower  boundary  of  the  heart,  are 
materially  lower  than  they  are  in 
health,  those  boundaries  being  behind 
the  lower  end  of  the  xyphoid  cartilage, 
instead  of  the  lower  end  of  the  sternum 
— a  full  inch  lower  than  in  the  healthy 
state. 

In  the  case  of  a  man  examined  by 


me  during  life,  they  were  .about  an  inch 
below  the  lower  end  of  the  xyphoid 
cartilage. 

The  lower  margin  of  the  right  lung  in¬ 
stead  of  being  behind  the  sixth  rib  and 
costal  cartilage,  is  behind  the  seventh 
rib.  The enlargedleftiungis  completely 
interposed  between  the  apex  of  the 
heart,  and  the  ribs  and  intercostal 
spaces  :  the  impulse  is  consequently 
no  longer  perceptible  between  the  in¬ 
tercostal  spaces,  as  the  upper  boundary 
of  the  cardiac  region  (that  portion 
of  the  heart  in  contact  with  the  walls 
of  the  chest)  is  behind  the  lowrer  mar¬ 
gin  of  thesternum,andthe  fifthandsixth 
costal  cartilage,  instead  of  the  middle  of 
the  sternum,  and  the  fourth  costal  carti¬ 
lage.  The  unusually  resonant  left  lung 
completely  replaces  the  usually  dull 
region  occupied  by  the  heart,  and  that 
region  is  seated  instead,  behind,  below, 
and  to  the  left  of  the  xyphoid  cartilage. 
At  that  region,  cardiac  dulness  may  be 
discovered  by  percussion;  and  there 
the  impulse  of  the  right  ventricle  is 
always  visible  and  to  be  felt,  the  im¬ 
pulse  at  the  apex  being  completely  un¬ 
felt,  owing  to  the  interposition  of  the 
enlarged  lung. 

Emphysema  may  be  usually  detected 
at  sight  by  the  want  of  impulse  between 
the  fifth  and  sixth  ribs,  and  by  its  pre¬ 
sence  behind,  below,  and  to  the  left  of 
the  xyphoid  cartilage.  This  is  exactly 
the  change  in  position  of  the  impulse 
that  takes  place  when  we  direct  a 
healthy  person  to  take  a  deep  breath, 
and  hold  it.  The  impulse  can  then  no 
longer  be  felt  between  the  fifth  and 
sixth  ribs,  but  is  perceptible  at  the 
xyphoid  cartilage. 

9.  The  whole  diaphragm  is  flattened 
and  lowered  in  emphysema.  The  dia¬ 
phragm  in  extreme  cases  is  lower 
than  it  can  be  in  health,  during  even 
the  deepest  inspiration.  This  is  not 
given  in  Galloway,  but  is  very  well 
seen  in  the  diagram  of  Hudson,  in 
the  paper  on  the  situation  of  the  in¬ 
ternal  organs;  in  him  the  upper 
boundary  of  the  right  convexity  of  the 
diaphragm  is  behind  the  lower  edge  of 
the  fifth  rib.  The  engravings  accompa- 
nyingmy  lastpaper,  on  the  effect  of  ab- 
dtiminal  distension  and  enlarged  liver 
on  the  position  of  the  internal  organs, 
Gazette,  July  21st,  offer  remarkable 
contrasts  to  the  engravings  of  emphy¬ 
sema  here  given.  In  the  former  case 
the  diaphragm  is  pushed  upward,  the 


INTERNAL  ORGANS  IN  VESICULAR  EMPHYSEMA  AND  BRONCHITIS.  411 


lungs  and  heart  elevated  and  com¬ 
pressed  ;  and  the  heart’s  impulse  un¬ 
usually  high,  and  to  the  left:  in  em¬ 
physema,  the  diaphragm  is  generally 
low  ;  the  lungs  and  heart  both  ampli¬ 
fied;  their  lower  boundaries  and  the 
heart’s  impulse  being  remarkably  low  ; 
and  the  abdominal  organs  are  displaced 
downwards. 

10.  Itmavbe  noticedthatthe  sternum 
and  clavicles,  the  costal  cartilages  and 
ribs,  are  all  remarkably  elevated,  the 
whole  thoracic  space  within  the  ribs 
being  unusually  enlarged,  in  proportion 
to  the  emphysematous  enlargement  of 
the  lungs.  The  cavities  of  the  heart, 
especially  the  right,  are  not  o^ly  ampli¬ 
fied,  but  their  great  vessels  are  elon¬ 
gated,  and  the  origins  of  the  innomi- 
natum  and  carotid  arteries  unusually 
low.  It  will  be  well  to  compare,  in 
these  particulars,  the  engravings  which 
accompany  this  paper  with  those  in 
the  papers  on  Health  (in  March  and 
April)  and  on  Abdominal  Distension. 

1 1.  The  liver,  it  will  be  seen,  is  unu¬ 
sually  low  in  Galloway;  at  first  sight  one 
would  suppose  it  to  be  much  enlarged, 
but  on  weighing  it,  so  far  is  this  from 
being  the  case,  that  instead  of  being 
above  it  is  below  the  average  weight 
(which  is  about  49  oz.),  as  in  Galloway 
the  liver  only  weighs  42  oz. 

Dr.  Boyd  weighed  the  liver  in  ten 
out  of  nineteen  of  his  cases  of  emphy¬ 
sema:  in  four  it  was  below  and  in  five 
above  the  average  weight;  in  four  of 
the  latter  class  emphysema  was  com¬ 
plicated,  in  two  with  bronchitis,  in  one 
wiih  pericardits,  and  in  one  with  pneu¬ 
monia. 

He  weighed  the  liver  in  eleven  cases 
of  bronchitis  :  in  seven  cases  it  was 
above,  in  two  it  was  at,  and  in  two  be¬ 
low,  the  average  weight. 

It  is  evident  that  the  liver  is  usually 
enlarged  in  bronchitis  ;  the  blood,  find¬ 
ing  a  difficulty  in  passing  through  the 
lungs,  accumulates  first  in  the  right 
cavities  of  the  heart,  and  then  in  the 
liver.  The  liver  consequently  becomes 
congestively  enlarged. 

Enlargement  of  the  liver  may  also, 
and  for  the  same  reason,  exist  in  em¬ 
physema,  especially  when  complicated 
0  with  bronchitis,  and  in  its  early  stages. 
But  as  emphysema  advances,  the 
amount  of  blood  that  passes  through 
the  lungs  becomes  materially  lessened, 
and  as  the  disease  is  often  of  the  dura¬ 
tion  of  a  long  life-time,  the  whole 
actual  amount  of  blood  in  the  system 


diminishes,  accommodating  itself  to  the 
small  amount  of  blood  capable  of  pass¬ 
ing  through  the  lungs.  The  liver  is 
consequently  not  necessarilly  enlarged 
from  congestion  in  emphysema,  but, 
on  the  contrary,  it  is  often  lessened  in 
size,  owing  to  the  blood  in  its  vessels 
being  lessened  in  quantity. 

It  is,  then,  clear  that  the  lowering  of 
the  liver  in  Galloway  is  due,  not  to  en¬ 
largement,  but  to  the  downward  dis¬ 
placement  of  that  organ,  owing  to  the 
descent  of  the  diaphragm. 

In  bronchitis,  and  in  some  cases  of 
emphysema,  especially  when  compli¬ 
cated  with  other  diseases,  the  mass  and 
lower  margin  of  the  liver  may  be 
lowered  from  the  increase  in  its  size, 
as  well  as  from  its  downward  displace¬ 
ment,  by  the  diaphragm. 

The  case  of  Galloway  proves  that 
when  the  lower  border  of  the  liver  is 
unusually  low,  it  is  not  necessarily  to 
be  inferred  that  the  liver  is  enlarged. 

To  decide  this  point  it  will  be  neces¬ 
sary  to  ascertain  whether  the  upper 
boundary  of  the  liver  is  lowered,  as  in 
emphysema — is  in  its  normal  position — - 
or  is  above  its  normal  position,  as  in 
the  case  of  enlarged  liver  figured  in 
the  paper  for  July  21. 

12.  In  Laennec’s  emphysema,  and 
in  bronchitis,  the  lungs  and  the  heart 
being  universally  enlarged,  the  whole 
cavity  of  the  chest  is  amplified  :  the 
sternum  and  clavicles  are  elevated — 
the  cartilages  and  ribs  are  raised  and 
expanded— the  diaphragm  is  remark¬ 
ably  low,  corresponding  with  the  ab¬ 
normally  low  position  of  the  bases  of  the 
lungs  and  the  lower  boundary  of  the 
heart,  and  the  upper  boundary  of  the 
liver  and  stomach.  The  whole  of  the 
abdominal  viscera  are  unusually  low, 
being  displaced  downwards  by  the  de¬ 
scent  of  the  diaphragm. 

The  lower  margin  of  the  lungs  are 
from  an  inch  to  an  inch  and  a  half  (or 
even  two  inches  in  the  most  extreme 
ca-es)  lower  than  in  health.  The  car¬ 
diac  region  (the  exposed  portion  of  the 
heart)  is  unusually  low  and  narrow, 
owing  to  the  descent  of  the  heart,  and 
the  encroachment  of  the  lung  between, 
the  heart  and  the  costal  walls ;  and 
the  heart’s  impulse,  instead  of  being 
felt  between  the  sixth  and  seventh, 
costal  cartilages,  is  perceptible  to  the 
eye  and  touch  in  the  epigastic  space 
behind,  below,  and  to  the  left  of  the 
xyphoid  cartilage. 


412  DESCRIPTION  OF  THE  EFFECTS  OF  CHLOROFORM. 

-  •  . ...  . . . . . 


NARCOTISM  by  the  INHALATION 
OF  VAPOURS. 

By  John  Snow,  M.D. 

Vice-President  of  the  Westminster  Medical 
Society. 

[Continued  from  p.  335.] 


j Description  of  the  physiological  effects 
of  chloroform ,  continued — when  in¬ 
haled  it  acts  on  the  nerves  as  well  as 
on  the  nervous  centres.  Phenomena 
attending  death  from  chloroform — its 
action  on  the  heart  of  the  f  rog. 

The  advent  of  the  third  degree  of  nar¬ 
cotism  is  marked  by  cessation  of  all 
voluntary  motion.  Usually  the  eyes 
become  inclined  upwards  at  the  same 
time ;  and  there  is  often  a  contracted 
state  of  the  voluntary  muscles,  giving 
rise  to  more  or  less  rigidity  of  the 
limbs.  This  contraction  is  greater  and 
more  frequent  from  chloroform  than 
from  ether,  and,  by  affecting  the  mus¬ 
cles  of  the  jaw,  it  sometimes  causes  a 
considerable  obstacle  to  operations  on 
the  mouth.  As  there  are  no  signs  of 
ideas  in  this  degree,  I  believe  that 
there  are  none,  and  that  the  mental 
faculties  are  completely  suspended : 
consequently  the  patient  is  perfectly 
secured  against  mental  suffering  from 
any  thing  that  may  be  done.  It  does 
not  follow,  however,  that  an  operation 
mayalways  be  commenced  immediately 
the  narcotism  reaches  this  degree,  for 
anaesthesia  is  not  a  necessary  part  of 
it;  and  unless  the  sensibility  of  the 
part  to  be  operated  on  be  suspended, 
or  very  much  obscured,  there  may  be 
involuntary  movements  sufficient  to  in¬ 
terfere  with  a  delicate  operation — not 
merely  reflex  movements,  but  also  co¬ 
ordinate  actions,  such  as  animals  may 
perform  after  the  cerebral  hemispheres 
are  removed,  the  medulla  oblongata 
being  left.  Under  these  circumstances 
an  operation  usually  causes  a  contrac¬ 
tion  of  the  features  expressive  of  pain, 
and  sometimes  moaning  or  cries,  but 
not  of  an  articulate  kind.  Whether  or 
not  these  signs  are  to  be  considered 
proofs  of  pain,  will  depend  on  the  defi¬ 
nition  given  to  the  word;  and  if  they 
do  not  interfere  with  the  operator,  or 
influence  the  recovery,  they  can  be  of 
no  consequence,  as  there  is  no  pain 
which  has  an  existence  for  the  patient. 


To  obtain  anaesthesia  when  it  does  not 
exist  in  this  degree,  and  thus  to  pre¬ 
vent  these  symptoms  if  we  desire,  it  is 
not  necessary  to  carry  the  narcotism 
further,  but  only  to  wait  at  this  point 
a  few  moments,  giving  a  little  chloro¬ 
form  occasionally  to  prevent  recovery,, 
and  allow  time  for  it  to  permeate  the 
coats  of  the  small  vessels,  and  act  more 
effectually  on  the  nerves.  The  sensi¬ 
bility  of  the  conjunctiva  is  a  correct 
index  of  the  general  sensibility  of  the 
body  ;  and  until  it  is  either  removed  or 
very  much  diminished,  an  operaion  oft 
delicacy  cannot  be  comfortably  per¬ 
formed.  Accordingly,  in  administering 
chloroform,  as  soon  as  the  patient  has 
inhaled  sufficient  to  suspend  voluntary 
motion,  I  raise  the  eyelid  gently, 
touching  its  free  border.  If  no  wink¬ 
ing  is  occasioned  the  operation  may 
begin  in  any  case,  but  if  it  is  I  wait  a 
little  time,  till  the  eyelids  either  become 
quite  passive  or  move  less  briskly.  The 
state  of  the  eye  itself  is  observed,  by 
this  means,  at  the  same  time.  It  is 
usually  turned  up,  and  the  pupil  con¬ 
tracted,  as  Mr.  Sibson  has  stated,*  in 
the  condition  which  I  term  the  third 
degree  of  narcotism.  The  vessels  of 
the  conjunctiva,  also,  are  sometimes 
injected,  but  more  frequently  they  are 
not. 

Dr.  Hughes  Bennet,  in  his  able  re¬ 
port  on  the  properties  of  chloroform,! 
argues  that  the  sensibility  of  the  nerves 
is  not  suspended  under  its  influence, 
because  respiration, circulation,  and  ute¬ 
rine  contractions  continue,  which  could 
not  be  the  case  if  the  sensibility  of  the 
nerves  connected  with  these  functions 
were  destroyed.  This  argument  would 
have  some  weight  if  the  nerves  of  com¬ 
mon  sensibility  did  not  differ  from  those 
of  the  organic  system,  or  those  which 
arise  from  the  respiratory  tract  of  the 
medulla  oblongata ;  but,  as  the  case 
stands,  it  has  none:  and  there  is  no- 
more  difficulty  in  conceiving  a  variable 
degree  of  susceptibility  and  of  resis¬ 
tance  to  the  effects  of  chloroform  in 
different  sets  of  nerves,  than  in  different 
nervous  centres.  A  careful  observation 
of  cases  shows  that  the  amount  of  local 
insensibility  by  no  means  keeps  pace 
with  the  degree  of  sopor  or  coma,  but 


*  Med.  Gaz.,  Feb.  18.  I  think  that  the  turn¬ 
ing  up  of  the  eyes  is  not  so  constant  as  Mr.  dib- 
son  believes,  as  I  have  been  unable  to  observe  it 
in  some  patients  at  any  stage, 
t  Monthly  Journal,  Jan.  1848. 


DESCRIPTION  OF  THE  EFFECTS  OF  CHLOROFORM:. 


413 


is  later  in  coming  on  and  going  off, 
and  varies  in  amount  in  different  pa¬ 
tients;  and  as  we  know  that  chloro¬ 
form,  like  other  narcotics,  produces 
some  effect  on  parts  to  which  it  is 
locally  applied,  the  conclusion  seems 
irresistible,  that  it  acts  on  the  nerves 
as  well  as  on  the  nervous  centres.  This 
view  of  the  subject  explains  some  cir¬ 
cumstances  which  before  seemed  inex¬ 
plicable;  such  as  that  of  the  patient  re¬ 
covering  his  consciousness,  and  telling 
the  bystanders  that  he  does  not  feel 
what  is  being  done.  For,  whilst  the 
vapour  is  escaping  from  the  blood  by 
way  of  the  lungs,  there  is  no  difficulty 
in  understanding  how  the  brain  may 
recover  its  influence  sooner  than  the 
branches  and  peripheral  expansion  of 
the  nerves ;  since,  in  the  brain,  not 
only  is  the  circulation  more  rapid,  but 
there  is  little,  if  any,  lymph  external 
to  the  vessels;  whilst,  in  the  body  at 
large,  the  chloroform,  having  transuded 
through  the  coats  of  the  capillaries 
into  the  extra- vascular  liquor  sangui¬ 
nis,  remains  there  for  a  little  time, 
acting  on  the  nervous  fibrillae,  before 
it  can  pass  again  by  endosmose  into 
the  vessels.  It  is  in  young  subjects,  in 
whom,  connected  with  the  more  active 
process  of  nutrition,  the  quantity  of 
lymph  external  to  the  vessels  is 
greatest,  that  the  general  insensibility 
most  frequently  remains,  whilst  the 
cerebral  hemispheres  are  resuming 
their  functions. 

In  the  fourth  degree  of  narcotism 
there  is  relaxation  of  the  voluntary 
muscles,  together  with  general  insensi¬ 
bility.  I  am  better  acquainted  with 
this  degree  as  induced  by  ether  than 
by  chloroform,  for  with  the  latter  agent 
the  third  degree  appears  to  encroach 
somewhat  on  this ;  chloroform  seeming 
to  differ  from  ether,  and  approaching 
somewhat  in  its  effects  to  benzin  and 
bisulphuret  of  carbon,  which,  we  have 
seen,  are  not  attended  with  muscular 
relaxation  at  any  stage  of  their  effects. 
Accordingly,  I  am  inclined  to  prefer 
the  use  of  ether,  to  assist  the  reduction 
of  dislocationsand  strangulated  hernise. 
There  is,  however,  often  sufficient  re¬ 
laxation  of  the  muscles  to  effect  these 
objects  even  in  the  second  degree  of 
narcotism,  especially  if  the  effect  have 
been  kept  up  a  little  time.  I  was  at 
one  time  inclined  to  believe  that  the 
functions  of  the  spinal  cord  were  more 
or  less  suspended  in  this  degree,  since  re¬ 


flex  movements  cannotbeexcited  by  any 
impressions  made  on  the  eyelids,  or 
general  surface  of  the  body ;  but  these 
reflex  movements  are  absent  in  every 
degree  of  narcotism,  when  the  common 
sensibility  is  abolished,  and,  thee  q  by 
the  circumstance  is  best  explaine 
attributing  it  to  the  narcotism  of  the 
nerves.  Other  functions  of  the  spinal 
cord  certainly  remain  ;  for  the  sphinc¬ 
ters  of  the  bladder  and  rectum  continue 
contracted,  and  respiration  goes  on. 
The  sensibility  of  the  glottis  continues, 
apparently  unimpaired,  in  this  degree 
of  narcotism,  but  that  of  the  pharynx 
is  probably  suspended;  for,  in  opera¬ 
tions  on  the  mouth  and  nose,  the  blood 
sometimes  finds  its  way  into  the  sto¬ 
mach,  without  any  visible  act  of  swal¬ 
lowing.  This  takes  place  frequently, 
when  the  narcotism  does  not  exceed 
the  third  degree.  In  these  cases,  it 
probably  runs  along  the  channel  there 
is  at  each  side  of  the  epiglottis.  The 
breathing  is  not  unfrequently  attended 
with  some  degree  of  stertor  in  the 
fourth  degree  ;  and  the  reason  why  one 
does  not  often  meet  with  stertor  in  ex¬ 
hibiting  chloroform,  is,  that  one  seldom, 
carries  the  narcotism  so  far.  There  is 
a  little  stertor  occasionally,  even  in  the 
third  degree  of  narcotism  ;  and  this 
symptom,  and  rigidity  of  the  muscles, 
are  met  with  altogether.  There  may 
be  simple  snoring  in  any  degree  of 
narcotism,  and  even  in  the  natural 
sleep  which  often  follows  the  state  of 
insensibility;  but  it  never  comes  on 
during  the  first  minutes  of  the  inhala¬ 
tion  of  chloroform,  unless  the  narcotism 
reaches  to  the  third  or  fourth  degree. 
The  iris  is  less  sensible  to  light  in  this 
degree  than  under  ordinary  circum¬ 
stances,  and  the  pupil  is  about  the 
usual  size.  I  have  never  observed  it 
widely  dilated,  or  totally  insensible  to 
light. 

I  have  not  mentioned  the  pulse  in 
the  above  outline  of  the  action  of  chlo¬ 
roform  on  the  human  subject,  as  it  is 
not  indicative  of  the  amount  of  narco¬ 
tism.  It  is  usually  somewhat  increased 
in  force  and  frequency,  as  it  is  by  a 
moderate  amount  of  fermented  liquor. 
This  effect  subsides  with  the  effect  of 
the  vapour;  but  I  have  not  remarked 
the  pulse  become  slower  after  chloro¬ 
form  than  it  might  be  expected  to  be, 
in  the  same  patient,  in  a  state  of  perfect 
repose.  52  is  the  slowest  pulse  I  have 
met  with,  and  that  was  in  a  healthy 


414 


DESCRIPTION  OF  THE  EFFECTS  OF  CHLOROFORM. 


man.  This  moderate  acceleration  is,  I 
believe,  the  only  direct  effect  of  chloro¬ 
form  on  the  pulse.  Indirectly,  it  may 
affect  it  in  other  ways.  If,  for  instance, 
the  breathing  is  interrupted  by  the 
pungency  of  the  vapour,  or  from  any 
other  cause,  the  pulse  becomes  small 
and  frequent,  and  when  sickness  is  in¬ 
duced,  it  is  diminished  in  force.  If  it 
is  very  frequent  at  the  beginning  of  the 
inhalation,  from  mental  perturbation, 
as  is  often  the  case,  when  the  patient 
is  about  to  undergo  an  operation,  the 
frequency  diminishes,  as  all  anxiety 
departs  with  the  loss  of  consciousness. 

When  animals  are  killed  with  chlo¬ 
roform,  and  not  too  abruptly,  there  is  a 
stage  between  the  fourth  degree  and 
the  cessation  of  respiration  in  which 
the  breathing  is  difficult,  and  some¬ 
times  slow  and  irregular.  This  I 
have  named  the  fifth  degree  of  narco¬ 
tism.  It  is  not  every  irregularity  of 
breathing  which  is  to  be  considered  in¬ 
dicative  of  this  degree, — for  patients 
occasionally  hold  their  breath  for  a 
short  time,  on  account  of  the  pungency 
of  the  vapour,  and  sometimes  also, 
without  any  evident  cause,  in  the 
second  or  third  degree;  but  that  need 
be  no  source  of  alarm.  The  fifth  de¬ 
gree  of  narcotism,  on  the  contrary,  is 
the  commencement  of^  dying.  I  have 
only  met  with  it  in  animals.  It  is 
sometimes  accompanied  with  convul¬ 
sive  movements  of  the  limbs — a  result 
I  never  witnessed  from  ether. 

Phenomena  attending  death  from  chlo- 
rojorm. 

When  the  animal  is  made  to  breathe 
vapour  of  chloroform  of  such  a  strength 
that  the  respiration  is  stopped  in  the 
course  of  a  few  minutes,  the  heart  con¬ 
tinues  to  beat  for  a  short  time,  and  the 
circulation  ceases  only,  as  in  asphyxia, 
for  want  of  the  respiration,  without  the 
heart  having  been  brought  under  the 
influence  of  chloroform.  The  reason 
of  this,  as  I  explained,  with  respect  to 
ether,  on  another  occasion,*  is  not 
that  the  vapour  is  incapable  of  affecting 
the  heart,  but  because  a  smaller  quan¬ 
tity  suffices  to  arrest  the  respiration, 
and  the  process  of  inhalation  ceases, 
without  the  heart  and  blood  vessels 
being  narcotised.  The  two  following 
experiments  illustrate  and  prove  these 
points : — 


Exp.  41  — A  nearly  full-grown  rab¬ 
bit  wras  placed  in  a  jar  containing  1600 
cubic  inches,  with  64  grs.  of  chloro¬ 
form,  being  four  grains  to  each  100 
cubic  inches.  At  first  it  tried  to  get 
out,  afterwards  it  struggled  involun¬ 
tarily,  and  then  sank  slowly  down,  and 
lay,  when  four  minutes  had  elapsed,  in 
a  flaccid  condition,  breathing  naturally. 

It  did  not  stir  afterwards,  except  from 
a  slight  convulsive  twfitch  of  its  paw 
once  or  twice.  In  three  or  four  minutes 
more,  the  breathing  became  slower,  and 
ten  minutes  after  it  was  put  in,  it 
breathed  its  last.  It  was  imme¬ 
diately  taken  out,  and  the  stetho¬ 
scope  applied  to  the  chest.  The 
heart  was  heard  to  beat  for  between 
two  and  three  minutes,  at  first  nearly 
as  rapidly  as  before  the  experiment,  but 
more  slowly  and  less  audibly  towards 
the  end.  The  chest  was  opened  a  few 
minutesafterwards,  and  feeble  rhythmic 
contractions  of  both  auricles  and  ven¬ 
tricles  were  observed, not  strong  enough 
to  expel  the  blood  with  which  the 
heart  was  filled,  but  not  to  distension. 
These  contractions  continued  unabated 
during  the  half  hour  the  inspection 
continued.  The  lungs  were  perfectly 
healthy,  and  not  congested.  Next 
morning  the  body  was  rigid,  and  the 
blood  in  tiie  heart  and  adjoining  vessels 
coagulated.  The  sinuses  in  the  cra¬ 
nium  were  filled  with  blood,  and  the 
vessels  on  the  surface  of  the  brain 
were  somewhat  injected,  but  not  those  ‘ 
in  its  substance. 

Exp.  42. —  Four  and  a  half  grains  of 
chloroform  were  introduced  into  a  jar 
containing  600  cubic  inches,  being 
three  quarters  of  a  grain  to  each  100 
cubic  inches,  and,  the  vapour  having 
been  equally  diffused,  two  frogs  were 
put  in.  They  tried  to  climb  up  the 
side  of  the  jar,  as  if  wishing  to  make 
their  escape,  and  one  or  the  other 
occasionally  ceased  to  breathe  for  a 
minute  or  two,  probably  from  dis¬ 
liking  the  vapour,  but  commenced  to 
breathe  again.  In  about  five  mi¬ 
nutes  the  efforts  to  escape  ceased, 
and  they  only  moved  to  adjust  their 
equilibrium  when  the  jar  was  dis¬ 
turbed.  They  were  now  breathing 
regularly,  and  continued  to  do  so  till 
about  ten  minutes  after  their  introduc¬ 
tion,  when  all  voluntary  power  ceased, 
and  the  breathing  began  to  be  per¬ 
formed  only  at  intervals.  They  were 
allowed  to  remain  till  half  an  hour  had 


*  On  the  Inhalation  of  Ether,  p.  81. 


PHENOMENA  ATTENDING  DEATH  FROM  CHLOROFORM, 


415 


elapsed,  during  the  last  ten  minutes  of 
which  time  no  respiratory  movement 
was  observed  in  either  of  them.  On 
taking  them  out,  and  laying  them  on 
their  backs,  the  pulsations  of  the  heart 
were  observed  on  each  side  of  the 
sternum.  These  pulsations  were  the 
more  distinct  from  the  lungs  being  ap¬ 
parently  empty.  Now  an  experiment 
with  chloroform  on  the  frog  does  not 
necessarily  cease  with  its  pulmonary 
respiration,  for  it  is  capable  of  both 
absorbing  and  giving  off  vapour  by  the 
skin.  Accordingly  I  continued  the 
experiment  on  these  frogs,  placing  one 
of  them  back  again,  in  the  course  of 
two  or  three  minutes,  in  the  same  jar, 
with  three  grams  of  chloroform,  and 
the  other  in  a  jar  of  400  cubic  inches 
capacity,  with  five  grains.  They  were 
laid  on  their  backs,  and  the  heart  of 
the  former  one,  in  air  containing  half 
a  grain  of  chloroform  to  each  100  cubic 
inches,  continued  to  beat  distinctly  and 
regularly,  45  times  in  the  minute,  for 
four  hours  that  it  remained  in  the  jar, 
and  it  was  not  observed  to  breathe 
during  the  whole  time,  although  it  was 
watched  almost  constantly.  The  re¬ 
spiration  commenced  again  within  half 
an  hour  after  its  removal.  In  about 
an  hour  it  recovered  its  power  of  volun¬ 
tary  motion,  and  it  was  not  injured  by 
the  long  narcotism. 

The  pulsations  of  the  heart  of  the 
other  frog,  in  air  containing  a  grain 
and  a  quarter  of  chloroform  to  each 
100  cubic  inches  of  air,  became  slower 
and  more  feeble,  and  in  a  quarter  of 
an  hour  could  not  be  observed.  The. 
frog  was  left  in  the  jar  a  quarter  of  an 
hour  longer,  and  removed  when  it  had 
been  in  half  an  hour.  The  under  part 
of  the  thorax  was  immediately  opened 
sufficiently  to  expose  the  heart.  It 
was  moderately  full  of  blood,  but  not 
contracting  at  all,  and  it  did  not  evince 
the  least  irritability  on  being  pricked, 
either  now  or  after  exposure  to  the 
air  for  some  time.  It  is  evident  that 
the  heart  of  this  last  frog  because 
paralysed  by  the  absorption  into  the 
blood  of  more  vaponr,  in  addition  to 
the  quantity  that  was  sufficient  to 
arrest  the  respiration.  The  tempera¬ 
ture  of  the  room  during  this  experi¬ 
ment  was  65°. 

The  effect  of  chloroform  on  the  heart 
of  the  frog  is  further  shewn  by  the 
next  experiment. 

Exp.  43. — A  frog  was  placed  in  the 


jar  containing  600  cubic  inches,  with 
six  grains  of  chloroform.  In  twenty 
minutes  the  respiration  had  ceased, 
but  the  heart  continued  to  pulsate 
strongly.  At  the  end  of  three-quarters 
of  an  hour  the  pulsations  were  more 
feeble,  and  had  diminished  from  40  to 
30  in  the  minute.  An  hour  and  five 
minutes  from  the  commencement  of 
the  experiment,  no  movement  of  the 
heart  could  be  observed.  The  frog 
was  taken  out  of  the  vapour,  and  a 
portion  of  the  sternum  and  integu¬ 
ments  removed,  so  as  partly  to  expose 
the  heart,  when  it  was  found  to  be  still 
contracting,  with  a  very  feeble  undu- 
latory  motion.  This  motion  increased 
in  force,  and,  in  a  quarter  of  an  hour 
after  its  removal,  the  heart  was  pulsat¬ 
ing  regularly  and  strongly,  the  ven¬ 
tricle  apparently  emptying  itself  per¬ 
fectly.  When  the  frog  had  been  out 
twenty  minutes,  it  was  placed  again  in 
the  same  jar,  with  the  same  quantity 
of  chloroform.  In  about  ten  minutes 
the  heart’s  action  began  to  fail  again, 
and  in  about  twenty  minutes  the 
slightest  movement  could  no  longer  be 
perceived  in  it.  The  frog  was  imme¬ 
diately  taken  out,  and  the  ventricle  of 
the  heart  was  pricked  with  a  needle. 
In  a  few  seconds  a  slight  quivering 
was  observed, — whether  the  result  of 
the  prick  is  not  certain,  and  the  action 
of  the  heart  became  gradually  re¬ 
established  as  before.  It  was  arrested 
a  third  time  by  exposure  to  the  vapour; 
and  although,  in  its  third  removal,  the 
anterior  extremities  of  the  frog  had 
become  rigid,  the  heart  resumed  its 
action  partially,  and  continued  to  con¬ 
tract  feebly  for  three  or  four  hours 
after  the  rigidity  of  death  had  invaded 
the  body  and  limbs  of  the  animal.* 
The  temperature  of  the  room  was  62° 
during  this  experiment. 

We  learned  from  some  of  the  experi¬ 
ments  detailed  in  the  early  part  of  this 
paper,  that  the  presence  in  the  blood 
of  one  twenty-second  part  as  much 
chloroform  as  it  would  dissolve,  had 
the  effect  of  arresting  the  respiration. 
From  the  last  experiment  we  can  de¬ 
termine  how  much  it  takes  to  stop  the 
action  of  the  heart.  One  grain  of 
chloroform,  as  was  stated  before,  pro¬ 
duces  0-767  of  a  cubic  inch  of  vapour; 


*  The  setting  in  of  rigidity  in  the  frog  is  ac¬ 
companied  by  a  partial  change  of  posture,  and 
the  contraction  is  sometimes  strong  enough  to 
move  the  whole  body. 


416 


DR.  CLARK  ON  EXUDATION  AND  THE  ELEMENTARY 


and  at  62° —  the  temperature  during 
this  experiment — air,  when  saturated, 
contains  13  8  cubic  inches.  Therefore 
0*767-*-13#8  gives  0  0555,  or  one- 
eighteenth  of  what  the  blood  would 
dissolve  as  the  quantity  which  has  the 
effect  of  arresting  the  heart’s  action. 

[To  be  continued.] 


ANTICIPATION  OF  THE 

VIEWS  OF  REINHARDT 

ON  THE  * 

EXUDATION  CORPUSCLE, 

TOGETHER  WITH  SOME  PRELIMINARY  OB¬ 
SERVATIONS  ON 

EXUDATION  AND  THE  ELEMENTARY 
FORMS  of  MORBID  PRODUCTS. 

By  Andrew  Clark,  M.D. 

Assistant- Surgeon  in  the  Royal  Navy;  of  the 
Pathological  Department  of  the  Royal  Hospital 
at  Haslar,  &c. ;  formerly  Chief  Assistant  in  the 
Pathological  Theatre  of  the  Edinburgh  Royal 
Infirmary. 

[Continued  from  p.  288.] 


Part  First — continued. 

In  our  former  communication  we  con¬ 
sidered  generally  the  subject  of  in¬ 
flammation,  and  the  conditions  of  its 
development.  We  gave  a  summary  of 
modern  researches  on  the  subject,  and 
enumerated,  in  the  form  of  proposi¬ 
tions,  the  particular  tendencies  to  which 
these  researches  appeared  to  point. 
We  have  now  to  continue  our  remarks 
on  Exudation  and  its  Products ,  and  to 
enter  upon  the  details  connected  with 
the  so  called  exudation  corpuscle. 

In  the  first  place,  then,  it  appears  to 
me  that  the  exudation  consequent  upon 
those  morbid  conditions  comprehended 
under  the  term  inflammation  is  of  two 
kinds— serous  and  fibrinous. 

The  serous  exudation  here  referred 
to  differs  entirely  from  what  is  termed 
serous  effusion,  which  is  justly  consi¬ 
dered  to  be  the  mechanical  result  of  ve¬ 
nous  obstruction,  and  other  forms  of  pas¬ 
sive  congestion,  or  venous  hyperaemia. 
Serous  effusion  differs  from  serous  exu¬ 
dation  in  its  physical  characters,  che¬ 
mical  composition,  and  vital  attributes. 
The  former  is  albuminous,  aplastic, 
watery,  and  holds  much  saline  matter 
in  solution  ;  the  latter  is  plastic,  viscid, 
or  gummy  to  the  touch,  and  contains 
fibrin.  Serous  effusion  rarely  contains 


cellular  forms,  which,  when  present, 
are  accidental ;  serous  exudation  always 
contains  cellular  forms,  which,  even 
post-mortem,  develope  definite  mani¬ 
festations  of  vitality.  The  former 
occurs  indiscriminately  in  every  tissue, 
in  every  organ,  and  under  conditions 
held  to  be  mechanical ;  the  latter  is 
found  either  in  serous  sacs  or  between 
the  pia  mater  and  surface  of  the  brain, 
and  occurs  under  conditions  which, 
from  their  complexity,  and  other  vague 
circumstances,  receive  the  term  vital. 
In  illustration  of  these  conditions,  we 
may  mention  hypersemia,  capillary 
stagnation,  and  the  physical  and 
vital  changes  said  to  occur  in  the 
part  affected,  and  in  the  tissues  adja¬ 
cent. 

The  presence  of  cellular  forms  in  one 
class  of  serous  effusions  was  first  ob¬ 
served  by  Helbert  in  1841.*  His 
observations  were  made  without  re¬ 
ference  to  the  individuality  and  dis¬ 
tinctive  characters  of  serous  effusions, 
and  were  brought  forward  simply  in 
confirmation  of  his  view  that  these 
effusions  occasionally  possessed  and 
developed  the  properties  of  blastemata. 

Helbert  observed  that  the  fluid  of  a 
blister,  produced  by  cantharides,  which, 
on  its  discharge,  contained  no  corpus¬ 
cular  particles,  exhibited,  after  stand¬ 
ing  some  hours  in  a  glass  jar,  nume¬ 
rous,  though  imperfectly  developed, 
granular  cells, f  the  developmental 
stages  of  which  are  pourtrayed  in  the 
drawings  which  illustrate  his  memoir. 
From  this,  and  similar  observations,  he 
conceived  the  fluid  of  a  blister  to 
possess  the  properties  of  a  blastema, 
and  considered  the  cellular  forms 
which  it  exhibited  to  be  new  forma¬ 
tions. 

The  observations  of  Helbert  were  too 
few  and  limited  safely  to  permit  of  any 
general  conclusion ;  and  the  presence 
of  cellular  forms  in  the  fluid  of  cuta¬ 
neous  vesications  can  be  so  easily  ac¬ 
counted  for  by  the  histological  pecu¬ 
liarities  of  the  skin,  that  the  view  is 
rendered  unworthy  of  any  formal  refu¬ 
tation. 

The  perusal  of  these  observations, 
however,  led  me  to  examine  more 
narrowly  than  I  had  previously  done, 
the  chemical  and  histological  charac¬ 
ters  of  serous  effusions.  I  commenced, 


*  Vide  Muller’s  Archives  for  that  year, 
f  Quoted  also  by  Vogel,  in  his  leones. 


FORMS  OF  MORBID  PRODUCTS. 


417 


therefore,  a  systematical  examination 
of  all  serous  effusions  ;  and  my  obser¬ 
vations  have  extended  over  87  in¬ 
stances,  of  which  there  were  kept  the 
following  details  :  — 

Effusion  into  the  cavity  of 

arachnoid . 14 

Effusion  between  pia  mater 

and  brain . 29 

Effusion  into  lateral  ven¬ 
tricles  of  brain  ....  8 

Effusion  into  pleural  sacs  .  9 

Effusion  into  the  pericar¬ 


dium  . 13 

Effusion  into  peritoneum  .  8 

Serous  infiltration  of  areolar 
texture . 6 


In  reference  to  this  table,  it  is  neces¬ 
sary  to  observe  that  serous  effusions 
inro  the  pleura  and  peritoneum  are 
commonly  accompanied  by  lymphatic 
exudation;  and  that  the  latter  is  found 
either  adherent  to  the  serous  membrane 
in  the  form  of  a  more  or  less  perfectly 
developed  fibrous  tissue,  or  floating 
free  and  unconnected  in  the  midst  of 
the  effusion  which  occupies  the  interior 
of  the  sac.  In  the  latter  case  the 
lymph  has  become  soft,  diffluent,  and 
so  intimately  commingled  with  the 
serum  as  to  simulate  pus,  by  which 
name  such  effusions  are  commonly  but 
erroneously  recognized.  The  above 
observations,  however,  were  made  on 
serous  effusions  unaccompanied  by 
lymphatic  exudation  ;  and  it  is  to  these 
that  I  desire  for  the  present  to  confine 
ray  observations.  Of  serous  effusions 
occurring  in  combination  with  lym¬ 
phatic  exudation,  and  of  their  chemi¬ 
cal  and  histological  relations  to  each 
other,  I  shall  treat  in  a  separate  me¬ 
moir. 

Our  observations,  then,  on  uncom¬ 
plicated  serous  effusions  tend  to  shew 
that  they  may  be  divided  into  two 
classes — the  one  dependent  on  mecha¬ 
nical  causes  (simple  serous  effusion), 
tae  other  on  highly  complex  condi¬ 
tions,  involving  increase  of  vital  action 
or  some  modified  form  of  nutrition, 
and  which  for  the  sake  of  distinction 
we  have  termed  serous  exudation.  To 
the  differential  characters  of  these 
forms  of  serous  effusion  I  have  already 
given  a  general  expression  :  of  the 
latter  only  we  shall  speak  in  detail. 

If  a  drop  of  the  serous  fluid  exhibit¬ 
ing  the  characters  peculiar  to  what  we 
have  here  termed  serous  exudation,  be 


examined  with  a  linear  magnifying 
power  of  about  200,  it  will  be  found  to 
exhibit  numerous  corpuscles,  varying 
considerably  in  their  physical  charac¬ 
ters  and  chemical  relations.  These 
corpuscles  possess  certain  characters 
in  common :  they  are  all  more  or  less 
spherical, — vary  in  size  from  two  to 
seven  times  the  diameter  of  the  human 
blood-disc  ;  and  the  majority  exhibit 
oval  eccentric  nuclei,  and  are  studded 
with  molecules  and  granules.  For  the 
sake  of  distinction,  however,  and  in 
point  of  hypothesis,  these  corpuscles 
may  be  divided  into  four  classes — re¬ 
presentative  of  so  many  morphological 
phases  of  one  body. 

1.  In  the  first  stage,  the  corpuscles 
are  oval  or  rounded,  from  three  to  four 
times  the  diameter  of  the  human  blood- 
disc,  of  a  pale  greyish  colour,  finely 
molecular,  and  generally  exhibiting  an 
oval  eccentric  nucleus.  Acetic  acid 
renders  the  cell  wall  and  its  contents 
almost  imperceptible;  potass  reduces, 
them  to  an  amorphous  magma,  and 
leaves  visible  only  the  dark  linear  out¬ 
lines  of  their  nuclei. 

2.  In  the  second  stage,  the  corpus¬ 
cles  are  larger,  and  more  nearly  spheri¬ 
cal.  Of  this  stage  there  are  two  varie¬ 
ties.  In  the  first,  the  molecules  exist¬ 
ing  between  the  nucleus  and  cell-wall 
have  become  indistinct,  and,  as  it  were, 
fused  into  a  homogeneous  mass  ;  the 
linear  outline  of  the  nucleus  is  des¬ 
troyed,  and  that  body  itself  transformed, 
apparently,  into  a  more  or  less  rounded 
heap  of  dark  refractive  granules.  Some¬ 
times  this  heap  of  granules,  substitut¬ 
ing  the  place  of  the  nucleus,  is  seen 
protruded  from  the  external  surface  of 
the  parent  cell,  attached  to  it  only  by 
a  narrow  neck,  and  appearing  as  if 
about  to  separate  and  assume  an  in¬ 
dependent  existence.*  In  the  second 
variety  of  this  stage,  the  corpuscle  is 
studded  with  dark  refracting  granules  ; 
its  outline  is  less  decided,  and  the  nu¬ 
cleus  has  either  disappeared  by  disin¬ 
tegration,  or  is  obscured  by  the  pre¬ 
sence  of  the  granules.  In  this  variety 
of  the  second  stage ,  the  corpuscles  ex¬ 
hibit  a  very  marked  tendency  to  adhere 


*  It  is  a  fact  worthy  of  remark,  that  the,  so- 
called,  pus  of  many  pulmonai'y,  hepatic,  and  re¬ 
nal  abscesses,  is  made  up  entirely  of  a  fluid 
holding  in  suspension  corpuscles  identical  in 
their  general  characters  with  those  here  de¬ 
scribed.  On  this  fact,  and  on  the  constitution 
of  purulent  fluids  generally,  we  shall  shortly 
speak  in  detail. 


418  ON  EXUDATION  AND  ELEMENTARY  FORMS  OF  MORBID  PRODUCTS. 


firmly  to  each  other  ;  and  they  are  less 
decidedly  affected  by  acetic  acid  :  caus¬ 
tic  potass  reduces  them  to  a  finely  mo¬ 
lecular  magma;  and  ammonia,  whilst 
it  renders  them  pale  and  finely  granular, 
gives  immediate  development  to  nu¬ 
merous  cruciform  and  stellar-shaped 
crystals  of  the  basic  phosphate  of  am¬ 
monia  and  magnesia.* 

3.  In  what  1  have  considered  as  the 
third  stage,  the  corpuscles  are  rather 
smaller  than  those  described  as  typical 
of  the  first, — they  are  more  or  less  re¬ 
gularly  spherical,  not  nucleated,  stud¬ 
ded  with  granules,  and  exhibit  an  ap¬ 
pearance  analogous  to  that  described  as 
occurring  in  the  interior  of  the  corpus¬ 
cles,  in  the  first  variety  of  the  second 
stage.  Like  the  form  of  corpuscle  im¬ 
mediately  preceding,  that  of  which  we 
now  speak  is  little  affected  by  acetic 
acid,  exhibits  similarly  shaped  crystals 
on  being  acted  on  by  ammonia,  and 
becomes  very  much  paler  on  the  addi¬ 
tion  of  boiling  aether. 

4.  In  the  fourth  stage  the  corpuscles 
have  attained  their  greatest  size,  being 
from  five  to  seven  times  the  diameter 
of  the  human  blood- disc,  and  are  per¬ 
fectly  spherical.  They  are  all  entirely 
deprived  of  their  molecular  and  granu¬ 
lar  contents,  but  a  very  few  retain  their 
nuclei,  and,  with  these  exceptions,  ap¬ 
pear  to  consist  simply  of  a  cell- wall 
and  fluid  contents. 

These  are  the  histological  characters 
of  this  serous  exudation,  when  ex¬ 
amined  immediately  after  its  removal 
from  the  body.  If,  however,  a  portion 
of  this  fluid  be  set  aside  in  a  glass  jar, 
and  examined  after  twenty-four  hours,  it 
will  be  seen  that  a  whitish,  opaque, 
and  consistent  membrane,  has  been 
formed  in  the  interval,  and  that  the 
supernatant  fluid  exhibits  but  few  of 
the  cellular  forms  above  described. 
The  membrane  here  adverted  to  is 
tenacious,  can  be  spread  out  upon  glass 
without  difficulty,  and  is  found,  by 
microscopic  examination,  to  be  com¬ 
posed  of  corpuscles  identical  with  those 
described  under  the  third  variety  of 
cellular  forms  characteristic  of  serous 
exudation.  With  oblique  light,  or  by 
the  aid  of  a  condenser,  the  cells  com¬ 
posing  the  membrane  are  seen  to  be 
surrounded  by  a  very  delicate  lym¬ 
phatic  fibrillation,  which,  after  a  short 

*  These  crystals  resembled  closely  the  figures 
given  by  Rayer  of  uric  acid  produced  by  artifi¬ 
cial  precipitation. 


time,  extends  over  the  whole  field  of 
vision,  and  accompanies  only,  and  in¬ 
variably,  the  presence  of  these  cellular 
forms.  Acetic  acid  renders  this  cellu¬ 
lar  membrane  paler  and  more  highly 
granular.  Ammonia  renders  it  at  first 
darker  and  more  granular,  and  ulti¬ 
mately  gives  development  to  crystals 
identical  with  those  already  referred  to. 

Three  questions  naturally  suggest 
themselves  for  solution  in  the  consi¬ 
deration  of  these  details  : — the  mode  of 
origin  of  these  corpuscles ;  their  rela¬ 
tions  to  each  other ;  and  the  nature  of 
the  causes  immediately  engaged  in  the 
production  of  the  cellular  membrane 
above  described. 

The  various  forms  of  corpuscles  de¬ 
scribed  as  peculiar  to  serous  exudation 
may  be  considered,  in  abstract,  to 
possess  one  of  two  modes  of  origin  : 
they  are  new  forms  of  morbid  products, 
or,  they  are  modifications  merely  of 
previously  existing  forms .  In  the  one 
case  they  are  developed  in  and  from 
the  serous  exudation,  which  must  be 
held  to  possess,  therefore,  the  proper¬ 
ties  of  a  blastema;  in  the  other,  these 
forms  of  corpuscles  can  be  considered 
as  representative  only  of  so  many  dis¬ 
eased  conditions  of  the  normal  cells 
peculiar  to  the  locality  in  which  the 
exudation  may  occur. 

The  tenor  of  our  preceding  remarks 
will  have  already  indicated  the  view 
which  our  researches  incline  us  to 
adopt.  We  believe,  in  short,  that  the 
serous  exudation  here  referred  to  does 
not  possess  the  characters  of  a  blas¬ 
tema,  and  that  the  cellular  forms  which 
it  exhibits  are  not  new  products ,  but 
only  the  representatives  of  so  many 
diseased  conditions  of  the  healthy  cells 
peculiar  to  the  part.  We  further  be¬ 
lieve  that  the  varieties  of  corpuscle 
described  under  head  3  are  representa¬ 
tive  merely  of  the  escaped  nuclei  of 
previously  existing  healthy  cells  modi¬ 
fied  bv  disease ;  and  we  consider  these 
as  particular  illustrations  of  a  general 
principle ,  that  the  elementary  forms  of 
morbid  products  are  not  necessarily 
new  forms ,  but  that  they  are  often ,  if 
not  always ,  modifications  merely  of 
previously  existing  organisms.* 

In  our  next  memoir,  which  will  be 
accompanied  with  the  necessary  illus¬ 
trations,  we  shall  enter  into  the  fur¬ 
ther  details  and  proofs  of  this  view. 

*  Vide  note,  p.  417. 

[To  be  continued.] 


ARE  CHOLERA  HOSPITALS  BENEFICIAL  OR  INJURIOUS  ? 


419 


EPICAL  GAZETTE, 


FRIDAY,  SEPTEMBER  8,  1848. 

It  cannot  be  imputed  to  the  Govern¬ 
ment  that  they  have  been  backward  in 
suggesting  measures  for  preventing  the 
spread  of  cholera,  should  the  disease 
unfortunately  reach  this  country.  The 
passing  of  the  Public  Health  Act  has 
tended  to  create  a  better  feeling  of 
security  than  existed  some  months 
since;  and  we  are  now  promised  a 
Nuisances  and  Contagious  Diseases 
Act,  of  a  more  efficient  and  permanent 
character  than  the  temporary  measure 
passed  about  two  years  since.  The 
new  Bill  was  read  a  second  time  in  the 
House  of  Lords  on  Tuesday  night,  and 
there  is  every  prospect  of  its  speedy 
enactment  into  a  law.* 

In  the  measures  recommended  for 
preventing  the  spread  of  cholera,  the 
first  question  which  meets  us  is  that 
which  refers  to  the  propriety  of  esta¬ 
blishing  cholera-hospitals  for  the  sick, 
or  of  affording  them  medical  treatment 
at  their  own  homes.  The  facts  accu¬ 
mulated  by  the  Metropolitan  Sanitary 
Commission  are  rather  adverse  to  the 
former  plan  : — 

The  measure  of  alleviation  chiefly 
relied  on  during  the  last  visitation 
of  the  disease  was  the  establish¬ 
ment  of  district  cholera  hospitals ; 
but  the  experience  of  the  results  of 
these  establishments  is  by  no  means 
farourable  for  their  re-adoption,  ex¬ 
cept  under  particular  circumstances 
anil  modifications.  The  prostration  of 
all  the  vital  powers  which  charac¬ 
terises  a  severe  attack  of  cholera,  is 
often  so  extraordinary  that  the  mere 
assumption  of  the  erect  position  for  a 
few  minutes  appears  often  to  deprive 
the  patient  of  the  slightest  chance  of 
recovery.  The  medical  testimony  is 
uniform  in  representing  the  fatigue  of 


removal  as  highly  injurious  in  great 
numbers  of  instances.  It  is  often 
strikingly  so  in  the  advanced  stage 
even  of  typhus.  It  not  unfrequently 
happens  that  when  a  patient  is  re¬ 
moved  to  the  fever-hospital  in  an  ad¬ 
vanced  stage  of  this  disease,  on  open¬ 
ing  the  door  of  the  carriage  in  which 
he  has  been  conveyed  he  is  found 
dead;  and  still  more  frequently  it 
occurs  that  when  he  has  not  actua  Uy 
expired  before  he  reaches  the  ward, 
and  is  placed  in  bed,  he  is  cold,  pulse¬ 
less,  and  insensible,  and  never  rallies, 
notwithstanding  all  that  can  be  done 
to  restore  animation.  In  typhus  this 
extreme  debility  does  not  take  place 
for  many  days ;  often  not  until  the 
,  end  of  the  second  or  third  week;  but 
in  a  severe  attack  of  cholera  it  occcurs 
in  two  or  three  hours,  and  is  some¬ 
times  present,  in  its  highest  degree, 
before  there  is  time  for  the  medical 
attendant  to  reach  the  bed-side  of  the 
patient.  This  circumstance  places  the 
extensive  employment  of  any  remedy 
which  involves  exertion,  or  even  slight 
motion,  out  of  the  question.” 

In  1831-2,  there  was  not  merely 
the  danger  arising  from  the  removal 
of  patients  ;  but  the  best  attempts  to 
afford  medical  relief  to  the  patients 
were  often  rendered  unavailing  by 
the  terror  inspired  at  the  idea  of  their 
being  associated  with  others  labouring 
under  the  disease.  The  poor  entered 
these  hospitals  with  reluctance;  and 
where,  in  consequence  of  the  number 
of  deaths,  the  hospital  had  acquired  a 
bad  reputation,  they  positively  refused 
to  go.  From  the  evidence  laid  before 
them,  the  Commissioners  are  not  in¬ 
clined  to  recommend  the  plan  of  con¬ 
structing  hospitals  for  the  special  re¬ 
ception  of  cholera  patients. 

“  Experience  having  thus  shown 
that  cholera  hospitals  failed  in  accom¬ 
plishing  their  object,  we  would  recom¬ 
mend  that  the  best  provision  practi¬ 
cable  should  be  made  for  rendering 
effectual  assistance  to  the  individuals 
who  may  need  it,  at  their  own  houses. 
This,  in  our  opinion,  would  be  the  best 
effected  by  the  selection  of  proper  per¬ 
sons,  who  may  be  instructed  as  nurses, 
and  engaged  to  devote  their  whole  time 


*  This  bill  lias  since  received  the  Royal  Assent, 
and  we  shall  shortly  notice  its  provisions. 


420 


ARE  CHOLERA  HOSPITALS  BENEFICIAL  OR  INJURIOUS? 


to  attendance  on  the  sick  at  their  own 
habitations,  under  the  directions  of  the 
medical  officer.  Prom  ptassistance  might 
thus  be  given  to  the  patient  without 
subjecting  him  to  any  risk  from  bodily 
fatigue,  and  without  anything  being 
done  calculated  to  excite  apprehension 
or  alarm.  At  the  same  time,  the  cura¬ 
tive  measures  employed  by  the  medical 
attendant  would  be  administered  under 
circumstances  peculiarly  adapted  to 
ensure  their  success.  Instances  have 
been  brought  under  our  notice  in  which 
the  treatment  of  the  sick  without  re¬ 
moval,  and  under  the  superintendence 
of  a  competent  nurse,  was  attended 
with  the  best  effect  both  on  the  patient 
himself  and  on  the  people  about  him. 

“  The  adoption  of  the  principle  here 
indicated,  that  of  sending  competent 
persons  to  attend  the  sick,  under  me¬ 
dical  direction,  at  their  own  abodes, 
would  be  attended  with  this  further 
advantage— -that  all  the  means  recom¬ 
mended  for  cleansing  the  interior  of 
the  house,  and  for  maintaining  the 
atmosphere  of  the  sick  room  in  the 
highest  attainable  state  of  purity,  might 
be  most  efficiently  carried  out  by  the 
same  agency. 

“  With  respect  to  medical  assistance, 
we  may  observe,  that  since  the  last 
visitation  of  cholera  considerable  pro¬ 
gress  has  been  made  in  the  organiza¬ 
tion  of  the  local  administration  for  re¬ 
lief  in  the  metropolis,  calculated  to 
meet  the  recurrence  of  that  event. 
The  service  of  the  medical  Union  offi¬ 
cers,  however  wide  the  room  for  im¬ 
provement,  is  yet  more  efficient  than 
the  parochial  medical  service  resorted 
to  on  the  former  occasion,  especially 
in  the  extent  and  regularity  of  atten¬ 
dance  on  out-door  patients;  and  the 
Union  medical  officers  might  be  aided 
by  the  relieving  officers.” 

There  are,  however,  cases  in  which 
it  will  not  be  possible  to  avoid  sending 
patients  to  cholera  hospitals.  The 
Commissioners  remark — • 

“Though,  for  the  reasons  just  as¬ 
signed,  we  deprecate  the  removal  of 
cholera  patients  to  separate  cholera 
hospitals,  yet,  should  the  pestilence 
become  prevalent,  cases  will  probably 
occur  of  such  extreme  destitution,  in 
abodes  so  exceedingly  unfitted  for  the 
curative  treatment  of  the  sick,  that 


some  better  provision  must  be  made  for 
them.  To  send  cholera  patients  to 
houses  already  crowded,  would  be 
obviously  improper  ;  but  the  newr  Union 
houses  have  generally  separate  fever 
wards  ;  and  where  the  isolation  is  suffi¬ 
ciently  complete,  it  is  possible  that 
these  fever  wards  might  be  adapted  for 
the  reception  and  treatment  of  such 
persons  as  it  may  be  indispensably 
necessary  to  remove  from  their  own 
abodes.  Where  there  is  adequate  pro¬ 
vision  for  fever  cases,  there  wall 
be  probably  sufficient  provision  for 
cholera  cases  ;  because,  as  has 
been  shown,  fever  is  always  more 
prevalent  than  cholera  ;  and,  as  far  as 
we  yet  know,  when  cholera  becomes 
epidemic,  fever  ceases  to  be  so.  But 
ure  do  not  feel  that  we  are  in  possession 
of  sufficient  information  to  offer  any 
opinion  on  the  kind  or  degree  of  ac¬ 
commodation  which  existing  establish¬ 
ments  are  capable  of  affording  to  meet 
the  contingent  necessity. 

“  In  our  opinion,  there  is  but  one  safe¬ 
guard  against  this  malady,  as  against 
other  diseases  of  the  same  class.  That 
safeguard  consists  in  sanitary  arrange¬ 
ments  ;  and  sanitary  arrangements,  to  be 
efficient,  must  be  such  as  will  secure 
the  purity  of  the  atmosphere,  particu¬ 
larly  by  the  immediate  and  complete 
removal  of  all  filth  and  refuse,  and  that 
not  only  from  the  principal  squares  and 
thoroughfares,  but  also  from  the  streets, 
courts,  and  alleys,  of  the  lowest  portion 
of  the  population.  But  this  requires  a 
general  and  proper  system  of  street 
and  house  drainage,  and  a  supply  of 
water  sufficient  for  keeping  the  drains 
and  sewers  clean,  for  surface  cleansing, 
and  for  domestic  use.  Were  the  ar¬ 
rangements  and  the  administration  Ur 
cleansing  thus  complete,  we  might  still 
not  be  able  to  obtain  an  absolute  ex¬ 
emption  from  the  visitation  of  cholera, 
but  we  should  have  done  what  might 
and  must  be  done  to  deprive  it,  should 
it  come,  of  the  means  of  support  and 
strength. 

“The  whole  tenor  of  the  evidence 
which  has  come  before  us,  shows  that 
it  is  only  by  measures  of  prevention  that 
we  can  hope  to  obtain  any  real  protec¬ 
tion  from  this  disease,  and  that  no 
measures  of  alleviation  can  materially 
avail  against  a  malady  which  almost 
sets  at  defiance  the  resourcesof  medical 
art,  which  begins  and  ends  its  mortal 
course  in  a  few  hours,  and  which 


RAVAGES  OF  THE  CHOLERA  AT  ST.  PETERSBURGH. 


421 


• 

destroys  one-half  of  those  whom  it 
attacks.” 

The  measures  lately  introduced  by 
Government,  are  calculated  to  meet  the 
suggestions  of  the  Sanitary  Commis¬ 
sioners.  Time  may  be  required  to  bring 
them  into  efficient  and  extensive  opera¬ 
tion,  but,  in  the  meanwhile,  we  have 
the  satisfaction  of  knowihg  that 
nothing  which  reason  and  experience 
could  suggest,  has  been  left  untried. 


We  have  just  received,  through  a  re¬ 
spectable  private  source,  the  subjoined 
letter  from  a  gentleman  who  has  been 
an  eye-witness  of  the  ravages  of  the 
cholera  at  St.  Petersburg!!.  It  is  dated 
the  lOthof  August,  1848  (July  28th, 
0.  S.):  — 

“  The  cholera  has  been  raging  here 
fearfully,  far  exceeding  the  visitation 
of  1831.  It  is  greatly  diminished  now  : 
the  cases  last  week  fell  to  about  60  a 
day.  The  official  accounts  give  out 
nineteen  thousand  seized,  and  about 
twelve  thousand  deaths  in  town  ;  but 
the  published  accounts  are  always 
misrepresentations,  and  the  real  num¬ 
ber  of  deaths  most  certainly  amount  to 
twenty-five  thousand  in  town.  A  great 
number  of  the  peasantry  fled  from 
town  to  escape  it,  and  died  in  hundreds 
along  the  roads  leading  to  the  capital. 
For  the  last  six  weeks,  St.  Petersburgh 
has  had  quite  a  deserted  look  :  hardly 
any  one  stirring,  except  on  business  : 
funeral  processions  met  you  every¬ 
where  in  the  streets.  The  poor  in¬ 
fatuated  populace  ascribed  the  disease 
to  poison,  and  consequently  there  have 
been  several  riots  in  the  city. 

“  About  two-thirds  of  those  that 
died,  died  from  neglect. 

“Mr.  Bell,  of  Alexandroffskoi,  had 
about  one  thousand  three  hundred 
people  under  his  care  during  the  pro¬ 
gress  of  the  epidemic,  and  he  has  lost 
only  about  three  per  cent.” 

It  would  be  desirable  to  have  some 


information  on  a  plan  of  treatment 
which  is  stated  to  have  been  attended 
with  such  extraordinary  success. 


iftebtefos. 


Remarks  on  the  Employment  of  Anaes¬ 
thetic  Agents  in  Midwifery.  By  G. 
T.  Gream,  Medical  Officer  of  the' 
Queen  Charlotte’s  Lying-in  Hos¬ 
pital,  &c.  Pamphlet.  8vo.  pp.  37* 
London  :  Churchill.  1848. 
Arguments  against  the  indiscriminate 
Use  of  Chloroform  in  Midwifery. 
By  S.  W.  J.  Merriman,  M.D. 
Cantab.  Pamphlet.  8vo.  pp.  27. 
London  :  Churchill.  1848. 
Practical  Observations  on  the  Adminis¬ 
tration  and  Effects  of  Chloroform , 
especially  in  its  application  to  Na¬ 
tural  Labour.  By  J.  H.  Stallard,  Esq. 
M.R.C.S.,  Surgeon  to  the  Leicester 
General  Dispensary.  Pamphlet. 
8vo.  pp.  22.  London:  Churchill. 
1848. 

We  have  placed  these  three  pamphlets 
together,  as  they  singularly  illustrate 
the  views  of  three  classes  of  practi¬ 
tioners  respecting  the  employment  of 
antesthetic  agents  in  the  practice  of 
midwifery.  Mr.  Gream  is  a  decided 
opponent  to  their  use,  Mr.  Stallard 
strenuously  advocates  their  employ¬ 
ment,  and  Dr.  Merriman  occupies  a 
neutral  position,  considering  that,  in 
certain  selected  cases  where  chloroform 
is  employed  by  an  experienced  man, 
it  will  materially  relieve  the  sufferings 
of  the  female  without  producing  mis¬ 
chief. 

M.  Gream’s  pamphlet  has  been  some 
time  before  us;  but  we  have  delayed 
noticing  it,  under  the  expectation  that 
we  might  be  able  to  contrast  the  au¬ 
thor’s  observations  with  those  made  by 
other  accoucheurs.  For  many  months 
chloroform  had  been  so  extensively 
employed  by  accoucheurs,  and,  as  it 
was  said,  with  such  marvellous  suc¬ 
cess,  that  it  required  some  moral 
courage  for  an  author  to  print  a 
work  condemnatory  of  its  use.  At 
the  same  time  it  was  generally  ad¬ 
mitted  that  chloroformists  were  going 
too  far  ;  and  that  serious  accidents  were 
likely  to  occur  from  its  indiscriminate 
employment  by  persons  who  had  had 
no  expe/ience  of  the  mode  of  adminis- 


422  ON  THE  EMPLOYMENT  OF  ANAESTHETIC  AGENTS  IN  MIDWIFERY. 


tering  it,  or  of  relieving  any  alarming 
symptoms  which  might  result  from  its 
use.  Mr.  Gream  is  not  opposed  to  the 
use  of  anaesthesia  during  surgical  ope¬ 
rations  ;  but  then  he  remarks — 

“There is  this  difference  between  the  use 
of  it  in  surgery  and  midwifery  :  in  the  one, 
a  few  minutes’  inhalation  only  is  necessary ; 
in  the  other,  a  prolonged  effect  must  be  kept 
up,  in  order  that  pain  may  be  allayed. 
There  is,  therefore,  a  decided  source  of 
danger  in  the  one  that  is  not  to  be  found  in 
the  other,  and  it  is  this  prolongation  of  its 
effect  that  forms  the  principal  hazard.” 

(p.  1). 

Mr.  Gream  is  right  in  stating,  that, 
since  the  first  introduction  of  etheriza¬ 
tion,  everything  likely  to  captivate 
public  feeling,  and  nothing  tending  to 
create  alarm,  has  been  put  forward  ; 
and  he  considers  that  no  woman  who 
has  yet  been  etherized  has  been  fairly 
warned  of  her  danger,  or,  indeed,  of 
any  of  the  ill  consequences  of  the  state 
of  narcotism. 

“The  introduction  of  etherization  has 
given  rise  to  a  system  of  writing,  not  for 
the  benefit  of  professional  men,  but  to  cap¬ 
tivate  the  public  at  large  ;  and  it  is  much 
to  be  regretted  that  men  of  talent  should 
permit  themselves  to  be  entrapped  in  a 
snare  which  will  inevitably  lead  to  their  de¬ 
struction.  The  word  *  quackery,’  in  con¬ 
junction  with  etherization  during  parturi¬ 
tion,  now  so  frequently  used  by  people  of 
standing  and  education,  sufficiently  indi¬ 
cates  the  feeling  that  prevails  with  regard  to 
its  employment. 

“  A  feature  deserving  cf  censure  is  to  be 
found  in  the  reports  of  many  of  the  cases  of 
labour  in  which  chloroform  has  been  used,* 
evidently  intended  to  cause  a  belief  in  ad¬ 
vantages  to  be  derived  from  this  agent  which 
in  fact  it  does  not  possess.  I  refer  to  the 
way  in  which  the  symptoms  attending  a 
second  or  third  delivery  are  compared  with 
those  accompanying  the  first.  To  unpro¬ 
fessional  readers  this  has  its  effect,  and  a 
pregnant  woman  who  with  her  first  child 
may  have  been  forty  hours  in  labour,  will 
at  once  rejoice  at  the  supposition  that  the 
inhalation  of  chloroform  will  prevent  the 


*  I  have  made  no  direct  distinction  between 
the  cases  in  which  sulphuric  ether  has  been  em 
ployed,  and  those  in  which  chloroform  has  been 
the  agent ;  the  effects  are  found  to  be  the  same; 
the  former,  however,  being  esteemed  the  least 
dangerous,  owing  to  the  more  gradual  super¬ 
vention  of  its  influence.  No  greater  mistake, 
perhaps,  has  been  made  than  in  recommending 
a  preference  for  chloroform  in  parturition  because 
of  its  more  speedy  effect— a  reason,  of  all  others, 
for  discarding  it  in  favour  of  any  more  slowly 
acting  agent. 


recurrence  subsequently  of  so  protracted  a* 
labour.  She  is  ignorant  of  the  fact  that  a 
severe  labour  is  generally  followed  in  sub¬ 
sequent  pregnancies  by  a  comparatively 
painless  and  much  more  expeditious  de¬ 
livery. 

“  Many  instances  might  be  quoted  to 
show  to  what  I  allude.  Thus  it  is  said  by 
an  author  on  ansesthesia,  in  relating  a  case 
of  labour  : — ‘  A  second  labour,  &c. — child 
was  expelled  in  fifty  minutes,  &c. — ‘  In 
her  first  or  preceding  confinement  she  had 
been  in  severe  labour  for  twenty  hours, 
followed  by  flooding  ;  no  haemorrhage  on 
the  present  occasion  — thus  leaving  the 
unprofessional  reader  to  suppose  that  the 
inhalation  expedited  delivery,  and  that  it 
prevented  flooding.  To  those  experienced, 
however,  it  would  be  known  that  no  such 
effects  could  be  attributed  to  it.  It  is  not 
at  all  necessary,  that  because  haemorrhage 
has  occurred  in  one  labour — a  first  and  a 
protracted  delivery — it  should  again  happen 
to  the  same  patient  in  subsequent  confine¬ 
ments.”  (p.  3). 

The  false  facts  that  are  thus  accumu¬ 
lated  afford  another  remarkable  instance 
of  the  post  hoc  propter  hoc  style  of  rea¬ 
soning  which  is  so  common  in  the 
records  of  medical  cases.  Among  the 
cases  supposed  to  indicate  the  bene¬ 
ficial  effects  of  anaesthesia  in  parturi¬ 
tion,  Mr.  Gream  gives  us  the  follow¬ 
ing 

“  A  woman  is  in  labour,  the  child  pre¬ 
sents  with  the  feet,  they  and  the  body  are 
expelled,  the  head  is  retained  ;  some  ergot 
is  given  and  repeated,  afterwards  ether  is 
inhaled,  and  it  is  at  once  attributed  to  the 
ether. 

“  I  cannot  help  thinking  an  attempt 
should  have  been  made  to  assist  the  birth 
from  the  first,  and  a  very  slight  effort  on  the 
part  of  the  practitioner  would  have  been 
followed  by  the  immediate  escape  of  the 
foetal  head.  In  this  case  there  were  cer¬ 
tainly  no  just  grounds  for  the  use  of  the 
ether. 

“  Another  case  appears  interesting,  for  in 
that,  by  a  happy  coincidence,  instead  of  the 
uterine  contractions  being  increased,  they 
were  diminished, — it  was  a  case  of  turning, 
in  which  the  uterine  fibres  were  so  relaxed 
that  it  was  performed  ‘  with  perfect  ease.’ 

“  A  case  is  also  recorded,  being  supposed 
to  favour  the  use  of  etherization,  but  in 
which  there  is  clear  evidence  of  delay  in  the 
birth  of  the  child  owing  to  its  employment ; 
the  uterus  alone  was  left  to  expel  it,  and  it 
had  not  the  power  to  do  so  speedily,  un¬ 
assisted  by  the  voluntary  action  of  the  abdo¬ 
minal  muscles. 

*  *  ^  $ 


ON  THE  EMPLOYMENT  OF  ANAESTHETIC  AGENTS  IN  MIDWIFERY.  423 


“Then  there  are  cases  of  convulsions 
reported,  all  cured  by  ether  and  chloroform, 
but  in  all  bleeding  and  other  remedies  had 
first  been  actively  employed.  Some  details 
of  cases  have  been  given  to  me  of  the  won¬ 
derful  effects  of  these  agents,  which  have 
caused  me  much  amusement.  But  I  cannot 
believe  that  I  heard  a  true  statement  of 
facts, — I  am  inclined  to  think  that  no  pro¬ 
fessional  man  would  expose  himself  to  ridi¬ 
cule  by  stating  to  his  patients  circumstances 
which  by.  no  possibility  could  ever  have 
occurred.  When,  however,  statements  ap¬ 
pear  in  print  by  authors  upon  whom  reliance 
may  be  placed  in  their  own  belief  in  them, 
but  which  allude  to  circumstances  that  never 
could  have  happened,  it  cannot  be  surprising 
that  others  should  follow  their  example,  and 
persuade  themselves  that  they  have  wit¬ 
nessed  much  more  extraordinary  actions  of 
these  agents  than  the  practitioners  who 
boast  that  they  have  introduced  them.  Each 
succeeding  author  has  observed  some  more 
wonderful  effect  than  his  predecessor. 

“  In  considering  that  etherization  is  said 
by  some  to  relax  uterine  contraction,  by 
othe  rs  to  increase  it ;  by  some  that  a  full 
effect  must  be  produced  in  order  to  allay 
pain,  by  others  only  a  partial  effect ;  by 
many,  that  it  will  cure  convulsive  attacks, 
while  it  has  been  distinctly  proved  to  induce 
them ;  by  some,  that  it  will  accelerate 
labour,  by  others  that  it  retards  it ;  by 
many,  that  it  saves  foetal  life,  while  it  pro¬ 
bably  tends  to  endanger  and  destroy  it; — in 
considering  these  circumstances,  that  they 
are  put  forward  by  the  advocates  of  anaes¬ 
thesia,  and  the  very  opposite  effects  are 
attributed  to  etherization  by  the  same 
authors  in  many  instances,  it  will  necessarily 
be  inquired  on  whom  can  we  rely  for  evi¬ 
dence,  aud  is  the  practice  of  those  who  have 
expressed  such  unstable  opinions,  that 
which  we  should  be  induced  to  follow.  But 
an  attempt  has  been  made  to  introduce  the 
most  pernicious  of  all  doctrines.  I  allude 
to  the  endeavour  to  persuade  women  that 
they  have  a  right  to  insist  upon  the  use  of 
chloroform  during  their  delivery,  and  that 
their  attendant  is  to  have  no  voice  in  the 
matter,  however  great  his  responsibility. 
Whatever  may  happen  elsewhere,  this  will 
never  be  the  case  in  this  metropolis.” 
(pp.  5-7). 

No  one  has  contributed  so  much  to 
a  sound  knowledge  of  the  action  of 
anaesthetic  agents  as  our  correspondent 
I)r.  Snow,  whose  valuable  communica¬ 
tions  on  this  subject  have  frequently 
appeared  in  our  pages.  Mr.  Gream 
makes  use  of  his  observations  respect¬ 
ing  the  different  stages  of  narcotism 
produced  by  ether  and  chloroform.  To 
these  it  is  unnecessary  to  advert.  Our 


author  considers  that  the  observations 
of  Dr.  Snow  are  calculated  to  shew 
that  the  use  of  these  agents  is  very 
liable  to  be  attended  with  serious  con¬ 
sequences  to  females  in  the  parturient 
state.  His  views  are  supported  by 
cases  quoted  from  various  sources,  and 
the  details  of  which  have  for  the  most 
part  appeared  in  this  and  other  medical 
journals.  He  dwells  most  properly  on 
that  cumulative  power  which  Dr.  Snow 
has  observed  to  be  more  forcibly 
marked  in  chloroform  than  ether. 
He  also  condemns  the  mode  of  admi¬ 
nistration  advised  by  Dr.  Simpson.  As 
to  the  cumulative  property  : — 

“A  person  may  inhale  a  drachm  of 
chloroform,  and  no  altered  sensation  will 
at  first  be  the  result,  but  after  a  certain 
length  of  time,  complete  insensibility  may 
supervene,  although  no  more  of  the  fluid  has 
been  inhaled;  and  thus,  again,  we  have  a 
source  of  danger,  for  it  might  be  the  case 
that  half  a  drachm  of  the  fluid  inhaled 
would  in  some  persons  be  sufficient  to  pro¬ 
duce  all  the  required  insensibility  to  pain, 
that  the  brain  and  spinal  marrow  may  be 
paralysed  by  it  to  the  extent  of  the  fourth 
degree  of  narcotism,  and  that  the  inhalation 
of  more  than  the  half  drachm  would  go  be¬ 
yond  the  fourth  degree,  and  would  paralyze 
the  medulla  oblongata,  producing  the  fifth 
degree,  or  death.  Now  it  is  evident  from 
the  facts  stated  in  a  former  page,  that  some 
persons  are  affected  much  more  readily  than 
others,  and  that  a  quantity  of  the  fluid 
which  could  scarcely  produce  any  altered 
condition  in  one  person,  would  cause  death  in 
another.  Let  it  be  supposed,  then,  that  a 
person  who  is  readily  influenced  inhales  chlo¬ 
roform  ;  a  drachm  or  more  is  inhaled,  and 
no  effects  are  produced  at  first,  but  in  a  few 
seconds,  without  further  inhalation,  the  re¬ 
sults  are  apparent,  and  now  the  patient  be¬ 
comes  insensible :  she  arrives  at  the  fourth 
stage  ;  half  the  quantity  she  has  inhaled  has 
been  sufficient  to  produce  complete  insensi¬ 
bility,  but  she  has  inhaled  as  much  again  as 
is  required, — can  it  be  re-taken  from  her? 
Is  there  any  antidote  at  hand  ?  No  ;  in  a  few 
minutes  the  cumulative  effects  of  the  whole 
quantity  have  developed  themselves,  respi¬ 
ration  has  ceased,  and  the  patient  is  no 
more.  This  has  absolutely  occurred. 

“  In  considering  this  property  of  chloroform, 
it  is  impossible  to  pass  over  the  direction 
given  by  Dr.  Simpson,  that  ‘  one  or  two 
teaspoonfuls  should  be  placed  on  a  handker¬ 
chief, ’  without  noticing  the  extreme  vague¬ 
ness  in  giving  directions  for  the  use  of  an 
agent  so  uncertain  and  so  powerful;  and  yet, 
after  having  given  this  loose  recommenda¬ 
tion,  he  has  thought  it  necessary,  at  the 


424  ON  THE  EMP!  OYMENT  OF  ANAESTHETIC  AGENTS  IN  MIDWIFERY. 


eleventh  hour,  and  not  until  casualties  have 
resulted,  to  recommend  the  employment  of 
most  active  means  for  the  restoration  of  per¬ 
sons  poisoned  by  etherization.”  (p.  22-23.) 

Mr.  Gream  gives  abstracts  of  the  fatal 
cases  of  Greener,  Walker,  and  Mrs. 
Parkinson,  and  advances  good  reasons 
for  the  view  whic  h  we  have  already 
taken — namely,  that  these  were  really 
cases  of  poisoning  hy  the  vapour  of 
chloroform,  although  the  advocates  of 
this  agent  were  strongly  disposed  to  re¬ 
fer  them  to  asphyxia,  syncope,  and  cer¬ 
tain  morbid  states  of  the  system. 
Several  other  cases  have  occurred  since 
the  publication  of  his  pamphlet.  Our 
author  is  disposed  to  think  that  anaes¬ 
thetic  vapours  may  produce  injurious 
effects  to  the  child. 

“  As  yet  I  have  not  referred  to  the  effect 
that  etherization  may  have  on  the  foetus  in 
utero,  and  on  the  infant  after  birth  ;  there 
are,  however,  many  reasons  for  supposing 
that  much  injury  may  arise  to  the  offspring  ; 
and  no  evidence,  either  theoretical  or  prac¬ 
tical,  has  as  yet  gone  to  prove  the  contrary. 

“  It  is  admitted  by  all  that  the  pulsations 
of  the  foetal  heart  are  greatly  increased  dur¬ 
ing  inhalation — indeed,  to  such  an  extent 
has  this  been  noticed,  that  in  some  instances 
the  pulsations  could  not  be  counted, — so 
much  were  they  accelerated.  Are  not  effu¬ 
sions  to  be  feared  from  this  ?  are  not  con¬ 
vulsions  after  birth  likely  to  ensue  ?  and  may 
not  that  occur  which  would  make  the  most 
heartless  mother  shudder  at  the  bare  possi¬ 
bility  of  herself,  by  her  want  of  courage, 
being  instrumental  in  producing  ?  may  not 
idiotcy  supervene  ?  Of  this  we  have  as  yet 
no  experience,  nor  shall  we  have,  perhaps, 
for  years  ;  but  when  one  such  case  occurs, 
will  there  then  be  found  any  one  who  will 
afterwards  be  persuaded  to  submit  herself  to 
etherization  during  pregnancy  ?  I  have  wit¬ 
nessed  the  death  of  a  child  within  a  few 
hours  after  its  birth,  born  while  the  mother 
was  under  the  influence  of  ether,  and  in  that 
child  the  pericardium  was  filled  with  serum  ; 
and  I  have  good  reason  to  suppose  that  this 
effusion  was  the  direct  effect  of  ether  in  in¬ 
creasing  the  heart’s  action  while  in  utero. 

“  There  was  no  difficulty  in  its  expulsion  ; 
the  child  was  full  grown  and  healthy  ;  some 
difficulty  was  experienced  in  establishing  re¬ 
spiration,  which  was  not  accounted  for  by 
any  circumstance  whatever  as  regarded  the 
presentation  or  the  duration  of  the  labour, 
which  was  short ;  but  at  length  both  respira¬ 
tion  and  circulation  were  to  a  certain  exient 
established  ;  the  child,  however,  constantly 
cried  as  if  in  pain  ;  after  a  few  hours  its  cries 
became  more  feeble,  its  lips  were  livid,  its 
extremities  cold,  and  the  heart’s  action 


weak,  the  muscles  of  the  face  being  partially 
convulsed,  and  it  ultimately  died ;  there 
were  no  morbid  appearances,  with  the  excep¬ 
tion  of  the  pericardium  being  filled  with 
serum.”  (p.  31-32.) 

The  great  danger  which  in  Mr. 
Gream’s  view,  is  to  be  apprehended  in 
the  use  of  chloroform,  is  its  tendency 
to  produce  congestion.  Experiments 
on  animals,  as  well  as  the  inspection  of 
the  bodies  of  those  persons  who  have 
already  fallen  victims  to  the  anaesthetic 
mania,  have  clearly  established  that 
each  degree  of  etherization  is  accom¬ 
panied  by  a  gradually-increasing  con¬ 
gested  stated  of  the  blood-vessels.  On 
this  our  author  remarks — 

“  Considering  the  almost  constant  predis¬ 
position  that  exists  in  pregnant  women  to 
congestion — considering  that  congestion  is 
the  direct  cause  of  puerperal  convulsions — 
considering  the  very  many  sequels  to  con¬ 
gestion  under  any  circumstance  to  which 
persons  are  liable,  but  especially  so  when 
pregnant, — I  assert,  without  the  fear  of  con¬ 
tradiction,  from  those  bound  by  the  moral 
and  legitimate  laws  of  the  practice  of  medi¬ 
cine,  that  the  exhibition  of  ether-vapour  in 
parturition  is  an  act  at  once  unjustifiable, 
and  I  question  whether  it  will  not  before  long 
be  considered  criminal  according  to  law. 

“  And  yet,  without  waiting  to  inquire 
what  are  the  disadvantages,  what  the 
dangers,  attending  etherization,  because  it  is 
said  to  relieve  pain  in  labour,  some  women 
are  found  who  yield  to  the  false  promises 
made  to  them,  and  seek  for  its  use;  and  let 
them  do  so  if  they  please,  but  do  not  let 
them  any  longer  urge  their  friends  to  commit 
themselves  to  its  baneful  influence  ;  for  they 
should  know  that  fatal  consequences  have 
ensued  from  the  use  of  chloroform  during 
parturition,  its  use  having  been  sought  ex¬ 
clusively  owing  to  the  urgent  recommenda¬ 
tions  of  near  relatives  :  the  feelings  of  these 
persons,  under  the  circumstances,  may  be 
readily  imagined.”  (p.  34-35.) 

Dr.  Merriman’s  pamphlet,  as  we  have 
already  remarked,  is  calculated  to  re¬ 
strain  ardent  chloroformists,  and  to 
teach  them  that,  without  more  precau¬ 
tion  than  they  have  hitherto  con¬ 
sidered  it  necessary  to  adopt,  they  m3y 
bring  the  use  of  anaesthetics  into  disre¬ 
pute,  and  lead  to  their  entire  expulsion 
from  the  practice  of  midwifery.  The 
great  error  in  those  who  have  sent 
their  communications  to  the  medical 
journals,  has  consisted  in  the  fact,  that 
they  have  not  taken  up  the  subject  on 
sufficiently  general  principles. 


ON  THE  EMPLOYMENT  OF  ANAESTHETIC  AGENTS  IN  MIDWIFEKY.  425 


“  The  writers  alluded  to  mention  a  few 
cases,  and  generalize  upon  them  ;  arguing 
thus  from  individual  to  general  practice,  not 
from  general  principles  as  laid  down  by  ex¬ 
perience,  to  individual  cases,  in  which  the 
general  rules  may  be  more  or  less  departed 
from  according  to  circumstances  affecting 
the  individual.  My  object  will  therefore  be 
to  study — first  the  history  of  midwifery  with 
reference  to  the  establishment  of  these 
general  rules  ;  secondly,  the  nature  and  pro¬ 
perties  of  the  anzesthetic  agents  ;  and  thirdly, 
to  endeavour  to  draw  from  these  considera¬ 
tions  the  rules  which  should  govern  the  pro¬ 
fession  in  their  employment  of  the  agents.” 
(p.  4.) 

We  need  not  enter  into  the  analo¬ 
gical  reasonings  whereby  the  author 
supports  his  views.  All  experienced 
men  agree  that  some  well-know  n  reme¬ 
dies,  the  employment  of  which  is  in 
general  undesirable,  are  occasionally 
of  great  value  to  the  accoucheur;  and 
no  one  can  doubt  the  propriety  of  the 
advice  that  nature  should  be  allowed 
to  conduct  the  whole  process  of  the 
birth,  the  physician  merely  interfering 
when  he  finds  morbid  action  commenc¬ 
ing,  or  when  the  birth  is  impracticable 
without  artificial  assistance. 

While  Dr.  Merriman  admits  that 
these  vapours  may  act  as  poisons,  and 
that  great  danger  may  arise  from  their 
cumulative  properties,  when  employed 
by  the  inexperienced,  he  differs  from 
Mr.  Gream,  in  considering  that  they 
may  occasionally  be  of  great  utility. 

“  Under  the  skilful  bands  of  a  person 
accustomed  to  administer  the  vapour,  this 
tendency  to  an  augmentation  of  the  depress¬ 
ing  effects  of  chloroform  will  be  of  slight 
moment  ;  but  if  extreme  care  be  not  taken 
it  may  prove  highly  injurious,  by  suppressing 
altogether  the  powers  of  life.  The  employ¬ 
ment  of  poisonous  substances  in  medicine 
is  by  no  means  novel,  for  in  all  times  some 
of  the  remedies  best  calculated  to  relieve 
pain  and  sickness,  have  been  deleterious  in 
certain  doses,  though  in  smaller  quantities, 
eminently  useful  as  medicine;  but  it  is  a 
perfectly  new  mode  of  proceeding  when 
these  anaesthetic  agents  are  administered  in 
such  quantities  as  to  suppress  almost  entirely 
the  vital  properties  of  the  living  system  ; 
the  idea  of  so  acting  upon  our  fellow-crea¬ 
tures  is  pregnant  with  alarm  ;  yet  it  has  been 
satisfactorily  proved  that  great  benefit  re¬ 
sults  from  this  use  of  the  agents,  not  only  in 
surgery,  but  also  in  operative  midwifery. 
Surgical  operations  are  constantly  performed 
now  without  any  suffering  on  the  part  of  the 
patient,  and  it  appears  undeniable  that  in 
many  cases  he  stands  a  better  chance  of  re¬ 


covering  his  health,  than  if  the  operation 
had  been  performed  without  the  employ¬ 
ment  of  an  anaesthetic.”  (p.  14-15.) 

Our  author  then  examines  theeffects 
produced  in  the  various  stages  of  anees- 
thesia,  tracing  them  up  to  the  produc¬ 
tion  of  actual  death.  In  the  last  stage 
we  have  a  cessation  of  action  in  the 
muscles  of  the  uterus,  then  in  those  of 
respiration,  and  finally  in  the  heart 
itself.  The  continuance  of  the  heart’s 
action  after  other  vital  actions  have 
ceased,  might  lead  to  a  hope  of  reco¬ 
very  ;  but  we  believe  there  is  no  in¬ 
stance  recorded,  in  which  a  person  has 
been  resuscitated  after  the  cessation  of 
respiration.  The  great  difficulties  con¬ 
nected  with  the  employment  of  chloro¬ 
form  in  midwifery-practice,  are  well 
set  forth  in  the  following  para¬ 
graphs  : — 

“  We  see,  therefore,  that  to  produce  the 
full  effects  of  the  anaesthetic  employed,  we 
must  reduce  the  patient  to  a  point  very  little 
separated  from  death  itself ;  and  this  does 
seem  to  me  to  be  an  interference  with  nature 
of  immense  importance,  and  justifiable  only 
under  very  peculiar  circumstances.  We 
have  found  that  other  practices  have  neces¬ 
sarily  been  abandoned,  because  they  occa¬ 
sionally  produced  irremediable  consequences, 
yet  they  apparently  interfered  less  with 
Nature’s  processes  than  does  the  chloroform. 
The  exhibition  of  chloroform  is  very  much 
under  control,  but  its  paralyzing  effects  are 
so  great  in  these  latter  stages,  that  a  very 
slight  increase  in  them  may  be  decisive  in 
destroying  life,  and  this  increase,  at  present, 
seems  on  some  occasions  unavoidable. 

“  I  have  alluded  to  a  sufficiently  sedative 
effect  for  purposes  of  midwifery  being  some¬ 
times  produced  in  the  third  stage  ;  this  may 
induce  sleep  on  some  occasions  of  excite¬ 
ment,  and  irregular  pains,  perhaps  better 
than  preparations  of  opium,  but  it  will  not 
be  sufficient  to  prevent  the  occurrence  of 
suffering  in  acute  pain,  and  the  continual 
administration  of  the  chloroform  will  be  very 
likely  to  bring  on  the  fourth  stage,  unless 
very  great  care  be  taken  in  its  administra¬ 
tion.  In  practice,  also,  there  will  always  be 
fear  of  impurities  in  the  chloroform.  Where 
an  article  requiring  very  nice  manipulation 
is  made  in  large  quantities,  persons  must  be 
employed  who  cannot  exercise  the  same 
watchful  vigilance  over  the  processes,  as  the 
chemist  would  in  making  small  quantities 
for  his  own  use.  It  is  therefore  necessary, 
in  considering  the  question,  whether  it  is 
right  to  employ  chloroform  generally  in 
midwifery,  to  recollect  the  probability  of 
adulterations.  I  am  not  aware  that  there 
have  been  many  instances  known  of  injury 


426  ON  THE  EMPLOYMENT  OF  ANAESTHETIC  AGENTS  IN  MIDWIFERY. 


from  adulteration  of  chloroform,  whether  in- 
tentional  or  accidental,  but  the  consequences 
of  administering  such  mixtures  might  be 
very  serious.  The  method  of  administering 
the  anaesthetics  is  one  eminently  calculated 
to  injure  the  delicate  structures  of  the  body, 
unless  the  vapours  employed  are  quite  pure. 
They  are  presented  to  an  absorbing  surface 
in  a  form  calculated  to  pass  into  the  blood 
with  the  greatest  facility  ;  if,  therefore,  there 
be  contained  in  the  vapour  any  deleterious 
adulterations  (chlorine,  or  alcohol,  for  in¬ 
stance),  great  injury  may  result  to  the  pa¬ 
tient,  and  its  further  administration  neces¬ 
sarily  be  at  once  omitted.  Chloroform  and 
ether  both  produce  convulsive  twitchings  in 
some  people  ;  other  anaesthetics  produce 
them  so  strongly  that  they  cannot  be  em¬ 
ployed  in  medicine  ;  may  not  this,  therefore, 
be  the  consequence  of  using  chloroform  or 
ether  which  has  been  adulterated  ?  That  such 
accidents  maybe  rare  is  my  hope  and  fervent 
prayer,  but  it  would  be  contrary  to  every 
experience  to  suppose  that  they  will  not 
occur.”  (p.  17-18.) 

As  to  the  rules  respecting  its  em¬ 
ployment,  Dr.  Merriman  remarks — 

“  If,  then,  chloroform  is  to  be  used  solely 
as  an  assuager  of  pain,  it  becomes  necessary 
to  inquire  whether  the  pain  endured,  or  the 
remedy  administered  to  assuage  it,  is  calcu¬ 
lated  to  produce  the  most  injury  to  the  pa¬ 
tient.  Now  we  have  ample  evidence  that 
the  ordinary  sufferings  in  labour,  nay,  even 
extreme  sufferings,  do  not,  in  the  vast  ma¬ 
jority  of  births,  produce  any  permanent  in¬ 
jury  to  the  mother,  but  we  have  yet  to  learn 
that  chloroform  is  equally  exempt  from  such 
a  tendency.  We  do  not  yet  understand  the 
way  in  which  it  acts  upon  the  living  system, 
but  we  do  know  that  its  action,  when  not 
limited  by  care  in  its  administration,  or 
when  given  in  certain  diseased  conditions  of 
the  chest  or  brain,  has  a  tendency  to  destroy 
life  very  rapidly  ;  a  property  which  requires 
extreme  attention  in  using  it  at  any  time, 
and  is  sufficient  to  warrant  abstinence  from 
it  altogether,  except  under  peculiar  circum¬ 
stances.  Given  in  proper  doses,  chloroform 
possesses  most  valuable  properties  as  a  seda¬ 
tive  ;  hence  its  value  in  surgical  and  in  ob¬ 
stetrical  operations,  to  lessen  the  pain  in¬ 
separable  from  the  use  of  preternatural 
means  to  accomplish  the  delivery,  and  to 
prevent  the  patient’s  struggles.”  (p.  22.) 
******** 

“  Whatever  may  be  the  real  effect  of  the 
chloroform  on  the  actions  of  the  uterus,  there 
appears  no  doubt  that  it  possesses,  in  the 
majority  of  cases,  the  power  of  abating 
materially  the  excitement  of  the  nervous 
system  :  that  it  thus  conduces  to  sleep, 
which,  under  favourable  circumstances,  be¬ 
comes  natural,  and  thus  invigorates  the  sys¬ 


tem  more  than  artificial  sleep  can  do,  and 
that  it  lessens  the  shock  to  the  nerves  from 
the  lengthened  continuance  or  intensity  of 
pain,  and  thus  renders  recovery  more  easy. 
In  parturition,  consequently,  where  the  posi¬ 
tion  of  the  foetus  in  the  womb,  and  the  bony 
structures  of  the  mother,  might  be  expected 
to  offer  no  unusual  impediment  to  the  birth, 
still,  should  the  condition  of  the  woman 
be  such  as  1o  cause  great  fears  that 
she  cannot  endure  the  pain  of  the 
birth  without  suffering  material  in¬ 
jury,  chloroform  may  be  administered  with 
propriety.  I  have,  however,  shown  above, 
that  such  cases  can  be  very  few,  and  scarcely 
come  under  the  limits  within  which  interfer¬ 
ence  with  nature  can  be  allowed  with  im¬ 
punity.  The  reasons,  therefore,  actuating 
the  physician  to  allow  the  inhalation  of 
chloroform  in  these  simple  cases  must  be  ex¬ 
ceedingly  strong,  or  he  will  violate  the  law 
of  non-interference  with  nature,  founded  on 
the  experience  of  so  many  physicians  of 
celebrity  during  a  succession  of  years  ;  and 
although  he  may  not  notice  any  immediate 
ill  consequences,  he  must  expect  to  find 
some  sooner  or  later. 

“  Where  the  labour  is  more  tedious,  ex¬ 
tending  to  twenty-four  hours  or  more,  or  if 
the  patient  has,  from  the  occurrence  of  false 
pains,  previously  to  the  commencement  of 
her  true  labour,  or  from  other  causes,  been, 
deprived  of  her  rest,  and  thereby  rendered 
unequal  to  bear  with  impunity  a  recurrence 
of  pains  for  many  hours,  chloroform  may  not 
improbably  become  a  fit  medicine  to  admi¬ 
nister,  to  obtain  that  repose  which  other 
measures  have  failed  to  procure  ;  but  these 
other  measures  ought  invariably  to  be  tried 
first.”  (p.  23-24.) 

The  following  words  of  advice  should 
be  borne  in  mind  by  those  who  are 
called  upon  to  decide  respecting  the 
employment  of  chloroform  in  a  parti¬ 
cular  case : — 

“  The  more  the  powers  of  nature  are  stu¬ 
died  in  the  act  of  childbirth,  the  less  neces¬ 
sity  will  be  found  for  the  use  of  medical  ap¬ 
plications  to  relieve  the  suffering;  so  that  I 
firmly  believe  that  the  administration  of 
chloroform  will  be  confined  eventually  to 
instrumental  or  very  tedious  labours.  When 
the  presentation  of  the  foetus  is  such  as  to  re¬ 
quire  manual  assistance  before  the  birth  canbe 
effected,  or  where,  from  failure  of  the  pains, 
or  malformation  of  the  pelvis,  the  pains  are 
unable  to  accomplish  their  task,  chloroform 
will  frequently  be  found  of  great  service; 
and  if  the  patient’s  health  be  sufficiently 
good,  the  accoucheur  will  do  well  to  recom¬ 
mend  the  inhalation.  But  even  here  he  will 
not  unfrequently  find  the  artificial  comple¬ 
tion  of  the  labour  so  easy,  that  inhalation 
seems  superfluous ;  in  some  instances  it 


ON  THE  EMPLOYMENT  OF  ANAESTHETIC  AGENTS  IN  MIDWIFERY.  427 


would  complicate,  in  appearance,  a  simple 
operation,  and  ought,  therefore,  to  be 
avoided.”  (p.  26-27.) 

*  *  *  ***** 

“  With  the  best  intentions,  our  exertions 
will  occasionally  be  insufficient  to  prevent  a 
fatal  consequence  ;  they  may  even  appear  to 
have  hastened  it.  If,  then,  a  practice  has 
been  resorted  to,  the  employment  of  which 
was  not  imperatively  called  for,  and 
death  ensues,  whether  arising  directly 
from  the  treatment,  or  from  other 
causes,  how  awful  is  the  reflection  that 
we  have  in  even  the  slightest  degree  has¬ 
tened  the  termination  of  life.  Let  us  bear 
incessantly  in  mind,  that  ordinary  cases  re¬ 
quire  only  ordinary  means  of  relief,  and  that 
extraordinary  remedies  can  only  be  properly 
employed  in  extraordinary  cases,  where 
ordinary  means  are  inapplicable  or  insuffi¬ 
cient.”  (p.  27.) 

Mr.  Stallard,  the  author  of  the 
third  pamphlet,  appears  as  a  strong  ad¬ 
vocate  of  the  use  of  chloroform.  He 
candidly  tells  his  readers,  that  this  un¬ 
limited  advocacy  of  what  is  now  proved 
to  be  a  dangerous  agent  is  based  upon 
his  own  successful  employment  of  it; 
but  we  would  here  in  limine  refer  him 
to  the  judicious  advice  given  by  Dr. 
Merriman.  Sound  medical  experience 
regarding  the  safety  or  danger  of  any 
particular  system  of  treatment,  can 
never  be  derived  from  isolated  trials. 
"We  must  argue  from  general  principles, 
and  not  from  individual  cases  to  which 
general  rules  may  not  be  fairly  appli¬ 
cable.  With  this  remark,  Mr.  Stallard’s 
pamphlet  may  be  taken  as  a  fair  state¬ 
ment  of  the  case  for  those  who  persist 
in  the  recommendation  of  the  use  of 
chloroform  under  all  circumstances. 

The  positions  assumed  by  the  author 
in  combating  some  of  the  objections  to 
the  use  of  chloroform  in  midwifery, 
are  certainly  of  an  extraordinary  kind. 

“  Another  objection  is  urged  against  the 
state  of  anaesthesia ;  viz.  that  unconscious¬ 
ness,  or  loss  of  mental  power,  also  ensues. 
Dr.  Ashwell  has  urged  this  objection  in  the 
following  terms  :  ‘  Supposing  the  case  to  be 
a  fatal  one,  a  circumstance  which  must  oc¬ 
casionally  happen,  I  would  not  envy  the  re¬ 
morse  which  must  follow  the  conviction, 
that  by  such  an  event  the  momentous  ar¬ 
rangements  of  a  dying  hour  have  been  en¬ 
tirely  prevented.’  Much  might  be  said  upon 
this  subject ;  but  the  question  is  at  once  an¬ 
swered  by  denying  the  production  of  entire 
unconsciousness  :  it  is  true  that  the  senses 
are  not  in  a  most  active  condition  in  the  first 
stage  of  anaesthesia,  but  the  intermission  of 


the  chloroform  will  always  (?)  restore  them 
after  a  few  minutes,  and  the  danger  is  never  (?) 
so  sudden  and  imminent  but  that  it  is  antici¬ 
pated  by  the  medical  attendant  in  full  time 
for  this  restoration.  But  further,  I  may 
confidently  appeal  to  all  who  may  have  wit¬ 
nessed  so  distressing  an  occurrence,  and  ask 
whether  unconsciousness  in  sudden  death 
during  delivery,  or  immediately  after ,  be 
not  rather  desirable  than  the  contrary.  The 
patient  is  surely  not  then  in  a  condition  to 
attend  to  the  momentous  question  of  salva¬ 
tion,  for  the  powers  of  mind  and  body  are 
convulsed  by  the  suffering  of  the  moment, 
and  the  most  terrible  restlessness  only  suc¬ 
ceeds  to  the  apathy  and  unconsciousness  of 
rapid  exhaustion.”  (p.  7.) 

The  author  is  here  decidedly  at  issue 
with  Mr.  Gream,  who  considers,  reason¬ 
ably  enough,  as  it  appears  to  us,  that  if 
the  degree  of  narcotism  be  slight,  it  will 
not  prevent  the  sufferings  of  labour, 
and  if  great,  that  it  will  be-  attended 
with  imminent  danger.  In  the  above 
remarks,  Mr.  Stallard  appears  to  take 
no  account  of  the  cumulative  proper¬ 
ties  of  chloroform. 

The  author  considers  that  the  occur¬ 
rence  of  a  sense  of  suffocation  is  an  in¬ 
dication  of  danger. 

“  But  it  may  be  objected  that  this  is  not 
a  certain  safeguard  in  all  conditions  ;  occa¬ 
sionally  a  patient  not  fully  insensible  to  the 
pain  she  is  suffering  is  over  anxious  to  inhale 
a  more  copious  dose  ;  in  doing  so  she  im¬ 
mediately  becomes  pallid,  the  pulse  becomes 
quickened,  and  the  respiration  heavy ;  she 
is  too  insensible  to  be  cognizant  of  the  sense 
of  suffocation,  and  the  lungs  become  more 
and  more  congested.  It  is  under  these  cir¬ 
cumstances  that  chloroform  is  really  dan¬ 
gerous  ;  yet  is  this  danger  entirely  obviated 
if  the  attention  of  the  medical  attendant  be 
solely  directed  to  its  administration  :  he  then 
watches  with  care  the  character  of  each  inspira¬ 
tion  ;  if  it  be  deeper  than  usual,  or  if  the  air 
inspired  be  fully  charged  with  chloroform, 
he  removes  the  handkerchief  and  permits  one 
or  two  inspirations  of  pure  air;  if  the  pulse 
become  quickened,  or  the  lungs  oppressed, 
or  the  insensibility  unnecessarily  deep,  he 
acts  in  the  same  manner.  The  restoration 
of  pure  air  affords  the  most  speedy  relief ; 
and,  as  in  cases  of  hanging  or  drowning,  the 
persons  easily  recover  if  they  have  been  as¬ 
phyxiated  only  a  short  time,  so  do  they  now 
recover  if  the  state  have  only  lasted  a 
few  seconds.  In  the  exhibition  of  chloro¬ 
form  I  recommend  that  the  quantity  inspired 
should  never  be  sufficient  to  induce  cough, 
irritation,  or  the  slightest  unpleasant  sensa¬ 
tion,  and  if  any  such  symptoms  occur,  its 
exhibition  should  be  suspended  for  a  few 


428  ON  THE  EMPLOYMENT  OF  ANAESTHETIC  AGENTS  IN  MIDWIFERY. 


seconds.  In  the  advanced  stage,  where  it 
is  required  to  keep  up  its  effect,  the  medical 
attendant  can  alone  supply  the  place  of  con¬ 
sciousness  ;  and  by  his  unremitting  attention 
he  must  recognise  the  earliest  approach  to 
these  serious  indications.  Entirely  to  pre¬ 
vent  them,  he  must  be  careful  not  to  exhibit 
too  large  a  dose  at  once  :  indeed,  I  would  re¬ 
commend  him  never  to  allow  the  patient  to 
breathe  the  vapour  throughout  an  entire  re¬ 
spiration  ;  if  the  handkerchief  be  removed 
when  half  the  inspiration  is  accomplished, 
the  latter  half  will  certainly  secure  a  suffi¬ 
ciency  of  atmospheric  air  for  the  purposes  of 
respiration.  By  observing  these  precautions 
I  have  repeatedly  succeeded  in  administering 
chloroform  to  ladies  of  the  most  excitable 
temperament,  and  of  delicate  constitution, 
without  hearing  from  them  a  single  com¬ 
plaint  ;  they  have  been  kept  under  its  in¬ 
fluence  for  an  hour  to  three  hours  respec¬ 
tively,  without  the  least  expression  of  pain 
or  discomfort ;  and  in  one  instance  the  pa¬ 
tient  was  in  the  first  stage  of  anaesthesia  up¬ 
wards  of  seven  hours,  without  any  other 
effect  than  relief  from  most  severe  pain, 
which  would  otherwise  have  induced  great 
depression  of  the  vital  power."  (p.  12-13.) 

Mr.  Stallard  considers  that  chloro¬ 
form  may  be  used  not  only  “  without 
the  least  shadow  of  danger,"  but  with 
positive  advantage  in  all  cases  of 
labour,  and  especially  in  those  which 
require  the  active  interference  of  the 
accoucheur.  The  statement  of  his  ex¬ 
perience  is  decidedly  in  favour  of  the 
use  of  this  agent  ;  but  he  appears  to 
us  to  have  too  much  of  that  enthusiasm 
for  its  use,  which  marked  the  first  in¬ 
troduction  of  chloroform  as  an  anaes¬ 
thetic.  He  differs  from  Mr.  Gream, 
inter  alia ,  in  considering  that  the  vapour 
exerts  no  injurious  effects  upon  the 
child. 

“  Nothing  but  a  very  extended  experience 
can  justify  any  conclusion  upon  this  head  ; 
as  far  as  my  own  experience  goes,  I  am  de¬ 
cidedly  of  opinion  that  chloroform  exerts 
no  perceptible  influence  upon  the  child. 
Now,  as  I  have  had  an  unusually  large  pro¬ 
portion  of  still-born  children  in  the  cases  I 
have  attended  this  year,  I  must  endeavour 
to  show  that  they  were  clearly  referrible  to 
other  causes.  In  the  case  of  Mrs.  P.  re¬ 
lated  above,  the  chloroform  was  given  for 
an  hour  and  a  half :  at  3  p.m.  the  child  was 
felt  to  be  alive  :  at  6  p.m.  she  again  took 
chloroform  for  ten  minutes  preceding  the 
birth,  which  was  at  10  p.m.  ;  she  was 
fourteen  hours  in  active  labour,  and  the 
pressure  was  sufficiently  great  to  account 
for  the  death  of  the  infant.  The  second  wras 
a  case  of  placenta  praevia,  in  which  turning 


was  had  recourse  to,  but  the  haemorrhage 
some  time  previously  had.  been  very  severe. 
The  third  case  was  nearly  like  the  first, 
with  the  exception  that  the  patient  had  the 
chloroform  for  seven  hours.  This  case  has 
already  been  related  ;  the  death  of  the  infant 
was  clearly  referrible  to  the  extreme  pressure 
to  which  it  had  been  subject.  The  fourth 
case  was  also  partial  placenta  praevia,  in 
which  haemorrhage  had  existed  at  intervals  for 
several  months,  and  there  was  every  reason  to 
believe  the  infant  had  been  dead  some  hours 
before  delivery.  She  had  the  chloroform 
for  one  hour.  The  last  case  was  a  frontal 
presentation,  occurring  in  a  female  aged  31, 
it  being  her  first  confinement.  The  labour 
had  been  lingering  for  three  days,  but  it 
lasted  eight  hours  in  its  acute  form  ;  she 
had  chloroform  during  the  last  three  hours. 
I  have  entered  thus  fully  into  the  above 
cases,  that  it  may  be  rendered  more  appa¬ 
rent  that  the  still  births  were  not  caused  by 
chloroform  ;  but  I  may  remark  in  addition, 
that  other  cases  have  occurred  in  which  it 
was  given  for  four  hours,  without  the  infant 
being  at  all  affected,  whilst  in  the  first  case 
in  which  I  gave  it  the  patient  was  kept  in  a 
perfectly  insensible  state  for  nearly  two 
hours,  and  yet  was  the  child  born  as  healthy 
and  as  well  as  usual."  (p.  18.) 

With  respect  to  the  other  uses  of 
chloroform,  he  observes — 

“  Chloroform  has  been  frequently  used  in 
dental  surgery,  and  I  have  repeatedly  given 
it  in  such  cases.  I  do  not,  however,  recom¬ 
mend  either  ether  or  chloroform  in  slight 
operations,  unless  the  patient  have  the 
remedy  administered  before  dinner,  and 
full  time  be  allowed  for  a  short  sleep 
after  the  operation  is  over :  nothing  is  so 
important  as  rest  and  sleep  after  the 
exhibition  of  chloroform  ;  if  sleep  be  not 
procured  and  permitted,  sickness  and  a 
sensation  of  confusion  frequently  remain. 

“  One  word  on  the  comparison  between 
ether  and  chloroform.  I  believe  the  former 
less  dangerous,  but  more  likely  to  produce 
vomiting,  confusion,  and  other  bad  symp¬ 
toms  ;  whilst  the  chloroform  is  more  likely 
to  produce  asphyxia."  (p.  20-21). 

We  have  here  allowed  the  authors  to 
speak  for  themselves,  by  making  co¬ 
pious  extracts  from  their  respective 
essays.  Although  much  of  the  interest 
connected  with  the  subject  has  died  off, 
it  is  desirable  to  hear  occasionally 
what  an  opponent,  an  advocate,  and 
an  amicus  curiae ,  have  to  say  on  the 
subject. 

Our  readers  will,  perhaps,  agree  with 
us,  that  Mr.  Gream  is  as  sweeping  in 
his  condemnation  as  Mr.  Stallard  is 
in  his  praise  of  the  employment  of 


THE  BATHS  AND  WATERING  PLACES  OF  ENGLAND. 


429 


aneesthetics  in  midwifery.  Mr.  Gream’s 
pamphlet  is  certainly  required  to  check 
the  ardour  of  many  young  accoucheurs, 
and  even  if  considered  to  be  marked  by 
something  like  a  bias  against  etheriza¬ 
tion,  the  wide  circulation  of  it  will  be 
attended  with  good.  Mr.  Stallard’s 
essay  is  a  reflection  of  his  own  obser¬ 
vations  in  a  limited  number  of  cases; 
and  it  will  serve  hereafter  for  the  medical 
historian  who  is  desirous  of  balancing 
the  individual  experience  of  practition¬ 
ers  on  this  singular  discovery.  Dr. 
Merriman’s  pamphlet,  which  is  very 
concisely  written,  contains  such  a  fair 
summary  of  the  advantages  and  dis¬ 
advantages  of  chloroform,  that  it  is  sure 
to  command  an  attentive  perusal,  and 
will  be  read  by  all  with  profit. 

The  Baths  and  Watering  Places  of 
England ,  considered  with  reference 
to  their  curative  efficacy,  fyc.  By 
Edwin  Lee.  2d  edition,  small  8vo. 
pp.  212.  London  :  Adams,  1848. 

Mr.  Lee  is  an  industrious  writer,  and 
has  shown  himself  equally  ready  to 
deal  with  subjects  of  a  grave  character, 
e.  g.  Medical  Reform,  or  with  those 
which  concern  health,  topography, 
and  climate,  and  which  are  especially 
adapted  for  the  perusal  of  invalids. 
The  little  guide-book  before  us  has 
reached  its  second  edition — a  proof  that 
the  author’s  labours  in  this  line  are 
approved  by  that  large  class  of  the 
population  which  is  always  seeking 
the  restoration  of  health  by  a  tempo¬ 
rary  residence  at  Baths  and  Watering 
Places.  In  the  first  part,  we  have  an  ac¬ 
count  of  those  localities  which  are  cha¬ 
racterized  by  thermal  andslighly  minera¬ 
lized  springs.  These  are  not  very  nu¬ 
merous.  In  the  second  part  we  have 
the  Saline,  Aperient,  and  Chalybeate 
Springs.  Such  a  division  is  artificial 
and  arbitrary.  Thus,  Bath  might  come 
under  either  head,  but  it  is  here  sepa¬ 
rated  from  the  Chalybeate  Springs. 
Part  3rd  is  devoted  to  a  topographical 
and  climatic  description  of  the  princi¬ 
pal  places  of  winter-resort  on  the 
English  coast.  Mr.  Lee  has  given  a 
concise,  but,  as  far  as  we  can  judge 
from  our  knowledge  of  several  localities, 
a  very  fair  account  of  these  sanitary 
resorts.  The  chemical  properties  of  the 
different  waters,  with  their  uses  in 
various  forms  of  disease,  are  described 
at  sufficient  length  for  the  non-medi¬ 


cal  reader.  In  the  topography,  there 
is  much  of  that  common-place  cha¬ 
racter,  which  we  are  accustomed  to 
find  in  the  ornamental  guide-books 
met  with  in  the  libraries  of  Watering 
Places.  What,  for  example,  in  the  de¬ 
scription  of  Bournemouth,  is  the  mean¬ 
ing  of  this  passage,  coming  from  the 
pen  of  a  medical  writer? — “Theemana- 
nation  from  the  pine- wood  is  highly 
salubrious  and  beneficial  to  persons 
labouring  under  pulmonary  disease.” 
This  is  surely  a  far-fetched  idea  derived 
from  some  ingenious  non-medical 
author,  who  wishes  to  make  the  most 
of  the  botany  and  geology  of  his  favou¬ 
rite  spot.  The  remarks  on  the  employ¬ 
ment  of  Mineral  Waters,  and  on  bath 
ing  and  Sea-Baths,  are  well  worthy  of 
perusal. 

On  the  whole,  we  are  inclined  to 
think  that  this  little  volume  will  be 
found  a  very  useful  companion  to  those 
who  resort  to  the  Baths  and  Watering 
Places  of  England. 


Principles  of  Medicine ,  comprising 
General  Pathology  and  Therapeutics , 
Sfc.  By  C.5J.  B.  Williams,  M.D. 
F.R.S.,  Prof,  of  the  Principles  and 
Practice  of  Medicine,  &c.,  University 
College.  8vo.  pp.  553.  2d  edition. 
London  :  Churchill.  1848. 

We  regret  that  we  have  not  before 
found  an  opportunity  of  announcing 
the  appearance  of  a  second  edition  of 
this  excellent  work.  In  the  course  of 
five  years,  the  author  has  found  occa¬ 
sion  to  add  considerably  to  the  contents 
of  the  volume,  and  it  may  be  as  well  to 
point  out  the  principal  additions  which 
have  been  made.  In  the  etiological 
portion,  they  refer  to  the  mechanical, 
chemical,  and  dietetic  causes  of  dis¬ 
ease,  defective  cleanliness,  ventilation, 
and  drainage.  In  pathology,  the  tabu¬ 
lar  views  of  the  elements  of  disease  ; 
reflex  action  and  sympathy  ;  elemen¬ 
tary  changes  in  the  blood  ;  congestion  ; 
determination  of  blood  ;  inflammation  ; 
degeneration  of  textures ;  cacoplastic 
and  aplastic  deposits,  with  a  chapter  on 
Hygienics,  comprising  food,  clothing, 
air  and  temperature,  exercise,  mental 
occupation,  sleep,  and  excretion. 

Dr.  Williams  struck  out  a  new  path 
in  the  publication  of  his  Principles. 
Instead  of  giving  a  dry  description  of 
diseases,  with  their  special  symptoms 
and  treatment,  he  takes  a  comprehen¬ 
sive  view  of  practical  medicine  in  its 


430 


dr.  willtams’s  principles  of  medicine. 


relations  to  general  pathology  and 
therapeutics.  That  he  has  succeeded 
in  his  object  is  sufficiently  apparent 
by  the  reputation  which  his  work  has 
already  acquired,  and  in  the  early  de¬ 
mand  for  another  edition.  His  mode 
of  treating  the  subject  is  in  many 
respects  so  novel,  that  his  treatise  will 
be  found  a  most  useful  addition  to  a 
medical  library,  however  rich  in  works 
on  practical  medicine.  The  seventh 
chapter,  on  Hygienics,  is  in  itself  a 
most  valuable  essay  on  an  important 
subject  hitherto  much  neglected  by  Eng¬ 
lish  medical  writers.  The  prevention  of 
disease  has  up  to  the  present  time 
excited  less  attention  than  its  removal 
by  treatment.  There  is,  however, 
now  a  complete  change  of  opinion. 
The  great  sanitary  movement  is  strik¬ 
ing  at  the  root  of  the  causes  of  disease  ; 
and  the  chapter  on  Hygienics,  inserted 
in  the  volume  before  us,  is  well  calcu¬ 
lated  to  aid  the  efforts  of  philanthro¬ 
pists,  by  directing  the  attention  of 
practitioners  to  the  injurious  influence 
on  health  of  a  neglect  of  dietetics, 
clothing,  ventilation,  and  exercise. 

It  is  scarcely  necessary  to  say  that 
we  think  highly  of  this  volume.  The 
author  has  obviously  bestowed  great 
pains  in  keeping  it  up  to  the  level  of 
the  present  state  of  scientific  medicine. 
Unlike  some  writers,  as  actively  en¬ 
gaged  in  practice  as  himself,  he  has 
not  been  satisfied  with  a  mere  reprint 
of  a  former  edition,  but  has  so  im¬ 
proved  the  work  as  to  render  it  a 
desirable  addition  to  the  library  of 
every  practitioner.  We  shall  conclude 
with  one  word  of  advice — namely,  that 
a  third  edition  should  not  be  allowed 
to  appear  without  a  copious  index.  No 
table  of  contents,  however  full,  can 
make  up  for  the  want  of  an  index  to  a 
volume  which  must  fall  into  the  hands 
of  men  whose  time  is  valuable,  and 
who  will  put  down  a  book  in  despair 
if  they  cannot  refer  immediately  to  a 
subject  on  which  they  desire  informa¬ 
tion.  We  know  that  this  suggestion 
will  impose  additional  labour  on  the 
author,  but  it  will  add  considerably  to 
the  value  and  utility  of  his  treatise. 
The  omission  of  an  index  to  a  work  of 
authority  we  hold  to  be,  in  general, 
an  indication  of  laziness  in  a  writer  : 
he  imposes  upon  the  possessors  of 
his  book  a  large  amount  of  trouble, 
in  order  that  he  may  save  him¬ 
self  from  some  inconvenience.  Such 


an  imputation  cannot  rest  upon  Dr. 
Williams,  since  the  contents  of  his 
volume  afford  sufficient  evidence  of 
extensive  research  and  great  industry. 
It  is  therefore  the  more  surprising  that 
he  has  not  supplied  this  palpable 
deficiency. 


©orrcgponbcncc. 


LITERARY  PIRACY. 

Sir, — The  following  note,  which  I  think 
requires  no  explanation,  was  sent  to  the 
editor  of  the  Lancet  nearly  five  weeks  ago. 
The  note  and  the  receipt  of  the  pamphlet 
were  acknowledged  the  next  week.  In  the 
following  Lancet  it  was  stated  that  “  the  con¬ 
tributor  of  the  article  was  in  the  country," 
but  that,  on  his  return,  the  circumstances 
should  be  made  public.  Two  Lancets  have 
since  been  published,  but  no  further  notice 
has  been  taken  of  the  matter.  I  think  you 
will  agree  with  me  that  this  is  not  just. 
As  it  must  be  evident  that  my  property  has 
been  purloined  by  some  one,  I  conceive  that 
it  was  not  too  much  to  expect  that  the  mis¬ 
take — if,  indeed,  it  be  a  mistake — should 
have  been  publicly  acknowledged  before 
this. 

I  shall  be  obliged  by  the  insertion  of  this 
and  the  following  in  your  next  number, 
and  am, 

Yours  very  truly, 

H.  M.  Hughes,  M.D. 

14,  St.  Thomas’s  Street, 

Sept.  2,  1848. 

“  To  the  Editor  of  the  Lancet. 

“  Sir, — I  beg  to  inform  you  that  the 
*  Statistical  Researches  on  Chorea’  in  the 
‘  Foreign  Department’  of  your  number  for 
July  15th  (page  73),  attributed  to  ‘  Dr. 
Easelmann,’  who  is  stated  to  have  collected 
the  cases  from  various  sources,  are  derived 
solely  and  entirely  from  a  paper  of  mine  in 
the  4th  volume  (New  Series)  of  the  Guy’s 
Hospital  Reports,  of  which  paper,  entitled 
‘  Digest  of  One  Hundred  Cases  of  Chorea/ 
I  herewith  enclose  you  a  copy. 

“  I  beg  also  to  inform  you  that  the  ma¬ 
terials  from  which  that  paper  was  composed 
were  collected  solely  and  entirely  by  myself 
from  the'records  of  Guy’s  Hospital. 

“  I  shall  therefore,  sir,  feel  obliged  to 
you  to  correct  the  mistake  into  which  you 
have  fallen,  by  the  introduction  of  this  note 
into  your  next  number ;  and  I  shall  feel  addi¬ 
tionally  obliged  if  you  will  kindly  inform  the 
professional  public  and  myself  from  what 
source  you  derive  the  facts  incorrectly  attri- 


OBITUARY  MEMOIR  OF  THE  LATE  BARON  BERZELIUS 


431 


buted  to  *  Dr.  Easelmann,’  of  whose  name 
I  do  not  recollect  to  have  previously  heard.* 
“  I  have  the  honour  to  be, 

“  Yours  See.  Sec. 

“  H.  M.  Hughes,  M.D. 

“  14,  St.  Thomas’s  Street, 

August  5,  1848.” 


ERRONEOUS  ENTRIES  IN  THE  MEDICAL 
DIRECTORY. 

[We  have  received  a  letter  on  the  above 
subject  from  a  respectable  source  ;  but  as 
the  writer  does  not  wish  his  name  to  appear 
in  reference  to  a  statement  upon  which  we 
have  no  authority  but  his  own,  we  are  com¬ 
pelled  to  omit  the  first  portion  of  his  letter. 
We  insert  that  part  of  his  communication 
which  is  less  open  to  objection;  but  we  are 
sure  the  editors  of  the  Directory  will  be 
thankful  to  him  for  any  private  information 
which  he  may  forward  to  them  on  the  erro¬ 
neous  entries  to  which  he  refers.] 

The  Directory  abounds  with  errors  of 
another  description,  which,  though  venial 
compared  with  the  above,  are  yet  likely  to 
prove  sources  of  inconvenience  and  confu¬ 
sion.  I  allude  to  the  insertion  of  high- 
sounding,  but  meaningless  titles,  and  to 
errors  in  dates.  Thus  we  find  the  follow¬ 
ing 

“  Cockle,  Jas.,  48,  New  Ormond  Street. 
In  practice  before  the  year  1815  ;  matricu¬ 
lated  at  the  University  of  Edinburgh, 
1801.” 

The  matriculation  at  Edinburgh  is  open 
to  any  one  paying  ten  shillings  and  sixpence, 
and  is  exacted  from  all  students  before  they 
are  allowed  to  fee  any  of  the  professors  in 
Divinity,  Literature,  Law,  or  Medicine. 
Mr.  Cockle  may  or  may  not  have  attended 
lectures  at  Edinburgh.  The  matriculation 
is  no  proof  that  he  has  :  but,  if  it  were,  is 
the  fact  of  any  value  ? 

Of  the  typographical  errors  in  dates,  there 
are  not  a  few  :  for  example,  Dr.  Lonsdale, 
of  Carlisle,  is  represented  as  having  gra¬ 
duated  in  1833,  in  place  of  1838. 

Your  obedient  servant, 

Argus. 

August  26th,  1848. 


iMctucai  Intelitgsnre. 


OBITUARY  MEMOIR  OF  THE  LATE  BARON 
BERZELIUS. 

W  e  recently  announced  the  death  of  the  cele¬ 
brated  Swedish  chemist,  Berzelius,  in  the 
69th  year  of  his  age.  He  had  been  for  a 
long  time  in  declining  health, — and,  although 
his  death  will  not  have  taken  Europe  by 

*  Easelmann  is  not  German.  I  is  probably 
misprinted  for  Eselmann : — Esel  signifying  one 
oi  the  Asinine  species. 


surprise,  there  will  be  but  one  feeling  of 
grief  for  so  great  a  loss.  In  a  century  which 
has  produced  a  greater  number  of  distin¬ 
guished  chemists  than  perhaps  of  any  other 
class  of  men  of  science,  Berzelius  stood  out 
as  a  star  of  the  first  magnitude.  If,  per¬ 
haps,  our  younger  students  of  chemistry 
have  in  some  measure  lost  sight  of  him, 
amidst  the  brilliant  researches  of  modern 
organic  chemists,  it  must  not  be  forgotten 
that  the  patient  labours  and  sagacious  inves¬ 
tigations  of  Berzelius  have  done  more  to  lay 
the  foundations  of  organic  chemistry  than 
those  of  any  other  chemist.  To  him  more 
than  to  any  other  man  belongs  the  honour 
of  applying  the  great  principles  which  have 
been  established  by  Dalton,  Davy,  Wollas¬ 
ton,  Gay-Lussac,  and  himself,  in  inorganic 
chemistry,  to  unfolding  the  laws  which  re¬ 
gulate  the  combinations  forming  the  struc¬ 
tures  of  the  animal  and  vegetable  kingdoms. 

It  is  to  the  honour  of  Sweden  that  Berze¬ 
lius  is  only  one  of  a  number  of  her  sons 
whom  the  cultivation  of  natural  science  has 
led  from  poverty  and  obscurity  to  the  highest 
dignities  and  emoluments  bestowed  by  the 
state.  Of  humble  parentage,  and  beginning 
life  with  limited  resources,  the  successful 
cultivation  of  chemistry  procured  for  him, 
not  only  the  respect  and  admiration  of  the 
world,  but  that  position  and  consideration  in 
his  own  country  which  the  man  of  science  has 
a  right  to  claim,  and  which  it  is  the  privilege 
of  sovereigns  and  states  to  bestow. 

Berzelius  was  born  in  the  village  of  Vaf- 
versunda,  in  the  canonry  of  Linkoping,  in 
Ostgothland,  on  the  29th  of  August,  1779, — 
not  at  Linkagring  on  the  20th  of  August,  as 
is  often  erroneously  stated  in  the  many  no¬ 
tices  of  him.  His  father  kept  the  parish 
school  in  the  village  where  young  Berzelius 
was  born,  and  there  he  appears  to  have  re¬ 
ceived  his  early  education.  At  the  age  of 
seventeen  he  commenced  his  studies  at  the 
University  of  Upsala,  hoping  to  qualify 
himself  for  the  medical  profession.  At  this 
time,  although  Sweden  could  boast  of  having 
produced  a  Bergmann  and  a  Seheele,  the 
more  brilliant  genius  of  Linnseus  had  given 
to  natural  history  such  an  impetus  that  che¬ 
mistry  was  scarcely  regarded  by  the  medical 
student.  It  is  true  that  Afzelius,  who  was 
a  nephew  of  Bergmann,  and  then  filled  the 
Chemical  Chair  at  Upsala,  had  performed 
some  very  creditable  chemical  analyses;  but 
his  health  was  bad,  and  he  was  assisted  by 
Ekeberg,  who,  though  a  skilful  analyst,  yet 
wanted  the  energy  and  other  qualifications 
for  a  successful  teacher.  The  lectures  on 
chemistry  were  read,  and  no  experiments  were 
performed.  These  unpromising  circum¬ 
stances  were  scarcely  likely  to  produce  a 
great  chemist,  but  they  seem  to  have  deve¬ 
loped  the  genius  of  Berzelius.  Prof.  John¬ 
ston  gives  Berzelius’s  own  account  of  the 


432 


OBITUARY  MEMOIR  OF  THE  LATE  BARON  BERZELIUS. 


influences  of  his  situation.  The  students 
were  allowed  to  work  in  the  laboratory  once 
a  week.  “  Berzelius,  like  the  rest,  went  to 
the  laboratory  soon  after  he  had  commenced 
his  chemical  course,  and  asked  for  an  opera¬ 
tion.  The  first  that  was  given  him  was  to 
form  colcothar  of  vitriol  (crocus  martis)  by 
heating  sulphate  of  iron  in  a  crucible. 
1  Well/  says  he,  ‘  every  servant  can  do  this. 
If  this  be  all  I  am  to  learn  I  may  as  well 
stay  away.’ — *  Oh,  but/  replied  Afzelius, 
*  your  next  operations  will  be  more  difficult.’ 
Accordingly,  when  he  asked  for  a  second 
operation,  he  was  instructed  to  prepare  caus¬ 
tic  potash  by  burning  cream  of  tartar  in  a 
crucible.  ‘  This  so  disgusted  me/  said  Ber¬ 
zelius,  *  that  I  vowed  I  would  never  ask  for 
another  operation.  Still  I  frequented  the 
laboratory ;  and  at  the  end  of  three  weeks 
found  myself  attending  regularly  every  day, 
though  I  had  no  right  to  do  so,  and  Afzelius 
could  have  turned  me  out,  yet  I  was  allowed 
to  return  and  operate  and  break  much  glass, — 
while  Ekeberg  especially  was  much  annoyed 
that  I  never  asked  a  single  question. — For/ he 
adds,  ‘  I  liked  better  to  seek  for  information 
from  reading  and  thinking  and  experiment¬ 
ing  than  from  men  who,  having  little  expe¬ 
rience  themselves,  gave  me,  if  not  evasive, 
at  least  unsatisfactory,  answers  regarding 
phenomena  they  had  never  themselves  ob¬ 
served/  ” 

In  the  year  1798,  Berzelius  passed  his 
philosophical  examination  as  preparatory  to 
the  final  one  for  M.D.  At  this  time  he  left 
the  University;  and  in  1799  we  find  him 
assistant  to  a  Dr.  Hedin,  a  superintendent 
physician  of  the  mineral  waters  of  Mediva. 
The  composition  of  these  waters  attracted 
the  attention  of  Berzelius,  and  his  first  pub¬ 
lished  essay  was  a  dissertation,  in  con¬ 
junction  with  Ekeberg,  on  these  mineral 
waters.  He  underwent  the  examination 
fora  license  to  practise  medicine  in  1801, 
and  graduated  at  Upsal  on  the  24th  of  May, 
1804.  On  leaving  Upsal,  Berzelius  repaired 
to  Stockholm,  where  he  became  assistant  to 
Andrew  Sparrman,  who  sailed  with  Cook  in 
one  of  his  voyages  round  the  wrorld,  and  was 
then  professor  there  of  medicine,  botany, 
and  chemical  pharmacy.  Sparrman  died  in 
1806, — and  Berzelius,  by  his  inaugural  dis¬ 
sertation  on  galvanism  and  other  papers,  had 
already  obtained  for  himself  a  sufficient  de¬ 
gree  of  confidence  to  be  appointed  his  succes¬ 
sor.  Although  this  chair  embraced  a  very 
wide  range  of  subjects,  as  was  frequently  the 
case  with  Swedish  chairs  at  that  time,  Berze¬ 
lius  more  especially  devoted  himself  to  che¬ 
mistry.  It  does  not  appear,  indeed,  that  he 
gave  any  lectures  on  botany,  except  at  the 
Military  College  of  Carlberg,  where  he  also 
held  anappointmentaslecturer.  Atfirsthewas 
not  more  successful  in  teaching  chemistry 
than  his  predecessors  ;  but  having  received  a 


I  hint  from  Dr.  Marcet,  of  Guy’s  Hospital,  Lon¬ 
don, thatchemicallecturesshouldbeillustrated 
by  experiments,  he  adopted  this  plan,  and 
likewise  abandoned  the  old  practice  of  read¬ 
ing  lectures.  He  used  to  express  himself  very 
strongly  on  the  inutility  of  merely  reading 
lectures.  Although  he  first  adopted  Dr. 
Marcet’s  experiments  in  his  class-room,  he 
soon  so  far  improved  upon  these  that  his 
own  became  a  model  for  the  chemical  class¬ 
rooms  of  Europe. 

During  the  early  period  of  his  residence 
at  Stockholm,  he  practised  the  profession  of 
medicine  ;  and  in  1807,  was  mainly  instru¬ 
mental  in  forming  the  Medical  Society  of  that 
capital.  In  1810,  he  was  made  President 
of  the  Royal  Academy  of  Sciences  at  Stock¬ 
holm  ;  and  in  the  same  year  received  the 
appointment  of  Assessor  of  the  Medical 
College,  and  was  made  a  member  of  the 
Royal  Sanitary  Board.  At  this  time,  though 
scarcely  more  than  thirty  years  of  age,  he 
had  obtained  great  reputation  as  a  chemist. 
He  had  published  a  work  on  animal  chemis¬ 
try,  containing  many  original  investigations 
on  the  fluids  of  the  animal  body  ;  and  which 
was  subsequently  translated — as,  indeed, 
have  been  most  of  his  works — into  almost 
every  language  of  Europe.  In  conjunction 
with  Hisinger,  he  commenced,  in  1806,  the 
publication  of  a  periodical  work,  entitled 
“  Afhandlingar  i  Fysik,  Kemi,  och  Minera- 
logi,”  which  contained  a  series  of  papers 
by  himself,  constituting  some  of  the  most 
valuable  contributions  that  had  yet  been 
made  to  analytical  chemistry.  His  labours 
were  regarded  as  of  so  much  importance  by 
the  Royal  Academy  of  Stockholm,  that  that 
body  decreed  him,  in  1811,  200  dollars 
yearly  for  his  chemical  researches.  In 
1812,  Berzelius  visited  England,  where  he 
was  most  cordially  received.  In  that  year 
he  communicated, through  Dr.  Marcet,  a  valu¬ 
able  paper  to  the  Medico-Chirurgical  Society 
of  London,  “  On  the  Composition  of  the 
Animal  Fluids.”  In  1818,  he  visited  France 
and  Germany — countries  in  which  he  was 
better  known  than  in  Great  Britain,  as  most 
of  his  papers  and  works  were  published  in 
the  language  of  those  countries  as  well  as  in 
that  of  Sweden.  In  the  same  year  he  w'as 
appointed  Secretary  to  the  Academy  of 
Sciences — a  post  which  he  held  till  his 
death.  In  1831,  he  was  allowed  to  retire 
from  the  active  duties  of  his  professorship 
at  the  Caroline  Institute,  but  he  still  held 
the  title  of  honorary  professor.  Up  to  this 
time  he  had  resided  in  apartments  provided 
for  him  at  the  building  occupied  by  the 
Academy  of  Sciences,  where,  on  the  same 
floor,  he  had  his  study  and  laboratory,  so 
that  he  could  with  little  difficulty  pass  from 
his  desk  to  his  crucible,  and  husband  his 
time  to  the  greatest  possible  extent.  He 
now,  however,  moved  to  a  house  of  his  own, 


OBITUARY  MEMOIR  OF  THE  LATE  BARON  BERZELIUS. 


433 


and  in  1835  married  a  daughter  of  the  town- 
councillor  (Staats-rathe)  Poppius.  Tn  1837, 
he  received  the  Great  Gold  Medal  of  the 
Royal  Academy  of  Stockholm, — and  in 
1840,  the  Diet  of  Sweden  voted  him  a  pen¬ 
sion  of  2,000  dollars  per  annum.  The 
scientific  societies  of  Europe  and  America 
contended  for  the  honour  of  enrolling  his 
name  amongst  their  members, — and  with 
eighty-eight  of  these  bodies  it  was  connected. 
Nor  was  his  sovereign,  Charles  John,  be¬ 
hindhand  in  recognising  the  most  distin¬ 
guished  of  his  adopted  countrymen.  In 
1815,  Berzelius  was  made  a  Knight,  and  in 
1821,  a  Knight  Commander,  of  the  Order 
of  Vasa.  In  1829,  he  received  the  Grand 
Cross;  and  in  1835,  was  made  a  Baron. 
The  intelligence  of  this  honour  was  conveyed 
to  Berzelius  by  the  hand  of  the  King,  who 
wrote  himself  a  letter  intimating  his  deep 
sense  of  the  merits  of  the  philosopher,  and 
expressing  a  hope  that  in  this  nomination 
the  world  would  recognise  a  homage  paid  to 
the  man  who  had  consecrated  his  life  to  those 
useful  researches  which  had  been  already  re¬ 
cognised  by  Europe,  and  which  it  was  the 
glory  of  Sweden  to  be  able  to  appropriate  as 
the  patrimony  of  one  of  her  children.  This 
letter  was  sent  to  Berzelius  on  his  wedding- 
day.  How  few  men  of  science  have  married 
with  a  patent  of  nobility  on  the  breakfast 
table  !  Sweden  had,  however,  yet  one  more 
ovation  for  her  beloved  son.  In  1843,  he 
had  been  a  quarter  of  a  century  Secretary  to 
the  Academy,  and  on  this  occasion  a  festival 
was  given  in  his  honour.  The  Crown- Prince 
was  in  the  chair, — and  a  portrait  of  the  che¬ 
mist,  painted  by  Lieut. -Col.  Sodemark,  was 
presented  to  the  Academy. 

Such  was  the  calm,  unruffled,  successful 
career  of  the  deceased  philosopher.  Would 
that  the  career  of  every  disciple  of  science 
were  as  happy  !  He  who  was  thus  honoured, 
merited  it — merited  it  on  account  of  his  un¬ 
wearied  industry,  his  clear  and  manly  intel¬ 
lect,  his  noble  and  amiable  disposition.  The 
diligence  with  which  he  worked,  both  in  his 
study  and  his  laboratory,  may  be  judged  of 
by  his  syst  ematic  works  and  original  contri¬ 
butions  to  science.  In  addition  to  the  works 
already  mentioned,  he  published  a  “  Manual 
of  Chemistry, ”  which  went  through  several 
editions,  that  of  1841  consisting  of  ten  vo¬ 
lumes, — and,  we  believe,  another  larger  edi¬ 
tion  has  since  been  published.  In  1822,  he 
commenced  the  publication  of  an  Annual 
Report  on  the  Progress  of  the  Physical 
Sciences,  which  has  been  published  every 
year  to  the  present  time.  These  volumes 
are  the  most  valuable  record  of  chemical 
research  extant,  and  contain  a  full  report  of 
the  discoveries  that  have  made  the  period  to 
which  they  relate  so  remarkable  in  the  his¬ 
tory  of  chemistry.  From  1806  to  1818,  he 
published,  with  Hisinger,  the  periodical  to 


which  we  have  before  alluded  ;  and  in  these 
volumes  we  find  forty-seven  papers  by  Ber¬ 
zelius,  all  giving  an  account  of  original  re¬ 
searches  by  himself.  In  addition  to  these, 
he  has  published  works  on  galvanism,  on 
analytical  chemistry,  on  mineralogy,  and  a 
vast  number  of  papers  in  various  Transac¬ 
tions. 

The  name  of  Berzelius  has  been  too  in¬ 
timately  connected  with  the  history  of  che¬ 
mistry  for  the  last  forty  years  for  us,  in  this 
slight  sketch,  to  give  an  adequate  idea  of  the 
influence  which  his  discoveries  and  generali¬ 
zations  have  exerted  upon  the  science.  To 
him  it  is  indebted  for  the  discovery  of  several 
new  elementary  bodies, — more  especially 
selenium  and  cerium.  He  first  demon¬ 
strated  the  acid  nature  of  silica,  and  was 
thus  enabled  to  throw  light  on  the  com¬ 
position  of  a  series  of  interesting  mineral 
compounds  of  silica  with  the  metallic  oxides. 
This  subsequently  led  to  an  entire  re-arrange¬ 
ment  of  the  mineral  bodies,  and  contributed 
greatly  to  the  advance  of  mineralogy.  His 
discovery  of  selenium  led  him  to  investigate 
its  various  compounds,  and  compare  them 
with  the  sulphurets.  These  investigations 
again  resulted  in  his  generalization  on  the 
nature  of  the  sulphur  salts,  and  a  new  classi¬ 
fication  of  the  various  salts.  Subsequently, 
he  investigated  the  compounds  of  fluorine, 
and  arrived  at  some  of  the  most  important 
and  valuable  results  that  have  yet  been  ob¬ 
tained  by  the  analytical  chemist. 

Whilst  Berzelius  was  writing  the  first  edi¬ 
tion  of  his  “  Manual  of  Chemistry,”  Dalton 
had  promulgated  his  idea  of  the  atomic  con¬ 
stitution  of  matter,  and  Davy  had  made  his 
great  discovery  of  the  metallic  bases  of  the 
alkalies.  These  directed  his  attention  to  the 
laws  of  combination.  He  was  led  to  insti¬ 
tute  researches  with  the  most  scrupulous 
care  into  the  combining  proportions  of  the 
various  elements,  giving  to  each  its  correct 
number,  and  was  enabled  to  obtain  results 
perfectly  harmonious  with  theoretical  calcu¬ 
lations  made  on  Dalton’s  laws.  He  was 
enabled  to  extend  Dalton’s  law  that  one 
atom  of  one  body  unites  with  one,  two,  or 
three,  &c.  atoms  of  another  body,  and 
showed  that  two  atoms  would  unite  with 
three  and  with  five.  He  also  pointed  out 
the  great  fact,  that  two  compounds  which 
contain  the  same  electro-negative  body, 
always  combine  in  such  proportions  that  the 
electro-negative  element  of  one  is  a  multiple 
by  a  whole  number  of  the  same  element  of 
the  other.  He  not  only  gave  to  the  elemen¬ 
tary  bodies  their  combining  numbers,  but 
introduced  the  system  of  symbols,  by  which 
chemical  labour  has  been  so  greatly  facili¬ 
tated.  Till  the  time  of  Berzelius,  organic 
chemistry  was  a  waste,  with  here  and  there 
an  attempt  to  explain  the  phenomena  of 
living  beings  upon  chemical  principles, — and 


434 


MEMOIR  OF  BERZELIUS.  THE  CHOLERA  IN  EGYPT. 


■which,  from  the  entire  want  of  experimental 
foundation,  was  even  worse  then  useless. 
The  compounds  found  in  plants  and  animals 
were  not  supposed  to  come  within  the  cate¬ 
gory  to  which  the  laws  of  combination  ap¬ 
plied.  Berzelius  was  the  first  to  show  that 
these  laws  could  be  applied  to  animal  and  \ 
vegetable  products ;  and  in  so  doing,  he 
opened  the  way  for  the  discoveries  of  Mul¬ 
der,  Liebig,  Dumas,  Boussingault,  and 
others. 

As  a  skilful  manipulator,  Berzelius  has 
had  few  equals  in  the  history  of  chemistry. 
To  this  we  are  indebted  for  the  immense 
variety,  number,  and  success  of  his  analyses. 
Many  of  the  analytical  processes  in  use  at 
the  present  time  have  had  their  origin  with 
him. 

The  personal  appearance  of  Berzelius  was 
that  of  a  strong,  healthy  man,  with  nothing 
in  his  habits  or  manners  to  imoress  a  stranger 
with  a  sense  of  his  powers.  A  chemist  who 
visited  him  says,  “  He  has  nothing  of  pre¬ 
tence,  reserve,  or  singularity  about  him  ;  so 
that  his  plainness  drew  from  a  fellow-travel¬ 
ler  of  mine,  whom  he  allowed  me  to  intro¬ 
duce  to  him,  the  observation,  ‘  I  would  never 
have  thought  him  the  great  man'he  is  said 
to  be.’  ”  His  attention  to  strangers  was 
very  great, — especially  to  those  who  took  an 
interest  in  chemistry.  With  these  he  would 
frequently  spend  hours  in  his  laboratory, 
explaining  to  them  his  methods  cf  working; 
and  on  their  departure,  he  left  the  impres¬ 
sion  that  he  was  the  honoured  party.  He 
was  an  early  riser, — and  gave  the  first  part 
of  the  day  to  his  most  important  work, 
whatever  that  might  be.  He  seldom  either 
wrote  or  experimented  in  the  evening,  leav¬ 
ing  that  part  of  the  day  for  reading  and 
social  relaxation.  He  had  no  particular 
times  for  writing  or  experimenting ;  when 
he  had  a  work  to  finish  he  would  write  some¬ 
times  for  months  without  performing  an  ex¬ 
periment, —  but  if  anything  of  importance 
occurred  to  him  during  his  writing  requiring 
further  investigation,  he  would  at  once  give 
up  the  pen,  and  work  perhaps  for  weeks  in 
his  laboratory.  Few  men  were  more  beloved 
in  the  city  of  Stockholm  than  Berzelius. 

Were  the  merits  of  this  great  chemist  less, 
we  might  not  be  able  to  afford  to  hint  at  any 
defects.  But,  regarding  him  at  a  distance, 
he  appears  to  us  to  have  carried  his  caution 
beyond  the  requirements  of  scientific  re¬ 
search.  His  feelings  were  conservative,  and 
though  constantly  going  forward  to  the  new, 
he  still  clung  with  tenacity  to  the  old.  He 
was  almost  the  last  chemist  of  eminence  that 
admitted  Davy’s  theory  of  the  elementary 
nature  of  chlorine.  Even  afrer  envy  and 
prejudice  had  given  up  their  opposition,  the 
caution  of  Berzelius  withheld  assent.  In 
the  recent  advances  of  organic  chemistry, 
also,  and  more  especially  in  its  applications 


to  the  physiology  of  plants  and  animals, 
Berzelius  has  looked  on  with  the  eye  of  a 
critic,  and  withheld  to  the  last  his  adhesion 
to  some  of  the  advanced  positions  of  this 
department  of  the  science.  We  will  allude 
to  his  criticisms  on  his  brother  chemists, 
which  were  sometimes  unnecessarily  severe, 
only  to  add  that  in  the  latter  years  of  his 
life  he  has  been  heard  to  say  that  he  re¬ 
gretted  having  expressed  himself  in  a  way 
that  could  have  given  unnecessary  pain  to 
others. — Athenceum. 

THE  CHOLERA  IN  EGYPT. 

The  cholera  alone  occupies  the  minds  of  the 
inhabitants  of  Alexandria  ;  there  is  no  busi¬ 
ness  doing,  and  the  greater  part  of  the  Euro¬ 
pean  residents  have  shut  themselves  up  in 
"  their  houses,  hoping  by  this  means  to  keep 
out  of  the  influence  of  the  epidemic.  At 
Alexandria,  the  number  of  deaths  from  cho¬ 
lera  has  been  rather  on  the  decrease,  and 
from  310,  the  highest  point  attained,  they 
are  now  about  100  daily ;  the  number  just 
reported  for  to-day  is  75. 

At  Cairo,  after  a  decrease,  the  deaths  from 
cholera  were  again  on  the  increase  ;  about 
250  w?ere  reported  daily,  but  to-day  the 
report  has  gone  down  to  170.  A  re¬ 
gister  is  kept  of  the  deaths  only;  the 
number  of  cases  is  not  knowm,  but  the  reco¬ 
veries  are  said  to  be  few.  Comparatively 
speaking,  the  European  population  has  not 
suffered  much  ;  and  the  mortality  among  the 
natives  may  be  attributed  to  their  improper 
mode  of  living,  and  their  irregularities  and 
sufferings  during  the  present  month  of  Ra¬ 
mazan,  when  they  fast  all  day  and  commit 
excesses  during  the  night. 

The  Deutsche  Allgemeine  Zeitung  has 
letters  from  Gallicia,  of  the  17th,  stating 
that  the  cholera  was  making  rapid  progress 
in  that  province,  and  had  advanced  as  far  as 
the  circle  of  Wadowitch,  which  touches  the 
frontiers  of  Silesia.  In  the  last- mentioned 
province,  some  cases  have  already  been 
declared.  It  is  said  that  of  14,000  men 
who  formed  the  Russian  corps  which  entered 
Wallachia,  1800  have  died  of  cholera. 

Letters  from  Stettin  of  the  19th,  announce 
21  cases  of  cholera  up  to  the  evening  of  the 
15th,  whereof  19  proved  fatal.  Among  the 
victims,  was  Lieutenant-Colonel  Schmidt, 
of  the  9th  regiment.  The  first  victim  of 
the  disease  in  Damm,  was  a  healthy  and 
robust  young  man,  who  succumbed,  after 
excruciating  agonies,  which  lasted  eight 
hours. 

The  Augshurgh  Gazette  has  letters  from 
St.  Petersburgh,  to  the  12th  August,  which 
inform  us  that  the  cholera  had  so  far  subsided, 
that  several  temporary  hospitals  and  laza¬ 
rettos  have  been  closed.  163  deaths  oc¬ 
curred  between  the  4th  and  10th  August. 
In  Moscow  and  Riga,  the  malady  is  gra- 


SUBSCRIPTIONS  IN  AID  OF  THE  POOR-LAW  MEDICAL  RELIEF  FUND.  435 


dually  subsiding,  but,  on  the  other  hand,  it 
rages  in  Pskow,  where,  in  the  space  of  seven 
days,  111  patients,  out  of  264,  succumbed, 
and  only  27  recovered. 

ERGOT  OF  RYE  A  REMEDY  FOR  EXCESSIVE 

DILATATION  OF  THE  PUPIL  FROM  BELLA¬ 
DONNA. 

M.  Comperat  has  announced  a  plan  by 
which  he  has  succeeded  in  removing  dilata¬ 
tion  of  the  pupil  produced  by  belladonna 
in  a  patient  of  his,  in  whom  the  iris  was 
scarcely  visible,  so  complete  had  been  the 
action  of  a  small  dose  of  belladonna  applied 
externally.  For  some  days  the  excessive 
dilatation  resisted  the  employment  of  various 
collyria.  He  prescribed  powdered  ergot 
of  rye,  taken  like  snuff.  The  dilatation  dis¬ 
appeared  in  a  few  seconds — it  soon  returned, 
the  same  remedy  was  again  employed,  and 
it  did  not  reappear.  He  thought  that  ergot 
might  be  thus  used  in  cases  in  which  dilated 
pupil  arises  from  other  causes. 

OBITUARY. 

At  the  latter  end  of  May,  John  Rolph  Lee, 
Esq.,  M.D.  This  promising  gentleman 
lately  graduated  at  M‘Gill  College,  Canada, 
and  was  on  his  return  homewards,  when,  in 
crossing  the  Grand  River  at  York,  the 
canoe  upset,  and  he  was  drowned. 

Suddenly  at  Windsor,  N.  S.,  the  4th  ult., 
Francis  Carten  Pike,  Esq.,  Surgeon,  a 
native  of  Hampshire,  England,  aged  64 
years. 

At  St.  Louis,  Kamouraska,  on  the  23d 
ult.,  Thomas  Horsman,  Esq.,  M.D.,  aged 
63  years.  Mr.  Horsman  was  born  at 
Swinton,  parish  of  Markham,  Yorkshire, 
England.  His  father,  a  wealthy  farmer, 
gave  him  a  liberal  education,  and  appren¬ 
ticed  him  to  the  celebrated  Dundas,  then 
apothecary  to  George  the  Third.  A  short 
time  after  he  emigrated  to  the  United  States, 
whither  he  followed  an  eider  brother.  Little 
satisfied  with  the  national  habits  of  our 
neighbours,  to  which  he  could  not  conform, 
after  a  sojourn  of  less  than  two  years  he 
quitted  the  United  States  for  Canada,  a 
little  before  the  war  of  1812.  He  studied 
at  Quebec  with  the  late  Dr.  Francis  Blanchet, 
who  had  him  appointed  surgeon  during  the 
last  war,  and  placed  over  a  hospital.  In 
1815,  the  hospital  being  closed,  Dr.  Hors¬ 
man  removed  to  Kamouraska,  where  his  pro¬ 
fessional  services,  his  sensibility,  and,  above 
all,  his  charity  towards  the  poor,  gained  him 
the  esteem  and  confidence  of  all. — Quebec 
Mercury. 

On  the  29th  ult.,  at  Cote  St.  Paul,  Dr. 
William  Dunlop,  aged  57,  late  M.P.P.  for 
Huron,  C.  W.  Dr.  D.  was  the  first  lec¬ 
turer  on  Medical  Jurisprudence  in  Great 
Britain. 


SUBSCRIPTIONS  IN  AID  OF  THE  POOR. 

LAW  MEDICAL  RELIEF  FUND. 

Sir, — When  the  great  meeting  of  Poor- 
Law  Medical  Officers  assembled  in  London 
last  October!  took  place,  and  a  Committee 
to  act  on  their  behalf  was  appointed,  it  was 
obvious  that  considerable  expenses  must  be 
incurred.  Their  labours  involved  charges 
for  advertisements,  printing,  stationery, 
postage-stamps,  and  the  salary  of  an  as¬ 
sistant-secretary.  The  National  Institute, 
however,  favoured  the  Committee  with  the 
free  use  of  their  office. 

To  defray  the  expenses  which  were  un¬ 
avoidable,  subscriptions  of  small  sums  from 
some  of  the  Poor-Law  surgeons  have  been 
received,  and  a  handsome  donation  of  ten 
pounds  from  Mr.  Pennington,  the  President 
of  the  National  Institute.  But  when  it  is 
considered  that  papers  were  to  be  forwarded 
to  2914  medical  officers  of  Unions,  the  cor¬ 
respondence  which  ensued,  with  the  various 
items  of  expense  already  mentioned,  it 
cannot  be  matter  of  surprise  that  further 
contributions  have  become  indispensably 
necessary. 

By  the  statement  of  account  appended  to 
the  report  recently  issued,  there  was  a  small 
sum  in  hand,  since  which,  however,  the  ba¬ 
lance  of  account  is  on  the  other  side. 

The  perusal  of  the  Report,  of  which  a 
thousand  copies  have  been  printed,  with  an 
equal  number  of  the  Address  to  the  Public, 
will  show  that  the  labours  of  the  Committee 
have  been  of  no  small  amount  ;  in  fact,  much 
more  considerable  than  is  generally  supposed. 
Gentlemen  have  come  up  repeatedly  from 
Buckinghamshire,  Derbyshire,  Staffordshire, 
and  even  Lancashire,  devoting  their  invalua¬ 
ble  time,  and  at  no  small  expense,  to  the  ob¬ 
ject  in  view. 

Those  members  of  the  committee  who  re¬ 
side  in  the  metropolis  and  its  neighbourhood 
have  been  able  to  give  a  more  frequent  at¬ 
tendance  ;  still,  at  some  expense,  and  the  ap¬ 
plication  of  valuable  time  and  of  earnest  and 
patient  thought. 

Under  these  circumstances,  the  profession 
at  large  would  not  wish  the  members  of  the 
Committee  to  be  without  pecuniary  resources 
to  defray  the  very  moderate  but  essentially 
necessary  official  expenses  which  will  accrue. 
And  it  is  acknowledged,  that  not  only  the 
Poor-Law  surgeons  immediately  interested, 
but  the  whole  profession,  should  unite  in 
giving  support  to  the  cause,  as  unquestion¬ 
ably  the  credit,  respectability,  and  honour 
of  the  whole  medical  profession,  of  which  we 
sometimes  boast,  may  fairly  be  considered  as 
identified  in  the  cause  of  the  Poor-Law  sur¬ 
geons. 

The  Report  as  been  reprinted,  more  or 
less  fully,  in  the  medical  journals,  also  in 
the  pamphlet  form,  which,  with  the  address 
to  the  public,  was  ottered  to  the  acceptance 
of  gentlemen  attending  the  recent  meeting 


436  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY,  ETC. 


at  Bath ;  and  I  shall  be  happy  to  forward 
copies  to  those  who  have  not  yet  seen  it. 

I  shall  now  be  glad  to  receive  subscrip¬ 
tions  towards  defraying  the  expenses  neces¬ 
sarily  incurred  for  official  purposes  by  the 
Committee,  by  post-office  order  or  other¬ 
wise. — I  am,  sir,  &c. 

Thomas  Martin, 
Treasurer  of  the  Poor-Law 
Medical  Officers  Committee. 

Reigate,  August  28,  1848. 


METEOROLOGICAL  SUMMARY. 


Mean  Height  of  Barometer .  29  93 

“  “  Thermometer1  . .  59'7 

Self-registering  do.b _ max.  92’5  min.  38* 

“  in  the  Thames  water  —  63'4  —  60’ 

a  From  12  observations  daily.  "  Sun. 


Rain,  in  inches,  0-91 :  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological. — The  mean  temperature  of  the 
week  was  about  2°  above  the  mean  of  the  month 
(57-8). _ _ 

BIRTHS  &  DEATHS  in  the  Metropolis 

During  the  week  ending  Saturday,  Sept.  2. 


Births. 
Males....  688 
Females..  640 


1328 


Deaths. 
Males....  528 
Females. .  470 

998 


Av.  of  5  Sum. 
Males ....  495 
Females..  477 


Causes  of  Death. 

All  Causes .  998 

Specified  Causes .  996 

1.  Zymofr'c(orEpidemic,Endemic, 

Contagious)  Diseases  . .  397 
Sporadic  Diseases,  viz. — 

2.  Dropsy,  Cancer,  &c.  of  uncer¬ 

tain  seat  .  38 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  .  95 

4.  Lungs  and  other  Organs  of 

Respiration .  72 

5.  Heart  and  Bloodvessels .  24 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion  .  63 

7.  Diseases  of  the  Kidneys,  &c.. .  16 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c .  8 

9.  Rhematism,  Diseases  of  the 

Bones,  Joints,  &c .  7 

10.  Skin,  Cellular  Tissue,  &c .  2 

11.  Old  Age .  36 

12.  Violence,  Privation,  Cold,  and 

Intemperance . I  50 

The  following  is  a  selection  of  the  numbers  of 
Deaths  from  the  most  important  special  causes: 


972 

Av.  of 
5  Sum. 

972 

968 

257 


45 

120 

80 

28 

79 

8 

10 

7 
1 

50 

8 


Small-pox  .  31 

Measles  .  9 

Scarlatina  . 137 

Hooping-cough..  22 

Diarrhoea  .  79 

Cholera  .  7 

Typhus  .  63 

Dropsy .  14 

Sudden  deaths  ..  8 


Paralysis .  13 

Convulsions  ....  30 

Bronchitis .  24 

Pneumonia .  31 

Phthisis . 107 

Dis.  of  Lungs,  &c.  8 

Teething .  10 . 

Dis.  Stomach,  &c.  5 
Dis.  of  Liver,  &c.  11 


Hydrocephalus..  20  Childbirth .  8 

Apoplexy . . ..  17  Dis.ofUterus,&c.  0 

Remarks. — The  total  number  of  deaths  was 
only  26  above  the  weekly  summer  average.  The 
deaths  from  zymotic  diseases  are,  however,  dis¬ 
proportionately  great,  and  it  is  worthy  of  remark 
that  scarlatina  is  especially  fatal,  the  registered 
deaths  being  no  less  than  137  to  a  weekly  average 
mortality  of  only  37  !  Of  these  deaths,  135  were, 
among  infants. _ 

BOOKS  received  during  THE  WEEK. 
Etiological,  Pathological,  and  Therapeutical  Re¬ 
flections  on  Asiatic  Cholera  as  observed  in 
Europe,  Asia  Minor,  and  Egypt.  By  A.  Hen- 
riques,  M.D.  F.R.C.S.L. 

A  Few  Plain  Directions  for  the  Homoeopathic 
Treatment  and  Prevention  of  British  and  Asia¬ 
tic  Cholera. 

Pharmaceutical  Journal.  September  184S. 

The  Ethnological  Journal,  No.  4.  A  Magazine  of 
Ethnography,  Phrenology,  and  Archaeology. 
Journal  of  Public  Health.  September  1848. 
British  Record  of  Obstetric  Medicine.  No.  17. 
Casper’s  Wochenschrift  fur  die  gesammte  Heil- 
kunde.  Nos.  32  and  33,  5th  and  12th  August. 
London,  Edinburgh,  and  Dublin  Philosophical 
Magazine.  September  1848. 

Zeitschrift  fiir  die  gesammte  Medicin,  von  F.  W. 
Oppenheim.  Nos.  4,  5,  6,  7,  April  to  July  1848. 

NOTICES  to  CORRESPONDENTS. 
The  communications  of  Mr.  Hancorn  and  Mr. 
J.  D.  M‘Donald  will  be  inserted  in  the  follow¬ 
ing  number. 

Mr.  Coates’s  letter,  with  the  drawings,  has  been 
Mr.  Lord’s  letter  in  our  next.  [received. 

Dr.  T.  Haworth. — Has  our  correspondent  found 
by  experiment  that  he  can  safely  respire  air 
through  an  aqueous  solution  of  chlorine,  and,  if 
so,  for  how  long  a  period,  and  of  what  strength 
was  the  solution?  At  present  it  appears  to  us 
his  plan  would  substitute  one  poisonous  gas 
for  another ;  for  they  who  have  been  exposed 
to  the  respiration  of  chlorine,  are  well  aware 
that  it  has  a  most  powerfully  irritant  action  on 
the  lungs.  We  wait  far  an  answer  to  this 
question  before  inserting  the  paper. 

Corrigendum. — In  our  last  number,  page  377, 
col.  1,  26  lines  from  foot,  for  “  58°.5,”  read 
58°.5.” 


THE  GENERAL  INDEX. 

We  have  to  announce  to  our  Subscribers  that  a  General 
Index  to  the  first  40  Volumes  of  the  London  Medical  Gazette 
will,  it  is  calculated,  form  a  large  Volume  of  about  700  pages. 
The  cost  of  the  Index  Volume,  respecting  which  many  inquiries 
have  been  made,  will  be  Twenty-four  Shillings ;  and  it  is  proposed 
to  commence  it  so  soon  as  the  Names  of  Five  Hundred  Subscribers 
have  been  obtained. — The  printers,  Messrs.  Wilson  and  Ogilvy, 
57,  Skinner  Street,  will  receive  the  Names  of  Subscribers. 


437 


'ftottUon  Mrtii'cal  Chtuttr. 


Snturcs. 


COURSE  OF  SURGERY, 
Delivered  in  the  years  1846  and  1847, 

By  Bransby  B.  Cooper,  F.R.S. 

Surgeon,  and  Lecturer  on  Surgery  at  Guy’s 
Hospital. 


Lecture  XXXVIII. 

Strangulated  hernia  —  characteristics  — 
symptoms — stercoraceous  vomiting — pro¬ 
gress  of  symptoms — alteration  in  physical 
characters  of  the  tumor  indicating  gan¬ 
grene — distinctive  marks  between  stran¬ 
gulation  of  intestine  and  omentum — diag¬ 
nosis  between  strangulated  and  obstructed 
hernia — general  treatment  of  strangu¬ 
lated  hernia  — taxis— question  as  to  im¬ 
mediate  operation — use  of  opium — cases 
—  inguinal  hernias — varieties  —  oblique 
inguinal  hernice — subdivided  into  bubono¬ 
cele ,  oscheocele,  and  congenital. 
Strangulated  bubonocele  —  diagnosis  is 
sometimes  difficult — cases — taxis — direc¬ 
tion  of  the  force — operation — division  of 
the  stricture  external  to  the  sac — open¬ 
ing  the  sac — comparative  danger  of  the 
operations — cases  —congenital  bubonocele 
— difficulties  that  may  arise  in  the  opera¬ 
tion  from  the  contents  of  the  tumor — 
cases — on  the  division  of  the  stricture — 
case — on  returning  intestine  after  the 
division  of  the  stricture — cases — adhe¬ 
sions  to  the  sac  or  omentum. 

Oscheocele — coverings — strangulated  scro¬ 
tal  hernia — taxis — operation — congenital 
scrotal  hernia — situation  of  testicle — 
difficulties  in  operation — case. 
Strangulated  hernia. — A.  hernia  is  said 
to  be  strangulated,  when  its  contents  are  so 
constricted  at  the  outlet  through  the  fascia 
as  to  prevent  the  performance  of  the  natural 
function  of  the  bowel. 

In  strangulated  hernia,  the  symptoms  often 
follow  immediately  upon  the  protrusion,  and 
they  are  severe  in  proportion  to  the  degree  of 
constriction  to  which  the  bowel  is  subjected. 
Usually  the  first  symptom  complained  of  is 
the  sensation  of  tightness  around  the  scrobi- 
culus  cordis  ;  and  this  is  sometimes  so  acute 
as  to  rpnder  the  patient  incapable  of  main¬ 
taining  the  erect  posture.  Vomiting  soon 
comes  on,  and  this  symptom  is  more  or  less 
severe,  according  to  the  proximity  of  the 
strangulated  portion  to  the  duodenum. 
Obstinate  constipation  also  forms  a  promi¬ 
nent  feature  in  strangulation,  which  is  gene¬ 
rally  attended  by  great  anxiety  of  countenance, 
restlessness,  small,  quick,  and  hard  pulse, 
and  a  general  sensation  of  coldness  over  the 

xlii. — 1085.  Sept.  15,  1848. 


whole  surface  of  the  body.  If  these  symp¬ 
toms  continue  for  any  length  of  time,  the 
vomited  matter  frequently  acquires  a  faecal 
or  stercoraceous  odour :  this  circumstance 
has  led  some  surgeons  to  suppose  that  the 
contents  of  the  large  intestines  are  regurgi¬ 
tated.  I  do  not,  however,  think  this  pos¬ 
sible,  but  believe  the  odour  to  proceed  from 
the  retention  of  the  contents  of  the  small  in¬ 
testine,  and  not  from  feculent  mattter  pass¬ 
ing  back  through  the  ileo-colic  valve.  If 
the  strangulation  be  not  overcome,  hiccup 
very  soon  supervenes,  the  surface  of  the  body 
becomes  covered  with  a  cold  sweat,  the  pulse 
is  scarcely  to  be  felt,  the  respiration  weak 
and  irregular,  and  the  pain  becomes  gradu¬ 
ally  less  severe.  The  physical  characters  of 
the  tumor  now  begin  to  change,  the  skin  be¬ 
comes  discoloured,  and,  on  pressing  the 
tumor,  a  fluctuation  is  felt,  instead  of  the 
tension  which  before  characterized  it, — these 
are  indications  that  the  bowel  had  given  way 
from  mortification.  If  such  urgent  symp¬ 
toms  were  to  succeed  each  other  rapidly,  it 
would  lead  to  the  diagnosis  of  intestine  being 
the  subject  of  strangulation, — for  where 
omentum  alone  is  protruded  and  strangu¬ 
lated,  although  fbe  above  symptoms  may 
occur,  they  are  always  in  a  milder  form,  and 
very  frequently  alvine  evacuations  may  be 
produced  by  purgative  remedies,  while, 
with  the  exception  of  the  constipation,  all 
the  other  symptoms  remain.  Even  when 
evacuation  does  take  place,  you  must  not  be 
too  hasty,  gentlemen,  in  forming  a  favourable 
prognosis, — for,  although  this  one  symptom 
is  relieved,  the  others  may  remain  insidiously 
operating  on  the  constitutional  powers,  to 
the  ultimate  destruction  of  the  life  of  the 
patient.  It  does  not  necessarily  happen 
that  the  acute  form  of  strangulated  hernia 
should  result  immediately  upon  protrusion  ; 
for  my  late  colleague,  Mr.  Wilkinson  King, 
has  shewn  from  a  statistical  account  of  98 
cases  of  strangulated  hernia  requiring  opera¬ 
tion,  that  94  of  them  became  strangulated 
at  various  distant  periods  after  their  protru¬ 
sion.  He  attributes  this  li  ibility  to  strangu¬ 
lation  to  “a  certain  decline  of  vigour  and 
health,  connected  with  the  manifest  deterio¬ 
ration  of  the  depurative  organs  of  the  body, 
rendering  the  protruded  part  more  liable  to 
tumefaction,  so  that  it  becomes  strangulated, 
owing  to  its  ready  turgescence.”  I  am  in¬ 
clined  to  believe,  however,  that  most  of  these 
cases  should  have  been  considered  to  result 
from  obstruction,  and  not  from  actual  stran¬ 
gulation  ; — the  first  being  an  influence  exer¬ 
cised  from  within  to  without ;  the  second 
from  without  to  within.  In  the  former  case, 
gentle  purgatives  and  enemata  are  frequently 
found  sufficient  to  overcome  the  obstacle; 
while  in  the  latter,  the  constriction  itself 
must  be  removed,  to  permit  of  the  tumor 
being  returned  into  the  abdomen. 


438 


TREATMENT  OF  STRANGULATED  HERNIA. 


Treatment  of  strangulated  hernia. — The 
first  object  in  case  of  strangulated  hernia  is 
to  effect  its  reduction,  if  possible,  by  means 
of  the  taxis;  and  where  the  symptoms  are 
not  very  acute,  this  may  be  attempted 
•without  any  preliminary  preparation  of  the 
patient ;  but  if  the  tumor  be  very  painful, 
and  general  febrile  symptoms  be  present,  re¬ 
course  must  be  had  to  bleeding,  warm-bath, 
and  the  application  of  ice  to  the  tumor,  as 
I  have  already  described.  Should  these 
means  fail,  however,  in  rendering  the  hernia 
reducible,  the  division  of  the  stricture  is  the 
only  alternative.  At  the  same  time,  no 
question  in  surgery  is  more  difficult  than 
to  decide  upon  the  proper  moment  at 
■which  the  operation  should  be  performed. 
When,  from  the  suddenness  and  severity  of 
the  symptoms,  and  the  tension  of  the  tumor, 
a  very  tight  stricture  is  indicated,  there 
can  be  no  doubt  that  the  operation  should 
be  performed  as  soon  as  possible, — for  the 
rapid  changes  which  take  place  in  an  intes¬ 
tine  subjected  to  such  constriction,  very  soon 
unfit  it  for  the  performance  of  its  natural 
duties,  even  ifit  were  restored  to  the  abdomen : 
the  severity  of  the  symptoms  may  indeed  be 
so  great,  that  the  operation  ought  to  be  per¬ 
formed  without  even  waiting  to  apply  the 
taxis.  When  symptoms  of  strangulation 
come  on  progressively,  as  in  old  hernia,  some 
delay  may  be  permitted,  even  beyond  that 
time  required  for  the  application  of  the  re¬ 
medies  already  recommended,  and  even 
when  those  prove  ineffectual  I  have  fre¬ 
quently  succeeded  by  giving  large  doses  of 
opium, —  in  some  cases  as  much  as  three  or 
four  grains.  Constipation  being  one  of  the 
most  urgent  symptoms  of  hernia,  and  opium 
having  a  tendency  to  produce  that  condition 
of  the  bowels,  you  will  naturally  ask,  gentle¬ 
men,  for  the  rationale  of  this  treatment.  I 
believe  that  the  opium  allays  irritation,  and 
checks  sickness,  by  diminishing  the  antiperi- 
staltic  motion  of  the  intestines,  and  thus  pro¬ 
duces  a  condition  of  quietude  through  the 
whole  intestinal  canal,  well  adapted  to  im¬ 
prove  the  state  of  the  protruded  parts.  I 
have  never  recommended  opium  by  choice 
as  a  substitute  for  the  operation  ;  but  in 
four  or  five  cases  in  which  the  patient 
would  not  submit  to  that  ordeal,  I  have  em¬ 
ployed  it  with  perfect  success.  I  first  acquired 
a  knowledge  of  this  practice  from  the  late 
Mr.  Bush,  of  Frome,  in  Somersetshire,  who 
informed  me  that  although  at  one  time  of 
his  life  he  had  had  to  perform  the  operation 
for  hernia  several  times  in  the  course  of 
every  year,  after  he  had  adopted  the  use  of 
opium  he  rarely  had  occasion  to  resort  to 
any  surgical  measures. 

In  July  1838,  I  admitted  a  man,  64  years 
of  age,  into  Guy’s  Hospital,  who  was  the 
subject  of  inguinal  hernia  of  five  days'  stand¬ 
ing  :  he  suffered  from  constant  vomiting,  in¬ 


superable  constipation,  and,  indeed,  from  all 
the  symptoms  of  strangulation  of  the  bowel. 

I  attempted  to  reduce  the  hernia,  but  could 
not  succeed,  and  therefore  proposed  an  im¬ 
mediate  operation.  To  this  the  patient 
would  not,  however,  accede.  I  then  ordered 
him  three  grains  of  solid  opium,  in  about 
four  hours  ;  the  sickness  was  much  relieved, 
and  some  flatus  passed  per  anum,  but  the- 
constipation  still  remained.  At  twelve  o’clock 
the  same  night,  my  dresser,  Mr.  Coleman, 
repeated  the  dose  of  opium.  The  patient 
passed  a  very  quiet  night,  and  in  the  morn¬ 
ing  the  vomiting  had  ceased,  and  a  copious 
motion  was  passed,  during  which  action  the 
hernia  returned  into  the  abdomen.  The 
patient  perfectly  recovered. 

In  June  1839,  a  married  woman,  aet.  54, 
was  admitted  into  Esther  ward,  with  a 
femoral  hernia  on  the  right  side.  The 
tumor  was  about  the  size  of  a  small  orange, 
tense,  and  very  tender  to  the  touch.  The 
patient  was  placed  in  a  warm- bath,  an  enema 
administered,  and  the  taxis  applied,  but  un¬ 
successfully.  I  consequently  proposed  the 
operation  :  the  patient  would  not,  however, 
consent  to  it.  I  therefore  ordered,  for  the 
time,  ice  to  be  applied  to  the  tumor.  The 
next  day,  all  the  symptoms  remaining  un¬ 
altered,  I  again  attempted  the  reduction, 
still,  however,  without  effecting  my  object ; 
and  I  therefore  ordered  her  to  take  four 
grains  of  solid  opium.  The  symptoms  were 
soon  relieved  ;  a  castor  oil  enema  was  admi¬ 
nistered,  and  on  the  second  evening  after 
her  admission  into  the  hospital  the  bowels 
were  slightly  evacuated,  and  my  dresser,  Mr. 
Day,  succeeded  in  reducing  the  hernia.  This 
patient  also  recovered. 

In  another  case  I  was  sent  for  by  Mr. 
Odling,  to  see  a  lady  at  Islington,  who  was 
suffering  from  all  the  urgent  symptoms  of 
strangulated  hernia.  The  warm-bath  had 
been  employed,  ice  applied  to  the  tumor, 
and  several  attempts  made  to  reduce  it  by 
tne  taxis.  This  treatment  was  not,  however, 
successful,  and  as  the  patient  would  not  sub¬ 
mit  to  an  operation,  four  grains  of  opium 
were  given :  the  symptoms  were  soon  all 
relieved,  and  early  the  next  morning  the 
bowels  were  evacuated,  after  which  the  pa¬ 
tient  herself  reduced  the  hernia  by  the  ap¬ 
plication  of  very  little  force. 

An  old  gentleman,  who  lived  in  Great 
Windmill  Street,  and  who  had  long  been  the 
subject  of  irreducible  hernia,  was  suddenly 
seized  with  symptoms  of  obstruction  of  the 
bowels,  which  did  not  yield  to  the  usual  re¬ 
medies  ;  and  as  sickness,  as  well  as  the  other 
signs  of  insuperable  constipation,  came  on, 
Sir  Astley  Cooper  was  sent  for.  He,  how¬ 
ever,  happened  to  be  unwell,  and  I  went  in 
his  stead  to  visit  the  patient.  I  ordered 
enemata,  ice  to  the  tumor,  and  calomel  and 
opium  to  be  taken  to  allay  the  vomiting- 


INGUINAL  HERNIA.  STRANGULATED  BUBONOCELE. 


439 


No  relief  was,  however,  obtained,  and  I  con¬ 
sequently  proposed  the  operation.  This  was 
at  once  objected  to,  and  I  was,  therefore, 
constrained  to  employ  some  further  medical 
treatment.  Four  grains  of  opium  were  ad¬ 
ministered,  and  five  hours  afterwards  I  again 
saw  the  patient :  the  sickness  had  ceased,  but 
no  evacuation  had  yet  taken  place.  I  then 
recommended  a  warm  gruel  injection,  with 
an  ounce  of  castor  oil,  and  in  the  evening, 
the  alvine  excretions  passed  freely,  and  the 
patient  shortly  recovered. 

Mr.  Shelly,  of  Epsom,  had  a  patient,  a 
lady,  40  years  of  age,  under  his  care,  who, 
during  three  days,  had  suffered  from  all  the 
urgent  symptoms  of  strangulated  hernia,  and 
when  first  seen  by  Mr.  Shelly,  she  had 
stercoraceous  vomiting.  He  attempted  to 
reduce  the  hernia,  but  not  suceeding,  re¬ 
commended  the  operation.  The  patient  re¬ 
fused  to  submit  to  this,  and  Mr.  Shelly,  jun., 
who  had  been  one  of  my  dressers,  and  who 
had  seen  the  effect  of  opium  in  one  or  tsvo 
cases  in  Guy’s  Hospital,  immediately  gave 
the  patient  two  grains  of  solid  opium,  and 
further  ordered  a  grain  to  be  taken  every 
two  hours.  She  took  four  doses  before  the 
sickuess  and  pain  ceased,  but  the  next  day 
the  bowels  were  relieved,  the  hernia  was 
easily  reduced,  and  she  perfectly  recovered. 

Should  every  means  fail,  however,  in 
effecting  the  reduction  of  a  strangulated 
hernia,  the  surgical  operation  must  neces¬ 
sarily  be  resorted  to  ;  and  as  every  species 
of  hernia  requires  some  peculiarity  in  the 
method  of  proceeding  with  the  operation,  it 
is  requisite  to  describe  the  steps  in  each 
particular  kind. 

Inguinal  hernia. — This  term  is  employed 
to  designate  the  protrusion  of  any  abdominal 
viscus  through  either  the  internal  or  exter¬ 
nal  abdominal  ring.  When  the  hernia  passes 
through  the  internal  ring,  it  is  termed  an 
oblique  inguinal  hernia  ;  when  through  the 
external  ring  only,  a  direct  inguinal  hernia. 
As  the  oblique  is  by  far  the  most  frequent 
I  shall  commence  with  its  description. 

An  Oblique  inguinal  hernia  protrudes 
through  the  internal  abdominal  ring  with 
the  spermatic  cord  in  the  male,  and  the 
round  ligament  in  the  female,  having  the 
epigastric  artery  placed  on  the  inner  side  of 
its  neck  :  it  has  been  designated  by  some 
surgeons  an  “  external  inguinal  hernia,”  in 
reference  to  its  position  with  regard  to  that 
artery.  An  oblique  inguinal  hernia  is  sub¬ 
ject  to  certain  varieties,  each  bearing  its  ap¬ 
propriate  name :  if,  for  instance,  the  hernia 
protrudes  only  into  the  inguinal  canal,  al¬ 
though  it  is  in  fact  still  an  oblique  inguinal 
hernia,  it  is  called  a  bubonocele ;  if  it  pro¬ 
ceed  downwards,  however,  so  as  to  pass 
.through  the  external  ring,  it  takes  the  name 
£>f  oscheocele,  or  scrotal  hernia ;  both  these 


hernise  are  usually  covered  by  a  distinct 
peritoneal  sac,  and  pass  through  the  rings 
in  front  of  the  spermatic  cord,  and  exterior 
to  the  tunica  vaginalis.  Sometimes,  how¬ 
ever,  when  that  tunic  is  not  closed  from  the 
great  peritoneal  cavity,  an  oblique  inguinal 
hernia  passes  down  into  it,  without  any  ad¬ 
ditional  covering  of  peritoneum,  constituting 
what  is  termed  congenital  hernia.  Each  of 
these  varieties  when  strangulated  has  the 
point  of  constriction  on  the  outer  side  of  the 
epigastric  artery,  and  requires  for  the  relief 
of  the  patient  either  the  successful  applica¬ 
tion  of  the  taxis,  or  the  division  of  the  stric¬ 
ture  by  operation. 

Strangulated  bubonocele. — The  diagnos¬ 
tic  marks  of  this  species  of  hernia  are  the 
situation  of  the  tumor  on  the  outer  side 
of  the  pubes,  and  above  Poupart’s  ligament : 
it  is  true  that  the  swelling  may  be  so 
large  as  to  cover  the  spinous  process  of 
the  pubes,  and  overlap  Poupart’s  ligament, 
so  as  to  descend  upon  the  thigh,  assuming 
the  appearance  of  femoral  hernia ;  but  a 
bubonocele  can  easily  be  distinguished  from 
the  latter  by  the  readiness  with  which  it  can 
be  pushed  upwards,  so  that  it  may  be  placed 
in  its  characteristic  situation  directly  on  the 
outer  side  of  the  pubes,  and  above  Poupart’s 
ligament.  But  still,  great  difficulty  does 
sometimes  occur  in  distinguishing  between 
them.  On  Monday,  January  20,  1840,  I 
admitted  a  patient  into  Esther  ward,  who 
was  the  subject  of  a  large  hernial  tumor  in  a 
state  of  strangulation,  but  it  was  of  such  an 
anamolous  form  that  there  was  a  difference 
of  opinion  as  to  whether  it  was  inguinal  or 
femoral,  in  consequence  of  its  encroachment 
on  the  labium  pudendi.  Having  employed 
the  usual  means  preparatory  to  the  applica¬ 
tion  of  the  taxis,  such  as  ice  and  an  injec¬ 
tion,  I  made  attempts  to  return  the  hernia, 
and  succeeded  in  restoring  to  the  cavity  of 
the  abdomen  all  but  a  very  small  portion  ; 
it  was  thus  rendered  quite  clear  that  it  was 
a  femoral  hernia.  It  seemed  that  the  pro¬ 
trusion  had  passed  out  of  the  saphenous 
opening  in  the  fascia  lata,  and  then  extended 
itself  between  the  skin  and  fascia  lata  to  the 
pudendum,  giving  it  the  appearance  of  an 
inguinal  hernia. 

A  servant  of  Dr.  Babington  was  the  sub¬ 
ject  of  a  strangulated  congenital  hernia, 
which  passed  partly  through  the  external 
abdominal  ring  into  the  scrotum,  but  by  far 
the  larger  portion  of  the  tumor  remained  in 
the  inguinal  canal ;  and,  from  its  size,  so 
overlapped  Poupart’s  ligament,  and  encroach¬ 
ed  on  the  thigh,  as  to  give  it  very  much  the 
appearance  of  a  femoral  hernia,  in  addition 
to  the  scrotal  one.  Mr.  Morgan,  however, 
by  a  long-continqed  application  of  taxis,  suc¬ 
ceeded  in  reducing  the  hernia,  and  clearly 
proved  that  the  apparent  femoral  portion  o£ 

t 


440 


OPERATION  FOR  STRANGULATED  BUBONOCELE 


the  swelling  had  in  fact  been  placed  in  the 
inguinal  canal,  in  which  an  undescended  tes¬ 
ticle  was  also  felt. 

When  the  particular  species  of  hernia  has 
been  ascertained,  the  first  step  is  to  proceed 
to  apply  the  taxis,  an  operation  which  re¬ 
quires  considerable  knowledge  of  the  ana¬ 
tomy  of  the  inguinal  canal  to  enable  the 
surgeon  to  obtain  from  it  its  full  advantages. 
The  inguinal  canal  is  placed  within  the  mus¬ 
cular  parietes  of  the  abdomen,  passing  ob¬ 
liquely  from  the  internal  ring  downwards  and 
inwards  to  the  external ;  the  pressure  to  re¬ 
duce  the  hernia  must  therefore  be  exerted 
upwards  and  outwards,  which  inverse  direc¬ 
tion  is,  however,  only  to  be  followed  in  cases 
of  oblique  inguinal  hernia.  If  it  be  found 
impracticable  to  reduce  the  hernia  by  the 
taxis,  the  stricture  must  be  removed  by 
surgical  operation. 

Operation  for  strangulated  bubonocele. — 
This  operation  consists  in  enlarging  the 
opening  of  the  internal  abdominal  ring 
through  which  the  hernia  has  escaped.  To 
effect  this  object,  the  inguinal  canal  must  be 
laid  open  for  the  purpose  of  exposing  the 
intrinsic  coverings  of  the  hernia  ;  an  incision 
is  made  in  the  course  of  the  tumor,  com¬ 
mencing  from  within  an  inch  of  the  internal, 
and  extending  to  the  external  ring,  cutting 
through  the  skin  and  superficial  fascia,  so  as 
to  expose  the  tendon  of  the  external  abdomi¬ 
nal  muscle  :  this  tendon  is  then  to  be  divided 
to  a  similar  extent,  and  in  the  same  direction 
as  in  the  first  incision.  The  hernial  tumor 
enveloped  by  the  internal  abdominal  fascia 
and  peritoneum  will  now  be  exposed,  partly 
overlapped,  perhaps,  by  the  free  edges  of 
the  internal  oblique  and  transversalis  muscle  ; 
these  may,  however,  be  turned  upwards  off 
the  tumor  by  means  of  the  finger,  and  with¬ 
out  cutting,  so  as  to  enable  you  to  proceed 
to  open  the  internal  abdominal  fascia  (often 
termed  the  fascia  spermatica  interna).  A  di¬ 
rector  is  now  to  be  passed  into  the  opening 
which  has  thus  been  made,  and  being  gently 
pushed  upwards,  enters  the  cavity  of  the  ab¬ 
domen  ;  the  force  required  for  this  being  in 
proportion  to  the  tightness  of  the  stric¬ 
ture.  A  hernial  knife  is  inserted  into  the 
gi'oove  of  the  director,  and  passed  along 
until  it  enters  the  abdomen,  having,  conse¬ 
quently,  been  pushed  beyond  the  point  of 
the  constriction  :  the  cutting  edge  of  the 
knife  is  then  turned  forwards  so  as  to  divide 
the  stricture ;  the  division  being  made  di¬ 
rectly  upwards  :  and,  indeed,  any  inward 
direction  is  to  be  especially  avoided,  owing 
to  the  proximity  of  the  epigastric  artery. 
This  division  of  the  stricture  external  to  the 
peritoneal  sac  usually  proves  sufficient,  and 
the  hernia  may  be  returned  by  gentle  mani¬ 
pulation  :  if  this  be  effected  the  operation  is 
completed,  but  if  there  be  any  adhesions 
between  the  contents  of  the  hernia  and  its 


peritoneal  sac,  or  any  other  cause  which  pre¬ 
vents  the  return  of  the  hernia,  the  peritoneal 
sac  itself  must  be  laid  open  for  the  purpose 
of  removing  the  obstruction. 

The  operation  of  dividing  the  stricture 
external  to  the  sac  may,  I  think,  be  looked 
upon  as  involving  little  more  danger  than 
the  ordinary  application  of  the  taxis,  for 
there  can  be  no  doubt  that  the  great  danger 
in  the  usual  operation  for  hernia  consists  in 
opening  the  peritoneal  cavity,  and  I  have 
frequently  had  patients  recover  after  the  ex¬ 
ternal  division  of  the  stricture  with  as  much 
freedom  from  dangerous  symptoms  as  when 
the  hernia  is  returned  by  the  application  of 
the  taxis  alone.  On  January  5th,  1844,  I 
operated  on  a  boy  for  strangulated  hernia, 
the  strangulation  having  existed  for  two 
days.  I  divided  the  stricture  external  to 
the  sac,  and  was  able  to  return  the  intestine 
by  a  very  slight  exertion  of  force  ;  not  a 
single  bad  symptom  supervened,  and  the  pa¬ 
tient  did  not  appear  to  suffer  more  than  in 
reduction  by  the  usual  method,  without  ope¬ 
ration.  I  had  also  a  patient  in  Cornelius 
ward,  on  whom  I  operated  for  a  strangulated 
inguinal  hernia,  on  which  Mr.  Key  had  ope¬ 
rated  three  years  before ;  in  this  case  I  di¬ 
vided  the  stricture  without  opening  the  sac, 
and  to  my  great  satisfaction  the  contents  of 
the  sac  were  easily  reduced  :  the  patient  did 
not  present  any  symptom  of  having  been 
subjected  to  an  operation,  and  even  the  col¬ 
lapse  almost  invariably  attendant  on  the 
operation  for  hernia  was  in  this  case  wholly 
absent ;  and  I  might  enumerate  several  cases 
equally  successful. 

To  Mr.  Key  is  attributable  the  introduc¬ 
tion  of  this  plan  of  treatment  in  cases  of  re¬ 
cent  hernia,  as  formerly  surgeons  1'ecom- 
mended  the  division  of  the  stricture  external 
to  the  sac  only  in  cases  of  very  large  hernia, 
and  such  as  were  of  long  continuance. 

Congenital  bubonocele. — If  the  bubono¬ 
cele  be  congenital,  the  operation  will  be  the 
same  as  that  just  described ;  the  stricture 
exists  at  the  same  point,  and  is  produced  by 
the  same  cause  ;  the  only  difference  is,  that 
the  congenital  bubonocele  passes  into  the 
tunica  vaginalis,  and  is  without  any  further 
peritoneal  covering.  If,  however,  circum¬ 
stances  render  it  necessary  in  the  operation 
for  a  strangulated  congenital  bubonocele  to 
lay  open  the  tunica  vaginalis,  the  testicle 
will  be  seen  lying  within  that  covering,  and 
usually  below  the  protruded  intestine,  so 
that,  even  before  the  opening  is  made,  the 
diagnosis  of  the  congenital  character  of  the 
hernia  may  be  formed  to  a  certain  extent, 
the  testicle  constituting  a  second  tumor  im¬ 
mediately  below  the  true  hernial  protrusion. 

There  are  certain  difficulties  which  may 
arise  in  the  operation  for  a  strangulated  bu¬ 
bonocele,  as  well  as  in  its  diagnosis  :  in 
making  the  first  incision,  for  instance, 


OPERATION  FOR  CONGENITAL  BUBONOCELE. 


441 


branches  of  the  external  epigastric  or  circum¬ 
flex  iliac  arteries  may  give  rise  to  a  haemor¬ 
rhage  that  will  render  it  necessary  to  apply  a 
ligature  to  those  vessels,  for  even  should  the 
bleeding  not  be  sufficient  to  produce  danger 
from  loss  of  blood,  it  would  obstruct  the 
after  steps  of  the  operation,  and  should  there¬ 
fore  be  immediately  arrested.  On  dividing 
the  tendon  of  the  external  abdominal  oblique 
muscle,  instead  of  exposing  the  hernial  sac, 
you  may  discover  a  varicose  condition  of  the 
spermatic  veins — a  hydrocele  of  the  cord — 
an  undescended  testicle — a  cyst,  perhaps, 
connected  with  the  ovarium,  or  a  steato- 
matous  tumor  may  conceal  the  hernia  from 
view.  It  is,  therefore,  necessary  in  all  cases 
to  be  prepared  for  such  contingencies,  and 
even  when  they  are  met  with,  if  the  symp¬ 
toms  of  hernia  are  present,  whatever  the 
concomitants  may  be,  the  malady  must  not 
be  referred  to  them,  but  careful  examination 
should  be  further  made  to  ascertain,  beyond 
all  question,  the  presence  or  absence  of  a  her¬ 
nial  protrusion.  In  a  former  lecture  I  men¬ 
tioned  the  case  of  a  surgeon,  who,  in  seeking 
for  hernia,  found  hydrocele  of  the  cord  ; 
without  further  investigation,  he  set  this 
down  as  the  origin  of  the  symptoms,  and 
allowed  the  hernia,  which,  in  fact,  existed, 
to  remain  constricted  until  the  life  of  the 
patient  became  sacrificed.  I  therefore  again 
urge  upon  you,  gentlemen,  the  necessity  for 
pushing  your  inquiries  in  such  cases  to  the 
most  extreme  limit.  I  have  myself  met  with 
considerable  difficulty  whilst  operating  in  a 
case  of  congenital  bubonocele,  from  mistaking 
a  non- descended  testicle  fora  hernial  sac:  very 
lately,  my  colleague,  Mr.  Cock,  in  operating 
in  a  case  of  bubonocele,  found  a  second  tu¬ 
mor  beside  the  protruded  intestine,  and  upon 
dividing  the  stricture,  a  quantity  of  viscid 
fluid  escaped.  Mr.  Cock  was  consequently, 
led  to  consider  it  as  an  encysted  tumor, 
proceeding  probably  from  the  ovarium.  The 
unexpected  occurrence  did  not,  however, 
prevent  the  completion  of  the  operation ; 
and  the  hernia  was  reduced  under  circum¬ 
stances  that  would  have  alarmed  a  less  scien¬ 
tific  surgeon,  and  might,  perhaps,  materially 
have  interfered  with  its  result :  the  patient 
recovered.  Psoas  abscess  sometimes  makes 
its  way  into  the  inguinal  canal,  and  when  it 
it  is  concomitant  with  bubonocele,  pus  might 
escape  during  the  operation.  A  case  oc¬ 
curred  some  time  ago  at  Epsom,  in  which, 
with  all  the  symptoms  of  hernia,  a  tumor 
was  discovered  in  the  abdomen ;  the  tumor 
was,  however,  distinctly  fluctuating,  it  was 
therefore  punctured,  and  pus  let  out :  the 
evacuation  of  the  matter  satisfied  the  sur¬ 
geon,  he  set  down  all  the  symptoms  to  the 
account  of  the  abscess,  and  did  not  seek  for 
any  further  cause.  As  the  opening  of  the 
abscess  did  not,  however,  relieve  the  patient 
(all  the  symptoms  of  hernia  remaining),  in  a 


short  time  he  died,  and  upon  post-mortem, 
examination  a  hernial  protrusion  was  found, 
in  addition  to  the  abscess  from  which  the 
matter  had  been  discharged.  Some  difficulty 
may  also  arise  in  the  division  of  the  stricture, 
whether  it  be  attempted  externally  to,  or 
within,  the  sac.  In  the  first  case  there  may 
be  a  difficulty  in  recognising  with  certainty 
the  fascia  spermatica  interna.  It  may  be 
supposed  that  this  tissue  is  exposed  before 
it  is  in  fact  reached,  and  until  it  is  opened 
the  stricture  cannot  be  divided  ;  the  best 
criterion  for  knowing  when  the  fascia  sper¬ 
matica  interna  is  laid  bare,  is  the  appearance 
of  the  fibres  of  the  cremaster  muscle,  the 
complete  division  of  which  must  expose  that 
intrinsic  covering  of  the  hernia. 

A  further  hindrance  to  the  division  of  the 
stricture  may  also  occur  from  the  tightness 
of  the  constriction  round  the  neck  of  the 
sac.  This  difficulty  renders  it  necessary  to 
employ  the  greatest  caution  both  in  passing 
the  director  through  the  stricture,  and  also 
in  passing  the  hernial  knife.  Many  cases 
are  on  record  in  which  the  intestine  has 
been  wounded  in  this  step  of  the  operation  ; 
and  I  believe  there  are  few  operating  sur¬ 
geons  who  have  not  met  with  this  accident. 
About  two  years  ago  I  was  sent  for  to  ope¬ 
rate  on  a  lady  who  was  labouring  under 
strangulated  hernia.  She  was  one  in  whom 
I  felt  a  more  than  usual  interest,  from  the 
earliest  associations  of  my  youth.  I  men¬ 
tion  this  only  to  shew  that  it  was  a  case 
which  commanded  my  utmost  care.  After 
I  had  divided  the  stricture  (which  was  very 
tight)  with  my  own  “guarded”  hernial 
knife,  a  quantity  of  fluid  escaped,  and  a 
violent  burning  pain,  attended  with  a  sensa¬ 
tion  of  extreme  tension  throughout  the 
abdomen,  was  immediately  experienced  by 
the  patient.  About  four  hours  after  the  ope¬ 
ration  she  expired ;  and,  in  a  post-mortem 
examination,  an  opening  was  found  in  the 
intestine,  and,  from  its  appearance,  I  have 
no  doubt  of  its  having  been  inflicted  by  the 
knife  during  the  operation  :  indeed,  it  may 
be  sometimes  impossible  to  avoid  this  acci¬ 
dent. 

The  effusion  from  the  bowel  which  proved 
fatal  in  this  case  may,  however,  take  place 
without  the  intestine  having  been  wounded 
by  the  knife,  as  lesion  of  the  protruded  part 
may  sometimes  be  produced  by  the  con¬ 
striction  to  which  it  is  subjected  :  but  I 
think  the  appearance  of  the  opening  in  the 
bowel  would  always  indicate  the  nature  of 
the  cause  which  produced  it.  The  liability 
to  wound  the  intestine  during  the  operation 
exists  equally  in  every  kind  of  strangulated 
hernia.  In  the  operation,  fresh  difficulties 
may  present  themselves  even  after  the  stric¬ 
ture  has  been  divided — viz.  in  returning  the 
intestine  into  the  abdomen.  The  difficul¬ 
ties  here  may  arise  from  the  quantity  of 


442  SCROTAL  HERNIA — LIABLE  TO  BECOME  STRANGULATED. 


intestine  protruded,  from  its  distension  with 
flatus,  its  abnormal  thickening,  or  its  adhe¬ 
sion  to  the  hernial  sac. 

In  September  1837,  I  operated  at  Guy’s 
Hospital  on  a  young  man  who  was  admitted 
with  strangulated  inguinal  hernia.  No 
difficulty  occurred  during  the  operation 
until  after  I  had  divided  the  stricture,  when 
I  found  it  totally  impossible  to  return  the 
bowel  into  the  abdomen.  I  punctured  the 
intestine  with  a  grooved  needle,  to  let  off 
the  gas  with  which  it  was  distended,  and 
the  patient  was  put  to  bed,  the  head  and 
lower  extremities  being  raised,  and  the  tu¬ 
mor  covered  by  a  light  cloth  kept  constantly 
wet  with  warm  water.  After  he  had  been 
two  hours  in  bed,  he  passed  a  large  quantity 
of  flatus  per  anum,  and  my  dresser  then 
succeeded  in  replacing  the  intestine.  The 
man  died,  however,  in  a  few  days,  of  peri¬ 
tonitis,  the  contents  of  the  bowels  not 
having  been  evacuated.  A  post-mortem 
examination  was  made,  but  no  cause  could 
be  found  for  the  difficulty  in  returning  the 
hernia  :  the  stricture  had  been  freely  divided, 
and  there  were  no  adhesions  of  the  intes¬ 
tine,  but  it  was  much  thickened,  and  had 
become  inelastic  and  of  a  leathery  consis¬ 
tence.  Mr.  Porter,  of  Dublin,  lately  de¬ 
scribed  a  case  to  me,  in  which,  after  having 
opened  the  sac,  and  divided  the  stricture, 
he  failed  in  every  attempt  to  return  the  pro¬ 
truded  intestine  into  the  abdomen,  and  his 
patient  died  in  three  days  with  symptoms  of 
strangulated  hernia.  On  dissection,  it  was 
found  that  the  colon  and  part  of  the  ileum 
had  protruded  under  Poupart’s  ligament, 
and  that  a  portion  of  the  ascending  colon 
had  fallen  over  the  entrance  of  the  ileum 
into  the  caput  coli,  so  as  to  completely  close 
the  valve,  and  thus  produce  the  symptoms 
of  strangulated  hernia,  and  prevent  the 
return  of  the  protruded  part,  as  the  air  and 
other  contents  of  the  sac  could  not  be 
pressed  back  through  the  ilio-colic  valve. 
In  August  1841,  one  of  my  colleagues 
admitted  a  patient  into  the  hospital  who  was 
suffering  from  a  large  strangulated  scrotal 
hernia.  The  hot  bath,  ice,  and  taxis,  were 
all  tried  without  success,  and,  the  operation 
being  therefore  determined  on,  the  sac  was 
laid  open,  and  the  stricture  divided,  but  it 
was  found  that  even  then  the  intestine  could 
not  be  returned  into  the  abdomen,  in  conse¬ 
quence  of  its  being  enormously  distended 
with  fluid :  this  was  evacuated  by  a  small 
puncture.  The  patient  died,  however,  in  a 
very  short  time.  If  adhesions  be  the  cause 
of  the  difficulty  in  returning  the  intestine, 
they  must  be  divided,  whether  they  are  to 
the  omentum  or  to  the  sac  itself,  and  I 
have  not  found  this  operation  so  difficult  as 
we  might  have  been  led  to  expect,  as  the 
adhesions  are  usually  of  recent  formation. 
They  may,  however,  be  so  firm  and  exten¬ 


sive  that  an  attempt  to  divide  them  would 
be  unjustifiable.  The  intestine  must,  under 
these  circumstances,  be  left  in  the  sac,  and 
of  course  remains,  in  that  case,  under  the 
form  of  an  irreducible  hernia.  The  prog¬ 
nosis  is  then  very  unfavourable. 

In  the  cases  I  have  just  described,  where, 
owing  to  its  great  distension,  the  bowel 
could  not  be  returned,  I  believe  that  it  is 
better  practice  not  to  puncture  it  either  for 
the  evacuation  of  air  or  fluid  ;  but  after  the 
stricture  is  freely  divided,  the  patient  should 
be  placed  in  bed,  and  the  protruded  intes¬ 
tine  covered  with  linen  dipped  in  warm 
fomentations,  leaving  it  to  the  chance  of  its 
spontaneous  action,  in  which  case  it  would 
be  easy  to  return  the  protrusion  into  the 
abdomen. 

The  cases  which  I  have  described  to  you, 
gentlemen,  in  this  kind  of  hernia,  I  have 
chosen  out  of  the  various  operations  I  have 
performed,  because  they  represent  to  you 
the  difficulties  which  you  may  meet  with  in 
your  own  practice  ;  for  if  I  only  recited  my 
successful  cases,  I  should  merely  describe 
the  steps  of  the  operation,  and  perhaps 
impress  you  with  the  idea  that  success 
might  be  always  insured  by  common  caution 
and  skill;  while,  on  the  contrary,  you  will 
now  perceive  the  necessity  for  being  ready 
to  meet  obstacles  for  which  you  could  only 
be  prepared  by  being  previously  aware  of 
the  probability  of  their  presenting  themselves. 

Oscheocele ,  or  scrotal  hernia. — When  a 
hernia  has  passed  through  the  external  ring 
and  issued  from  the  inguinal  canal  into  the 
scrotum,  it  is  no  longer  termed  a  bubonocele, 
but  takes  the  name  of  oscheocele  :  it  is, 
in  point  of  fact,  placed  under  different  ana¬ 
tomical  circumstances,  as  it  does  not  now 
receive  any  covering  from  the  tendon  of  the 
external  abdominal  oblique  muscle,  but  has 
acquired  new  ones  from  the  cremaster 
muscle,  and  fascia  spermatica  externa.  The 
latter  can  scarcely,  however,  be  regarded  as 
a  fresh  covering,  as  it  is  a  continuation  of 
the  superficial  fascia  of  the  abdomen,  pro¬ 
ceeding  downwards  into  the  scrotum  ;  and, 
by  its  close  connection  with  the  circum¬ 
ference  of  the  external  ring,  closes  it  exactly 
as  the  internal  ring  is  closed  by  the  fascia 
spermatica  interna. 

The  coverings  of  a  scrotal  hernia  are — 
skin,  superficial  fascia,  and  cremaster  mus¬ 
cle,  which  constitute  its  extrinsic,  while  the 
fascia  spermatica  interna  and  peritoneal  sac 
form  its  intrinsic  coverings. 

An  oscheocele  is  liable  to  become  stran¬ 
gulated,  and  then  precisely  similar  treatment 
to  that  in  bubonocele  is  necessary.  The 
taxis  is  to  be  applied  in  the  same  manner 
and  in  the  same  direction,  the  object  being 
to  push  the  viscus  back  along  the  course  of 
the  inguinal  canal,  and  through  the  internal 


OPERATION  FOR  SCROTAL  HERNIA. 


443 


abdominal  ring,  into  the  abdomen.  If  the 
redaction  cannot,  however,  be  effected,  an 
operation  must  be  had  recourse  to  for  the 
relief  of  the  strangulation. 

The  operation  is  commenced  by  making  an 
incision  through  the  skin  along  the  neck  of 
the  tumor,  beginning  immediately  below  the 
external  abdominal  ring,  and  being  con¬ 
tinued  downwards  for  about  an  inch  and  a 
half,  first  cutting  through  the  skin  ;  next,  the 
superficial  fascia  must  be  divided  to  an 
equal  extent :  this  must  be  done  with  great 
care,  and  the  dissection  continued  in  depth 
until  the  fibres  of  the  cremaster  muscle  are 
brought  into  view.  As  the  fascia  is  divisi¬ 
ble  into  layers,  there  may  be  some  difficulty 
in  recognising  the  cremaster  muscle ;  but 
this  is  a  very  important  point,  as  it  exactly 
indicates  to  the  surgeon  the  progress  he  has 
made  in  the  operation.  When  the  cremaster 
muscle  is,  however,  distinctly  recognised,  it 
must  be  cut  through,  by  which  the  fascia 
spermatica  interna  (internal  abdominal 
fascia)  will  be  reached.  This  tissue  is  then 
to  be  very  cautiously  opened,  and  a  director 
passed  upwards  as  far  as  the  stricture.  The 
director  being  between  the  fascia  and  the 
peritoneal  sac,  is  to  be  insinuated  beneath 
the  stricture  ;  and,  when  brought  into  the 
proper  position,  the  groove  being  directed 
forwards,  the  hernial  knife  is  to  be  passed 
along  the  groove,  and  the  stricture  divided 
in  the  same  manner  as  I  described  when 
upon  the  subject  of  bubonocele.  The  seat 
of  the  stricture  in  strangulated  scrotal 
hernia  is  generally  at  the  internal  ring ;  but 
the  latter  does  not,  as  in  bubonocele,  remain 
in  its  normal  position  midway  between  the 
anterior  and  superior  spinous  process  of  the 
ileum  and  pubes,  but  is  forced  downwards 
by  the  propulsion  of  the  tumor  until  it  is 
brought  into  close  proximity  to  the  external 
ring ;  so  that,  in  dividing  the  stricture, 
there  is  no  necessity  for  laying  open  the 
inguinal  canal,  as  would  be  requisite  if  the 
rings  were  not  brought  so  close  to  each 
other.  If,  after  the  stricture  has  been 
divided  externally  to  the  peritoneum,  the 
sac  cannot  be  emptied,  it  must  be  opened, 
in  order  to  remove  the  obstruction  which 
prevents  the  reduction.  Oscheocele  is 
sometimes  congenital :  in  that  case  the 
testicle  will  be  found  descended  into  the 
scrotum,  instead  of  remaining  in  the  in¬ 
guinal  canal,  as  is  frequently  seen  in  bubo¬ 
nocele. 

No  difficulties  offer  themselves  in  this 
kind  of  oblique  inguinal  hernia  (a  scrotal 
hernia)  beyond  those  which  have  already 
been  described  as  appertaining  to  the 
“  bubonocele,”  unless  we  admit  the  great 
liability  of  an  increase  of  size  in  the  hernial 
tumor  when  it  has  reached  the  scrotum,  as 
offering  a  peculiarity.  If  a  scrotal  hernia 
has  acquired  a  great  size,  the  hernial  sac 


should  not  be  opened,  but  the  stricture  freely 
divided,  and  the  sac  emptied  of  its  contents, 
if  practicable  ;  but  if  this  cannot  be  effected, 
an  opening  just  large  enough  to  admit  the 
director  into  the  sac  should  be  made,  and, 
the  director  being  passed  upwards  into  the 
abdomen,  the  neck  of  the  sac  should  be 
divided,  and  the  finger  gently  introduced  to 
seek  for  any  adhesions  which  may  prevent 
the  bowel  from  being  returned  ;  but,  should 
its  reduction  prove  still  impracticable,  it  is 
better  for  it  to  be  left  in  the  scrotum  than 
for  the  whole  sac  to  be  laid  open.  Hydro¬ 
cele  or  haematocele  of  the  tunica  vaginalis 
may  be  concomitant  with  scrotal  hernia, 
and  lead  to  some  diagnostic  difficulties,  or  a 
complication  of  a  direct  with  an  oblique 
inguinal  hernia  might  possibly  occur ;  so 
that  it  is  always  judicious,  after  the  intestine 
seems  to  be  reduced  by  being  pushed  through 
the  external  ring,  to  examine  whether  any 
tumor  still  remains  in  the  inguinal  canal. 

A  very  curious  case  of  hernial  complica-  i 
tion  occurred  to  me  in  consultation  with 
Mr.  Francis  Toulmin,  of  Hackney.  In 
August  1847,  he  consulted  me  about  a 
patient  who  was  suffering  under  symptoms 
of  strangulated  hernia.  Upon  examining 
the  patient,  a  slight  degree  of  fulness  was 
felt  in  the  right  inguinal  canal,  but  not  con¬ 
veying,  from  its  appearance  or  feel,  the  evi¬ 
dence  of  a  hernial  tumor.  We  determined, 
therefore,  on  giving  some  calomel  and  opium 
to  allay  the  sickness,  and  to  wait  the  effect 
of  the  medicine.  The  symptoms,  however, 
continuing  the  same,  the  next  day  we  laid 
open  the  inguinal  canal,  to  examine  the 
cause  of  the  slight  protrusion  in  that  region. 
As  we  expected,  from  the  general  character 
of  the  swelling,  no  hernial  sac  was  found,  nor 
did  we  discover  any  visceral  protrusion,  but 
what  we  regarded  as  a  thickened  and  vari¬ 
cose  spermatic  chord.  We  therefore  closed 
the  wound,  ordered  some  stimulus,  as  our 
patient  was  now  become  very  low,  and  con¬ 
sidered  that  he  was  dying  of  some  internal 
cause  of  obstruction.  The  next  day,  indeed, 
he  died. 

Mr.  Francis  Toulmin,  twenty-four  hours 
afterwards,  made  a  post-mortem  examina¬ 
tion,  and  the  following  is  his  account  of  the 
investigation  : — 

“  I  send  you  herewith  the  right  testis, 
with  the  appendix  cseci  and  spermatic 
chord  attached,  and  the  result  of  my  fur¬ 
ther  examination  of  the  body  twenty-four 
hours  after  death.  The  skin  was  yellow ; 
the  abdomen  tumid.  Upon  opening  this 
cavity,  the  intestines  in  situ  were  deep  in 
colour,  and  slightly  glued  together  by  re¬ 
cently-effused  lymph.  I  first  examined  the 
left  internal  ring,  and  found  it  would  easily 
admit  the  point  of  the  finger  from  the  abdo¬ 
men  into  the  inguinal  canal,  which  contained 
nothing  abnormal.  Upon  laying  open  the 


444 


COLLECTION  OF  FACTS  ILLUSTRATIVE  OF 


right  inguinal  canal  completely  into  the 
abdomen,  for  it  had  already  been  laid  open 
by  operation  before  death,  the  appendix 
cseci  vermiformis  was  found  passing  through 
the  internal  ring  and  inguinal  canal,  and, 
terminating  by  a  bulbous  extremity,  was 
adhering  firmly  to  the  right  testicle,  which 
was  situated  just  below  the  external  ring  : 
the  spermatic  chord  took  its  course  behind 
the  appendix,  and  they  were  firmly  adherent 
to  each  other.  About  eighteen  inches  of  the 
intestinum  ileum,  forming  numerous  intri¬ 
cate  convolutions,  were  firmly  bound  down 
to  the  rectum  by  a  considerable  quantity  of 
plastic  lymph,  forming  a  mass  which  com¬ 
pletely  filled  up  the  cavity  of  the  pelvis.  On 
separating,  or  rather  unravelling,  this  mass, 
some  pus  flowed  out.  About  six  inches  of 
the  intestine  was  completely  empty,  con¬ 
tracted,  and  almost  impervious.’' 

From  the  history  of  the  symptoms  in  this 
case,  as  well  as  from  the  post-mortem  exami¬ 
nation,  it  is  quite  clear  that  the  protru¬ 
sion  of  the  vermiform  process  of  the  caecum 
was  not  the  cause  of  obstruction  to  the 
bowels,  but  the  adhesion  of  the  small  intes¬ 
tines  to  each  other.  One  of  the  strongest 
proofs  of  this  fact  is,  in  my  mind,  the 
urgency  of  the  sickness,  which  constituted  a 
prominent  feature  in  the  disease  ;  while,  had 
protrusion  of  the  caecum  been  the  exciting 
cause,  vomiting  would  have  been  only  a 
secondary  symptom. 


ON  A  PECULIAR  PROPERTY  OF  COKE.  BY 
MR.  J.  NASMYTH. 

The  following  interesting  fact  was  discovered 
some  years  ago,  and  it  appears  to  furnish 
additional  evidence  as  to  the  identity  of  the 
diamond  with  carbon,  namely,  that  coke  is 
possessed  of  one  of  the  most  remarkable  pro¬ 
perties  of  the  diamond,  in  so  far  as  it  has 
the  property  of  cutting  glass.  I  use  the 
term  “  cutting  ”  with  all  due  consideration — 
in  contradistinction  to  the  property  of 
scratching,  which  is  possessed  by  all  bodies 
that  are  harder  than  glass.  The  cut  pro¬ 
duced  by  coke  is  a  perfectly  clear  diamond¬ 
like  cut,  so  clean  and  perfect  as  to  exhibit 
the  most  beautiful  prismatic  colours,  owing 
to  the  perfection  of  the  incision.  Coke  has 
hitherto  been  considered  as  a  soft  substance, 
doubtless  from  the  ease  with  which  a  mass 
of  it  can  be  crushed  and  pulverized  ;  but  it 
will  be  found  that  the  minute  plate-formed 
crystals,  of  which  a  mass  of  coke  is  com¬ 
posed,  are  intensely  hard ,  and  as  before 
said,  are  possessed  of  the  remarkable  pro¬ 
perty  of  cutting  glass.  This  discovery  of 
the  extreme  “  diamond-like  ”  hardness  of 
the  particles  of  coke  will,  no  doubt,  prove 
of  value  in  many  processes  in  the  arts,  as 
well  as  interesting  in  a  purely  scientific 
sense. — British  Association,  Athenceum  re¬ 
port. 


(Original  ©omimmtcattong. 


A  COLLECTION  OF  FACTS  ILLUSTRATIVE  OF 
THE 

MORBID  CONDITIONS  OF  THE 
PULMONARY  ARTERY. 

AS  BEARING  UPON  THE  TREATMENT  OF 
CARDIAC  AND  PULMONARY  DISEASES. 

By  Norman  Chevers,  M.D. 
Assistant -Surgeon,  Bengal  Army. 
[Continued  from  p.  361.] 


Dilatation  of  the  Pulmonary  Artery. 

The  fact  that  as  life  advances  the  pulmonary 
artery,  in  common  with  all  other  parts  of 
the  vascular  system,  is  liable  to  become 
gradually  and  permanently  dilated;*  and 
that  the  establishment  of  fixed  causes  of 
obstruction,  either  in  the  lungs,  left  heart, 
or  systemic  circulation,  are  at  all  periods 
liable  to  produce  a  similar  result, — have 
already  been  commented  upon  in  previous 
chapters  of  this  memoir.  It  now  merely 
remains  to  cite  a  few  examples  in  which 
remarkable  dilatation  of  this  vessel  was 
found  to  have  occurred  under  somewhat 
unusual  circumstances,  f 

We  have  seen  that  an  unnaturally  wide 
condition  of  this  vessel  is  found  in  several 
classes  of  cases  of  cardiac  malformation. 
The  following  instance  presented  at  once 
the  largest  amount  of  simple  dilatation  of 
this  vessel  that  has  ever  fallen  within  my 


*  General  dilatation  and  loss  of  elasticity  are 
the  only  visible  physical  changes  to  which  the 
tissues  of  the  pulmonary  artery  appear  to  be 
liable  in  extreme  old  age,  independently  of  the 
operation  of  accidental  morbid  influences.  In 
most  of  the  hearts  of  very  aged  persons  which  I 
examined,  the  structures  of  this  vessel  retained, 
to  the  eye,  a  nearly  healthy  appearance ;  the 
valves  especially  presenting  a  striking  contrast 
to  those  of  the  aorta.  Morgagni  describes  the 
condition  of  the  heart  in  a  man  of  98,  in  whom 
all  the  valves  belonging  to  the  orifices  of  the  right 
ventricle  were  not  only  not  rigid  nor  thickened, 
but  even,  like  those  which  belong  to  the  pulmo¬ 
nary  artery,  they  seemed  to  be  formed  of  a 
thinner  membrane  than  usual.  The  mitral 
valves,  however,  were  found  thicker  than  they 
ought  to  be ;  and  the  aortic  valves  were  all  bony, 
inflexible,  and  protuberating  internally,  &c. 
The  arch  of  the  aorta  and  its  vessels  were  free 
from  bony  scales,  which  were  however  seen  in 
the  remaining  part  of  the  aorta. — Letter  XXI. 
A.  15.  It  appears,  in  fact,  that  degeneration  of 
the  tissues  of  this  vessel  is  not  by  any  means  a 
necessary  attendant  of  old  age,  but  is  mrst  fre¬ 
quently  the  result  of  over-distension  and  other 
accidental  morbid  influences. 

f  Cases  of  too  great  capacity  of  the  pulmonary 
artery  are  described  by  Cooper  (in  Farre),  Riche- 
rand,  Corvisart,  Testa,  J.  F.  Meckel,  Hufeland, 
Lawrence,  Young,  &c. 


THE  MORBID  CONDITIONS  OF  THE  PULMONARY  ARTERY. 


445 


notice,  and  one  of  the  most  singular  con¬ 
genital  irregularities  that  has  been  known  to 
occur  in  the  heart  of  an  adult1'  :  — 

A  woman,  45  years  of  age,  dropped  sud¬ 
denly  in  the  street,  near  Guy’s  Hospital, 
and  died,  gasping  and  pallid,  without  any 
convulsions,  immediately  after  she  had  been 
brought  into  the  house.  Some  suspicion 
was  entertained  that  she  had  swallowed 
about  a  drachm  of  nux  vomica  powder  an 
hour  before  her  death,  but  this  was  not 
proved  to  have  been  the  case.  I  was  present 
at  the  autopsy,  July  12th,  1S44.  The  body 
was  lean,  but  scarcely  had  the  appearance 
of  being  wasted.  The  extreme  parts  of  the 
body  were  remarkably  blue.  Some  of  the 
muscles,  especially  the  internal  ones,  were 
very  pale.  The  chest  was  much  deformed, 
the  ribs  being  compressed  laterally  below 
the  prsecordial  region,  apparently  by  the 
tight  lacing.  The  pericardium  contained  a 
considerable  quantity  of  clear  fluid.  The 
heart  was  very  large,  owing  entirely  to  the 
dilated  condition  of  its  right  cavities,  which 
were  distended  with  dark  semi-fluid  coagula. 
The  pulmonary  artery  was  very  conspicuous  ; 
there  were  some  white  patches,  like  cica¬ 
trices,  upon  its  left  side  ;  posteriorly  it  was 
adherent  to  the  aorta  by  strong  bands. f 
The  auricles  communicated  by  an  oblique 
opening  capable  of  admitting  the  ends  of 
three  fingers;  in  the  remains  of  the  septum 
below  this  was  an  oblique  passage,  closed 
on  the  side  of  the  left  auricle ;  this  was 
evidently  the  vestige  of  a  foramen  ovale  : 
therefore  there  must  have  been  originally 
two  of  these  communications  in  this  indivi¬ 
dual — one  of  which  had  closed,  the  other 
remaining  permanently  open.  Four  pulmo¬ 
nary  veins  were  found  opening  into  the  right 
ventricle,  as  did  the  common  termination  of 
the  coronary  veins,  which  was  furnished 
with  a  well-formed  valve.  The  right  auricle 
was  very  capacious.  The  tricuspid  valve 
was  not  malformed.  The  right  ventricle 
was  capacious  and  thick.  Toe  pulmonary 
valves  were  bordered  with  a  few  vegetations  ; 
their  tissue  was  unusually  thick,  but  still 
retained  its  pliability.  Immediately  below 
its  valves  the  orifice  of  the  artery  measured 
four  inches  and  four  lines  in  circumference  ; 
at  the  upper  attachments  of  the  valves  it 
was  about  one  line  wider  (the  normal  mea¬ 
surement  of  these  parts  being  respectively 
38^  and  324  lines).  Notwithstanding  this 
dilatation  of  the  vessel,  there  was  no  reason 
to  doubt  that  its  valves  were  perfectly  effi¬ 
cient.  The  left  auricle  was  less  capacious 


*  Full  details  of  this  case  have  been  published 
by  Mr.  Alfred  Taylor,  in  the  Medical  Gazette, 
vol.  xxxvi.  p.  19. 

t  It  is  known  to  all  anatomists  that  in  some 
subjects  the  pulmonary  artery  is  united  to  the 
ascending  aorta,  and  that  in  others  a  consider¬ 
able  interval  is  found  between  these  vessels. 


than  the  right.  The  left  ventricle  appeared 
remarkably  small  when  compared  with  the 
right ;  its  parietes  were  by  no  means  thia, 
but  their  muscular  structure  was  soft.  The 
aortic  orifice  was  structurally  healthy,  but  it 
was  remarkably  narrow,  measuring  some¬ 
what  less  than  two  inches  below  the  valves. 
The  vessel  was  small  throughout  its  entire 
course  ;  but,  immediately  below  the  left  sub¬ 
clavian  artery,  it  was  in  a  marked  degree 
more  contracted  than  elsewhere.  Several 
enlarged  bronchial  glands  were  found  near 
this  spot ;  these  may  have  encroached 
slighty  on  the  aorta,  or  the  dilated  pulmo¬ 
nary  artery  may  have  somewhat  compressed 
it,  but  there  was  po  distinct  structure  here  : 
and  the  undilated  state  of  the  left  ventricle 
and  ascending  aorta  proved  that  this 
narrowing  of  the  vessel  had  not  caused  much 
impediment  to  the  circulation.  Neither  the 
internal  mammary,  nor  the  intercostal 
arteries  were  perceptibly  dilated.  The  lungs 
were  in  parts  highly  emphysematous,  and 
were  generally  much  congested.  The  liver 
was  congested.  The  spleen  small,  and  sur¬ 
rounded  by  adhesions.  The  kidneys  were 
small,  and  tolerably  healthy. 

It  was  ascertained  that  this  person  was 
one  of  twins  born  at  the  eighth  month.  She 
had  always  been  liable  to  shortness  of  breath, 
and  to  become  blue  upon  unusual  exertion. 
Her  habits  had  been  irregular  and  intem¬ 
perate.* 

It  is  evident  that  this  female  must  have 
always  been  liable  to  great  pulmonary  con¬ 
gestion  ;  and  it  is  certainly  most  extraordi¬ 
nary,  considering  the  nature  of  the  con¬ 
genital  defect  of  her  heart,  and  the  artificial 
deformity  of  her  chest,  that  she  should  have 
reached  the  middle  period  of  life.  It  will 
be  observed  that  in  this  case  the  orifice  of  the 
pulmonary  artery  had  become  widened  to  a 
degree  considerably  beyond  that  to  which  it 
is  naturally  dilatable — a  circumstance  to 
which  I  have  alluded  at  the  commencement 
of  this  paper,  as  producing  a  tendency  to 
sudden  death,  upon  the  occurrence  of  any 
circumstances  which  occasion  over  distension 
of  the  right  cavities.  It  is  evident  that  the 

*  A  case  somewhat  similar  to  this  occurred  to 
Mr.  Harrinson,  who,  in  1844,  presented  to  the 
Reading  Pathological  Society  the  heart  of  a  child 
two  years  and  two  months  old,  who  had  been 
the  subject  of  cyanosis.  The  right  side  of  the 
heart  was  enormously  distended  with  clots  of 
librine ;  the  auricle  and  ventricle  were  greatly 
enlarged.  The  auriculo-ventricular  orifice  was 
so  much  enlarged  or  dilated  as  to  annihilate  the 
functions  of  the  valves.  The  pulmonary  artery 
was  greatly  dilated.  The  ductus  arteriosus  was 
impervious.  On  the  left  side  the  auricle  was 
very  small,  and  the  foramen  ovale  open ;  its 
edges  rounded,  and  no  va'vular  apparatus  ;  the 
auricular  appendages  absent.  No  appearance  of 
the  entrance  of  any  pulmonary  veins ;  left  ven¬ 
tricle  very  small.  Mr.  Harrinson  conjectured 
that  the  pulmonary  veins  must  have  terminated 
either  in  the  vena  azygos  or  in  the  superior 
cava. 


446 


COLLECTION  OF  FACTS  ILLUSTRATIVE  OF 


degree  of  mental  perturbation  which  could 
have  urged  this  unfortunate  individual  to 
procure  the  means  of  committing  suicide, 
was  amply  sufficient  to  produce  fatal  em¬ 
barrassment  of  a  heart  so  weakened  and 
malformed. 

The  average  circumference  of  the  pulmo¬ 
nary  artery,  at  its  widest  part,  is  about  38 
lines.  Dr.  Hope  has  described  a  case  in 
which  this  vessel  measured  five  inches  half 
way  up,  and  four  and  a  half  near  the  valves. 
Here  the  sygmoids  were  stretched,  and  were 
considered  to  be  inefficient.* *  In  such  in¬ 
stances  as  these,  the  duration  of  the  patient’s 
life  must  obviously  depend  chiefly  upon  the 
strength  of  the  right  and  left  ventricles,  and 
the  degree  of  safety-valve  action  of  the  tri¬ 
cuspid. 

It  is  usual  to  find  the  pulmonary  artery 
with  its  valves  more  or  less  (sometimes 
extremely)  dilated,  coarse  in  structure,  and 
irregularly  thickened  and  opaque,  in  cases  of 
old  bronchitis  and  extensive  emphysema  of 
the  lungs,  &c.,  as  well  as  in  instances  where 
death  results  from  mitral  and  aortic  obstruc¬ 
tion. f 

In  cases  of  old  bronchitis,  mitral  and 
aortic  obstruction,  Sic.,  it  is  usual  to  find 
the  entire  tract  of  the  pulmonary  artery 
more  or  less  inordinately  dilated.  In  the 
generality  of  examples  of  this  <  hinge,  the 
branches  of  the  vessel  are  observed  to  have 
.undergone  the  greatest  amount  of  structural 
.^Iteration,  presenting  an  almost  varicose  ap¬ 
pearance,  their  anterior  being  thickened  and 
opaque,  and  discoloured  by  striae  and 
patches  of  atheromatous  deposit.  In  more 
'.extreme  examples,  the  main  trunk  and 
valvular  apparatus  of  the  artery  are  also 
found  to  have  undergone,  in  addition  to 
their  dilatation,  a  marked  degree  of  thicken¬ 
ing,  and  to  have  become  the  seat  of  a  certain 
amount  of  opaque  interstitial  deposit — ap¬ 
pearances  which  deprive  the  vessel  of  its 
characteristic  appearance,  and  give  it  an 
aspect  very  closely  resembling  that  of  the 

e  *  I  have  never  myself  seen  any  case  in  which 

•  the  pulmonary  valves  had  become  inefficient  in 
consequence  of  retroversion,  or  from  any  other 
effect  of  dilatation  independently  of  mechanical 
violence  or  congenital  defect. 

t  Instances  of  too  great  capacity  of  the  pul¬ 
monary  artery  are  also  described  by  Cooper  (in 
'  Farre),  Rieherand,  Corvisart,  Testa,  J.  F.  Meckel, 
Hufeland,  Lawrence.  Young,  and  others-  Otto 
has  also  given  the  foilowmgreferencesto  recorded 
cases  ot  aneurism  of  this  artery.— And.  Csesalpin, 

•  Catoptrices,  Lib.  vi.  cap.  20;  Blancard,  Anat. 
Tract  Rat.  Cent.  ii.  Obs  74 ;  Fabrig.  von  Hilden, 

■Ohservat.  et  Cur.  Chir.  Cent:,  ii.  Obs.  89; 
Eggerdes,  in  Misc.  Acad.  Nat.  Cur.  Dec.  11,  An. 
VI.  16S7,  p.  415  ;  Morgagni,  Epist.  XXIV.  Art. 
36;  Matani  de  Aneurismal.  Prtecordior.  Morbis, 
p.  125;  Baader,  Observat.  Med.  Incis.  Cadav. 
I  Must.  Frib.  1765;  Bach  v.  Richter’s  Chir.  Biblio- 
theck,  vol.  viii.  p.  498;  Essenchmidt,  in 
Schmucker’s  Vermischt  Schriften,  vol.  ii.  p. 
■  241  ;  J.  C.  Stark,  in  Abhandlungen  der  Erlangen 

•  Physic  zn  Alexander,  Trans,  vi.  765. 


ascending  aorta.  The  following  case,  with 
which  I  have  been  kindly  favoured  by  my 
friend  Dr.  Peacock,  affords  a  very  excellent 
example  of  the  class  of  lesions  now  under 
consideration. 

Wm.  Cassidy,  set.  72,  cooper,  admitted 
into  the  Royal  Free  Hospital,  July  3d,  and 
died  July  5th,  1847.  He  was  dying  when  I 
saw  him.  The  face  was  pale,  the  cheeks 
livid,  and  the  jugulars  were  distended  and 
pulsating.  The  hands  were  cold  and  livid. 
He  was  greatly  emaciated,  and  the  abdomen 
and  the  cellular  membrane,  of  the  lower 
extremities  more  especially,  were  distended 
with  fluid.  The  chest  sounded  dull  on  per¬ 
cussion  of  the  level  of  the  nipple  on  the 
left  side  ;  and  on  the  right,  from  a  some¬ 
what  lower  point,  a  loud  and  rough  systolic 
murmur  was  audible  at  the  prsecordia,  and 
was  followed  by  a  flat  second  sound.  This 
sound  was  most  intense  an  inch  and  a  half 
to  two  inches  below  the  nipple,  and  external 
to  a  vertical  line  drawn  from  it.  The  pulse 
was  unequal  in  strength,  and  occasionally  in¬ 
termitted.  No  history  of  his  previous  illness 
could  be  obtained. 

The  brain  was  below  the  average  weight, 
or  only  42  oz.  4  dwt.  avoirdupois.  There 
was  some  fluid  beneath  the  arachnoid  mem¬ 
brane  and  in  the  ventricles. 

A  considerable  amount  of  fluid  was  con¬ 
tained  in  each  pleural  sac.  The  lungs  were 
partly  compressed  by  the  fluid,  and  partly 
emphysen  atous  :  on  section,  they  yielded 
much  spumous  fluid.  The  bronchi  were  of 
large  capacity,  and  the  cartilages  unusually 
hard  and  thick.  The  dilatation  extended 
throughout  the  bronchial  ramifications,  and 
the  mucous  membrane  was  generally  red¬ 
dened,  and  the  tubes  filled  with  a  glairy 
mucous  fluid. 

There  was  a  large,  thick,  and  opaque 
patch  of  old  lymph  on  the  anterior  surface 
of  the  right  ventricle,  which,  when  removed, 
left  the  pericardium  beneath  it  smooth  and 
glistening.  The  right  auricle  was  studded 
with  small  nodular  concretions  of  old  lymph. 
There  was  but  little  fat  in  the  heart.  The 
heart  weighed  14  oz.  There  was  great  dila¬ 
tation  and  hypertrophy  of  the  right  ventricle, 
the  cavity  being  4  in.  and  3  lines  in  length, 
and  its  walls  three  lines  thick  at  the  base ;  four 
and  a  half  at  the  mid-point,  and  one 
and  a  half  at  the  apex.  The  tricuspid  aperture 
was  very  large,  allowing  of  the  passage  of  a 
ball  measuring  five  inches  in  circum¬ 
ference.  The  pulmonary  orifice  was  also 
extremely  large,  allowing  of  the  passage  of  a 
ball  measuring  three  inches  and  nine  lines  in 
circumference.  The  tricuspid  and  pulmonic 
valves  were  somewhat  thickened,  but  not  other¬ 
wise  diseased.  The  trunk  of  the  pulmonary 
artery  was  very  much  dilated,  and  the  sinuses 
at  its  origin  especially  so.  Its  branches  were 
throughout  very  large,  and,  though  the  lining 


THE  MORBID  CONDITIONS  OF  THE  PULMONARY  ARTERY. 


447 


membrane  of  the  trunk  was  free  from  ap¬ 
pearances  of  disease,  that  of  the  primary  and 
secondary  divisions,  and  the  smaller  branches, 
was  the  seat  of  extensive  atheromatous  de¬ 
posit.  In  the  smaller  vessels  the  coats  were 
so  much  thickened  that  on  section  they  re¬ 
mained  wide  open,  and  in  some  there  were 
small,  hard,  and  partly  adherent  pinkish- 
coloured  coagula.  The  left  ventricle  was 
also  hypertrophied  and  dilated,  measuring 
three  inches  in  length,  and  from  six  lines  to 
two  and  a  half  lines  in  width.  The  mitral 
valve  displayed  some  u  ammillary  thickening, 
and  the  ree  fold  was  somewhat  atheromatous. 
The  aortic  valves  were  thickened  at  their  free 
edges,  but  not  incompetent.  The  aorta 
around  the  angles  of  the  valves  was  exten¬ 
sively  ossified,  and  the  orifice  of  the  right 
coronary  artery  was  nearly  closed  by  a  de¬ 
posit  of  this  kind.  The  other  coronary 
artery,  and  the  right  throughout  the  re¬ 
mainder  of  its  course,  was  not  materially  dis¬ 
eased. 

The  lining  membrane  of  the  aorta  was  ex¬ 
tensively  studded  with  atheromatous  patches. 
The  sinuses  of  Valsalva  were  much  dilated, 
and  the  aorta  generally  was  large,  and  its 
ascending  portion  elongated. 

The  liver  was  large,  lobulated  and  coarsely 
granular.  The  kidneys  large,  mottled,  irre¬ 
gular  in  shape,  and  studded  with  smaller  or 
larger  sized  cysts. 

The  peritoneal  cavity  contained  much 

fluid. 

The  occurrence  of  atheromatous  deposit  in 
the  pulmonary  artery,  and  especially  in  the 
branches  of  that  vessel,  is  now  generally  re¬ 
cognised  as  a  by  no  means  unusual  patholo¬ 
gical  appearance  :  it  is  usually  associated 
with  a  greater  or  less  amount  of  hypertrophy 
or  dilatation  of  the  right  ventricle,  and  with 
a  proportionate  degree  of  congestion  of  the 
general  venous  system.  These  latter  abnor¬ 
mal  conditions  may  exist  either  as  the  direct 
results,*  or  as  the  mere  coincidents  of  the 
arterial  lesions. 

Aneurism  of  the  pulmonary  artery. 

The  occurrence  of  aneurism  in  this  vessel 
has  rarely  been  observed :  the  great  disa¬ 
bility  of  the  ascending  portion  of  the  artery 
appears  to  be  the  principal  cause  of  its  im¬ 
munity  from  this  lesion,  while  its  internal 
branches  are  still  further  protected  by  the 
elastic  support  afforded  by  the  pulmonary 
tissue.  Indeed,  when  we  take  the  true 
nature  of  aneurism  into  consideration,  it 
becomes  probable  that  the  morbid  appear- 

*  In  one  of  his  valuable  papers  on  cardiac  dis¬ 
ease,  Dr.  G.  H.  Barlow  alludes  to  a  case  occur¬ 
ring  in  his  own  experience,  in  which  thickening 
and  rigidity  of  the  coats  of  the  pulmonary  arteries , 
extending  into  their  smaller  ramifications,  had 
produced  engorgement  of  the  right  ventricle,  and 
its  consequences.  [“Select  Clinical  Reports,” 
Guy’s  Hospital  Reports,  vol.  v.  N.S.  p.  177.] 


ances  which  will  be  described  in  the  follow- 
ing  cases  were  not  due  to  a  process  strictly 
analogous  to  that  by  which  aneurisms  of  the 
systemic  arteries  are  produced  :  in  fact,  the 
condition  appears  to  be  more  nearly  allied  to 
a  form  of  varix  which  occasionally  affects 
the  larger  veins.* 

The  following  case  occurred  in  the  practice 
of  Dr.  Fletcher,  of  Birminghamf  : — 

A  thin,  pale  girl,  aet.  19,  a  screw-wormer, 
was  admitted  to  the  Birmingham  General 
Dispensary.  She  complained  of  violent  pain 
in  the  head,  and  of  some  pain  in  the  left  side 
of  the  chest,  great  dyspnoea,  and  trouble¬ 
some  cough.  Immediately  under  “  (on  ?)” 
the  left  of  the  sternum,  between  the  second 
and  third  ribs,  there  was  dulness  on  percus¬ 
sion  over  a  space  measuring  nearly  four 
square  inches.  Over  this  spot  a  very  liquid 
pulsation  was  felt,  accompanied  by  a  purring 
thrill,  so  rough  and  so  close  to  the  surface, 
that  it  seemed  almost  to  grate  on  the  fingers. 
At  the  same  place  a  hollow  rasp  sound  was 
heard  with  the  systole  of  the  heart,  and  also 
for  a  moment  at  the  commencement  of  Ihp 
diastole,  as  if  the  blood  was  receding.  The 
patient  lived  a  year  after  these  symptoms 
were  observed,  and,  after  repeated  attacks  of 
bronchitis  and  pneumonia,  died  rather  sud¬ 
denly. 


*  The  diseased  state  of  the  vena  cava  observed 
in  the  following  case  seems  to  have  approached 
as  nearly  to  the  condition  of  aneurism  as  did  the 
lesions  of  the  pulmonary  artery  in  any  of  the 
examples  which  have  next  to  be  cited. 

Dr.  Edward  R  Squibb  has  recorded  the  his¬ 
tory  of  a  mulatto  man,  aged  37  years,  who,  for 
ten  months  previously  to  his  death,  sulfered 
from  a  violent  but  remittent  pain  in  the  abdo¬ 
men,  with  irritability  of  stomach,  a  sensation  of 
obstruction  after  taking  food,  and  occasional 
vomiting.  Shorly  before  his  death,  the  pain 
abated,  and  the  patient  felt  able  to  sit  up  in  bed. 
The  exertion  of  rising  up  caused  a  feeling  of 
great  weakness  and  tendency  to  faint.  He  was 
immediately  laid  down,  but  expired  in  a  few 
hours. 

On  examination,  the  abdominal  viscera  were 
found  imbedded  in  and  quite  hidden  by  masses 
of  coagulated  blood,  the  viscera  themselves  ap¬ 
pearing  to  be  quite  in  a  healthy  condition.  A 
rupture  of  the  ascending  cava  was  discovered 
just  below  the  lower  concave  surface  of  the  liver. 
The  veins  at  this  point  had  been  very  much 
dilated,  and  its  coats  much  diseased  and  thin¬ 
ned.  A  semi-organized  mass  or  clot,  which  was 
contained  in  the  dilatation,  was  connected  by  its 
surface  to  the  softened  coats  of  the  expanded 
vessel,  and  the  rupture  had  occurred  at  the  junc¬ 
tion  of  the  edge  of  this  mass  with  the  side  of  the 
vessel,  and  not  at  the  projecting  point  of  the 
dilatation.  The  tumor  was  on  the  anterior  portion 
of  the  circumference  oi  the  vessel,  and  was  over¬ 
lapped  by  the  lower  edge  of  the  liver,  and  by  a 
portion  of  the  stomach,  which  latter  circum¬ 
stance  may  account  for  the  sensation  of  obstruc¬ 
tion  so  constantly  complained  of  during  life. — 
Philadelphia  Med.  Examiner ,  Oct.,  1846,  p.  583. 

f  This  case  has  been  detailed  at  length  by  Dr. 
Fletcher,  in  the  25th  volume  of  the  Medico- 
Chirurgical  Transactions;  but  for  the  sake  of 
brevity,  I  have  here  given  the  account  published 
by  Dr.  Blakiston  in  his  recent  work  on  “  Certain 
Diseases  of  the  Chest,”  p.  98. 


448  THE  MORBID  CONDITIONS  OF  THE  PULMONARY  ARTERY. 


Inspection. — The  pulmonary  artery  was 
found  dilated  into  a  pouch,  the  interior  cir¬ 
cumference  of  which  measured  nearly  six 
inches,  and  which  pointed  principally  in  the 
anterior  direction,  where  the  internal  and 
middle  coats  were  wanting,  and  where  a 
fibrinous  clot  was  found.  One  of  the  pul¬ 
monary  valves  was  contracted.  The  aorta 
was  first  a  little  dilated,  and  then  contracted, 
particularly  where  it  was  joined  by  the 
ductus  arteriosus.  There  was  also  a  per¬ 
manent  communication  between  the  two 
ventricles. 

Ambrose  Pare  has  recorded  the  somewhat 
doubtful  case  of  a  certain  tailor,  who,  “by 
an  aneurisma  of  the  artenous  vein  [pulmo¬ 
nary  artery],  suddenly,  whilst  he  wasplaying 
at  tennis,  fell  down  dead, —  the  vessel  being 
broken.  His  body  being  opened,  Pare  found 
a  great  quantity  of  blood  poured  forth  into 
the  capacity  of  the  chest  ;  but  the  body  of 
the  artery  was  dilated  to  the  largeness  of  a 
man’s  fist,  and  the  inner  coat  thereof  was 
bony.  For  which  cause  Par£,  within  a 
while  after,  shewed  it  to  the  great  admiration 
of  the  beholders,  in  the  Physicians’  School, 
whilst  he  publiquely  dissected  a  body 
there.”* 

It  is  much  to  be  regretted  that  the  details 
of  the  following  case  have  not  been  more 
satisfactorily  given.  I  quote  the  account 
from  a  periodicalf,  having  failed  to  procure 
a  sight  of  the  work  in  which  it  was  originally 
published. 

In  September  1814  Dr.  Harlan  assisted 
Dr.  Parrish  in  the  examination  of  the  body 

of  Captain  M - ,  a  middle-aged  person  of 

robust  constitution.  His  disease  had  never 
confined  him  to  his  house ;  and  the  day  pre¬ 
ceding  his  death  he  called  on  Dr.  Parrish, 
and  complained  of  dyspnoea  and  pain  in  the 
back  of  his  neck.  His  symptoms  were  re- 
ferred  to  stricture  of  the  oesophagus  ;  and 
Professor  Winstar,  who  was  consulted,  ad¬ 
vised  the  use  of  the  probang  :  the  patient 
deferred  this  operation,  and,  during  the 
same  night,  was  attacked  with  increased 
difficulty  of  breathing  and  exacerbation  of  all 
his  symptoms.  A  bleeder  being  sent  for, 
he  lost  some  blood,  with  temporary  relief; 
but  in  a  short  time  afterwards  he  expired  in 
convulsions. 

The  autopsy  very  unexpectedly  developed 
an  aneurism  of  the  pulmonary  artery,  the 
sac  of  which  extended  so  far  back  as  to  press 
upon  the  oesophagus,  and  produce  symptoms 
of  stricture  in  that  part.  There  was  con¬ 
siderable  effusion  in  the  lungs,  and  a  lump 
of  coagulated  blood  in  the  trachea,  near  the 


*  Book  1st,  De  Tumoribus,  Cap.  XXVIII. 
Condon  edition,  fol.  1649,  p.  204. 

+  Medico-Chirtirgical  Rtview,  July  1839,  from 
Medical  and  Physical  Researches,  by  R.  Har- 
M.D.  F.R.S.  London  and  Philadelphia, 

loo5. 


glottis,  which  most  probably  occasioned  his 
sudden  death.  The  effusion  was  occasioned 
by  the  rupture  of  the  aneurismal  sac,  which 
was  adherent  to  the  air-cells  of  the  lungs. 
Dr.  Harlan  justly  observes  that  it  was  fortu¬ 
nate  the  probang  was  not  employed,* 

Mr.  Fearn,  of  Derby,  has  recordedf  the 
case  of  a  patient  who  died  from  haemopty¬ 
sis,  in  whom  an  aneurismal  sac  of  the  size  of 
a  nutmeg  w  as  found  jutting  into  a  tubular 
extremity  on  the  upper  lobe  of  the  left  lung. 
The  parietes  of  the  sac  were  thin,  and  did 
not  contain  any  fibrinous  layers  ;  a  vessel, 
the  size  of  a  small  crow-quill,  leading  from 
a  considerable  trunk  of  the  pulmonary 
artery ,  was  distinctly  traceable  into  the  sac. 

Dr.  Peacock  has  also  met  with  an  instance 
in  which  a  pulmonary  branch  of  the  size  of  a 
crow-quill  was  found  so  dilated  at  one  spot 
as  to  be  capable  of  holding  a  bean.  This 
dilatation  was  situated  within  a  cavity  hol¬ 
lowed  out  in  the  parenchyma  of  the  lung  con¬ 
taining  blood  ;  the  lining  membrane  of  the 
vessel  was  continuous.  Several  other  cavi¬ 
ties,  containing  pus,  existed  at  the  upper 
part  of  the  lung.  Dr.  Peacock  attributes 
this  lesion  to  the  loss  of  support  which  the 
vessel  must  have  sustained,  owing  to  the  re¬ 
moval  of  the  elastic  substance  of  the  lung  in 
its  vicinity.  He  also  very  justly  denies  the 
identity  of  this  lesion  with  aneurism,  as  it 
occurs  in  the  systemic  arteries. 

The  preparation  numbered  1450GO  in  the 
collection  at  Guy’s,  displays  an  artery  of 
considerable  size,  traversing  the  wall  of  a 
phthisical  cavity,  and  presenting  two  small 
aneurismal  dilatations,  one  of  which  has 
burst  into  the  cavity.  The  lining  of  the 
vomica  appears  to  be  unusually  thin. 
Another  branch,  of  equal  diameter,  occupies 
another  portion  of  the  wall  of  the  excavation; 
its  canal  appears  to  be  obliterated. 

The  lesion  which  destroyed  life  in  the 
following  case  appears  to  have  been  closely 
similar  to  that  form  of  rupture  of  the  proper 
tonics  of  the  aorta  which  usually  gives  rise  to 
dissecting  aneurism  : — A  Pontonier.  twenty- 
one  and  a  half  years  of  age,  who  had  enjoyed 
good  health  excepting  slight  dyspnoea  dur¬ 
ing  three  months  he  had  been  in  the  army, 
after  having  engaged  in  carrying  wood  during 
the  day,  was  roused  in  the  night  by  a  violent 
pain  at  the  right  of  the  sternum,  with  great 
dyspnoea,  which  subsided  in  a  few  minutes. 


*  The  use  of  this  instrument  cannot  be  too 
strongly  deprecated  in  doubtful  cases  of  dyspha¬ 
gia.  I  have  met  with  two  instances  in  which  the 
oesophagus  was  greatly  compressed  by  aneurisms 
or  the  descending  aorta ;  and  in  each  of  which 
— the  structures  of  the  oesophagus  having  be¬ 
come  completely  removed— there  remained  a 
arge  rounded  aperture,  which  was  merely  closed 
oy  thick  layers  of  coagulum.  Had  a  probang 
been  introduced  in  either  of  these  cases  it  must 
have  inevitably  caused  instantaneous  death,  by 
entering  the  aneurismal  sac. 
t  Lancet,  Feb.  6,  1848. 


ON  THE  ANALOGIES  EXISTING  BETWEEN  THE  EYE  AND  THE  EAR.  449 


He  afterwards  became  much  relieved.  Dur¬ 
ing  the  afternoon  of  the  following  day  he 
asked  for  drink,  became  pale  and  collapsed, 
and  died.  On  examination,  a  number  of 
calcareous  concretions  were  found  on  the 
outer  side  or  the  pulmonary  artery ,  close  to 
its  origin,  and  extending  towards  the  right 
ventricle.  The  inner  coat  was  separated 
from  the  elastic  for  ’the  space  ot  three  inches 
from  the  point  at  which  it  joins  the  right 
ventricle,  and  torn  into  shreds,  which  pro¬ 
jected  into  and  narrowed  the  cavity.  The 
whole  lining  membrane  was  coated  with  a 
thin  layer  of  fibrine.  At  its  origin  from  the 
ventricle,  exactly  in  the  situation  where  the 
concretions  terminated,  was  a  hole  of  the 
size  of  a  fourpenny- piece,  through  which  the 
blood  had  escaped  into  the  pericardium  ;  the 
neighbourhood  of  this  opening  was  of  a 
blood -red  colour.  The  lungs  were  healthy 
and  bloodless.* 


OBSERVATIONS  ON  THE 

FUNCTIONAL  AND  ANATOMICAL 
ANALOGIES  EXISTING 

BETWEEN 

THE  EYE  AND  THE  EAR. 
By  J.  D.  Macdonald,  Esq. 

King’s  College. 


An  anatomical  parallel  has  often  been 
attempted  to  be  traced  between  the 
organs  of  vision  and  hearing,  but 
their  special  functions  have  not  been 
duly  born  in  mind  in  any  case,  so  as 
to  furnish,  not  only  an  anatomical,  but 
also  a  physiological  analogy  between 
them.  There  seems  to  be  as  close  a 
correspondence  in  the  structure  of  the 
eye  and  the  ear,  as  there  exists  in  the 
properties  of  light  and  sound;  while 
any  peculiarity  occurring  in  either  or¬ 
gan  may  be  found  to  be  in  accordance 
with  some  special  quality,  characteris¬ 
ing  its  appropriate  stimulus,  although, 
in  the  present  state  of  our  knowledge, 
nothing  decisive  can  be  said  as  respects 
the  function  of  many  wonderful  and 
delicately  constructed  parts  in  both  or¬ 
gans,  which  manifestly  fulfil  some  im¬ 
portant  offices,  as  their  very  existence 
must  demonstrate :  either  indicating 
the  presence  of  many  laws  in  optics 
and  accoustics,  which  experimental 
phil  osophy  has  not  yet  fully  expound¬ 
ed,  or  exhibiting  a  marvellous  applica¬ 
tion  of  known  laws  to  the  fulfilment 


*  Foreign  Med.  Review,  Oct.  1842,  p.  547 :  Dr. 
Helmbrecht,  Casper’s  Wochenschrift. 


of  certain  requirements  in  the  constitu¬ 
tion  of  special  functions.  So  that  it 
would  be  fruitless  to  attempt  a  purely 
anatomical  analogy  apart  from  any 
functional  considerations ;  indeed,  it 
would  seem  more  reasonable  to  trace  a 
physiological  or  functional  parallel  be¬ 
tween  the  eye  and  the  ear,  merely  re¬ 
ferring  to  those  anatomical  points 
which  bear  reference  to  particular  parts 
of  the  subject,  as  they  come  under  no¬ 
tice;  and  the  more  especially  as  a 
greater  complexity  appears  to  be  called 
for  in  the  organization  of  the  ear  for 
the  exercise  of  certain  functions  mani¬ 
festly  analogous  to  those  of  the  eye ; 
and  therefore  the  following  observa¬ 
tions  shall  be  in  accordance  with  this 
arrangement. 

Agreeable  with  those  properties  of 
light  and  sound,  whereby  their  power 
and  intensity  diminish  with  the  square 
of  the  distance,  nature  adopts  suitable* 
means  for  collecting  the  diffused  rays 
of  those  agents  in  sufficient  quantity, 
preparatory  to  their  further  concentra¬ 
tion,  that  an  impression  of  a  necessary 
strength  may  be  conveyed  to  the  seat 
of  perception.  Thus,  in  the  case  of 
the  eye,  the  collection  of  the  rays  of 
light  is  effected  by  dense  refracting 
media  ( the  cornea  andaqneoushumour), 
presenting  an  expanded  convex  surface 
anteriorly,  while  a  funnel-shaped  ap¬ 
paratus  (the  extended  and  generally 
concave  surface  of  the  auricle  and  ex¬ 
ternal  auditory  canal),  is  employed  for 
a  similar  purpose  in  the  ear. 

Now,  although  the  auricle  and  mea¬ 
tus  auditorius  externus,  with  its  short 
hairs  and  glandular  apparatus  (anato¬ 
mically  considered),  unquestionably 
correspond  with  the  palpebral  appen¬ 
dages  of  the  eye,  comprehending  espe¬ 
cially  the  tarsal  fibro  cartilages,  the 
cilice  and  meibomian  follicles,  yet  the 
office  of  the  auricle,  in  receiving  the 
rays  of  sound,  and  transmitting  them 
by  the  external  meatus  to  the  middle 
ear,  is  too  important  a  function  to  be 
passed  over  in  the  simple  notice  of  the 
anatomical  analogy  just  mentioned. 
Indeed,  the  eyelids  rather  tend  to  di¬ 
minish  the  quantity  of  light  entering 
the  eye,  being  watchful  guardians 
against  its  excess,  or  the  injurious  con¬ 
tact  of  foreign  matters;  nevertheless, 
among  savage  tribes  a  corresponding 
function  is  enjoyed  by  the  auricle  and 
outer  orifice  of  the  meatus :  for  the  mus¬ 
cles  of  the  auricular  region,  and  the 


450  MB.  MACDONALD  ON  THE  FUNCTIONAL  AND  ANATOMICAL 


small  muscles  of  the  prima  itself  (which 
are  delicate  and  rudimentary  in  civi¬ 
lised  nations),  are  largely  developed, 
fulfilling  all  their  offices  (merely  indi¬ 
cated  by  the  course  and  attachment  of 
their  fibres  in  the  European)  with  more 
or  less  energy.  But  the  action  of  the 
attrahens,  attaints,  and  retrehens  auris, 
in  perking  or  otherwise  adjusting  the 
auricle,  bears  a  strict  relation  to  its  re¬ 
ception  of  sonorous  undulations,  and 
their  transmission  to  the  tympanum. 

We  have  next  to  consider  the  means 
adopted  by  nature  in  both  the  eye  and 
ear  for  the  further  concentration  of 
their  appropriate  stimuli,  effecting  dis¬ 
tinct  vision  and  hearing  in  the  respec¬ 
tive  organs.  In  the  eye  this  require¬ 
ment  is  fulfilled  by  a  body  (the  lens) 
of  greater  density  and  refracting  power 
than  those  employed  primarily  in  col¬ 
lecting  the  luminous  rays  :  and  in  the 
^ar  by  a  membranous  expansion  (the 
membrana  tympani),  having  a  coni¬ 
cally  depressed  external  surface,  beau¬ 
tifully  adapted  for  convening  the  rays 
of  sound  falling  upon  it,  and  bringing 
them  to  bear,  by  means  of  another 
much  smaller  membrane  (the  membra- 
na  fenestra  ovalis),  connected  with  it 
through  the  medium  of  several  small 
and  dense  bones  (the  ossicula  auditus), 
in  a  concentrated  form  upon  the  inter¬ 
nal  ear. 

Now,  whether  (in  a  purely  anatomi¬ 
cal  point  of  light)  we  consider  the 
tnembrana  tympani,  overlaid  with  the 
lining  membrane  of  the  meatus  au- 
ditonus,  to  represent  the  cornea  of  the 
eye,  with  its  investment  of  conjunctive 
membrane,  or  to  correspond,  as  Dr. 
Wharton  Jones  ingeniously  supposes, 
to  an  accidental  mediate  anchyloble- 
pharon,  which  is  unquestionably  the 
true  opinion,*  it  is  certain  that  sound 


*  In  examining1  the  organ  of  vision  in  serpents, 
we  perceive  that  what  would  at  first  sight  be 
taken  for  a  cornea,  is  in  reality  a  natural  mediate 
anchyloblepharon,  which  may  be  said  to  be  ana¬ 
logous  to  the  tnembrana  tympani.  Between  it 
and  the  eye-ball  itself  a  space  exists  correspond¬ 
ing  with  the  cavity  of  the  tympanum.  This 
space  is  lined  by  the  true  conjunctiva  (the  occulo- 
palpebral  sac  of  Cloquet),  agreeing  with  the 
lining  of  the  tympanic  cavity  :  into  this  bag  the 
lachrymal  ducts  open,  and  the  lachrymal  sac 
communicating  with  it  is  answerable  to  the  Eus¬ 
tachian  tube  of  the  ear. 

There  seems  to  be  a  greater  similarity  of  ar¬ 
rangement  in  the  organization  of  the  eye  and 
ear,  in  this  order  of  beings,  than  can  be  said  to 
exist  in  higher  forms  of  animal  life ;  and  also  (as 
contrasted  with  the  comparison  of  both  organs 
in  such  animals)  a  stronger  analogy  between  the 
eye  of  the  former  and  the  ear  of  the  latter :  and 


suffers  no  further  concentration  than 
what  the  membrana  tympani  and  ossi¬ 
cles  effect  upon  it,  independent  of  the 
influence  which  the  otakania  may  have 
in  strengthening  the  impression  ;  just 
as,  in  the  case  of  the  eye,  no  farther 
concentration  of  light  takes  place  after 
its  transmission  through  the  lens,  al¬ 
though  we  may  as  yet  be  unable  to  say 
what  office  the  club-shaped  particl.  s  of 
Jacob’s  membrane,  and  other  complex 
parts  of  the  retina,  may  exert  in  aug¬ 
menting  its  operation  upon  the  nerve. 

Besides  the  power  which  the  exter¬ 
nal  ear  enjoys  (more  or  less)  in  modi¬ 
fying  the  amount  of  sound  entering 
into  the  internal  ear,  analogous  to  that 
possessed  by  the  eyelids  in  preventing 
an  injurious  excess  of  light  from  im¬ 
pinging  on  the  retina,  there  are  in 
both  organs  additional  parts  fulfilling 
this  office  more  efficiently,  and  having 
reference  both  to  the  due  exercise  of 
the  functions  and  the  safety  of  each 
organ,  and  also  seeming  to  effect  those 
adaptive  changes  in  them  which  must 
vary  with  the  distance  from  whence 
their  natural  stimuli  arise,  and  to  in¬ 
duce  in  the  eye  and  ear  respectively  a 
distinct  perception  of  those  objects  or 
sounds  to  which  the  mind  is  especially 
directed,  amongst  a  great  many.  Thus, 
in  the  eye,  the  iris,  from  its  wonderful 
sympathy  with  the  optic  nerve,  allows 
only  those  luminous  rays  to  impinge 
on  the  retina  which  are  necessary  for 
distinct  vision,  shutting  out,  by  con¬ 
traction  of  the  pupil,  all  that  are  super¬ 
fluous  and  injurious  ;  while  the  ciliary 
muscle,  by  constricting  the  ciliary  pro¬ 
cesses,  and  thereby  drawing  upon  the 
anterior  wall  of  the  canal  of  Pettit, 
which  is  fixed  into  the  forepart  of  the 
capsule  of  the  lens,  appears  to  effect 
the  necessary  adaptation  to  distance ; 
for  the  lens  being  soft  and  compressi¬ 
ble  towards  the  surface  will  admit  of 
such  changes  in  its  figure  as  shall  alter 
its  convening  power,  and  insure  a  dis¬ 
tinct  image  at  all  distances.  These 
functions,  as  far  as  we  yet  know,  are 
performed  in  the  ear  by  the  muscular 
apparatus  in  connection  with  the 
moveable  ossicula  auditus,  which  by 
altering  the  tension  of  the  membrana 
tympani,  and  exerting  pressure  on  the 
membrana  fenestra:  ovalis,  and  thereby 


thus,  by  comparative  anatomy,  is  indicated  the 
relative  superiority  of  the  organ  of  vision  to  that 
of  hearing. 


ANALOGIES  EXISTING  BETWEEN  THE  EYE  AND  THE  EAlt.  451 


upon  the  perilymph ,  render  the  con¬ 
ducting  power  of  those  media  more  or 
less  perfect,  and  thus  adapt  the  organ 
to  the  reception  of  strong  or  weak, 
high  or  low,  near  or  distant,  sounds. 

The  cochlea,  with  the  membranous 
spiral  lamina  and  membrana  fenestras 
rotunda ,  may  be  noticed  here,  as  an¬ 
swering  the  purpose  of  a  safety  valve, 
preventing  the  injurious  influence  of 
undue  force  applied ;  for,  as  Weber  has 
shown,  any  pressure  exerted  by  the 
stapes  on  the  oval  membrane  causes  a 
protrusion  of  the  membrana  fenestras 
rotundas  towards  the  tympanum ;  so 
that  the  yielding  nature  of  tliis  mem¬ 
brane,  and  no  doubt  the  membranous 
spiral  lamina,  compensates  such  pres¬ 
sure,  and  a  delicate  adjustment  is  ef¬ 
fected,  as  the  nature  of  the  case  may 
require. 

Considering  the  external  and  middle 
divisions  of  the  organ  of  hearing  as 
necessary  appendages,  supplied  in  ac¬ 
cordance  with  the  general  laws  of 
sound,  and  affording  those  analogies, 
functional  and  anatomical,  as  relates 
to  the  organ  of  vision,  which  we  have 
endeavoured  to  trace  above,  the  inter¬ 
nal  ear  remains  to  be  noticed. 

In  this  essential  division  of  the  organ 
of  hearing  (which  has  been  appro¬ 
priately  termed  the  ear-bulb),  a  very 
close  analogy  is  afforded  to  the  eye-ball 
in  nearly  every  particular  ;  but  there 
are  many  modifications  in  the  figure 
and  repetitions  of  the  parts  of  the  for¬ 
mer,  rendering  the  consideration  of  the 
subject  complex. 

The  membrana  rotunda  (called  also 
membrana  tympani  secondaria )  has 
been  likened  to  the  cornea.  The  scala 
tympani  and  scala  vestibuli  of  the  coch¬ 
lea  have  been  respectively  considered 
to  correspond  to  the  anterior  and  pos¬ 
terior  chambers  of  the  eye,  filled  with 
the  aqueous  humour  (considered  by 
Breschet  as  analogous  to  the  peri¬ 
lymph),  the  helicotrema  being  answera¬ 
ble  to  the  pupil.  The  endolyrnph  cor¬ 
responds  to  the  vitreous  humour;  and 
the  otokonia,  or  calcareous  concretions, 
have  been  compared  to  the  lens  ;  while 
the  several  divisions  of  the  auditory 
nerve,  taken  collectively  of  course,  re¬ 
present  the  retina. 

With  regard  to  the  membranes,  and 
many  important  considerations,  refe¬ 
rence  must  be  had  to  Dr.  Wharton 
Jones’s  excellent  parallel  (in  Dr.  Todd’s 
Cyclopaedia).  But  there  is  one  point 


that  has  been  overlooked  by  the  writer 
of  that  article,  which  is,  that  the  direct 
current  of  sonorous  undulations  un¬ 
questionably  passes  along  the  dense 
chain  of  ossicles  to  the  labyrinth, 
through  the  membrana  fenestra  ova  is  ; 
and  the  mere  consideration  of  its  yield¬ 
ing  character,  as  bearing  an  analogy  to 
the  thinning  of  the  sclerotica  in  the 
eye  of  the  Greenland  seal,  is  not  satis¬ 
factory,  for  the  functional  parallel  will 
distinctly  show  that  it  must  be  recog¬ 
nised  as  fulfilling  the  office  of  cornea 
to  the  ear,  as  well  as  the  membrana 
rotmda,  which  cannot  be  exclusively 
assigned  to  the  latter;  and  besides,' it 
is  alone  in  virtue  of  the  membrana 
ovalis  that  an  analogous  function 'to 
that  performed  by  the  iris  can  be 
effected  by  the  spiral  lamina  in  the 
cochlea ;  except,  indeed,  what  the 
cochlearis  muscle  (described  in  Dr. 
Todd  and  Mr.  Bowman’s  Physiology) 
may  exert  in  altering  its  tension  :  and 
the  current  of  sound  in  the  scala 
vestibuli  must  undoubtedly  pass  in  the 
inverse  direction  to  that  which  the 
anatomical  analogy  would  lead  us’  to 
suppose.  Indeed,  it  appears  that  the 
sonorous  current  entering  by  the  mem¬ 
brana  rotunda ,  has  its  operation  alone 
upon  the  cochlear  nerve,  the  anatomical 
arrangement  of  which  favours  this 
opinion.  This  current  in  the  scala 
tympani  may  be  strengthened  or  modi¬ 
fied  in  its  operation  by  that  from  the 
scala  vestibuli.  v 

This  consideration  in  reference!  to 
the  cochlea  is  of  deep  interest ;  and 
how  far  it  may  be  connected  with  the 
perception  of  pitch  in  sounds  it  is  at 
present  impossible  to  say  :  whethei*  by 
a  property  of  refrangibility  in  them, 
analogous  to  that  of  colours,  a  collision 
of  the  currents  above  noticed  may  take 
piece  in  different  parts  of  the  scala 
tympani,  according  to  the  pitch,  and 
thus  (impressing  the  cochlear  nerve  in 
particular  localities),  enable  the  mind 
to  perceive  the  relation  that  one  note 
bears  to  another  in  the  musical  scale  : 
or  whether,  simply  by  the  flowing  of 
the  currents  of  sound  in  opposite  direc¬ 
tions  (the  impression  being  in  effect 
doubled),  the  mind  is  better  able  to 
discriminate  between  notes  of  different 
pitches,  and  associate  them  according 
to  their  natural  sympathies  :  and  the 
due  exercise  of  the  law  of  interference 
no  doubt  is  favoured  by  a  such  an 
arrangement.  This  supposition  is 


452  MR.  HANCORN  ON  THE  TREATMENT  OF  ASIATIC  CHOLERA. 


heightened  by  the  fact,  that  the  most 
exalted  function  which  the  human  ear, 
as  well  as  that  of  the  lower  animals, 
possesses,  is  the  discrimination  of  the 
pitch  of  sounds;  and  the  existence  of 
the  cochlea  is  the  highest  mark  of 
perfection  in  the  organization  of  the 
ear. 

There  are  many  more  points  to  be 
noticed  in  the  functional  analogy  under 
consideration,  which  must  be  defered 
for  a  future  communication. 

[To  be  continued.] 


ON  THK 

TREATMENT  of  ASIATIC  CHOLERA. 
By  J.  R.  Hancorn,  Esq. 


In  times  of  great  and  natural  anxiety 
arising  from  the  apprehended  approach 
of  a  most  formidable  and  fearful  disease, 

• — the  more  especially  as  the  true  nature 
of  that  disease  is  so  indistinctly  under¬ 
stood,— it  appears  to  me  requisite  to  call 
upon  the  proper  authorities,  whoever 
they  may  be,  whether  the  Royal  Col¬ 
lege  of  Physicians,  ora  Central  Board 
of  Health,  to  come  forward  and  pro¬ 
pose  some  legitimate  line  of  treatment 
for  the  guidance  of  the  profession 
generally,  the  majority  of  whom  are  in 
a  great  state  of  uncertainty  as  to  the 
best  mode  of  meeting  the  enemy,  many 
not  having  seen  a  case,  and  all  in 
doubt,  which  must  necessarily,  at  the 
onset,  lead  to  a  fearful  loss  of  life 
before  their  experience  teaches  them 
to  pursue  some  rational  mode  of  treat¬ 
ment. 

In  the  absence  of  an  authorised 
mode  of  treatment,  it  behoves  every 
practitioner  who  has  had  the  misfor¬ 
tune — or,  1  may  say,  under  the  circum¬ 
stances,  the  good  fortune — to  witness 
this  direful  disease,  to  come  forward 
and  shew  his  experience  for  the 
guidance  of  others.  This  is  my  pre¬ 
sent  object;  and,  without  entering 
into  a  long  and  useless  dissertation 
upon  the  pathology  of  the  disease,  I 
propose  to  offer  a  systematic  course  of 
medicinal  remedies  which,  in  1831  32, 
I  found  most  successful  in  the  treat¬ 
ment  of  a  large  number  of  cases.  This 
statement  can  be  corroborated  by  Dr. 
Warden,  then  surgeon  of  Sheerness 
Dockyard;  Di„  Gooch,  of  the  Ocean 


flag-ship  at  the  same  port ;  and  other 
surgeons. 

Cholera  is  sometimes  ushered  in  by 
simple  diarrhoea;  and  at  others  it 
commences  at  once  in  the  most  agrrra- 
vated  form,  and  terminates  in  death  in 
the  short  period,  as  I  have  witnessed 
it,  of  four  hours. 

In  the  former  case  it  would  be  pre¬ 
mature  in  me  to  offer  suggestions ; 
nevertheless,  it  will  be  perhaps  advisa¬ 
ble  to  give  my  treatment  from  its  com¬ 
mencement  to  its  termination. 

If  the  attack  begin  with  a  feeling  of 
nausea,  a  very  gentle  emetic  may  pre¬ 
face  the  other  remedies,  as  Pulv. 
Ipecac.  3ij.;  but,  if  there  be  merely 
uneasiness  and  relaxation  of  the 
bowels,  then  the  following  : — |jc  Ext. 
Opii,  gr.  ij. ;  Hvd.  Chlorid.  gr.  iv.  in 
pill,  to  be  followed  in  two  hours  by 
castor  oil,  f  oz.  About  two  hours  after 
this  give  two  table-spoonfuls  of  the 
following  mixture  every  two,  three,  or 
four  hours,  according  to  the  urgency  of 
the  symptoms: — ^  Ammon.  Sesqui- 
carb.  3j. ;  Soda?  Sesquicarb.  5i- ;  Conf. 
Aromat.  5j* ;  Tinct.  Capsici,  nqxxx.  ; 
Liq.  Opn  Sedat.  ITfxxx. ;  Misturse 
Camph,  ad  ^vj.  Misce. — Hyd.  c. 
Cret.  gr.  iij. ;  Pulv.  Capsici,  gr.  iij.  in 
powder,  to  be  taken  every  four  hours, 
as  well  during  the  collapse  stage  as  that 
of  simple  diarrhoea,  always  taking  care 
that  the  mercurial  preparation  be  not 
carried  too  far;  it  being  of  the  utmost 
importance  to  keep  up  the  secretion  of 
the  liver,  the  proper  action  of  which 
will  be  found  to  be  the  great  security 
against  the  after-consequences,  viz. 
typhus  fever. 

Should  the  Asiatic  cholera  super¬ 
vene,  I  would  strongly  urge  my  pro¬ 
fessional  brethren  to  try  the  styptic 
remedy  which  l  found  so  remarkably 
successful  in  1832,  viz.  Tmctura  Ferri 
Sesquichloridi.  This  was  my  sheet- 
anchor,  and  I  gave  it  in  as  concentrated 
a  form  as  possible  immediately  after 
each  ejection. 

Whatever  may  be  the  nature,  cause, 
or  original  seat  of  disease  in  Asiatic 
cholera,  the  effect  produced  appears  to 
be  an  atony  of  the  secretory  and  ex¬ 
cretory  ducts  and  mucous  follicles.  It 
therefore  follows  as  a  natural  indica¬ 
tion  to  restore  power  and  tone  to  these 
vessels  as  speedily  as  possible,  and  this 
is  best  effected  by  the  administration 
of  styptics.  When  I  used  the  Tinct. 
Sesquichlor.  in  1831-32,  its  immediate 


FORMATION  OF  PEARLS  IN  THE  URINARY  BLADDER  OF  A  BULLOCK.  453 


effect  in  reducing  the  quantity  of  fluid 
ejected  was  truly  astonishing,  and  it 
gradually  diminished  after  each  dose, 
until  it  ceased  altogether,  and  the  cure 
was  effected.  It  should  be  remarked, 
that,  after  this  medicine,  the  evacua¬ 
tions,  instead  of  being  like  rice-water, 
are  black.  This  should  be  explained, 
otherwise  the  b)standers  become  much 
alarmed,  and  fancy  that  mortification 
has  ensued. 

As  a  local  application  for  the  relief 
of  cramp,  I  found  the  following  lini¬ 
ment  far  preferable  to  mustard  poul¬ 
tices,  not  only  from  its  stimulating 
properties,  but  because  the  requisite 
friction  in  using  it  is  of  itself  an  effica¬ 
cious  remedy  : Acid.  Sulph.  Fort. 
5iss.;  01.  Olivse,  ^iss.  M.  ft.  lini¬ 
ment.  ;  the  only  objection  to  its  use 
being  its  destructive  action  on  the 
linen,  which  is  of  little  moment,  con¬ 
sidering  the  direful  nature  of  the 
malady. 

The  hot-air  bath  should  be  had  re¬ 
course  to.  This  is  easily  effected  by 
means  of  a  small  spirit-lamp  and  appa¬ 
ratus  on  the  principle  of  Sir  H.  Davy’s 
safety-lamp,  which  is  merely  placed 
under  the  bed-clothes,  when  any  de¬ 
gree  of  heat  may  be  induced. 

I  cannot  too  strongly  urge  the 
avoidance  of  brandy  or  large  doses  of 
opium  :  they  both  enervate  the  sys¬ 
tem,  prostrate  the  vital  energies,  and 
though  the  extreme  coldness  of  the 
surface  of  the  body,  the  coldness  of 
the  tongue — nay,  the  coldness  of  the 
breath  itself — wrnuld  seem  to  indicate 
the  former,  yet  it  is  not  so,  for  the 
patient  complains  of  the  most  agonising 
thirst,  and  intense  heat  in  the  epigas¬ 
tric  region,  which  is  best  allayed  by 
the  free  use  of  iced  soda-water,  iced 
champagne,  and  even  small  pieces  of 
ice  retained  in  the  mouth,  and  occa¬ 
sionally  swallowed. 


ON  THE 

FORMATION  OF  PEARLS  IN  THE 
URINARY  BLADDER  OF 
A  BULLOCK. 

By  Alfred  S.  Taylor,  F.R.S. 
Lecturer  on  Chemistry,  &c.  in  Guy’s  Hospita]. 


I  lately  received  from  Mr.  Image,  of 
Bury  St.  Edmunds,  several  concretions 
which  had  been  taken  from  the  urinary 


bladder  of  a  bullock.  They  were 
perfectly  spherical,  and  varied  in  dia¬ 
meter  from  about  the  sixteenth  to  the 
eighth  of  an  inch.  They  had  a  light 
yellowish  colour,  and  some  of  them 
were  strongly  iridescent  with  a  dis¬ 
tinct  pearly  lustre.  The  largest,  which 
was  about  the  eighth  of  an  inch  in 
diameter,  weighed  only  06  grain,  but' 
it  was  bulky  compared  with  its  weight. 
The  mean  specific  gravity  of  four  of 
the  calculi  was  found  to  be  2.  The 
surface  had  no  appearance  of  rough¬ 
ness,  or  of  a  crystalline  character :  it 
was  smooth  and  shining;  and,  from 
the  examination  of  a  fractured  portion, 
it  was  found  that  the  calculus  was 
made  up  of  very  thin  concentric  la¬ 
minae,  having  the  same  pearly  irides¬ 
cent  lustre.  It  was  so  hard  as  to 
require  trituration  in  an  agate-mortar, 
in  order  to  reduce  it  to  a  fine  powder. 
The  first  effect  of  pulverizing  the 
calculus  was  to  separate  it  into  fine 
scales,  having  a  strong  nacreous  lustre, 
and  of  a  light  golden  yellow  colour. 
There  was  no  nucleus. 

A  portion  of  the  fine  powder,  which 
was  of  a  brownish  white  colour,  when 
heated  on  platina  gave  out  the  smell 
of  burning  animal  matter,  and  a  slight 
carbonaceous  residue  was  left.  When 
this  was  burnt  off,  a  white  alkaline  ash 
was  obtained,  which  was  proved  to  be 
lime.  Another  portion  of  the  pow¬ 
dered  calculus  was  entirely  dissolved 
by  all  acids  with  effervescence,  and  the 
solution  was  found  to  consist  of  a  salt 
of  lime,  without  any  admixture  of 
magnesia  or  phosphoric  acid.  There 
was  no  uric  acid  present.  Hence  the 
concretion  was  proved  to  be  carbonate 
of  lime  arranged  in  spherical  layers, 
and  intermixed. with  a  small  portion 
of  animal  matter. 

Mr.  Image  informs  me  that  no  less 
than  150  of  these  calculi  were  taken 
from  the  bladder  of  the  bullock. 

Urinary  concretions  of  carbonate  of 
lime  are  very  unusual  in  the  human 
subject.  They  are,  however,  frequently 
met  with  in  a  rough  and  amorphous 
state  in  herbivorous  animals.  Dr. 
Bird*  is,  so  far  as  I  can  ascertain,  the 
only  writer  who  has  pointed  out  the 
strong  resemblance  to  pearls  which 
these  concretions  occasionally  possess. 
This  singular  fact  is  not  noticed  by 
Scharling,  Vogel,  or  L’Heritier,  nor 


*  Urinary  Deposits,  2d  edition,  p.  247. 


454 


THE  ESSEX  POISONINGS — CAUSES  OF  THE 


can  I  find  any  description  of  them  in 
the  last  edition  of  Dr.  Prout’s  work  on 
Renal  Diseases.  Dr.  Bird  appears  to 
have  met  with  them  of  very  small  size 
compared  with  those  examined  in  the 
present  case,  since  he  speaks  of  their 
appearance  under  the  microscope.  He 
says  of  them — “These  beautiful  little 
bodies  present  a  remarkable  resem¬ 
blance  to  pearls,  the  well-known  con¬ 
cretions  of  the  pearl-oyster.  Indeed, 
they  may  almost  be  regarded  as  urinary 
pearls.” 

I  have  since  procured  some  of  the 
oyster-pearls  rejected  by  jewellers  in 
consequence  of  their  dark  colour,  and 
find  them  to  be,  in  physical  structure 
and  chemical  composition,  ident  cal 
with  those  taken  from  the  bladder  of 
the  bullock.  There  is  nothing  sur¬ 
prising  m  this  analogy,  when  it  is  con¬ 
sidered  that  the  oyster  is  partly  com¬ 
posed  of  mucus  similar  to  that  of  the 
mucous  lining  of  the  urinary  bladder, 
and  that  the  base  lime  is  present  in 
sea- water  as  well  as  in  urine.  Under 
some  morbid  condition  of  the  system, 
the  lime  meets  with  carbonic  acid,  and, 
when  the  deposit  takes  place  very 
slowly  and  uniformly  around  a  centre, 
a  sphere  of  carbonate  of  lime,  having  a 
pearly  lustre,  may  be  thus  formed  in 
either  case.  Pearl  consists  of  concen¬ 
tric  layers  of  carbonate  of  lime  inter- 
stratified  with  animal  matttr.*  When 
this  is  abundant,  and  of  a  dark  colour, 
the  pearl  is  rejected  as  unfit  for  orna¬ 
mental  purposes.  Dr.  Ure  states  that 
the  oyster- pearl  is  formed  under  a  dis¬ 
ease  caused  by  the  introduction  of 
foreign  bodies  within  the  shells.  In 
making  a  careful  examination  of  an 
oyster-pearl,  I  have  found  no  foreign 
body  :  the  whole  consisted  of  carbonate 
of  lime,  the  internal  portion  being  of 
a  brownish  colour,  and  amorphous, 
while  the  external  portion  was  com¬ 
posed  of  thin  concentric  layers  having 
the  usual  pearly  lustre. 


*  From  an  analysis  made  by  Mr.  Hatchett,  a 
pearl  was  found  to  consist,  in  100  parts,  of  66 
carbonate  of  lime,  and  34  of  animal  matter. 
Mother  of  pearl  has  the  same  composition.  The 
iridescence  of  pearl  is  very  great  when  the 
grooves  or  edges  of  the  laminae  are  made  to 
appear  by  artificial  cutting.  It  is  not  commonly 
known  that  pearl,  thus  cut,  will  give  an  irides¬ 
cent  impression  on  black  sealing-wax  or  fusible 
metal :  thus  proving  that  colour  often  depends  on 
the  physical  conformation  of  surface. 


MEDICAL  GAZETTE. 


FRIDAY,  SEPTEMBER  15,  1848. 


In  another  part  of  the  journal*  we 
insert  two  letters  in  reference  to  a  sub¬ 
ject  which  has  of  late  greatly  attracted 
the  attention  of  the  public — namely, 
the  concealment  of  murder  by  secret 
poisoning.  The  one  is  addressed  to 
the  Times  by  Mr.  Payne,  Coroner  for 
the  City  of  London,  and  the  other  to 
our  respectable  contemporary,  the  Pro¬ 
vincial  Medical  Journal.  The  latter 
will  be  found  to  furnish  a  satisfactory 
answer  to  the  former.  Mr.  Payne’s 
remedy  for  an  evil  of  this  kind  is — 
“  More  coroners’  inquests  while  Mr. 
Prichard  suggests  “  More  post-mortem 
inspections,  and  greater  circumspec¬ 
tion  in  holding  inquests.”  That  Mr. 
Payne,  occupying  the  office  of  coroner, 
and  deriving  a  salary  from  the  number 
of  inquests  held,  should  consider  the 
remedy  to  lie  in  increasing  the  num¬ 
ber,  is  natural  enough  ;  but  his  conclu¬ 
sion  is  so  little  supported  by  the  facts 
which  he  adduces,  and  is  so  adverse 
to  that  which  a  comprehensive  and 
disinterested  view  of  the  subject  would 
suggest,  that  we  must  take  the  libeity 
to  examine  his  statements  rather 
closely.  This  is  the  more  incumbent 
upon  us,  because  the  subject  is  really 
one  of  great  public  importance ;  and,  in 
an  article  recently  published,  we  have 
arrived  at  conclusions  wholly  different 
from  those  advocated  by  Mr.  Payne. 
Like  an  unskilful  logician,  he  adduces 
instances  of  impediments  thrown  in 
the  way  of  holding  inquests  in  all 
other  districts  except  in  that  which  is 
especially  in  question.  It  cannot, 
we  think,  be  imputed  to  the  coroners 
or  magistrates  of  Essex  that  they  are 

*  See  pages  471  and  172. 

son  ni, 41  s  of  3  fir  afsanpnr  io  lodo 


455 


CONCEALMENT  OF  SECRET  MURDER  BY  POISON. 


neglectful  in  the  performance  of  their 
public  duties.  On  the  contrary,  we 
have  reason  to  believe  that  there  is 
no  county  in  England  provided  with 
coroners  more  active  in  their  office, 
or  with  magistrates  more  liberal  in 
awarding  those  expenses  which  are 
necessarily  incurred  in  the  investiga¬ 
tion  of  crime.  The  conduct  of  the 
justices  of  Devon,  therefore,  in  re¬ 
fusing  payment  of  the  fees  for  an 
inquest  held,  as  we  believe,  most  un¬ 
necessarily,  or  of  the  Norfolk  or  Lan¬ 
cashire  magistrates,  is  quite  irrelevant 
to  the  present  inquiry.  The  dis¬ 
couragement  of  inquests  by  magis¬ 
trates  has  not  yet  extended  to  Essex : 
hence  Mr.  Payne’s  theory  fails  to 
account  for  the  temporary  concealment 
of  murders  by  poison  perpetrated  in 
that  county.  The  array  of  facts  which 
he  has  brought  forward,  appears  to 
shew  that  coroners’  inquests  are  not 
held  so  frequently  as  they  ought  to  be  ; 
but  we  could  easily  collect  a  much 
larger  number,  proving  clearly  that 
they  are  too  often  held  in  cases  in 
which  not  the  least  suspicion  of  death 
from  violent  causes  could  be  enter¬ 
tained.  The  fact  is,  an  excess  of 
officiousness  one  way  begets  neglect  in 
another.  An  aged  person  dies  in  the 
presence  of  credible  witnesses,  or  while 
under  the  supervision  of  a  respectable 
medical  practitioner.  Neither  food 
nor  medicine  may  have  passed  the  lips 
of  this  person  for  many  hours  pre¬ 
viously  to  death :  there  can  therefore 
be  no  pretence  for  alleging  that  the 
individual  has  been  poisoned,  and 
there  is  not  the  slightest  reason  to 
suppose  that  any  violence  has  been 
offered  to  accelerate  or  cause  death. 
Such  a  case,  however,  is  very  fre¬ 
quently  made  the  subject  of  an  inquest, 
apparently  on  no  other  ground  than 
that  the  salary  of  an  over-zealous 
coroner  is  actually  dependent  upon  the 
number  of  inquests  held.  It  cannot 


be  for  the  purpose  of  what  Mr.  Payne 
denominates  “  the  certainty  of  detec¬ 
tion”  of  crime,  for  the  plain  reason 
that,  in  nineteen  out  of  twenty  such 
cases,  a  post-mortem  inspection  is  not 
considered  necessary  :  and  how,  in  a 
case  really  demanding  inquiry,  there 
can  be  any  certainty  of  detecting  crime 
without  this  very  necessary  procedure, 
we  are  quite  at  a  loss  to  understand. 
But  then  we  are  told  by  the  writer: — 

“  It  is  the  certainty  of  investigation 
that  operates  as  the  preventive  to 
crime  ;  and  nothing  tends  so  much  to 
the  encouragement  of  crime,  as  the 
course  adopted  in  some  counties  of 
discouraging  these  investigations.” 

We  fully  agree  in  this  proposition, 
but  it  rather  tells  against  Mr.  Payne’s 
argument;  because,  while  he  is  calling 
out  for  more  inquests,  the  public  and 
profession  have  the  strongest  reason  to 
complain,  that,  in  the  majority  of 
cases,  inquests  are  held  in  so  slovenly 
a  manner,  that  certainty  of  investiga¬ 
tion  is  entirely  lost  sight  of.  Let  us 

take  the  second  case  adduced  bv  Mr. 

* 

Prichard,*  which  is  only  the  type  of 
some  hundreds  of  cases  that  occur 
yearly  in  this  country.  A  child  is 
found  dead  in  bed;  an  inquest  is  held; 
the  jury  look  at  the  body,  and  come  to 
the  conclusion,  without  a  post-mortem 
inspection,  which  the  coroner  does  not 
consider  necessary,  that  the  child  has 
died  in  a  jit !  Is  this  “  the  certainty  of 
investigation”  which  Mr.  Payne  re¬ 
gards  as  a  sure  method  of  suppressing 
the  crime  of  secret  poisoning  ?  Or,  to 
put  the  question  in  another  form,  is  it 
not  likely  to  encourage  murder  by 
poison,  to  hold  what  is  called  an  in¬ 
quest  on  a  body,  without  requiring  a 
post-mortem  examination?  The  most 
ignorant  person  knows  that  the  traces 
of  the  action  of  poison  can  be  detected 
in  no  other  way ;  and  murderers  are 


*  See  page  472. 


456 


THE  ESSEX  POISONINGS - CAUSES  OF  THE 


thus  taught  to  speculate  upon  the 
chance  that,  if  an  inquest  should  be 
held,  the  crime  may  be  overlooked. 
Mr.  Prichard’s  case  is  by  no  means  a 
solitary  one  :  the  former  volumes  of 
this  journal,  as  well  as  of  our  contem¬ 
porary  the  Lancet,  abound  in  letters  of 
complaint  from  medical  practitioners 
on  the  neglect  of  post-mortem  inspec¬ 
tions  at  coroners’  inquests,  and  on  the 
concealment  of  deaths  from  suspicious 
causes.  The  Registrar-General  has 
also,  in  his  yearly  reports,  called  espe¬ 
cial  attention  to  the  general  neglect  of 
inspections  on  the  part  of  coroners, 
and  of  their  allowing  verdicts  to  be  re¬ 
turned  upon  mere  conjecture.  A  valued 
correspondent,  quoting  the  report  of 
the  Registrar- General  for  1841,*  states 
that  out  of  no  less  than  6708  cases  of 
sudden  death,  whichbecamethesubjects 
of  coroners’  inquests,  during  the  years 
1838-9,  the  cause  of  death  was  not 
ascertained  in  one  !  In  fact,  in  twro 
out  of  three  sudden  deaths,  the  verdict 
is  what  is  called  open,  i.  e.  “  found 
dead,”  “  died  by  the  visitation  of  God,” 
&c.  We  should  not  object  to  this,  if 
inspections  were  made,  but  they  are 
not  made,  and  thus  many  instances 
of  death  from  poison  must  certainly  es¬ 
cape  detection. f  With  a  knowledgeof 
these  facts,  accessible  to  every  one 
holding  the  office  of  coroner,  we  must 
express  our  great  surprise  that  a  writer 
should  have  the  courage  to  state  in  a 
public  journal,  that  more  inquests  are 
required  if  wre  wish  to  suppress  the 

*  See  our  volume  xxxvi.  p.  592. 

f  For  three  cases  of  this  kind,  see  the  paper 
above  alluded  to,  vol.  xxxvv  p.  592.  Since  these 
remarks  were  in  type,  we  have  been  informed 
of  a  case  of  recent  occurrence,  which  is  well 
calculated  to  test  the  value  of  Mr.  Payne’s 
remedy  of  “  more  inquests.”  A  boy  died  some¬ 
what  suddenly,  and  there  was  a  suspicion  that 
he  had  died  from  a  violent  cause.  The  coroner 
did  not  require  a  post-mortem  inspection,  and, 
under  his  direction,  the  jury  returned  a  verdict  of 
“  Died  by  the  visitation'of  God  ”  The  body  was 
subsequently  examined  by  a  medical  gentleman, 
who  found  in  the  trachea  a  mass  of  the  pith  of 
elder,  which  had  blocked  up  the  bronchi  and 
led  to  death  by  suffocation !  So  much  for  the 
certainty  of  detecting  the  cause  of  death  by 
inquests 


crime  of  secret  poisoning;  when  the 
fact  is,  that  in  two-thirds  of  all  inquests, 
as  at  present  conducted,  no  pains  are 
taken  to  determine  the  cause  of  death, 
and  the  case  is  left  exactly  where  the 
coroner  found  it,  to  be  re-examined  by 
magistrates  when  an  enormous  expense 
has  been  already  saddled  on  the 
country  by  fruitless  investigations. 

Thus,  then,  the  very  condition  which 
the  writer  of  this  letter  holds  to  be 
necessary — namely,  “certainty  of  de¬ 
tection,”  is  proved  to  be  actually  want¬ 
ing.  A  coroner’s  inquest  without  a 
post-mortem  examination,  in  a  case  of 
real  suspicion  (and  under  no  other  cir¬ 
cumstances  is  an  inquiry  for  pub  tic  pur¬ 
poses  really  demanded),  is  “  a  mockery, 
a  delusion,  and  a  snare.” 

If  Mr.  Payne  had  stated  the  whole 
case  fairly,  he  might  have  quoted  at 
least  half  a  dozen  instances  within 
the  last  two  years,  where  murder  by 
poison  had  been  proved  on  the  ex¬ 
humation  of  bodies  some  months  after 
interment,  —  although  coroners’  in¬ 
quests  had  been  held  (without  in¬ 
spection  !)  immediately  after  death, 
and  verdicts  of  deaths  from  natural 
causes  had  been  returned.  Thus,  then, 
we  are  really  constrained  to  arrive  at 
the  conclusion,  that  Mr.  Payne’s  re¬ 
medy  for  this  social  evil  is  no  remedy 
at  all.  It  is  not  the  mere  holding  of 
an  inquest  which  will  put  an  end  to 
secret  poisoning.  This,  as  Mr.  Prichard 
observes,  may  be  most  important  to  the 
coroner  ;  but  the  other  party  concerned 
— namely,  the  public,  has  a  right  to 
expect  that  there  shall  be  a  proper  de¬ 
gree  of  care  in  the  investigation,  for, 
without  this,  there  can  be  no  certainty 
of  detecting  crime.  Post  mortem  in¬ 
spections  undoubtedly  entail  great 
trouble  and  expense, — they  cause  fre¬ 
quent  adjournments, — give  rise  to heavy 
medical  charges, — and  swell  the  quar¬ 
terly  accounts.  Against  these  evils 
must  be  balanced  the  shock  to  public 


CONCEALMENT  OF  SECRET  MURDER  BY  POISON. 


457 


feeling  occasioned  by  the  exhumation 
of  bodies  months  and  years  after  burial, 
with  the  discovery  that  an  extensive 
conspiracy  against  life  has  been  going 
on  in  the  midst  of  a  population,  uncon¬ 
trolled  and  unchecked,  and  that  mur¬ 
ders  by  poison  have  been  registered  as 
“  bowel-complaints,”  or  actually  con¬ 
cealed  under  the  solemn  mockery  of 
an  ill-conducted  coroner’s  inquest. 

We  have  been  induced  to  make  these 
remarks,  from  the  conviction  that  the 
ad  capttmdum  argument  of  “  more 
inquests,”  is  unsupported  by  fact  or 
reasoning.  Addressed  to  a  public 
journal  like  the  limes,  it  is  calcu¬ 
lated  to  have  a  certain  effect  with 
tho'e  who  are  not  aware  of  the  whole 
bearings  of  this  question,  even  al¬ 
though  it  obviously  proceeds  from 
the  pen  of  one  w7ho  has  a  direct  in¬ 
terest  in  increasing  the  number  of  in¬ 
quests.  Itshouldhave  been  fairly  stated 
—  1,  that  these  secret  murders  by  poison 
had  been  discovered  in  cases  in  which 
a  coroner’s  jury  had  already  returned 
an  erroneous  verdict  upon  an  imperfect 
inquiry,  which  it  was  in  the  coroner’s 
power  to  make  perfect  ;  2,  that  for  the 
detection  of  death  by  poison,  an  in¬ 
spection  of  the  body  is  imperatively 
necessary,  and  that  in  the  greater  num¬ 
ber  of  inquests  r.o  inspection  is  made  ; 
and  3,  that,  although  “  certainty  of  in¬ 
vestigation”  is  a  sure  preventive  to 
crime,  the  coroners’  i>  quest,  as  at  pre¬ 
sent  conducted,  does  not  ensure  this. 
On  the  contrary,  in  the  most  difficult 
and  insidious  form  of  violent  death — 
namely,  by  poisoning,  it  affords,  by 
the  neglect  of  post-mortem  inspections, 
a  ready  means  of  escape  to  the  guilty. 

We  shall  conclude  by  remarking 
that  Mr.  Payne’s  facts  are  as  little  to 
the  purpose  as  his  reasoning.  His 
letter  professes  to  be  on  the  Essex 
poisonings  ;  but,  as  we  have  already 
remarked,  he  can  adduce  no  ground 
of  complaint  against  the  coroners  or 


magistrates  of  that  county.  The  case 
which  has  called  forth  this  strong 
advocacy  of  inquests  as  a  panacea  for 
provincial  Thuggism,  has  no  bearing 
upon  the  frequency  or  infrequency 
of  holding  such  investigation,  unless 
the  writer  means  to  contend  that  an 
inquest  shall  be  held  upon  the  body  of 
every  person  who  dies, — a  very  profit¬ 
able  doctrine  to  coroners,  but  one  of  a 
very  uncomfortable  nature  to  the  pub¬ 
lic,  whether  regarded  in  a  financial  or 
social  point  of  viewx  The  case  of 
murder,  which  has  called  forth  his 
letter,  would,  most  probably,  have 
been  overlooked  and  treated  as  one  of 
natural  death,  by  the  keenest  constable 
and  coroner  in  the  land.  The  deceased 
lived  with  his  w'ife  and  servant.  He 
had  been  for  some  time  an  invalid, 
labouring  under  an  affection  of  the 
stomach  and  bowels,  for  which  he  re¬ 
ceived  medical  attendance  occasionally. 
He  was  taken  rather  suddenly  ill,  and 
was  nursed  only  by  his  wife,  (who  was 
charged  with  having  administered  arse¬ 
nic  to  him),  the  servant-girl  being  kept 
out  of  the  wuiy.  The  deceased  had 
thrown  off  blood,  and  from  the  account 
given  to  the  medical  attendant  by  the 
wdfe  and  servant,  he  was  induced  to 
assign  as  a  cause  of  death,  spitting  of 
blood.  This,  we  believe,  was  regis¬ 
tered  accordingly.  Moral  circum¬ 
stances  which  have  since  come  to  light 
were  kept  studiously  concealed, and,  in 
short,  there  wTas  nothing  to  excite  sus¬ 
picion  or  apparently  to  call  for  an  in¬ 
quest.  Many  such  cases  have  very 
likely  occurred  in  other  localities,  and 
perhaps  still  remain  concealed.  The 
“  discouragement  of  inquests,”  there¬ 
fore,  has  no  more  to  do  with  this  case 
than  Tenterden  Steeple  with  the  Good¬ 
win  Sands.  Any  medical  practitioner 
may  be  deceived  by  false  statements; 
and  where  there  is  only  one  ignorant 
witness,  the  truth  is  not  likely  to 
transpire.  Medical  men  are  especially 


THE  ESSEX  POISONINGS - CAUSES  OF  THE 


458 

liable  to  be  thrown  off  their  guard, 
when  they  have  been  for  some  time 
previously  in  attendance  upon  the  de¬ 
ceased.  Haemoptysis  also  is  not  an 
unfrequent  cause  of  sudden  death. 
These  facts  offer  some  apology  for  the 
practitioner  in  this  case,  but  there  is 
no  doubt  that  more  caution  is  demanded 
from  medical  men  in  furnishing  certi¬ 
ficates  of  the  causes  of  death.  To 
suspect  poison  in  all  cases  of  sudden 
death,  would  be  productive  of  great  in¬ 
justice  :  at  the  same  time,  the  symp¬ 
toms  of  poisoning  are  often  very 
obscure,  and  of  an  anomalous  kind  ; 
and  thus  one  not  accustomed  to  the 
investigation  of  such  cases  may  be 
readily  deceived.  There  is,  however, 
one  rule  which  it  would  be  advisable  for 
a  practitioner  to  follow— namely,  to  de¬ 
cline  giving  a  certificate  without  a 
post-mortem  examination,  when  the 
deceased  has  not  been  seen  by  him 
recently  before  death ,  and  when  the 
only  account  of  his  illness  can  be  ob¬ 
tained  from  one  or  two  ignorant  per¬ 
sons  around  him.  In  such  a  case,  it  is 
quite  obvious  that  a  medical  man  has 
nothing  whereon  to  found  an  opinion* 
and  he  had  better  leave  it  to  the 
wisdom  of  a  coroner’s  jury  to  return 
a  verdict  from  an  outside  view  of  the 
body,  to  the  effect  that  the  deceased 
had  died  from  “natural  causes,”  than 
to  take  that  responsibility  upon  him¬ 
self. 

There  is  another  circumstance  upon 
which  medical  men  have  often  justly 
complained.  The  certainty  of  detect¬ 
ing  death  by  poison  depends  generally 
upon  chemical  and  pathological  re¬ 
searches  of  a  most  elaborate  kind. 
Some  coroners,  when  compelled  by  the 
public  nature  of  the  case  to  call  for  this 
assistance,  manifest  the  greatest  un¬ 
willingness  to  remunerate  the  medical 
practitioner  for  his  time  and  services. 
In  some  instances,  as  our  own  pages 
have  testified,  the  claimant  has  had  to 


seek  his  remedy  in  the  County  Court 
even  for  the  small  Parliamentary  fee, 
and  has  been  then  defeated  by  some 
technical  quibble.  In  short,  the  whole 
system  of  investigating  crime  is  defec¬ 
tive,  and  until  it  has  undergone  a 
thorough  reformation,  we  cannot  hope 
to  avoid  those  discoveries  of  secret  mur¬ 
der  by  poison,  which  have  of  late  years 
been  laid  before  the  public. 


It  would  not  be  fair  if  we  did  not 
state  that  the  efforts  of  coroners  to 
perform  their  duties,  with  a  due  regard 
to  the  responsibility  involved  in  the 
result,  are  in  certain  districts  thwarted 
by  the  injudicious  economy  of  the 
magistrates.  The  following  extract, 
taken  from  the  Times  of  Saturday  last, 
will  show  to  what  an  extent  this  evil 
prevails  in  the  great  metropolis: — 

Middlesex  Sessions. 

“  The  Coroner’s  Accounts. — The  re¬ 
port  of  the  committee  for  accounts  and 
general  purposes  having  been  read,  it 
appeared  that  that  body  had  made  a 
deduction  from  the  account  of  Mr, 
Bedford  of  £4  4s.,  which  had  been  paid 
by  that  gentleman  for  what  we  presume 
were  some  extra  professional  services 
rendered  by  a  second  medical  gentle¬ 
man  in  the  post-mortem  examination, 
of  the  body  of  Mary  Anne  Theresa 
Dore.  The  matter  was  thus  alluded  to 
in  the  report : — 

“  ‘  As  regards  Mr.  Bedford’s  account, 
your  committee  have  to  observe,  that 
in  the  voucher  of  disbursements  in  the. 
case  of  an  inquest  held  on  the  body  of 
Mary  Anne  Theresa  Dore,  there  is  a 
charge  of  £4  4s.  paid  for  “  sundry 
analyses,”  in  addition  to  a  fee  of 
£2  2s.  paid  to  another  medical  witness 
for  making  a  post-mortem  examination, 
which  is  the  fee,  with  or  without  an 
analysis  of  the  contents  of  the  stomach, 
authorised  by  the  6th  and  7th  William 
IV.,  c.  89,  to  be  paid;  and  as  it  appears 
to  your  committee  that  the  court  are 
precluded  from  allowing  the  said  charge 
of  £4  4s.,  they  have  deducted  the 
same.’ 

“  The  report  was  received  and 
adopted.” 


CONCEALMENT  OF  SECRET  MURDER  BY  POISON. 


459 


In  this  case  two  medical  gentlemen, 
as  we  understand,  inspected  the  body 
for  the  inquest,  for  which  the  usual 
Parlimentary  fee  of  two  guineas  was 
allowed.  Being  unable,  we  presume, 
to  make  an  analysis  of  the  stomach 
and  its  contents,  these  were  sent, 
under  the  sanction  of  Mr.  Bedford  the 
coroner,  to  another  medical  gentleman 
living  near  them,  who  was  engaged  in 
researches  of  this  kind,  and  the  result 
was,  that  poison  was  detected  in  the 
stomach.  The  fee  of  four  guineas  was 
exceedingly  moderate,  considering  the 
nature  of  the  services  rendered  ;  and 
the  coroner  paid  it.  The  magistrates 
now  refuse  to  reimburse  the  coroner, 
and  have  thereby  actually  fined  him  four 
guineas ,  because  the  chemical  analysis 
was  entrusted  to  one  who  had  given 
attention  to  the  subject!  TheMiddlesex 
magistrates  have,  therefore,  practically 
decided,  by  this  refusal  to  allow  a 
necessary  and  reasonable  charge,  that 
coroners  in  the  metropolitan  districts 
must  hereafter  adopt  one  of  two 
courses :  1st,  either  compel  those  who 
inspect  a  dead  body,  whether  they 
know  anything  of  chemistry  or  not, 
to  make  an  analysis  and  give  an 
opinion  which  cannot  be  sustained  at 
a  trial ;  or  2nd,  to  pay  out  of  their  own 
pockets  the  fee  which  may  be  neces¬ 
sary  to  secure  the  labour  and  judgment 
of  one  who  is  competent,  and  on  whose 
opinion  some  reliance  may  be  placed. 
This  is  a  serious  alternative;  and  it  is 
clear  that  either  the  course  of  public 
justice  must  suffer,  or  the  coroner  must 
bear  an  onerous  charge,  wholly  incom¬ 
mensurate  with  his  fees  of  office.  This 
will  be  found  to  be  a  foolish  system  of 
economy  in  the  end.  Men  will  not 
be  found  who  will  give  their  time  to 
the  post-mortem  examination  of  a  body, 
including  a  complete  chemical  analysis, 
that  may  occupy  two  or  three  days,  for 
the  paltry  sum  of  twTo  guineas.  It  is 
no  answer,  that  the  Act  of  Parliament 
does  not  allow  jnore  ;  the  objection  is, 


that  it  does  not  allow  enough  to  cover 
even  reasonable  expenses,  where  these 
intricate  researches  are  properly  carried 
out.  If  an  Act  of  Parliament  fixed  a 
CoronePs  fee  for  each  inquest  at  five 
shillings, and  threw  upon  this  officer  all 
the  expenses  attending  the  inquiry,  no 
one  would  be  found  to  take  the  office  ! 
There  would  be  no  satisfaction  in 
knowing  that  coroners  atone  time  (like 
medical  witnesses,  until  the  passing  of 
the  6th  and  7th  Will.  IV.,  c.  89),  per¬ 
formed  these  responsible  duties  with¬ 
out  being  paid;  and,  although  an  Act 
of  Parliament  is  all-powerful,  it  cannot 
compel  any  man,  in  a  case  of  this  kind, 
to  give  his  scientific  labour  for  less 
than  it  is  worth.  As  in  the  former  part 
of  this  article  we  have  condemned  the 
sophistry  of  one  metropolitan  coroner, 
in  endeavouring  to  improve  on  a  recent 
murder,  for  the  sake  of  increasing  the 
number  of  inquests,  we  feel  in  justice 
bound  to  defend  the  conduct  of  another 
who  has  only  performed  his  duty  con¬ 
scientiously.  We  must  take  leave  to 
remind  the  Middlesex  magistrates,  that 
this  system  of  disallowing  necessary 
fees  will  be  attended  with  one  of  two 
consequences.  Either  cases  of  poison¬ 
ing  will  go  without  detection,  or  if  sent 
for  trial  on  the  opinions  of  gentlemen 
not  used  to  chemical  investigations, 
they  will  certainly  end  in  an  acquittal; 
and  while  the  expense  to  the  county 
will  be  thus  increased  tenfold,  the  ends 
of  justice  will  be  defeated,  and  the 
law  defied. 


Iftcbtefog. 


A  Treatise  on  Diet  and  Regimin.  By 
William  Henry  Robertson,  M.D., 
Physician  to  the  Buxton  Bath 
Charity.  Fourth  edition,  in  2  vols. 
8vo.  pp.355,  362.  London:  Churchill. 
1848. 

This  book  is  one  of  those  the  object  of 
which  is  to  convey  information  to  the 
general  reader  on  subjects  which  are 
but  little  known  to  the  public  generally, 


460 


DR.  ROBERTSON  ON  D JET  AND  REGTMEN. 


although  constituting  the  elementary 
knowledge  of  the  medical  student. 

Besides  the  direct  importance  of  sub¬ 
jects  having  reference  to  health,  the 
author  anticipates  that  information  of 
this  nature,  diffused  among  the  reading 
public,  will  tend,  more  than  any 
legislative  act,  to  the  suppression  of 
quackery. 

In  his  introductory  chapter,  which 
treats  of  Hygiene,  Dr.  Robertson 
says— 

“  It  is  a  question  that  is  intimately  bound 
up  with  the  well-being  of  the  people,  and 
which  is  essentially  dependent  on  the  per¬ 
sonal  efforts  made  by  medical  men,  to  extend 
to  the  masses  of  the  population  some  general 
information  as  to  the  principles  and  rea¬ 
sonings,  the  facts  and  deductions,  on  which 
the  art  and  practice  of  medicine  are  founded 
and  built.  This  is  no  less  than  the  suppres¬ 
sion  of  quackery  in  the  treatment  of  the 
diseases  of  mankind,  or,  at  least,  its  gradual 
removal — an  end  perhaps  only  to  be  at¬ 
tained,  or  even  approached,  by  these  means. 
It  would  probably  signify  but  little  even  if 
the  Legislature  were  to  resign  its  greater  or 
less  profits  on  the  sale  of  quack  medicines, 
and  no  longer  invest  them  with  the  legal 
stamp,  which  gives  them  a  sort  of  national 
sanction.  It  might  not,  perhaps,  have  any 
very  great  influence,  even  if  our  Universities 
and  Colleges  were  to  make  a  decided  stand 
against  empiricism  in  all  its  shapes,  and 
signalize  the  determination  by  expelling  from 
their  numbers  every  member  of  the  profes¬ 
sion  proved  to  have  lent  himself  to  any  of 
the  impostors  that  delude  mankind, — con¬ 
signing  those  w!>o  practise,  and  those  who 
aid  and  abet  the  practice,  of  any  of  the 
forms  of  charlatanism,  to  a  notable  dis¬ 
missal  from  our  ranks.  It  might  signify 
but  little  if  the  Legislature  were  even  to 
forbid  the  sale  of  unprescribed  medicines, — 
to  place  the  health  of  the  people  at  large  in 
the  care  of  public  and  fully  qualified  medical 
officers,  and  ascertain  duly  the  fitness  of 
every  one  practising  the  profession  in  the 
cases  of  individual  disease, — visiting  every 
one  found  guilty  of  practising  without 
such  qualification  with  an  amount  of  punish¬ 
ment  proportionate  to  the  degree  of  misde¬ 
meanour.  All  such  means,  admitting  that 
they  are  steps  in  the  right  direction,  and 
such  as  a  well-informed  Legislature  might 
be  justified  in  adopting,  and  the  protection 
of  the  public  from  the  wrong  inflicted  by 
the  ignorant  or  the  knavish  might  appear  to 
demand,  are  liable  to  be  regarded  as  an 
unfair  and  uncalled-for  interference  with  the 
liberty  of  the  people,  until  the  public  mind 
is  so  fully  informed  of  the  expediency  of 
such  measures,  so  fully  alive  to  the  irra¬ 
tionality  and  knavishness  of  quackery  in  all 


its  shapes,  as,  in  fact,  to  require  no  protec¬ 
tion  from  its  machinations,  unless  in  the 
case  of  the  lowest  and  least  informed  remnant 
of  the  people,  over  whom  a  Legislature 
might  feel  the  kindness  and  necessity  of 
throwing  the  shield  of  its  enactments,  as  a 
safeguard  against  the  efforts  of  the  designing 
and  unprincipled.”  (p.  26). 

In  his  second  chapter,  the  author 
considers  the  process  of  digestion,  and 
examines  the  degree  of  digestibility  of 
various  kinds  of  food,  and  ihe  relative 
quantity  of  nutriment  which  they  con¬ 
tain,  as  well  as  the  effects  of  cookery 
upon  aliment,  &c.  We  do  not  recog¬ 
nize  any  original  views  in  this  part  of 
the  work,  except  perhaps  in  the  follow¬ 
ing  paragraph,  which  refers  to  the 
action  of  alcohol. 

“  The  probable  action  of  alcohol  on  the 
economy  of  the  system  is,  by  permeating 
the  tissues  rapidly,  to  come  into  very  speedy 
and  very  general  contact,  by  many  and 
extensive  surfaces,  with  the  oxygen  of  the 
arterial  blood,  and  to  combine  with  it, 
giving  its  carbon  to  the  oxygen,  forming 
carbonic  acid, — its  hydrogen  to  the  oxygen, 
forming  water;  the  effect  being  the  dis¬ 
engagement  of  heat,  independently  of  any 
alteration  of  the  tissues,  or  of  the  conversion 
of  arterial  into  venous  blood  by  the  union  of 
oxygen  with  the  carbon  of  the  blood,  upon 
which,  under  ordinary  circumstances,  the 
elevated  temperature  of  the  body  is  known 
to  depend.”  (p.255). 

Dr.  Robertson  also  considers  the 
subject  of  the  quantity  of  food  neces¬ 
sary  for  the  support  of  man,  and  in 
order  to  elucidate  this  point,  he  pro¬ 
duces  the  diet-tables  of  hospitals, 
workhouses,  and  gaols,  and  comments 
on  their  results. 

The  second  volume  is  devoted  to  the 
consideration  of  Hygienics,  including 
exercise,  ventilation,  clothing,  bathing, 
the  use  of  mineral  waiters,  sleep,  the 
effect  of  occupation  on  health,  and  on 
cultivation  of  the  mind. 

If  there  is  nothing  original  in  the  au¬ 
thor’s  views  oi  these  subjects,  or  in  the 
mode  in  which  he  treats  them,  he  has 
carefully  looked  for  the  best  authori¬ 
ties,  and  has  taken  pains  to  render  his 
book  useful  to  those  who  seek  this  kind 
of  information.  The  reader  will  find 
enough  of  good  sense  and  perspicuity, 
as  well  as  importance  in  the  matter 
itself,  to  repay  him  for  the  perusal  of 
these  volumes. 


THE  ETHNOLOGICAL  JOURNAL.  461 


The  Ethnological  Journals  A  Magazine 
of  Ethnography,  Phrenology,  and 
Archaeology,  considered  as  Elements 
of  the  Science  of  Races.  Edited  by 
Luke  Burke,  E^q.  Nos.  1,  2,  and 
4 — J une,  J uly,  September.  London : 
Bail  Here,  and  Renshaw.  1848*. 

Clericus  clericum  non  decimat.  In 
bringing  before  our  readers  a  short 
notice  of  a  new  contemporary  journal, 
devoted  to  a  new  subject,  we  do  not 
mean  to  violate  the  above  wholesome 
rule.  In  the  present  instance  there 
would  certainly  be  no  occasion  for  its 
violation,  since  the  novelty  and  interest 
of  the  contents  of  the  new  journal  are 
sufficient  to  call  for  high  commenda¬ 
tion. 

What  is  Ethnology  ?^  Most  of  our 
readers  will  not  require  to  be  told  that 
it  is  “  the  science  of  races,”  or,  to  adopt 
the  definition  of  the  Editor,  it  is  that 
science  which  indicates  the  mental  and 
physical  differences  of  mankind,  and 
the  organic  laws  upon  which  they 
depend,  and  seeks  to  deduce  from  these 
investigations  principles  for  human 
guidance  in  all  the  important  relations 
of  social  existence. 

Such  a  science  appears  to  have,  at 
first  view,  but  little  relation  to  medi¬ 
cine;  it  rather  concerns  the  philoso¬ 
pher,  the  political  economist,  and  the 
legislator.  Mr.  Burke,  however,  strives 
to  prove,  and  we  must  admit,  not  un¬ 
successfully,  that,  although  less  appa¬ 
rent,  it  has  some  bearings  upon  the 
science  of  medicine. 

“  Every  experienced  physician  knows  the 
importance  of  an  accurate  estimate  of  tem¬ 
perament  in  the  administration  of  medicines 
and  the  general  treatment  of  disease.  But 
Ethnology  will  shew  that  temperament  is 
but  another  term  for  race ,  and  that  it  is 
only  by  a  careful  study  of  races,  whether 
pure  or  mixed,  that  the  physician  can  ever 
hope  for  accurate  knowledge  in  the  intricate 
subject  of  constitutional  idiosyncrasies. 
Even  in  its  present  condition,  Ethnology  is 
capable  of  supplying  to  the  practitioner 
many  valuable  principles  and  rules  of  action. 
In  a  more  advanced  stage  it  will  be  con¬ 
sidered  as  an  essential  branch  of  medical 
science.”  (p.  3). 

Our  student-readers  need  not  be 
under  any  apprehension  that  the  study 
of  this  science  will  be  speedily  added 


*  No.  3  of  this  journal  has  not  reached  us. 
t  Derived  from  «0k>s,  tribe  or  race,  and  Aoyo?, 
discourse. 


to  the  curriculum  of  a  medical  educa¬ 
tion.  The  Examiners  of  the  various 
Colleges  are  as  yet  unprepared  to  put 
ethnological  questions ;  and  the  pro¬ 
fession  must  undergo  a  complete  re¬ 
formation  before  the  study  of  the  phi¬ 
losophy  of  medicine  is  made  impera¬ 
tive  upon  those  who,  when  they  have 
received  a  diploma,  are  compelled  to 
make  a  hard  struggle  for  a  living,  and 
are  often  induced  to  abandon  the  pro¬ 
fession  in  despair.  By  these  remarks 
we  do  not  intend  to  depreciate  the 
subject:  it  has  interest  and  value 
which  will  always  recommend  it  to 
those  who  have  reached  that  easy  stage 
of  professional  existence  in  which  they 
can  withdraw  from  practice  and  devote 
a  portion  of  their  time  to  the  cultiva¬ 
tion  of  science. 

The  first  number  of  the  Journal  con¬ 
tains,  in  a  series  of  propositions,  the 
fundamental  doctrines  of  Ethnology. 
Some  of  them  will  startle  readers  who 
have  not  hitherto  considered  the  range 
of  the  new  science  ;  but  they  open  out 
enlarged  views  of  the  physical  history 
of  mankind.  Writers  on  this  subject 
have  hitherto  contented  themselves 
with  the  accumulation  of  facts  ;  but  we 
have  in  this  publication  deductions  from 
the  facts,  and  a  practical  application  of 
principles  with  a  view  to  social  im¬ 
provement. 

The  nature  of  the  contributions  to  the 
journal  may  be  understood  from  the  list 
of  papers  in  the  three  numbers  be¬ 
fore  us.  Outlines  of  Ethnology.  A 
Critical  Analysis  of  the  Hebrew 
Chronology.  The  Ruling  Idta  of  the 
present  political  era.  On  Varieties  of 
Colour  in  the  Human  Hair.  J  he  De¬ 
struction  of  Atlantis,  with  Glimpses  of 
the  Antique  History  of  the  Sacred 
Races.  On  Varieties  of  Complexion  in 
the  Human  Races.  The  v  ature  and 
Origin  of  Mythology.  On  the  true 
nature  of  Animal  Mechanism,  fyc.  A 
portion  of  the  journal  is  also  devoted 
to  the  criticism  of  works  bearing  on 
the  subject  of  Ethnography. 

The  titles  of  these  articles  are  suffi¬ 
ciently  novel  to  excite  curiosity  ;  but 
in  some  which  we  have  read,  this  feel¬ 
ing  Swon  gave  place  to  a  deep  interest. 
The  subject  of  the  physical  differences 
of  mankind  is  very  ably  treated;  and 
we  can  bestow  great  praise  upon  an 
article  in  the  first  number,  entitled  The 
Ruling  Idea  of  the  present  political 
era;  although  it  might  be  inferred 


462 


MM.  ROUX  AND  MALGAIGNE  ON  GUN-SHOT  WOUNDS. 


from  this  title,  that  the  essay  had  a 
closer  relation  to  ephemeral  polities 
than  to  scientific  anthropology.  We 
have  not  met  with  a  subject  more  ably 
handled  in  the  best  critical  reviews. 
The  mode  in  which  the  recent  eventful 
changes  among  nations  are  traced  to 
their  ethnological  bearings,  is  not 
merely  ingenious,  but  so  far  as  we  are 
able  to  judge,  based  upon  sound  views 
of  human  nature.  The  style  is  excel¬ 
lent,  and  the  language  often  eloquent. 
The  reprint  of  this  article,  and  its 
general  circulation,  would,  we  are  per¬ 
suaded,  be  productive  of  much  good. 
It  would  serve  as  a  perfect  antidote  to 
the  poison  of  the  revolutionary  dema¬ 
gogue,  whether  in  politics  or  medi¬ 
cine. 

From  these  remarks  our  readers  will 
judge  that  we  think  favourably  of  our 
new  contemporary.  The  articles  con¬ 
tained  in  the  three  numbers  before  us 
display  more  than  that  average  amount 
of  ability  which  we  are  accustomed  to 
meet  with  in  a  new  periodical  devoted 
to  a  difficult  and  untried  subject. 


■^voccebtngs  of  j&octetteg. 

ACADEMY  OF  MEDICINE. 

August  1,  184S. 

President — M.  Royer  Collard. 


MM.  Roux  andMALGAiGNE  on  the  gun-shot 
wounds  admitted  under  their  care  after 
the  insurrection  of  June. 

M.  Roux. — The  Academy  has  not  forgotten 
the  different  circumstances^which,  since  1830, 
have  offered'  to  the  surgeons  of  Paris  the 
opportunity  of  observing  gun-shot  wounds. 
The  Parisian  hospitals  have  several  times  re¬ 
ceived  a  great  number  of  wounded,  and  the 
surgeons  have  thus  acquired  that  experience 
which  is  usually  reserved  for  army  medical 
officers.  The  events  of  1830,  both  in  re¬ 
relation  to  science  and  art,  were  not  un¬ 
fruitful.  Dupuytren  gave  some  excellent 
lectures,  which,  being  collected  by  his  pupils, 
remain  to  science.  M.  Jobert  published  the 
results  of  his  numerous  observations  ;  and, 
with  the  permission  of  the  Academy,  I  would 
recal  my  own  surgical  memoirs  of  the  days 
of  July. 

Other  occasions  have  presented  themselves 
since,  especially  in  June  1832,  when  we  were 


called  on  to  observe  gun-shot  wounds ;  but 
silence  was  then  a  duty.  The  last  insurrec¬ 
tion,  so  disastrous,  and  at  the  same  time  so 
full  of  instruction,  imposes  on  surgeons  the 
obligation  to  state  what  they  have  seen  and 
done  ;  for  the  revolution  of  1830  had  not  so 
many  victims  as  the  insurrection  of  June 
1848. 

It  seems  to  us  that  the  peculiar  circum¬ 
stances,  as  well  for  the  wounded  as  the  sur¬ 
geon,  which  result  from  these  street  combats, 
permit  certain  observations  which  cannot  be 
made  on  the  field  of  battle.  It  was  thus 
that,  in  1830, 1  was  able  to  call  attention  to 
certain  peculiarities,  hitherto  unknown,  with 
regard  to  primary  haemorrhages.  The 
wounded  in  our  insurrections  are  not  under 
the  same  conditions  as  the  wounded  on  the 
field  of  battle :  they  receive  aid  more 
promptly  ;  they  have  not  to  pass  over  great 
distances  in  being  carried  to  the  hospitals :  and 
on  the  other  hand,  the  surgeons  may  observe 
the  patients  very  soon  after  the  receipt  of 
their  wounds. 

There  is  another  point  of  interest  in  the 
comparison  that  we  may  make  between  these 
different  great  catastrophes  which  result 
from  our  unfortunate  civil  discords.  Al¬ 
though  gun-shot  wounds  always  present  the 
same  characters,  yet  they  offer,  in  addition, 
certain  varieties,  according  to  times,  circum¬ 
stances,  and  political  events.  In  the  same 
way  that  each  great  epidemic,  even  where  the 
nature  of  the  disease  is  the  same,  offers  a  phy¬ 
siognomy — a  character  which  is  proper  to  it, 
so  we  may  say  that  these  great  traumatic  epi¬ 
demics  (so  to  speak)  offer  characteristic  fea¬ 
tures  distinguishing  them  one  from  the  other. 
Recal  the  sad  spectacle  which  was  presented 
by  our  wounded  in  1814  and  1815 — their 
morale  being  broken  down  by  defeat,  yield¬ 
ing  them  up  victims  to  typhus  and  hospital 
gangrene.  In  1830,  on  the  contrary,  we  had 
only  victors,  exalted  by  victory,  on  whom 
deleterious  agents  took  less  effect.  In  the 
late  events,  the  vanquished  are  sad  and 
silent — the  victors  have  neither  exaltation  nor 
enthusiasm  ;  they  have  the  cold  and  calm 
sense  of  a  duty  accomplished,  a  feeling  not 
reacting  materially  on  the  wounded  condition 
in  which  they  have  been  placed. 

I  shall  divide  into  two  parts  what  I  have 
to  say  :  in  the  first  I  will  present  a  view  of 
the  facts  which  I  have  observed ;  in  the  se¬ 
cond  I  will  consider  certain  controverted 
points  as  to  the  treatment  of  gun-shot 
wounds. 

Relation  of  the  facts. — The  Hotel-Dieu, 
from  its  central  position  and  proximity  to 
the  seat  of  the  insurrectionary  combats,  re¬ 
ceived  a  great  number  of  wounded.  These 
were  distributed  under  three  principal  sur¬ 
geons — MM.  Blandin,  Boyer,  and  myself. 

The  number  of  those  devolving  to  my  care 


MM.  ROUX  AND  MALGAIGNE  ON  GUN-SHOT  WOUNDS. 


46  a 


were  179 — 1 68  being  men,  11  women.  It 
is  the  fit  st  time  I  have  received  so  great  a 
number  of  women.  In  the  former  events, 
those  who  have  been  brought  were  wounded 
accidentally  ;  in  the  last,  the  greater  part  of 
them  received  their  wounds  combatting 
either  with  the  defenders  of  order  or  the  in¬ 
surgents. 

Among  our  wounded  there  were  but 
twelve  insurgents  ;  the  rest  belonged  to  the 
National  Guard  or  the  different  corps  of  the 
army.  They  were  almost  all  young,  we 
even  received  a  boy  of  twelve  years  of  age, 
the  oldest  was  forty- two  years  of  age. 

Their  appearance  was  generally  tranquil. 
Here  I  may  be  permitted  to  pay  a  just  tri¬ 
bute  to  the  wounded  among  the  “  garde 
mobile.”  These  youths,  who  have  been  so 
admirable  in  valour  during  the  battle,  have 
not  been  less  admirable  in  patience,  resigna¬ 
tion,  modesty,  and  courage.  The  dejection 
of  the  wounded  insurgents  has  not  been  such 
as  we  have  observed  among  those  wounded 
under  different  circumstances,  especially  in 
1830. 

Notwithstanding  these  favourable  circum¬ 
stances,  we  have  a  somewhat  great  mortality  : 
it  had  been  twenty-five  during  the  first 
twenty-four  hours,  now  it  is  sixty, — that  is, 
the  third  of  our  wounded.  One  or  two  more 
may  yet  sink  among  the  forty  remaining 
under  treatment.  The  results  were  slightly 
more  favourable  in  1830.  I  received  then 
nearly  the  same  number  of  wounded,  and 
the  mortality  was  somewhat  less.  I  per¬ 
formed,  at  the  two  periods,  nearly  the  same 
number  of  amputations  ;  among  these  the 
mortality  was  nearly  the  same.  I  am  in¬ 
duced  to  think  that,  at  the  different  periods, 
the  statistical  results  were  nearly  the  same. 

We  have  had  very  few  sword  wounds  ;  all 
the  others,  except  one,  were  caused  by  balls 
or  other  analogous  projectiles.  Nothing 
whatever  authorises  the  belief  that  the  balls 
were  roughened  (a  plan  that  would,  I  con¬ 
ceive,  have  no  influence  on  the  gravity  of  the 
wounds)  or  poisoned. 

Almost  all  the  balls  presented  a  complete 
traject ;  that  is  to  say,  had  an  opening  of 
entry  and  one  of  exit,  so  that  I  have  only 
had  to  extract  five  balls. 

Wounds  were,  perhaps,  more  frequently  in 
the  upper  part  of  the  body  among  the  insur¬ 
gents,  and  hence  there  was  among  them  a 
greater  mortality.  This  is  explained  by  the 
different  position  of  the  combatants.  The  in¬ 
surgents,  concealed  behind  their  barricades, 
only  received  wounds  when  they  exposed 
the  upper  parts  of  their  bodies ;  while  the 
defenders  of  order  exposed  equally  all  parts 
of  their  body  to  the  fire  of  the  barricades. 
Among  our  wounded  the  variety  of  the  seat 
of  wound  was  great :  we  had  sixty  wounds 
of  the  limbs.  We  have  practised  ten  pri¬ 
mary  amputations,  namely — 
aiflovmoJ  au.vmvob  to  uKfmur 


Deaths. 

3  disarticulations  of  the  arm  (shoulder 

.  j°int) . 1 

1  disarticulation  of  the  elbow  .  1 

I  partial  amputation  of  the  foot 
1  amputation  of  the  leg  .  .1 

3  amputations  of  the  arm  ...  2 

1  amputation  of  the  thigh  .  .  .  1 

Total — 6  deaths  in  10  primary  amputations. 

We  have  practised  four  secondary  ampu¬ 
tations,  namely — 

1  amputation  of  the  arm  ...  1 

2  amputations  of  the  thigh  ...  2 

1  amputation  of  the  leg 

Total  3  deaths  in  4  secondary  amputations. 

I  might  make  many  observations  on  these 
tables,  but  I  reserve  them  for  the  second 
part  of  this  communication.  I  cannot,  how¬ 
ever,  refrain  from  remarking  that,  of  three 
disarticulations  of  the  arm  (shoulder  joint) 
two  have  succeeded.  This  operation,  at 
first  sight  so  formidable,  is  not  so  grave  as 
has  been  supposed.  We  know  the  practice 
and  energetic  conviction  of  M.  Larrey  on 
this  point ;  we  know  how  frequently  he  dis¬ 
articulated  the  arm  for  wounds,  which,  in 
the  eyes  of  the  greater  number  of  surgeons, 
would  only  have  demanded  amputation  at 
the  arm  :  perhaps  Larrey  may  be  reproached 
with  abusing  this  operation,  but  I  have  my¬ 
self  arrived  at  the  conviction  that  amputa¬ 
tion  at  the  shoulder-joint  is  not  more  grave, 
so  far  as  life  is  concerned,  than  amputation 
of  the  arm,  and  that  it  is  indifferent  whether 
we  practise  one  or  other  of  these  operations 
(movement). 

One  disarticulation  of  the  elbow  has  been 
practised,  and  it  has  been  fatal.  This  ope¬ 
ration  was  performed  in  my  absence.  I 
never  would  amputate  at  the  elbow-joint, 
and  I  consider  the  operation  contrary  to 
sound  surgery.  I  would  be  understood  not 
to  blame  my  colleague,  who,  on  this  point, 
does  not  share  my  convictions. 

Of  the  four  secondary  amputations,  three 
died— a  painful  result,  which  confirms  the 
opinions  I  have  developed  on  the  incontes¬ 
table  advantages  of  primary  amputation. 

In  1830,  I  obtained  results  more  advanta¬ 
geous  for  primary  amputation  than  I  have 
this  year,  since,  after  ten  primary  amputa¬ 
tions,  I  had  but  three  deaths.  The  secon¬ 
dary  amputations  were,  on  the  other  hand, 
more  fatal,  since,  after  five  amputations,  not 
one  recovered  !  Nevertheless,  I  ought  to 
state  that  in  February  my  secondary  ampu¬ 
tations  were  more  fortunate,  since  three 
have  succeeded  (two  at  the  arm  and  one  at 
the  forearm),  as  also  succeeded  an  amputa¬ 
tion  at  the  shoulder-joint,  on  a  youth  of 
fifteen  years  of  age,  the  only  primary  ampu¬ 
tation  I  had  occasion  to  perform  at  that 


464 


MM.  ROUX  AND  MALGAIGNE  ON  GUN-SHOT  WOUNDS. 


In  one  remarkable  case,  a  wound  of  the 
head  occasioned  paralysis  of  the  arms. 

Among  the  whole  of  the  cases  we  have  had 
no  case  of  primary  haemorrhage,  and  only  one 
in  which  there  was  secondary  haemorrhage, — 
a  case  requiring  the  ligature  of  the  brachial 
artery ;  gangrene  has  only  occurred  once ; 
there  has  been  no  tetanus, — this  is  probably 
due  to  the  prompt  assistance  afforded  :  if 
tetanus  appear  more  frequently  in  the  army, 
is  it  not  due  to  the  peculiar  position  of  the 
wounded,  exposed  to  long  marches  and  the 
vicissitudes  of  the  weather  ?  As  an  offset  to 
these  favourable  results,  we  have  had  many 
cases  of  purulent  absorption. 

I  have  to  consider  the  question  of  surgical 
treatment,  but,  with  the  permission  of  the 
Academy,  I  will  continue  the  subject  at  their 
next  meeting. 

8th  of  August. 

President — M.  Royer  Collard. 

The  discussion  on  gun-shot  wounds  was 
resumed. 

M.  Baudens  read  an  extensive  memoir 
on  the  subject  under  discussion. 

M.  Roux,  not  being  well,  gave  place  to 

M.  Malgaigne,  who  said  :  I  intended 
only  to  have  treated  of  one  of  the  subjects 
connected  with  the  point  under  discussion, 
but  the  memoir  we  have  just  heard  will 
oblige  me  to  go  into  other  points.  I  would 
say,  at  first,  that  we  have  been  less  success¬ 
ful  than  M.  Baudens,  having  lost  a  greater 
number  of  our  wounded,  but  I  consider  that 
fifty  of  olir  cases  w'hich  were  forwarded  to 
the  Val  de  Grace,  ought  doubtless  to  be 
added  to  the  list  of  our  successful  cases. 

The  point  to  which  1  wish  particularly  to 
draw  the  attention  of  the  Academy  is  the 
treatment  of  fractures  of  the  thigh  from 
gun-shot  wounds. 

It  is  the  generally  received  opinion  that 
fractures  of  the  thigh  from  gun-shot  wounds 
demand  amputation.  The  reception  of  this 
opinion  is  especially  due  to  military  surgeons. 

On  inquiring  into  the  annals  of  military 
surgery,  we  find,  first,  that  Ravaton,  having 
lost  all  the  wounded  under  his  care  with 
fracture  of  the  thigh,  was  led  to  propose  the 
disarticulation  of  the  thigh,  to  endeavour, 
he  said,  to  save  the  wounded  from  inevitable 
death.  But  Ravaton  preferred  to  await  the 
result  for  all  other  members  ;  and  even  for 
fractures  at  the  neck  of  the  humerus,  after 
having  followed  the  practice  then  adopted  of 
disarticulating  at  the  shoulder  in  all  cases, 
he  renounced  it,  and  only  had  recourse  to 
amputation  in  case  of  evident  necessity. 

Larrey,  less  rigorous  than  Ravaton, 
thought  we  might  yet  preserve  the  thigh 
when  the  ball  has  broken  the  thigh  by  a 
simple  fracture  in  inferior  fourth  or  third  of 
the  bane;  but,  according  to  him,  every  frac¬ 
ture  from  gun-shot  wound  at  the  middle  or 


upper  portion  of  the  bone  demands  imme¬ 
diate  amputation. 

Ribes  in  a  special  memoir,  confirms 
Larrey’s  view  as  to  the  fractures  of  the  mid¬ 
dle  third  of  the  femur;  he  even  goes  further, 
and  says,  that  when  the  fracture  is  at  the 
upper  part,  it  is  almost  as  if  it  had  happened 
to  the  middle  of  the  bone.  He  then  adds ,  that 
fractures  at  the  extremities  of  the  bone  are 
almost  as  grave  as  at  the  middle.  Further 
on,  he  places  fractures  of  the  lower  half  of  the 
bones  of  the  leg  among  the  most  dangerous 
class,  for  which  one  may  retard  but  not  pre¬ 
vent  bad  results.  He  finally  ends  with  a 
still  more  sweeping  conclusion  :  he  declares 
that  one  may  often,  without  risk  to  the  life 
of  the  wounded,  attempt  to  save  the  arm, 
however  severe  may  be  the  wound,  but  that, 
in  “  fracas”  to  the  bones  of  lower  extremi¬ 
ties,  produced  by  gun-shot  wounds,  the  least 
delay  in  amputation  will  almost  always  com¬ 
promise  the  life  of  the  wounded. 

The  author  leaves  no  doubt,  in  the  course 
of  his  memoir,  that  this  “  fracas  ”  appears 
to  him  inseparable  from  fracture  ;  he  even 
mentions,  as  it  were  to  illustrate  his  ideas, 
two  of  the  wounded  having  fractures  of  the 
thigh,  who,  having  been  struck  from  a  dis¬ 
tance,  appeared  to  him  to  have  simple  frac¬ 
tures,  and  who  even  died  more  quickly  than 
the  rest. 

I  have  myself  professed  this  opinion,  and 
I  have  put  it  in  practice  in  a  large  field  of 
battle,  but  the  result  was  far  from  answer¬ 
ing  my  expectations,  as,  in  the  campaign  of 
Poland,  I  lost  all  my  cases  of  amputation 
who  had  had  fractures  of  the  thigh  from 
gun-shot  wounds. 

On  re-reading  the  memoir  of  Ribes,  I 
was  struck  for  the  first  time  with  an  im¬ 
portant  fact,  which  he  relates  with  remark¬ 
able  impartiality.  He  says,  of  4000  in¬ 
valids,  I  have  not  found  a  single  case  of 
fracture  of  the  thigh  from  gun-shot  wound — 
a  proof,  to  him,  that  all  those  thus  wounded 
musthavedied.  But  among  the  4000  invalids, 
he  has  not  found  a  single  case  in  which  the 
thigh  had  been  amputated — a  proof  to  me, 
that  all  those  who  had  suffered  amputation, 
died,  and  that  amputation  offers  no  better 
chance  of  life  than  non-amputation. 

But  in  studying  the  question  with  addi¬ 
tional  details,  I  soon  saw  that  it  was  not 
only  as  to  amputation  of  the  thigh  that 
serious  doubts  may  arise,  but  also  as  to  all 
amputations  practised  after  gun-shot  wounds : 
we  may  say  that  this  question  of  immediate 
amputationis  the  surgical  question  of  the  age. 
Already,  in  the  ancient  Royal  Academy  of 
Surgery,  it  was  the  object  of  a  long  discus¬ 
sion,  and  Boucher  said,  that  after  accurate 
observation,  about  two-thirds  of  those  ampu¬ 
tated,  died,  especially  where  the  leg  was 
amputated. 

After  the  battle  of  Fontenoy,  Faure  as- 


MM.  ROUX  AND  MALGAIGNE  ON  GUN-SHOT  WOUNDS. 


465 


certained  that  the  success  resulting  from 
about  300  amputations  was  reduced  to  30 
or  40. 

Bilguer  says,  that  in  the  war  of  the  seven 
years,  among  a  crowd  of  persons  on  whom 
amputation  had  been  performed,  scarcely 
were  one  or  two  saved. 

Here  are  more  recent  statements,  alto¬ 
gether  opposed  to  the  preceding.  Fercoq, 
who  is  scarcely  known  but  for  this  remark, 
says,  that  of  60  amputations,  there  were 
only  2  deaths,  or  1  in>i30.  Percy  has  been 
a  little  less  successful ;  of  92  amputations  of 
the  leg,  thigh,  and  arm,  he  had  but  6  deaths, 
or  1  in  15.  Guthrie,  at  New  Orleans,  had 
45  amputations  and  7  deaths,  or  1  in  7  ;  at 
the  battle  of  Toulouse,  47  amputations,  9 
deaths,  or  1  in  5.  In  the  English  Army, 
during  the  Spanish  Campaign,  there  were 
291  amputations,  24  deaths,  or  1  in  8. 

Del.  Signore,  at  Navasin,  31  immediate 
amputations,  1  death,  or  1  in  30. 

English  surgeons,  at  the  battles  of  Abou- 
kir  and  Camperdown,  30  immediate  ampu¬ 
tations,  30  successful  cases  !  !  ! 

Larrey,  during  the  days  of  the  27th  and 
29th  Brumaire,  13  immediate  amputations, 
2  deaths,  or  1  in  6.  Larrey,  reviewing 
all  his  cases,  after  30  years  of  war,  estimates 
that  three- fourths  of  his  amputations  were 
saved.  But  Alexander  Blandin,  his  aide- 
major,  in  a  well-prepared  memoir,  says, 
that  with  judicious  care,  of  5  amputations, 
we  may  hope  to  save  three — that  is  to  say. 
three-fifths. 

These  documents  are  very  contradictory, 
and  seem  to  oppose  the  opinion  of  Boucher. 
Had  Boucher  badly  seen  or  badly  appre¬ 
ciated  ?  One  method  remained  for  me  ;  it 
was  to  inquire  what  passed  in  the  Parisian 
hospital,  in  a  situation  doubtless  much  better 
than  on  a  field  of  battle,  and  where  our  sur¬ 
geons  yield  to  no  one  in  ability  and  know¬ 
ledge. 

I  have  then  made  an  exact  extract  of  all 
the  amputations  practised  in  Paris  for  trau¬ 
matic  lesions  during  a  period  of  ten  years, 
from  1836  to  1846.  Here  is  the  extract, 
which  is  of  great  interest. 

I  have  found  165  amputations  for  wounds 
among  men,  and  17  among  women.  The 
mortality  has  been  107  among  the  men,  and 
10  among  the  women — nearly  two  thirds. 

Of  these  amputations,  among  men — 


Amputations.  Deaths. 


Thigh  .  44 
Leg  .  67 
Foot  .  8 

Shoulder  7 
Arm  .  29 

Forearm  10 


34  morethan  three-fourths 
42  nearly  two-thirds 
5  more  than  half 
7 

17  nearly  two-thirds 
2  one-fifth 


Thus  you  see  that  the  leg  and  the  arm  re¬ 
present  the  average  of  the  mortality  ;  this 


mortality  attains  its  maximum  for  amputa¬ 
tion  of  the  thigh,  and  its  minimum  for  that 
of  the  fore  arm. 

Thus,  we  see  that  in  Paris,  in  the  best  ap¬ 
pointed  hospitals  possible,  with  the  best 
surgeons  in  the  world,  the  opinion  of  Bou¬ 
cher  is  confirmed,  that  primary  amputations, 
in  mass,  are  followed  by  a  mortality  of  two- 
thirds. 

Certainly,  these  results  are  unexpected, 
and  they  ought,  it  appears  to  me,  to  throw 
doubt  on  the  reported  success  ! 

In  limiting  the  question  still  more  to  the 
results  of  amputation  or  non-amputation 
for  fractures  of  thigh  and  leg,  I  find  another 
illustrative  document  not  less  precious. 

In  1830,  Dupuytren,  after  deducting 
double  fractures,  fractures  of  the  knee  and 
of  the  hip-joint,  and  immediate  deaths, 
treated,  at  the  Hotel-Dieu,  13  fractures  of 
the  femur,  for  which  he  did  not  amputate: 
5  were  cured,  and  7  died ;  another  he  am¬ 
putated  at  a  later  stage,  and  he  died. 

For  fractures  of  the  knee  or  the  leg  he 
performed  5  primary  amputations  of  the 
thigh,  of  which  cases  3  died ;  and  he  per¬ 
formed  4  secondary  amputations  of  the 
thigh,  all  of  which  cases  died. 

For  the  other  fractures  of  the  leg,  the 
following  table  shews  the  results  in  Dupuy- 
tren’s  cases  where  he  did  not  amputate  : — 

14  fractures  of  the  leg — 6  cured,  8  died. 

2  ,,  ,,  tibia  1  ,,  1  ,, 

2  ,,  „  fibula— 1  „  1  „ 

Dupuytren  performed  immediate  amputa¬ 
tion  of  the  leg  in  two  cases,  and  both  died. 

These  exact  statistics  prove  that  the  opi¬ 
nion  of  military  men  as  to  the  advantageous 
results  of  immediate  amputation,  either  in 
general  or  for  fractures  of  the  thigh,  does 
not  rest  on  solid  grounds. 

We  arrive,  then,  at  this  conclusion — that, 
in  seeking  to  save  the  limbs  of  the  wounded, 
we  do  not  expose  them  to  a  greater  risk  of 
death  than  in  amputating  them. 

From  all  these  considerations,  I  have 
modified  completely  my  opinion  as  to  the 
value  of  immediate  amputation,  and  I  have 
consequently  changed  my  mode  of  practice 
since  the  campaign  of  Poland. 

The  events  of  June  have  furnished  me 
with  a  sad  opportunity  to  verify  for  myself 
the  accuracy  of  my  new  opinions ;  and  I 
place  before  the  Academy  the  results  which 
1  have  obtained  at  St.  Louis,  where  I  re¬ 
ceived  a  great  number  of  the  wounded. 

There  are  cases  about  which  all  discusson 
as  to  amputation  is  impossible.  Where  the 
knee  or  hip-joint  are  shattered  by  a  gun¬ 
shot  wound,  amputation  is  imperative. 
After  deducting  such  cases,  the  followng 
table  shews  the  results  of  my  treatment  of 
cases  of  fracture  in  which  I  have  not  am¬ 
putated  : — 


466  MM.  ROUX  AND  MALGATGNE  ON  GUN-SHOT  WOUNDS. 


5  fractures 

of  the  thigh. 

2  cured. 

2  dead. 

1  amputated  secondarily  in  greafc 
danger. 

6 

2  ,, 

„  leg- 

,,  tibia. 

2  going  on  well. 

2  >»  i) 

4  dead. 

4  „ 

,,  fibula. 

2  u 

2  dead. 

3 

5 

,,  arm. 

,,  forearm. 

1  cured. 

5  cured. 

2  dead. 

bin  i 

2 

metacarpus. 

1  going  on  well. 

1  dead. 

27 — total. 

15  cured. 

11  dead. 

1  amputation  secondarily,  who  is 
in  great  danger. 

I  have  only  practised  primary  amputa¬ 
tion  once;  and  I  am  almost  ashamed  to 
own,  after  the  energetic  attack  of  M.  Roux, 
that  it  was  an  amputation  of  the  elbow 
joint.  But  what  atones  a  little  for  my  error 
is  this — that  the  patient  is  cured.  I  own  I 
do  not  understand  M.  Roux’s  objections  to 
this  operation,  which  I  find  to  be  thoroughly 
surgical. 

Thus,  of  the  1 7  fractures  of  the  thigh  and 
leg  which  I  have  treated  without  amputa¬ 


tion,  8  have  been  almost  completely  cured. 
Dupuytren  obtained  13  cures  out  of  31  cases. 
Thus  my  results  are  more  consoling  than 
those  which  M.  Bouchez  attributes  with 
reason  to  immediate  amputation,  cases  of 
which  two-thirds  perish. 

The  following  results  were  obtained  by 
my  colleague,  M.  Gosselin,  in  the  same 
hospital,  in  fractures  for  which  he  no  longer 
practises  amputation  : — 


3  fractures  of  the  thigh. 

1  gives  hope. 

2  dead. 

3 

1* 

leg. 

1  uncertain. 

2  dead. 

4  >> 

99 

ankle-joint. 

1  nearly  well. 

1  dead.  2  secondarily  air 

lputated. 

2 

99 

shoulder-joint. 

2  well. 

2 

99 

arm. 

2  well. 

3  „ 

99 

elbow-joint. 

1  uncertain. 

2  secondary  amputation — 

-dead. 

8  „ 

99 

forearm. 

8  well. 

25 — total. 

16  successful 

cases. 

The  following  is  the  proportion  in  which  death  has  seized  the  insurgents  and  the 
military : — 

Among  the  17  fractures  of  the  thigh  and  leg  treated  by  me — 

5  were  insurgents.  4  died.  1  cured  (fracture  of  the  thigh). 

12  ,,  soldiers.  4  died.  7  going  on  well.  1  amputated — alive. 


This  great  mortality  among  the  insurgents 
is  certainly  due  to  the  depression  following 
their  defeat;  but  it  has  been  in  part  also 
caused,  1  ought  to  say,  by  the  want  of  pre¬ 
cautions  adopted  in  interrogating  these  un¬ 
fortunate  people,  which  has  been  done  with¬ 
out  consulting  the  heads  of  the  surgical  staff ! 

These  general  results  are  encouraging. 
They  are  due,  in  the  first  place,  to  this,  that 
the  wounded  in  our  insurrections  are  placed 
in  better  circumstances — transport  more 
prompt,  care  more  immediate ;  but  they 
are  also,  I  ought  to  say,  due  to  the  treat¬ 
ment. 

1  abstain,  as  much  as  possible,  from  open¬ 
ings  and  incisions.  I  only  apply  the  most 
simple  apparatus,  necessitating  for  its  change 
no  movement  of  the  limb. 

In  addition,  I  make  the  patients  eat.  As 
soon  as  they  feel  hungry  they  are  supplied 
wi  h  food.  I  scarcely  ever  bleed  them,  and 
there  must  be  very  pressing  symptoms  in¬ 
deed  that  would  induce  me  to  make  any  kind 
of  bloody  evacuation.  My  present  opinions 
on  this  point  are  not  what  I  formerly  held. 
Pupil  at  the  Val-de-Grace — pupil  of  Brous- 
sais,  of  whom  I  had  the  honour  to  be  “  chef 


de  clrnique,”  I  was  long  preoccupied  and 
oppressed  with  the  idea  of  inflammation — of 
gastritis — and  I  acted  accordingly.  But  I 
saw  the  deplorable  results  of  a  severe  diet 
and  emissions  of  blood.  A  document,  ema¬ 
nating  from  the  administration  of  Hospitals 
of  Paris,  which  it  is  much  to  be  regretted 
has  not  been  published,  throws  light  upon 
this  question.  It  is  the  table  of  mortality 
among  the  wounded  of  different  nations  re¬ 
ceived,  in  1814,  into  the  hospitals  of  Paris,  a 
table  in  which  the  regimen  of  the  wounded 
is  stated. 

In  this  table  figure  French,  Prussians, 
Austrians,  and  Russians :  the  wounded  of 
the  first  class  were  submitted  to  a  severe 
system  of  diet ;  the  Russians,  on  the  con¬ 
trary,  were  rarely  submitted  to  a  single 
bouillon,  more  rarely  to  low  diet ;  the  less 
severely  wounded  had  a  full  diet,  and  the 
rest  middle  diet :  and  in  addition  they  had 
wine  and  brandy. 

The  mortality  was — for  the 

French  soldiers  .  .  1  in  7 

Prussian  ,,  .  .  1  in  9 

Austrian  ,,  .  .  1  in  11 

Russian  „  ?  '  >”l  in  27 


MM.  ROUX  AND  MALGA1GNE  ON  GUN-SHOT  WOUNDS. 


467 


This  enormous  difference  is  sufficiently 
eloquent.  It  sufficed  to  modify  altogether 
my  practice  with  regard  to  regimen,  and  my 
results  are  not  unfavourable.  Although  I 
do  not  give  the  wounded  brandy,  yet  I  give 
them  a  certain  quantity  of  wine,  and  unless 
there  is  an  immediate  counter  indication,  I 
give  them  food  if  they  are  hungry ;  and  the 
results  prove  that  this  is  the  right  course  to 
pursue. 

I  have  yet  other  matters  to  bring  forward, 
but  I  defer  them  until  a  future  occasion. — 
(L'  Union  Medicate.) 

MM.  Roux  and  Malgaigne  are  each  of  them 
the  extreme  advocates  of  an  opposite  line  of 
treatment,  M.  Roux  advocating  in  almost  all 
cases  primary  amputation,  M.  Malgaigne 
altogether  opposing  it ;  and,  on  the  contrary, 
attempting  to  save  all  fractures,  even  of  the 
thigh,  not  implicating  the  joints  ;  for  in  such 
cases  even  M.  Malgaigne  would  immediately 
amputate.  M.  Velpeau,  who  is  now  an 
advocate  of  immediate  amputation,  in  most 
cases  of  gun-shot  fractures  of  the  thigh,  at¬ 
tempted,  in  1830,  to  save  eight  or  nine  com¬ 
plicated  gun-shot  wounds  of  the  thigh ;  of 
these  he  only  saved  two,  three  others  re¬ 
covered  after  secondary  amputation,  and  the 
rest  died. — {Lancet.) 

Larrey,  under  precisely  analogous  circum¬ 
stances,  lost  one  in  seven  ;  Mr.  Wasdell  (not 
Mr.  Guthrie,  as  M.  Malgaigne  erroneously 
reports),  lost  one  in  seven,  after  the  affair  at 
New  Orleans  ;  and  Mr.  Guthrie  one  in  five, 
after  the  battle  at  Toulouse. 

It  may  be  here  stated,  that  after  the  New 
Orleans  engagement,  Mr.  Wasdell  lost  five 
out  of  seven  of  his  secondary  amputations, 
and  that  from  June  to  December,  1813,  the 
British  Army  in  Spain  lost  19  out  of  128 
amputations  of  the  lower  extremity,  per¬ 
formed  on  the  field  (about  1  in  ;)  and  149 
in  255  performed  in  hospital  (about  3  in  5.) 
One  is  tempted  to  throw  out  of  sight  the  30 
successful  cases  out  of  30  amputated  by  the 
English  surgeons  after  Aboukirand  Camfar- 
dotnia,  quoted  by  M.  Malgaigne,  as  he  does 
not  give  his  authority  ;  and  Mr.  S.  Cooper, 
in  his  Dictionary,  only  quotes  from  Larrey 
with  regard  to  Aboukir  the  evidence  of  a 
French  surgeon,  M.  Masclet,  that  of  11  pri¬ 
mary  amputations  all  were  recovering, 
while  of  their  secondary  amputations  all 
died. 

In  the  British  Legion  (Spain,)  Mr.  Alcock 
reports,  that  in  the  Military  Hospital, 

May  to  December ,  1836. 

Primary  Amputations  .  .  16 — died  5 

Secondary  Amputations  .  33 — died  8 

January  to  June ,  1837. 

Primary  Amputations  .  .  25 — died  16 

Secondary  Amputation  .  33 — died  23 


It  is  interesting  to  note,  how  in  the  same 
hospitals  the  mortality  (always  rather  in 
favour  of  secondary  amputation)  rose,  from 
1  in  3  in  the  earlier  months,  to  3  in  5  in  the 
latter. 

Epidemic  sickness,  and  the  state  of  the 
hospital,  will  derange  all  comparative  returns. 

An  interesting  illustration  of  the  difficulty 
of  establishing  accurate  averages  of  results 
is  given  by  Mr.  Alcock,  who  lost  but  1  out 
of  the  first  16  amputations,  primary  and 
secondary  ;  while  out  of  the  next  8  amputa¬ 
tions  he  only  saved  1. 

The  English  surgeon  cannot  but  be  sur¬ 
prised  at  the  one  sided  and  opposite  systems 
of  treatment  adopted  by  different  eminent 
French  surgeons. 

M.  Malgaigne’s  observations  with  regard 
to  the  successful  result  among  the  well  fed, 
highly  stimulated  Russian  patients,  are  an 
extreme  but  interesting  illustration  of  the 
soundness  of  the  present  English  practice. 
In  such  cases  a  nutritious  diet  is  usually 
given  at  an  early  period,  and  under  copious 
discharges  the  system  is  well  and  repeatedly 
propped  with  food  and  stimulants.  Indeed, 
the  majority  of  these  cases  may,  even  when 
in  extreme  danger,  terminate  favourably  by 
such  means. 

The  writer  has  in  eye  many  serious  cases 
received  into  a  large  hospital,  saved  by  this 
treatment,  after  being  almost  in  a  state  of 
collapse. 

One  important  remedial  means  of  stimu¬ 
lating  the  system  is  opium,  often  as  effective 
in  allaying  irritability  and  excitability,  and 
rousing  from  collapse,  as  it  is  under  similar 
circumstances  in  delirium  tremens.  M. 
Velpeau  gives  opium  occasionally  to  produce 
sleep,  but  he  does  not  seem  to  be  aware  of 
its  power  as  a  stimulant,  of  which  power  the 
great  Sydenham  says,  4‘  prsestantissemum 
sit  remedium  cardiacum  {unicum  pene 
dixerim)  quod  in  rerum  natura  hactenus  est 
repertum  so  that  he  would  not  only  make 
it  the  chief,  but  almost  the  only  true  cardiac 
stimulant. 

MM.  Roux  and  Malgaigne  do  not  state 
whether  they  used  chloroform  during  the 
operations  which  they  performed  on  the 
wounded.  M.  Velpeau  did  not  use  chloro¬ 
form  in  his  cases  in  February,  because  he 
says  that  agent  evidently  depresses  the  ner¬ 
vous  system  ;  and  as  great  prostration  alwayg 
exists  in  patients  who  have  recovered  from 
gun-shot  wounds,  it  is  advisable  to  refrain 
from  any  anaesthetic  agent. 

Considering  that  this  was  the  impression 
and  practice  of  M.  Velpeau  in  February,  it 
is  rather  singular  that  he  did  not  allude  to 
this  opinion  when  he  supported  the  use  of 
chloroform  so  indiscriminately  during  the 
discussion  on  the  case  of  death  from  chloro¬ 
form  at  Boulogne.  3 


468  THE  MEDICAL  PROTECTION  SOCIETY  AND  ITS  OPPONENTS. 


(£omgpont)cnce. 


THE  MEDICAL  PROTECTION  SOCIETY  AND 
ITS  OPPONENTS. 

Str, — It  has  long  appeared  to  me  very  de¬ 
sirable,  for  the  advantage  of  medical  men,  to 
establish  a  Society  whose  special  business 
should  embrace  all  those  interests  of  the 
profession  which  are  separate  from  its  art 
and  science.  The  extensive  part  of  such  an 
undertaking,  placed  on  a  sound  footing, 
which  would  collect  many  of  the  debts  due 
to  members,  should  not  be  held  in  low 
estimation. 

No  class  of  men  do  so  much  work  for 
nothing,  or  find  so  many  bad  debts  where 
they  had  expected  to  receive  a  just  requital, 
as  “  general  practitioners.”  No  class  of 
gentlemen,  having  toiled  through  life,  leave 
their  widows  and  children  more  destitute. 

It  was  a  saying  of  the  late  Mr.  Burton 
Brown’s,  who  made  a  creditable  fortune  by 
practice, — always  carried  an  abstract  of  his 
ledger  in  his  pocket  or  carriage, — gained  and 
retained  the  confidence  and  regard  of  his 
patients, —  was  raised  to  the  bench  of  ma¬ 
gistrates,  &c.  &c.  —  “We  do  not  blend 
enough  the  mercantile  with  the  profes¬ 
sional.” 

In  early  life,  decoyed  by  “  the  bubble  re¬ 
putation,”  earnest  in  the  pursuit  of  know¬ 
ledge  and  learning — enamoured,  too,  with  the 
high  usefulness  and  dignity  of  art  and 
science, — all  except  the  grovelling  are  apt  to 
value  below  par  mere  matters  of  pounds  and 
pence.  Yet  how  many,  neglecting  the  mer¬ 
cantile,  have  rashly  made  shipwreck  of 
“honour,  happiness,  and  fair  renown,” 
each  of  which  might  have  been  secured,  had 
more  pains  been  taken  to  reap  the  honest 
earnings  for  professional  skill  and  labour. 

On  my  receiving  the  first  address  and 
prospectus  of  the  “  Medical  Protection 
Society,”  these  feelings  were  strongly  re¬ 
awoke  ;  and  I  now  feel  it  a  duty  to  address 
my  professional  brethren  through  the  king¬ 
dom,  respecting  this  Office,  lately  opened, 
and  advanced  with  considerable  claim  to 
public  notice  and  confidence. 

It  is  true,  sir,  that  “  good  wine  needs  no 
hush  ;”  yet,  as  a  traveller,  I  have  found  it 
well  to  gain  information  of  those  who  have 
gone  the  road  :  and  a  wrinkle,  or  a  word  of 
counsel  from  an  observant  fellow-passenger, 
has  often  had  more  influence  in  leading  to 
comfortable  quarters,  than  the  puffs  of  a 
“  toutef ,”  or  the  loud  voice  of  a  rival, 
greedy  of  gain,  or  fearful  of  loss. 

Approving  of  the  outline  of  the  “new 
project,”  I  looked  with  interest  to  see  names 
associated  with  it  which  might  give  a  con¬ 
fidence  to  the  public  beyond  the  consequence 


inseparable  from  the  scope  and  utility  of  the 
plan.  I  found  this  in  Mr.  Propert  and 
others,  and  became  a  subscriber.  The  sub¬ 
sequent  movement  taken  by  the  Office,  re¬ 
lating  to  the  position  of  the  Union  surgeons 
(more  zealous,  perhaps,  than  discreet,  as  the 
subject  was  already  under  the  care  of  the 
Hanover  Square  Convention,  who  are  in 
communication  with  the  President  of  the 
Poor-Law  Board,  and  the  Home  Office), 
furnished  at  least  a  fresh  point  of  interest  to 
me,  which  was  rather  increased  than  lessened 
by  the  cowardice  of  an  anonymous  letter  to 
Mr.  Propert,  disparaging  the  “  new  project.” 
On  many  accounts  it  is  to  be  wished  that 
the  venerable  Mr.  Pennington  had  not  hesi¬ 
tated,  on  account  of  his  advanced  life,  to  be 
the  co-trustee  with  Mr.  Propert.  New 
names  must  be  sought,  that  the  Trustees 
and  Committee,  as  a  body,  may  be  strong 
in  numbers,  and  beyond  suspicion. 

Brave  men,  with  good  intentions,  satisfied 
of  the  practicability  and  usefulness  of  an 
object,  are  neither  ashamed  nor  surprised  to 
stand  alone  for  a  time  in  advocating  a 
beneficial,  though  novel,  measure.  “  Fair 
weather  birds”  cautiously  keep  aloof  till  a 
degree  of  success  have  crowned  the  under¬ 
taking,  and  then  sometimes  they  encumber 
it  with  help,  unless  through  supineness  or 
timidity  they  have  allowed  the  golden  oppor¬ 
tunity  of  doing  good  to  pass,  and  the  plan 
fail  through  lack  of  timely  succour. 

There  can  be  no  doubt  of  the  importance 
of  aiming  to  suppress  all  illegal  practice. 
Many  gross  quackeries,  such  as  Patent  Me¬ 
dicines,  are  unhappily  sanctioned  “  by  law.” 
Yet  those  who  issue,  puff,  or  vend  these 
articles,  are,  in  my  eye,  “honest  knaves,” 
compared  with  the  impudent,  pretending, 
unqualified  practitioners,  who,  sailing  under 
false  colours,  laugh  at  the  profession,  which 
they  insult — at  the  pub'ic,  which  they  de¬ 
ceive  and  injure — and  at  the  law,  which  they 
outrage  with  impunity.  Pro-ecutions  against 
these  defaulters  are  too  expensive  or  trouble¬ 
some  for  individuals  to  undertake.  Though 
the  cost  and  process  are  now  reduced,  and 
made  more  summary,  the  Apothecaries’ 
Company  does  not  act :  hence  this  branch  of 
the  Medical  Protection  Office  may  be  par¬ 
ticularly  useful  and  consolatory  to  the  injured 
feelings  of  those  gentlemen  who  live  under 
the  conviction  that  they  suffer — suffer  un¬ 
justly — through  the  neglect  of  the  company 
authorised  by  Parliament  to  defend  them. 

The  mode  in  which  the  few  business  trans¬ 
actions  in  which  the  office  has  acted  for  me 
has  been  conducted,  has  impressed  me 
favourably  regarding  the  address,  vigilance, 
and  even  courteous  delicacy,  with  which  the 
interests  of  medical  men  are  there  treated. 
This  fact  must  be  of  vital  importance  to  the 
social  feelings,  as  well  as  the  “  status,”  of  those 
gentlemen,  who  are  more  or  less  pained  to 


REPORTED  IMPORTATION  OF  CHOLERA. 


469 


press  for  money,  being  familiar,  generally, 
with  the  domestic  and  pecuniary  affairs  of 
their  patients:  many  of  whom,  however, 
are  often  deficient  in  gratitude  and  moral 
principle,  more  than  even  in  money  itself. 

The  highest  abstract  excellence,  the  for¬ 
mation  and  distribution  of  the  benovelent 
fund,  at  which  the  Office  aims,  may  be  the 
most  difficult  to  attain  to.  The  profession 
must  be  prosperous,  confiding,  disinterested 
in  an  eminent  degree,  before  this  can  thrive. 
The  existence  of  a  similar  fund  attached  to 
the  Provincial  Medical  and  Surgical  Associa¬ 
tion  (adorned  by  Mr.  Newman,  its  treasurer 
and  secretary)  need  not  hamper  its  opera¬ 
tions,  nor  lead  to  rival  interest.  The  field 
is  capacious  enough — the  metropolitan  one 
is  particularly  unoccupied.  While  wrants  are 
wide  spread,  the  assuagement  should  be 
equally  so.  in  matters  of  diffusive  benevo¬ 
lence,  tv.  o  parties,  like  twin  brothers,  may 
live  side  by  side,  “  prospering  and  to 
prosper.” 

As  an  agency  establishment  in  all  its  mul¬ 
tifarious  ramifications,  this  Office  appears 
qualified  to  take  a  high  position  :  the  bold¬ 
ness  of  its  designs;  the  magnitude  of  its 
operations ;  and  the  character  of  even  its 
subordinate  officers,  with  whom  I  have  come 
in  contact,  speak  much  in  behalf  of  the 
judgment,  liberality,  and  enterprise,  shewn 
by  the  originators  of  the  scheme. 

But,  sir,  I  have  nearly  fallen  into  the 
error  of  puffing  an  institution  to  the  objects 
or  principles  of  which  1  mainly  wish  to  draw 
attention,  being  chiefly  solicitous  for  the  plan 
of  co-operative  efforts,  on  which  some  such 
society  should  be  based.  The  one  in  question 
promises  to  accomplish  much  by  this,  and  I 
cannot  doubt  its  meeting  with  much  con¬ 
currence  and  ultimate  success,  if  it  continue 
to  embody  in  its  operations  the  spirit  of  the 
motto,  “  faites  bien,  et  laissez  dire  should 
this  be  departed  from,  I  must  feel  it  right 
again  to  intrude  upon  your  columns. 

I  remain,  sir, 

Your  obedient  servant, 

Charles  F.  J.  Lord. 

Hampstead,  September  5,  1848. 

***  It  is  worthy  of  remark,  as  an  indica¬ 
tion  highly  favourable  to  the  new  project, 
that  they  who  support  it  do  not  hesitate  to 
attach  their  names  to  their  communications, 
while  those  who  are  opposed  to  it  are  afraid 
to  announce  themselves  openly.  Their  at¬ 
tacks  are  anonymous  and  personal,  and  are 
quite  opposed  to  the  English  system  of 
“  fair  play.”  We  at  present  know  nothing 
of  this  Society  or  its  objects  ;  but  consider¬ 
ing  that  some  highly  respectable  names  are 
publicly  attached  to  it,  and  that  its  opponents 
confine  themselves  to  vague  insinuations,  and 
take  care  so  to  conceal  their  names  that  the 
value  of  their  testimony  cannot  be  estimated, 


we  are  inclined  to  augur  most  favourably  of 
the  Medical  Protection  Society.  The  best 
project  for  the  relief  of  medical  grievances 
will  always  find  secret  opponents. 


ON  THE  PERIODICAL  ANNOUNCEMENT  OF 
SUBJECTS  FOR  PRIZE  ESSAYS  IN  THE 
MEDICAL  JOURNALS. 

Sir, — May  I  suggest,  through  the  medium 
of  your  journal,  that  once  a  year,  or  more, 
(say  in  October,)  a  list  of  prizes  offered  by 
the  different  societies,  and  the  titles  of  the  pro¬ 
posed  subjects,  should  be  published.  I  believe 
many  who  see  the  announcement  of  subjects 
for  prize  essays,  months  after  they  were  first 
announced,  are  thus  prevented  from  entering 
the  ranks  as  competitors.  It  is  true,  the 
subjects  are  always  “advertised,”  but  an 
occasional  published  list  of  them  would  be 
useful.  If  the  Medical  Directory  is  again 
published,  it  would  be  the  best  means  of 
making  it  generally  known. 

I  remain,  sir, 

\  our  obedient  servant, 

C.  S. 

September  6th,  1848. 

***  This  is  a  reasonable  suggestion.  Our 
columns  will  always  be  open  to  any  commu¬ 
nications  respecting  Medical  Prize  Essays. 


Jl'Uiural  Ihudltgenre. 


REPORTED  IMPORTATION  OF  CHOLERA. 

A  report  had  been  circulated  through 
Greenock  that  two  persons  had  died  of 
cholera  on  board  of  the  brig  Reliance,  which 
had  just  arrived  from  Cronstadt,  the  port  of 
St.  Petersburgh.  According  to  the  Scotch 
papers,  a  considerable  degree  of  uneasiness 
has  been  the  consequence,  but,  as  the  affair 
has  been  greatly  exaggerated,  no  apprehen¬ 
sion  whatever  need  be  felt.  There  was  one 
case  of  cholera,  of  a  most  malignant  cha¬ 
racter,  on  board  the  Reliance,  which  took 
place  about  17  days  before  she  arrived  in  the 
Clyde,  and  so  rapid  wras  the  progress  of  the 
disease  that  the  unfortunate  subject  expired 
after  two  hours’  illness.  On  the  vessel’s 
arrival  hjre  there  was  one  case  of  sickness 
on  board,  and  the  tide-surveyor,  who  exa¬ 
mined  the  vessel,  immediately  sent  for  a 
medical  man,  when  it  appeared  that  the 
patient  had  merely  a  facial  disease — some¬ 
thing  like  erysipelas.  He  was  at  once  taken 
to  the  infirmary,  and  the  vessel  was  relieved 
from  quarantine.  The  order  of  the  Board 
of  Customs  to  the  tide-officers,  dated  the 
15th  of  June  last,  is  to  the  effect  that  any 
vessel  which  may  have  had  a  case  of  cholera 
on  board,  but  not  within  ten  days  prior  to 


470 


PROGRESS  OF  THE  CHOLERA  ON  THE  CONTINENT 


her  arrival,  and  none  of  whose  crew  may 
have  within  that  period  exhibited  symptoms 
of  the  malady,  shall  be  relieved  from  qua¬ 
rantine. 

The  Glasgow  Examiner  of  Sept.  9th,  an¬ 
nounces  that  another  death  from  cholera  has 
occurred  on  board  a  Montrose  vessel  lying 
at  Riga — the  schooner  Helen.  The  victim 
in  this  case  was  a  brother  of  the  master, 
Flockart,  and  he  has  left  a  widow  and  seven 
young  children. 

***  We  by  no  means  object  to  the  rule 
adopted  by  the  Board  of  Customs :  on  the 
contrary,  we  think  it  consistent  with  com¬ 
mon  prudence;  but  how  is  such  a  rule  re¬ 
concilable  with  the  statements  recently 
made  in  Parliament  by  Lord  Lansdowne 
and  other  ministers  ?  In  what  way  can  it 
be  reconciled  with  the  reports  of  the  Metro¬ 
politan  Sanitary  Commission  ?  The  Com¬ 
missioners  say — “  The  non-transmissibility 
of  cholera  in  any  manner  whatsoever  ap¬ 
pears  to  us  to  be  a  demonstrated  fact .* 
Either  this  is  true  or  false.  If  true,  it  is 
evident  that  the  Board  of  Customs  is  not 
justified  in  making  any  restrictions  whatever 
on  the  admission  of  ves>els  in  which  fatal 
cases  of  cholera  have  appeared,  even  although 
the  date  of  attack  may  have  been  on  the 
day  of  arrival.  If  false,  as  this  order  to  the 
Board  of  Customs  appears  to  imply,  the 
sooner  it  is  retracted  and  disavowed 
the  better.  Epidemics  which  possess  no 
contagious  or  infectious  characters  do  not 
traverse  seas  in  sailing  vessels  ! 

PROGRESS  OF  THE  CHOLERA  ON  THE 
CONTINENT. 

We  bring  on  our  intelligence  of  the  progress 
of  the  cholera,  from  the  most  authentic 
sources,  up  to  the  latest  dates  received. 

St.  Petersburgh. — On  the  24th  August 
(12th  O.  S.)  there  were  25  new  cases,  and 
16  deaths  :  482  persons  were  affected  with 
the  disease.  25th. — The  number  of  patients 
under  treatment  had  diminished  to  448,  and 
on  the  22d  of  August  to  396.  The  numbers 
attacked  were  daily  becoming  diminished. 

Berlin ,  August  22d. —  The  number  of 
patients  attacked  with  cholera  was  104 ; 
deaths,  74  ;  recoveries,  12.  On  the  23d, 
the  number  of  new  cases  was  24.  On  the 
26th  there  were  167  patients  labouring 
under  cholera — 108  deaths,  and  19  reco¬ 
veries. 

28th. —  The  new  cases  were  96.  In  one 
house  in  the  Blumenstrasse,  no  less  than 
fifteen  persons  died  from  cholera.  The 
number  of  patients  is  not  great  compared 
with  the  population,  but  the  attack  is  almost 
always  mortal. 

Sept.  1. — The  latest  intelligence  to  this 
date  announces  that  377  persons  were 

*  See  our  last  volume,  p.  1085. 


affected  with  the  disease.  The  deaths  were 
305,  and  the  recoveries  only  3S. 

Warsaw,  August  26th. — The  number  of 
cases  of  Asiatic  cholera  was  27:  there  were 
5  recoveries,  and  12  deaths. 

These  reports  tend  to  confirm  the  general 
belief  that  this  terrible  disease  is  slowly  but 
surely  extending  its  progress  westward. 
This  progressive  advance  from  town  to 
town  and  city  to  city  in  the  great  lines  of 
human  intercourse,  is,  in  our  opinion,  quite 
inconsistent  with  a  purely  epidemic  cha¬ 
racter.  Thus  we  cannot  he  surprised  at  the 
Government  of  almost  every  country  at¬ 
tempting  to  enforce  quarantine  restrictions. 
Experience  has  shewn  that  these  have  not  in 
all  cases  succeeded  in  excluding  the  malady  ; 
but  this  is  no  reason  why  we  should  freely 
admit  into  our  ports  vessels  on  board  of 
which  patients  have  recently  died  of  cho¬ 
lera.  Salus  populi  suprema  lex ;  and  even 
if  it  be  a  mistake,  it  is  a  mistake  on  the 
right  side. 

Gallicia. — Letters  from  the  frontiers  of 
Gallicia  state  that  the  cholera  has  appeared 
with  such  violence  in  the  Government  of 
Lublin,  in  Poland,  that  in  the  small  town  of 
Krasnystaw  alone  more  than  400  personsdied. 
The  malady  declared  itself  after  the  arrival  of, 
some  regiments  of  Cossacks,  of  whom  a  con¬ 
siderable  number  were  the  first  victims. 

At  Moscow ,  it  was  reported  that  the  cho¬ 
lera  was  much  abated.  On  the  1 7th  and 
18th  ult.  58  new  cases  had  appeared,  and  24 
deaths.  There  remained  379  cases  under 
cure.  At  Riga  220  new  cases  were  declared 
between  the  19th  and  22d  ult.,  and  68  deaths. 
At  Helsingfors,  the  capital  of  the  Grand 
Duchy  of  Finland,  the  cholera  had  attacked 
48  persons,  of  whom  27  had  died. 

THE  CHOLERA  AT  CONSTANTINOPLE  AND 
IN  GREECE. 

The  latest  accounts  of  the  cholera  at 
Constantinople,  show  that  it  was  sensibly 
declining.  At  Trebizond,  the  disease  had 
also  greatly  declined.  At  Smyrna  it  was 
raging  with  violence,  and  for  some  time  had 
carried  off  50  or  60  victims  a  day.  More 
than  30,000  persons  had  quitted  the  city, 
which  presented  a  most  desolate  appearance. 
The  breaking  out  of  the  disease  had  inter¬ 
fered  with  business  to  such  an  extent,  that 
there  was  an  almost  total  suspension  of  trade 
at  a  period  when  it  was  usually  most  active. 
The  bazaars  were  closed,  and  numbers  of 
families  were  leaving  the  city,  in  order  to 
avoid  the  risk  of  contagion.  At  Salonica 
and  Aleppo,  the  disease  was  raging  with 
violence.  Letters  recently  received  at  Lloyd’s 
from  Salonica,  state  that  the  cholera 
had  made  its  appearance,  and  had  created 
such  alarm,  that  the  town  was  nearly  de¬ 
serted,  and  the  bazaars  were  all  closed. 
Among  the  dismayed  fugitives,  were  many 


471 


THE  ESSEX  POISONINGS — MOPE  CORONERS’  INQUESTS. 


of  the  local  medical  profession,  who  chose  to 
retire  from  the  scene  of  practice  rather  than 
encounter  the  virulence  of  the  disease.  In 
Greece,  in  consequence  of  its  approach,  the 
lazaret  of  Skiathos  had  been  closed  till  new 
orders,  and  that  of  Spezzia  closed  against 
all  arrivals  trom  infected  places.  The  disease, 
however,  had  broken  out  at  Skiathos,  and 
carried  off  21  persons.  The  Government 
and  sanitary  committee  of  Athens  had 
ordered  measures  to  be  taken  to  prevent  the 
spread  of  the  frightful  malady. 

DEATHS  FROM  CHOLERA  IN  EGYPT. 

Since  the  first  outbreak  of  the  Asiatic  cholera 
at  Cairo,  on  the  16th  of  July,  the  deaths 
from  the  disease  have  been  6641 

In  Alexandria  (from  July  26)  .  .  4032 

In  Tanlah  (from  12  to  26  July)  .  1800 

In  the  rural  districts  .  .  .  .  7000 


Total  deaths  19473 

The  disease  is  reported  to  have  become 
considerably  abated  in  the  virulence  of  its 
attacks. 

THE  IMPORTANCE  OF  CORONERS’  INQUESTS 
- THE  ESSEX  POISONINGS. 

To  the  Editor  of  the  Times. 

Sir, — The  powerful  and  important  leading 
article  in  your  journal  of  the  lstinst.  on  the  sub¬ 
ject  of  poisonings,  induces  me  to  trouble  you 
with  the  following  statement  of  facts,  tending 
to  show  that  the  increase  of  the  crime  may 
be  in  a  great  measure  attributed  to  the  want 
of  what  you  aptly  term  “  the  certainty  of 
detection”  which  ought  to  follow  every  case 
of  that  nature,  but  which  is  not  effected  in 
many  instances  from  the  impediments  impro¬ 
perly  thrown  in  the  way  Oj  holding  inquests 
in  some  districts. 

In  the  county  of  Devon  the  justices  came 
to  a  determination  not  to  allow  the  fees  for 
holding  any  inquest  where  a  verdict  of  na¬ 
tural  death  was  returned,  and  they  commu¬ 
nicated  that  determination  to  the  constables 
and  the  parish  officers  ;  and  the  result  was, 
that  many  cases  which  ought  to  be  inquired 
into  were  not  reported  to  the  coroners. 

In  1846  the  cases  of  poisoning  in  Norfolk 
were  brought  to  light  after  a  lapse  of  12 
months.  In  that  county  the  magistrates  had 
sent  a  circular  to  the  parish  officers,  endea¬ 
vouring  to  limit  the  holding  of  inquests,  by 
preventing  information  being  given  to  the 
coroners  in  certain  cases  ;  the  effect  of  which 
was,  that  the  numerous  deaths  from  poison 
which  had  occurred  were  not  inquired  into 
for  a  year  after  they  had  taken  place.  On 
the  inquest  being  held,  the  foreman  said, 
‘‘The  jury  wished  it  to  be  understood  that 
in  their  opinion  inquests  were  not  held  so 
frequently  as  they  ought  to  be ,  in  cases  of 
sudden  death.  It  often  happened  that  parish 
officers,  in  consequence  of  written  instruc¬ 


tions  furnished  them,  were  unwilling  to  send 
for  the  coroner,  and  that  in  many  cases  of 
great  importance,  but  attempted  to  investi¬ 
gate  the  matter  themselves.  They  all  wished 
to  keep  down  the  county  expenses,  but  not 
at  a  sacrifice  of  human  life,  and  he  trusted 
that  that  wholesale  case  of  poisoning  would 
operate  as  a  caution  to  parishes  generally  as 
to  the  necessity  of  a  coroner’s  investigation 
where  the  least  suspicion  was  attached.” 

Sir  J.  Graham,  the  then  Secretary  of  State, 
when  speaking  on  the  subject  in  the  House 
of  Commons  on  the  12th  of  June,  1846,  took 
occasion  to  remark  upon  the  infrequency  of 
coroners’  inquests  in  many  parts  of  the 
country,  lie  said — “  There  was  reason  to 
believe  that  in  the  county  of  Norfolk  no 
fewer  than  20  persons  had  died  from  poison 
administered  by  one  individual,  and  in  none 
of  those  cases  had  an  inquest  been  held.  The 
law  was,  that  any  person  having  reason  to 
believe  that  a  death  had  occurred  under  sus¬ 
picious  circumstances,  was  entitled  to  call 
upon  the  coroner  of  the  district  to  hold  an 
inquest.  Within  the  last  few  years,  however, 
an  indisposition  had  arisen  to  pay  the  charges 
connected  with  coroners’  inquests,  and  the 
consequence  had  been  that  inquests  had  not 
been  held  in  many  cases  where,  according  to 
the  law  of  the  country,  they  ought  to  have 
been  held.  The  magistrates  of  the  county 
of  Devon  had  even  gone  the  length  of  coming 
to  a  resolution  not  to  pay  the  costs  of  any 
coroner’s  inquest  where  the  verdict  was  ‘  died 
by  the  visitation  of  God.’  This  resolution 
had  had  a  most  injurious  effect  in  preventing 
inquests  in  many  cases  where  they  ought  to 
have  been  held.” 

In  the  county  of  Essex,  in  the  same  year, 
cases  were  discovered  of  poisonings  which 
had  occurred  a  year  and  a  half  previous,  and 
in  which  no  investigation  before  the  coroners 
had  taken  place. 

In  Shropshire  an  inquest  was  held  in 
October,  1846,  on  the  body  of  a  child  who 
died  in  the  May  previous;  and  though  the  cir¬ 
cumstances  attending  the  death  were  very 
suspicious,  the  length  of  time  which  had 
elapsed  prevented  a  satisfactory  result. 

In  September,  1846,  in  the  same  county, 
a  child,  which  had  been  strangled  by  its 
mother,  was  registered  as  having  “  died  in  a 
fit but  the  body  being  afterwards  exhumed 
and  the  case  investigated,  a  verdict  of  “  Wil¬ 
ful  murder”  was  returned  against  her. 

In  October,  1846,  some  of  the  town  coun¬ 
cil  of  the  extensive  borough  of  Manchester 
found  fault  with  the  Crown  for  holding  89 
inquests  in  four  months;  but  the  Registrar- 
General  in  his  report,  published  at  that  time, 
says,  that  in  Manchester  no  less  that  “  1'3, 362 
children  perished  in  seven  years,  over  and 
above  the  mortality  natural  to  mankind.” 

At  the  summer  assizes  in  1847  several 
persons  were  tried  for  committing  murder  in 


472  CORONERS*  INQUESTS - NECESSITY  OF  POST-MORTEM  EXAMINATION. 


order  to  obtain  the  burial  money  from  a 
benefit  society  ;  and  in  January,  1848,  an 
inquest  was  held  in  the  county  of  Monmouth 
on  the  body  of  a  man  who  had  been  buried 
in  the  November  previous,  which  ended  in 
the  widow  and  servant  of  the  deceased  being 
charged  with  having  poisoned  him,  it  being 
discovered  on  the  post-mortem  examination 
that  he  had  died  from  arsenic,  and  the  evi¬ 
dence  pointing  them  out  as  the  persons  who 
had  administered  it. 

In  the  county  of  Stafford  the  Finance 
Committee  of  Justices  have  in  the  present 
year  recommended  the  disallowance  of  more 
than  100  inquests,  many  of  which  were  cases 
of  burns  and  scalds,  and  others  suspicious  of 
poison.  Is  it,  then,  to  be  wondered  at,  if 
inquiries  are  stifled  and  prevented,  that  mur¬ 
ders  will  go  undiscovered  ?  It  is  the  cer¬ 
tainty  of  investigation  that  operates  as  the 
preventive  to  crime ,  and  nothing  tends  so 
much  to  the  encouragement  of  crime  as  the 
course  adopted  in  some  counties  of  discou 
raging  those  investigations  ;  and  it  might  as 
well  be  resolved  that  every  prosecution  should 
be  condemned  which  ends  in  an  acquittal,  and 
no  costs  allowed  therein,  as  to  say  that  no 
expense  of  holding  a  coroner’s  inquest  should 
be  allowed  because  the  verdict  happens  to  be 
“  Natural  death.” 

I  cannot  conclude  this  letter  without  an 
extract  from  a  leading  article  in  The  Times 
of  the  22d  of  June,  1846,  on  the  subject  of 
the  poisonings  in  Norfolk  : — 

“  It  appears  that  coroners’  inquests  are 
looked  upon  as  expensive  burdens  on  the 
county,  to  be  alleviated  by  all  practical 
methods,  and  a  circular  was  actually  sent  to 
the  village  of  Happisburgh,  amongst  others, 
to  inculcate  the  necessary  economy.  We 
trust  that  the  frightful  result  of  this  flagitious 
and  illegal  parsimony  will  be  a  warning  to 
the  whole  kingdom.  Had  an  inquiry  been 
instituted  at  the  first  death  there  is  little 
doubt,  even  if  detection  had  not  ensued,  that 
numberless  lives  would  have  been  spared,  and 
this  astrocious  career  of  guilt  cut  short.” 

Look  at  the  poisonings  in  Essex  now  under 
investigation,  and  say  how  has  this  advice 
been  followed  ? 

I  am,  Sir,  your  obedient  servant, 

William  Payne. 

London,  Sept.  4. 

***  The  italics  in  this  and  the  subjoined 
letter,  excepting  in  the  last  paragraph  but 
one,  are  our  own. 

DEFECTIVE  CORONERS’  INQUESTS. 

To  the  Editor  of  the  Provincial  Medical 
and  Surgical  Journal. 

Sir, — I  shall  be  glad  if  you  will  insert  the 
following  cases  in  the  Provincial  Journal. 

Your  obedient  servant, 

Augustin  Prichard. 

Bristol,  August  23,  1848. 


An  old  gentleman  called  upon  me  some 
time  ago  labouring  under  bronchitis  senilis, 
to  such  an  extent,  that  after  prescribing  for 
him,  I  felt  much  relieved  when  he  was  placed 
in  a  fly,  and  taken  back  to  his  hotel.  The 
next  morning  he  was  found  dead  in  his  bed 
by  the  porter  who  had  been  directed  to  awake 
him.  An  inquest  was  held,  and  the  porter 
who  found  him  was  called  upon  to  give  evi¬ 
dence,  as  was  also  a  neighbouring  medical 
man,  who  had  been  called  in,  in  the  hurry  of 
the  moment,  when  the  gentleman  was  dis¬ 
covered  to  be  dead,  and  who,  without  having 
seen  him  during  life, — without  any  post¬ 
mortem  examination ,  and  in  thorough  reck¬ 
lessness  of  all  medical  etiquette, — helped  the 
jury  to  arrive  at  the  conclusion  that  Mr. 
Prichard  had  ordered  the  patient  some  pills 
and  drops  for  his  cough,  and  that  he  was 
found  dead  in  his  bed. 

A  few  days  ago  I  was  called  about  six  a.m., 
to  see  a  child,  which  was  said  to  be  very  ill. 
The  child  was  dead,  and  its  body  nearly  cold. 
From  what  I  could  learn  by  inquiries,  I  sus¬ 
pected  that  it  had  been  overlain.  An  inquest 
was  held,  and  the  jury  having  looked  at  the 
body ,  determined  that  the  child  had  died  in 
a  fit  !  In  both  ca?es  I  had  left  word  that  I 
was  ready  to  attend  if  it  was  deemed  requi¬ 
site,  thinking,  of  course,  that  in  both,  but 
more  especially  the  latter,  an  examination  of 
the  body  was  indispensable. 

Some  years  ago,  a  surgeon  of  this  city  died 
rather  suddenly,  after  a  month’s  confinement 
to  bed,  from  ah  accident.  The  coroner  in¬ 
sisted  upon  an  inquest,  and  took  occasion  to 
express  his  opinion  of  the  great  importance 
of  coroners'  inquests.  The  two  cases  which 
I  have  just  adduced  authorize  us  to  conclude, 
that  by  these  words  he  merely  meant  to  ex¬ 
press,  in  an  abbreviated  form,  the  importance 
to  the  coroner  of  his  receiving  his  fees  for 
the  inquests  ,’  for  it  was  a  mere  form,  no 
cause  of  death  was  discovered  in  either  in¬ 
stance,  and  any  real  value  of  an  inquiry  of 
this  nature  was  completely  nullified. 

There  may  possibly  be  some  remote  advan¬ 
tage  in  publishing  such  abuses  in  medical 
journals  ;  but  it  is  only  to  avoid  the  charge 
of  bringing  myself  unnecessarily,  and  in  an 
unprofessional  way,  before  the  public,  that  I 
do  not  send  these  remarks  to  one  of  our  local 
papers. 

dr.  reid’s  plan  of  extinguishing  fires 

ON  BOARD  OF  VESSELS  AT  SEA,  BY  MEANS 

OF  CARBONIC  ACID  GAS. 

Dr.  Reid,  who  is  well  known  for  his  re¬ 
searches  on  ventilation,  has  recently  suggested 
a  singular  chemical  process  for  the  extinction 
of  fire  on  board  of  sailing  vessels.  The  re¬ 
cent  destruction  of  the  Ocean  Monarch,  off 
the  English  coast,  appears  to  have  led  him 
to  direct  his  attention  to  the  subject.  His 
process  consists  in  producing  suddenly  in 


mulder’s  chemical  counterblast  against  the  potato.  473 


that  part  of  the  vessel  where  the  lire  happens 
to  break  out,  a  large  quantity  of  carbonic 
acid  gas,  relying  upon  the  well-known  effect 
of  this  gas  in  extinguishing  lighted  candles, 
when  it  is  in  a  proportion  exceeding  twenty 
or  twenty  five  per  cent,  of  the  volume  of  air. 
For  the  production  of  carbonic  acid,  he  recom¬ 
mends  chalk  and  diluted  sulphuric  acid, which 
might  be  conveyed  by  a  moveable  hose  (made 
of  gutta  percha)  from  a  cistern  containing  it, 
to  the  spot  where  the  chalk  is  thrown.  The 
cost  of  material  for  a  ship  of  1000  tons  would 
not  exceed  fifteen  or  twenty  pounds,  and  the 
expense  of  laying  the  tubes,  &c.,  will  not 
exceed  thirty  or  forty  pounds.  As  the  result 
of  experiments  which  he  has  made,  he  finds 
that  from  five  tons  of  chalk,  as  much  car¬ 
bonic  acid  may  be  obtained  as  will  fill  a  vessel 
of  1000  tons  burthen. 

We  have  some  doubt  how  far  this  plan  is 
likely  to  become  available  in  practice.  The 
rapidity  with  which  a  fire  spreads,  in  a  space 
in  which  everything  around  is  highly  com¬ 
bustible,  and  the  difficulty  of  approaching 
near  enough  to  adjust  the  contact  of  the 
chalk  and  diluted  sulphuric  acid,  must  to  a 
certain  extent  interfere  with  its  application. 
Then  we  have  to  consider,  that  with  a  small 
quantity  of  carbonic  acid,  subjected  to  rare¬ 
faction  by  intense  heat,  and  liable  to  be  dis¬ 
persed  by  strong  currents  of  air,  we  cannot 
put  out  a  fire ;  and  with  a  large  quantity  of 
carbonic  acid,  i.  e.  enough  to  fill  a  vessel  of 
1000  tons  burthen  we  might  extinguish  the 
lives  of  the  crew,  and  thus  put  an  end  to  the 
necessity  for  the  operation. 

PROFESSOR  mulder’s  CHEMICAL  COUN¬ 
TERBLAST  AGAINST  THE  POTATO,  AS  AN 

ARTICLE  OF  DIET. 

In  a  work  recently  published,  Mulder,  the 
learned  Professor  of  Utrecht,  has  put  forth 
a  counterblast  against  the  potato.  As  an 
article  of  diet,  he  regards  it  as  innutritious, 
and  contends  that  it  is  the  cause  of  the  moral 
and  physical  degeneration  of  those  nations 
which  use  it  as  food !  He  admits  that  life 
may  be  supported  on  potatoes  alone  ;  but  it 
is  not  an  elastic  or  healthy  life  !  In  fact,  the 
potato  fills  the  stomach  with  a  mass  of  pro- 
vender,  from  which  but  little  healthy  nutri¬ 
ment  can  be  extracted.  He  contends  that 
we  shall  never  see  the  abuse  of  spirituous 
liquors  got  rid  of  until  potatoes  are  abolished 
as  a  common  article  of  food,  on  the  principle 
that  a  certain  amount  of  stimulus  is  indis¬ 
pensable,  and  that  therefore  the  ignorant  will 
have  recourse  to  one  that  is  destructive  to 
them,  so  long  as  a  salubrious  excitement  is 
denied. 

All  this  is,  chemically  speaking,  very  inge¬ 
nious  ;  but  we  cannot  agree  in  the  inference. 
Potatoes,  as  an  adjunct  to  animal  food,  are, 
we  consider,  highly  serviceable  to  the  sup¬ 
port  of  the  system  ;  and  we  think  a 


person  would  thrive  upon  such  food  much 
better  than  upon  a  concentrated  essence 
of  Mulder’s  favourite  protein,  or  its  com¬ 
pounds.  It  does  not  at  all  follow  that  sub  - 
stances  holding  but  little  nitrogen  and  sul¬ 
phur  are  unadapted  to  the  support  of  the 
system  ;  nor  is  it  to  be  admitted,  that  bodies 
which  abound  in  these  elements,  are  thereby 
fitted  to  sustain  life  in  its  maximum  of  in¬ 
tegrity.  Such  wild  inferences  are  the  result 
of  the  ultra-chemical  views  which  Liebig  and 
Mulder  are  disposed  to  force  on  physiologists. 
Experience  is  against  the  first  assumption ; 
and  if  the  second  were  true,  gutta  percha , 
caoutchouc,  and  urea,  might  take  the  place  of 
beef,  mutton,  and  pork,  when  these  sources 
of  food  were  deficient  ! 

A  CHEMICAL  PROCESS  OF  EJECTMENT. 

ALLEGED  POISONOUS  EFFECTS  OF  PHOS- 

PHURETTED  HYDROGEN. 

The  following  singular  case  was  heard  at  the 
Bow-street  Police  Office,  on  Friday  last : — 

John  Dolby,  of  No.  289,  Strand,  described 
as  a  “  practical  chemist,”  was  charged  be¬ 
fore  Mr.  Jarcline  with  having  nearly  suffo¬ 
cated  the  wife  and  children  of  Ebenezer 
Wild,  his  second-floor  lodger,  by  wilfully 
exposing  them  to  the  noxious  fumes  of  phos- 
phuret  of  calcium  in  a  state  of  decomposi¬ 
tion. 

The  complainant  stated  that  he  is  a  wood- 
engraver,  and,  with  his  wife,  an  infant,  and 
three  other  children,  occupies  the  second 
floor  of  the  defendant’s  house.  On  Wed¬ 
nesday  afternoon  he  was  sent  for  home,  and 
on  his  arrival  found  that  his  wife  and  children 
had  been  taken  suddenly  ill,  and  were  then 
scarcely  able  to  support  themselves,  owing 
to  a  powerfully  nauseous  vapour  emanating 
from  the  contents  of  a  saucer  which  had 
been  placed  by  the  defendant’s  orders  be¬ 
tween  his  sitting-room  and  bed-room.  The 
children  were  crying  and  clinging  to  their 
mother’s  dress,  while  the  infant,  about  nine 
weeks  old,  appeared  lifeless  and  cold.  The 
preparation  in  the  saucer  had  been  ignited, 
and  was  still  smoking ;  and,  finding  that  a 
strong  vapour  still  arose  from  it,  he  removed 
it  to  the  coalbin,  although  scarcely  able  to 
do  so  from  the  effect  which  it  had  upon 
himself.  On  asking  an  explanation  of  the 
occurrence  from  the  defendant,  he  said  that 
he  was  determined  to  get  them  out  of  his 
house,  and  referred  to  a  quarrel  which  had 
taken  place  between  his  wife  and  complain¬ 
ant’s  the  same  morning.  He  treated  the 
matter  with  great  levity ;  and  when  told 
that  the  child  was  dying,  said  merely  that 
“  it  was  not  dead,”  and  laughed.  Com¬ 
plainant  added  that  all  his  family  were  still 
suffering  severely  from  the  occurrence,  and 
his  wife  had  been  so  dangerously  ill  that  he 
was  obliged  to  send  for  a  doctor  that 
morning. 


474  THE  UNIVERSITY  AND  ACADEMY  OF  SCIENCES  OF  BERLIN. 


Mr.  H.  P.  Davis,  surgeon,  of  Clarendon- 
square,  said  that  he  was  in  the  habit  of  at¬ 
tending  the  complainant’s  family,  all  of 
whom  he  left  in  good  health  about  a  week 
ago.  He  had  seen  Mrs.  Wild  and  her  chil¬ 
dren  that  morning,  and  found  the  former 
very  unwell,  although  evidently  suffering 
chiefly  from  the  effects  of  great  alarm.  The 
children  appeared  slightly  indisposed ;  but 
he  was  unable,  so  long  after  the  occurrence, 
to  trace  their  illness  to  the  cause  assigned, 
although  such  might  be  the  effects  of  it. 
The  infant  seemed  to  be  better  than  the 
other  children. 

Professor  Miller,  of  King’s  College  Hos¬ 
pital,  proved  that  the  saucer  contained  phos- 
phuret  of  calcium,  which,  in  a  state  of  de¬ 
composition,  would  emit  a  very  noxious , 
(offensive  ?)  although  not  an  injurious  gas, 
unless  taken  in  great  quantities. 

The  defendant  said  he  would  not  mind 
taking  two  gallons  of  it.  He  persisted  in 
the  harmlessness  of  the  vapour,  which  he 
had  caused  to  be  placed  up-stairs  to  coun¬ 
teract  a  more  offensive  one. 

As  the  complainant  wished  to  take  the  case 
to  the  Sessions,  the  defendant  was  remanded, 
but  liberated  from  custody  on  his  own  re¬ 
cognizances. 

%*  It  must  be  admitted  that  Mr.  Dolby 
has  shown  great  ingenuity  in  attempting  to 
get  rid  of  troublesome  tenants  by  a  chemical 
process.  While  we  cannot  approve  of  his 
proceedings,  it  is  very  clear  that  the  effects 
of  the  phosphuretted  hydrogen,  evolved 
when  phosphuret  of  calcium  is  placed  in 
water,  have,  in  this  case,  been  most  absurdly 
exaggerated.  The  gas  in  a  concentrated 
state  is  undoubtedly  poisonous,  owing  to  the 
phosphorus  which  it  contains,  but  it  pos¬ 
sesses  so  powerful  and  offensive  an  odour 
(resembling  that  of  stinking  fish),  in  a  much 
less  than  poisonous  proportion  when  mixed 
with  air,  that  no  person,  unless  rendered 
insensible  from  other  causes,  could  remain 
long  enough  to  breathe  a  poisonous  dose  of 
the  vapour.  A  few  pieces  of  the  phosphuret 
will  thus  evolve  a  gas  which  will  render  the 
air  of  a  large  apartment  most  offensive  (but 
not  strictly  speaking  noxious)  to  respire. 
It  is  impossible  to  suppose  that  the  ingenious 
landlord  contemplated  the  murder  or  man¬ 
slaughter  of  his  tenants  by  this  chemical 
trick,  or  to  refer  the  illness  of  the  children 
to  such  a  cause  ;  nevertheless,  his  “  practical 
chemistry”  might  be  directed  to  better  and 
more  laudable  objects. 

THE  UNIVERSITY  AND  ACADEMY  OF 
SCIENCES  OF  BERLIN. 

The  University  of  Berlin  is  the  first  in 
Germany,  although  the  latest  in  point  of 
establishment.  Occupying  three  sides  of  a 
parallelogram,  of  which  the  free  side  opens 
upon  the  finest  street  in  the  capital,  this 


immense  edifice  is  situated  in  the  centre  of 
the  town,  surrounded  by  the  Opera,  the 
Royal  Library,  the  Academy  of  Sciences, 
the  palace  of  the  Prince  of  Prussia,  and  the 
Arsenal.  Of  an  imposing  architecture, 
divided  into  two  stages,  containing  under 
the  same  roof  five  large  museums  (the 
physical,  mineralogical,  zoological,  surgi¬ 
cal,  and  anatomical),  thirty-three  lecture 
rooms,  various  bureaux  for  the  senate  of 
the  academical  tribunal,  and  other  pur¬ 
poses,  and  the  great  hall  of  ceremony, 
called  the  Aula ,  this  building  is  a  small 
town,  where  2000  pupils  receive  instruction, 
conveyed  by  170  different  masters.  There 
are  three  classes  of  teachers : — Private 
tutors,  who,  after  being  l'ecognised,  give 
private  instruction,  and  seek  to  make  them¬ 
selves  known  by  publication  and  teaching. 
Those  who  are  most  distinguished  among 
them  are  promoted  to  the  rank  of  Extra¬ 
ordinary  Professors.  These,  by  additional 
services,  attain  to  a  higher  degree,  under 
the  title  of  Ordinary  Professors,  who  re¬ 
ceive  complete  emoluments,  and  become 
permanently  established  in  the  Faculty  of 
Theology. 


In  the  Ordinary  Extra- 
Faculty  of  pro-  ordinary 
fessors.  professors. 
Theology  .  5  5 

Law  .  .  9  3 

Medicine  .13  10 

Philosophy  33  31 


Private. 

4 

5 
15 
32 


Stu¬ 

dents. 

314 

767 

294 

700 


345  courses  of  lectures  were  announced 
last  year,  of  which  227  were  private  and 
paid,  and  118  public  and  gratuitous.  Of 
this  number  there  were  in  medicine  50  pri¬ 
vate  and  paid  courses,  and  25  public  and 
gratuitous.  In  the  private  course,  from 
four  to  six  lectures  are  delivered  weekly  ;  in 
the  public,  seldom  less  than  two. 

The  Academy  of  Sciences,  founded  110 
yews  before  the  University,  under  the  di¬ 
rection  of  Liebnitz  (1700),  is  the  prin¬ 
cipal  learned  society,  comprising  all  the 
scientific  men  of  the  land.  Such,  at 
least,  is  its  design.  It  is  divided  into  two 
classes :  the  physico-mathematical  class, 
comprising  29  members,  and  the  philo- 
sophico-historical,  containing  24:  in  the 
whole,  there  are  53  academicians.  To  the 
title  is  attached  an  annual  pension  of  300 
dollars,  and  the  necessity  to  furnish  in  turn 
a  memoir  at  the  monthly  sittings  of  the 
Academy.  Incke  and  Baeckh,  the  celebrated 
astronomer  and  the  illustrious  scholar,  are 
the  perpetual  secretaries.  The  Academy 
(which  holds  a  single  public  meeting  in 
January)  is  under  the  protection  of  the 
King,  and  publishes  annually  in  one  vo¬ 
lume  a  selection  from  the  memoirs  read  at 
the  meetings.  The  Academy  is  recruited 
almost  entirely  from  the  University.  Of  its 
52  members,  30  are  professors,  and  the 


DISTINCTION  BETWEEN  RIVER  AND  WELL  WATER.  475 


greater  part  of  the  rest  have  been  professors 
formerly. 

Besides  these  learned  bodies,  there  are 
numerous  particular  associations  recognised 
by  the  State  :  among  these  there  are  twenty- 
five  other  scientific  societies.  —  V  Union 
Medicate.  2 

THE  USE  OF  AETHEREAL  SOLUTION  OF  PRE¬ 
PARED  COTTON  IN  BURNS.  BY  J.  CRAW¬ 
FORD,  M.D.,  LECTURER  ON  CLINICAL 

MEDICINE,  M'GILL  COLLEGE. 

I  observe  in  the  last  number  of  your  jour¬ 
nal,  a  short  notice  (taken  from  the  Boston 
Journal )  of  a  new  remedy,  as  a  surgical  ap¬ 
plication  to  wounds,  namely,  an  “  sethereal 
solution  of  prepared  cotton.”  I  have  lately 
had  an  opportunity  of  trying  this  remedy  in 
the  case  of  a  severe  burn,  and  had  the  plea¬ 
sure  of  witnessing  a  most  satisfactory  result. 
I  have  to  thank  Dr.  Payne,  dentist,  of  this 
city,  not  only  for  the  suggestion,  but  also 
for  having  afforded  me  the  means  of  trying 
it  on  the  occasion.  My  patient,  a  young 
gentleman  residing  in  the  same  house  with 
Dr.  P.,  had,  a  few  moments  previously, 
received  a  severe  burn  of  the  face  and  hands, 
from  the  accidental  inflaming  of  camphine,  or 
some  such  allied  fluid  :  after  placing  his  hands 
in  iced  water,  I  was  preparing  cotton-wad¬ 
ding  as  the  most  convenient  application  for 
the  face,  when  Dr.  Payne  mentioned  to  me 
that  he  had  lately  received  from  the  United 
States  a  new  remedy,  which  he  had  tried  to 
an  abrasion  on  his  hand  that  day  with  im¬ 
mediate  relief.  The  wound  so  treated  ap¬ 
peared  covered  by  a  thin  glazing  or  varnish, 
which  perfectly  excluded  the  atmospheric 
air — the  principal  desideratum  in  these  cases. 
I  at  once  adopted  the  suggestion,  perceiving 
that  it  appeared  to  promise  a  very  light  and 
convenient  covering,  while  the  aether,  during 
its  evaporation,  would  be  likely  to  afford  a 
cooling  application. 

The  solution  was  accordingly  brushed 
lightly  over  the  face,  and  a  glazing  was  soon 
observed,  and  the  painful  sensation  almost 
instantly  subsided. 

The  want  of  a  sufficient  quantity  of  the 
fluid  to  cover  the  hands  in  like  manner,  pre 
vented  me  treating  them  in  the  same  way. 
It  will  be  sufficient  for  my  present  object  to 
state  that  nothing  could  be  more  satisfactory 
than  the  result  of  this  application,  and  I 
know  of  none  at  all  to  be  compared  with  it 
for  convenience,  as  well  as  efficacy,  in  super¬ 
ficial  burns  of  the  face. — Brit.  Amer.  Jour., 
August  1848. 

DISTINCTION  BETWEEN  RIVER  AND  WELL 
WATER.  BY  DR.  R.  D.  THOMSON. 

The  purest  water  which  occurs  in  a  state  of 
nature,  is,  as  is  well  known,  rain-water, 
since,  in  a  great  measure,  it  resembles  dis¬ 
tilled  water ;  but  even  rain-water  is  not  per¬ 


fectly  pure,  because  it  may  contain  traces  oi 
substances  soluble  in  water,  which  are  found 
in  the  atmosphere,  such  as  carbonic  acid, 
nitrate  of  ammonia — the  latter  only  during 
thunderstorms,  and  besides,  both  during 
summer  and  winter,  when  there  is  less  diffu¬ 
sion  of  electricity  in  the  atmosphere,  it  may 
contain,  dissolved  in  it,  ammonia,  which  is 
now  known  to  pervade  the  atmosphere  in  the 
form  of  carbonate.  It  is  thus  obvious  that 
even  in  the  purest  forms  of  waters,  as  they 
occur  in  nature,  there  is  liability  to  impurity. 
The  rain  descending  with  these  substances  in 
solution  to  the  earth,  must  convey  these 
soluble  bodies  to  the  soil.  The  soil  becomes 
thus,  to  a  certain  extent,  contaminated  by 
foreign  matter  from  the  atmosphere,  by  the 
instrumentality  of  the  purest  natural  water. 
In  taking  into  consideration,  then,  the  source 
of  the  dissolved  matters  contained  in  less 
pure  forms  of  water,  it  is  necessary  to  keep 
in  view  this  constantly  operating  cause  of 
impurity.  To  such  an  extent  does  this  cause 
produce  an  influence,  that  we  find  in  all 
soils  a  certain  amount  of  ammonia  present, 
varying  in  quantity  towards  the  surface,  ac¬ 
cording  as  the  soil  is  either  close- bottomed 
or  loose — thus  showing  that  when  there  is 
less  obstruction  to  its  percolating  down¬ 
wards,  it  disappears  from  the  surface,  and 
penetrates  to  the  lower  strata.  A  portion 
at  least  of  this  ammonia  is  conceived  to  be 
derived  from  the  atmosphere,  and  acts  as 
food  for  plants. 

Supposing,  then,  this  water,  charged  with 
mere  traces  of  impurity,  should  fall  upon  a 
scanty  soil,  overlying  a  hard  and  with  difficulty 
decomposable  rock,  we  should  expect  that 
this  water  would  take  up  but  a  small  amount 
of  soluble  matter,  in  consequence  of  the  ab¬ 
sence  of  any  such  substances  in  the  soil  upon 
which  it  fell.  Hence  it  is  that  streams  and 
rivers  which  rise  among  rocks  of  granite  or 
slate,  trap  or  greenstone,  are  exceedingly 
pure.  It  is  thus  we  account  for  the  superi¬ 
ority  of  the  waters  of  the  Highlands,  and 
other  elevated  parts  of  Scotland.  The  waters 
of  the  Dee,  for  example,  which  are  used  for 
the  supply  of  the  city  of  Aberdeen,  are  per¬ 
haps  the  purest  of  any  waters  employed  by 
an  equally  large  community  in  this  country. 

From  a  knowledge  also  of  the  nature  of 
the  rocks  with  which  waters  come  in  con¬ 
tact,  we  can  predicate  the  presence  or  ab¬ 
sence  of  certain  ingredients.  For  example, 
we  should  not  expect  the  presence  of  potash 
in  the  waters  derived  from  the  neighbour¬ 
hood  of  Glasgow,  as  the  rocks  themselves 
usually  contain  soda. 

If  rain-water  were,  instead  of  falling  upon 
a  hard  rock,  to  be  precipitated  upon  a  soft 
and  easily  decomposable  stratum,  and  filter 
downwards,  we  might  expect  that  it  would 
gradually  dissolve  a  considerable  quantity 
of  soluble  substances.  If,  again,  the  water 


476 


REPORT  ON  THE  AIR  AND  WATER  OF  TOWNS. 


were  to  descend  upon  a  sandy  or  clay  soil, 
having  interspersed  through  its  particles 
saline  matter  filtering  in  from  various  impure 
sources,  it  is  obvious  that  the  water  would 
be  rendered  still  more  impure  than  in  either 
of  the  previously  supposed  cases.  This 
is  rendered  still  more  obvious  in  respect 
to  wells,  if  we  remember  that  the  water 
found  in  them  is  originally  derived  from  the 
atmosphere,  and  makes  its  way  into  wells  by 
filtering  through  a  considerable  extent  of 
soft  matter,  containing  of  course  soluble 
substances  imbedded. 

The  quantity  of  matter  dissolved  will  de¬ 
pend  in  some  measure  upon  the  rapidity 
with  which  the  water  percolates,  and  the 
amount  which  passes  through  the  strata ; 
and  hence  we  may  expect  that  in  rainy  wea¬ 
ther  the  solutions  will  be  much  more  dilute, 
and  that  the  consiitution  of  the  well  waters 
may  vary  considerably  at  different  seasons  ; 
just  as  we  find  that  rivers  contain  much  less 
solid  matter  in  a  given  weight  of  these  waters 
during  rains  than  during  the  dry  seasons  of 
the  year.  In  addition,  however,  to  the  mat¬ 
ter  contained  in  the  rain  water,  which  is 
derived  from  the  atmosphere,  there  is  a  large 
amount  of  gaseous  and  saline  matter  derived 
from  the  rejected  materials  of  living  beings, 
which  of  course  increases  in  proportion  to 
the  number  of  the  inhabitants.  A  certain 
proportion  of  such  substances  will  no  doubt 
be  evaporated  into  the  atmosphere,  but  the 
greater  part  undoubtedly  either  will  sink  into 
the  earth,  or  be  carried  into  the  common 
sewers,  from  which  more  or  less  of  it  cannot 
fail  to  filter  into  the  surrounding  porous  and 
absorbent  materials  through  which  they  are 
excavated. — Journal  of  Public  Health. 


jsdecttong  from  ^Journals. 

/  1 

REPORT  ON  THE  AIR  AND  WATER  OF 
TOWNS.  BY  DR.  SMITH. 

It  has  long  been  believed  that  air  and 
water  have  the  most  important  influence 
on  health  ;  and  superstitions  have  there¬ 
fore  constantly  attached  themselves  to  re¬ 
ceptacles  of  the  one  and  the  emanations  of 
the  other.  The  town  has  always  been 
found  to  differ  from  the  country  :  this 
general  feeling  is  a  more  decisive  experiment 
than  any  that  can  be  made  in  a  laboratory. 
The  author  then  proceeds  to  examine  all 
the  sources  from  which  the  air  or  the  water 
can  be  contaminated.  The  various  manu¬ 
factures  of  large  towns,  the  necessary  con¬ 
ditions  to  which  the  inhabitants  are  sub¬ 
jected,  and  the  deteriorating  influences  of 
man  himself,  are  explained.  If  air  be  passed 
through  water,  a  certain  amount  of  the 
organic  matter  poured  off  from  the  lungs 


is  to  be  detected  in  it.  By  continuing 
this  experiment  for  three  months,  Dr* 
Smith  detected  sulphuric  acid,  chlorine,  and 
a  substance  resembling  impure  albumen. 
These  substances  are  constantly  being  con¬ 
densed  upon  cold  bodies,  and  in  a  warm 
atmosphere  the  albuminous  matter  very 
soon  putrefies  and  emits  disagreeable  odours. 
The  changes  which  this  substance  under¬ 
goes  by  oxidation,  &c  is  next  examined,  and 
shown  to  give  rise  to  carbonic  acid,  am¬ 
monia,  sulphuretted  hydrogen,  and  proba¬ 
bly  other  gases.  The  ammonia  generated 
fortunately  from  the  same  sources  as  the 
sulphuretted  hydrogen  materially  modifies 
its  influences.  The  consequences  of  the 
varying  pressure  of  the  atmosphere  have 
been  observed ;  and  it  is  shown  that  the 
exhalations  of  sewers,  &c.  are  poured  out  in 
abundance  from  every  outlet  when  the 
barometric  pressure  is  lowered.  By  col¬ 
lecting  the  moisture  of  a  crowded  room  by 
means  of  cold  glasses  and  also  dew  in  the 
open  air,  it  was  found  that  one  was  thick, 
oily,  and  smelling  of  perspiration,  capable  of 
decomposition  and  of  producing  animalcules 
and  confervse,  but  the  dew  was  beautifully 
clear  and  limpid.  Large  quantities  of  rain¬ 
water  have  frequently  been  collected  and 
examined  by  Dr.  Smith ;  and  he  says — I 
am  now  satisfied  that  dust  really  comes 
down  with  the  purest  rain,  and  that  it  is 
simply  coal  ashes.  No  doubt  this  accounts 
for  the  quantity  of  sulphites  and  chlorides 
in  the  rain,  and  for  the  soot,  which  are  the 
chief  ingredients.  The  rain  is  also  often 
alkaline,  arising  probably  from  the  ammonia 
of  the  burnt  coal,  which  is  no  doubt  a 
valuable  agent  for  neutralizing  the  sulphuric 
acid  so  often  found.  The  rain-water  of 
Manchester  is  about  2^°  of  hardness — ■ 
harder,  in  fact,  than  the  water  - from  the 
neighbouring  hills  which  the  town  intends 
to  use.  This  can  only  arise  from  the  in¬ 
gredients  obtained  in  the  town-atmosphere. 
But  the  most  curious  point  is  the  fact  that 
organic  matter  is  never  absent,  although  the 
rain  be  continued  for  whole  days.  The 
state  of  the  air  is  closely  connected  with 
that  of  the  water  ;  what  the  air  contains  the 
water  may  absorb,  what  the  water  has  dis¬ 
solved  or  absorbed  it  may  give  out  to  the 
air.  The  enormous  quantity  of  impure 
matter  filtering  from  all  parts  of  a  large 
town  into  its  many  natural  and  artificial 
outlets,  does  at  first  view  present  us  with  a 
terrible  picture  of  our  underground  sources 
of  water.  But  when  we  examine  the  soil  of 
a  town  we  do  not  find  the  state  of  matters 
to  present  that  exaggerated  character  which 
we  might  suppose.  The  sand  at  the 
Chelsea  Waterworks  contains  only  1'43  per 
cent,  of  organic  matter  after  being  used 
for  weeks.  In  1827  Liebig  found  nitrates 
in  twelve  wells  in  Giessen,  but  none  in 


ON  OPEN  FORAMEN  OVALE.  VISION  AT  DIFFERENT  DISTANCES.  477 


wells  two  or  three  hundred  yards  from  the 
town.  Dr.  Smith  has  examined  thirty  wells 
in  Manchester,  and  he  finds  nitrates  in  them 
all.  Many  contained  a  surprising  quan¬ 
tity,  and  were  very  nauseous.  The  exa¬ 
mination  of  various  wells  in  the  metropolis 
showed  the  constant  formation  of  nitric 
acid ;  and  in  many  wells  an  enormous 
quantity  was  detected.  It  was  discovered 
that  all  organic  matter,  in  filtering  through 
the  soil,  was  very  rapidly  oxidized.  The 
presence  of  the  nitrates  in  the  London  water 
prevents  the  formation  of  any  vegetable 
matter — no  vegetation  can  be  detected  in 
such  water  by  a  microscope,  even  after  a 
long  period.  The  Thames  water  has  been 
examined  from  near  its  source  to  the  me¬ 
tropolis,  and  an  increasing  amount  of  im¬ 
purity  detected.  In  the  summary  to  his 
report,  Dr.  Smith  states  that  the  pollution 
of  air  in  crowded  rooms  is  really  owing  to 
organic  matter,  and  not  merely  to  carbonic, 
acid — that  all  the  water  of  great  towns 
contains  organic  matter — that  water  purifies 
itself  from  organic  matter  in  various  ways, 
but  particularly  by  converting  it  into  nitrates 
—  that  water  can  never  stand  long  with 
advantage  unless  on  a  large  scale,  and  should 
be  used  when  collected,  or  as  soon  as 
filtered.  —  British  Association,  Athenceum 
report. 


ON  OPEN  FORAMEN  OVALE.  BOR.  MAYNE. 

One  of  the  consequences  of  this  organic 
defect  is,  to  permit  the  venous  blood  to  pass, 
in  quantities  more  or  less  considerable,  from 
the  right  side  of  the  heart  directly  into  the 
left,  without  traversing  the  lungs  or  under¬ 
going  the  process  of  respiration.  The  as¬ 
semblage  of  symptoms  produced  in  this 
manner  hy  the  admixture  of  the  venous  with 
the  arterial  current  at  the  left  side  of  the 
heart,  and  the  consequent  circulation, 
throughout  the  system  at  large,  of  blood  im¬ 
perfectly  areated,  constitutes  a  form  of  cya¬ 
nosis  well  known  to  physicians.  Compara¬ 
tive  anatomists  are  also  aware,  that  the 
human  circulation,  thus  perverted,  is  some¬ 
what  analogous  to  the  normal  plan  of  the 
circulation  in  many  of  the  reptile  tribes,  and 
that  individuals  so  afflicted  resemble  in  cer¬ 
tain  functions  the  animals  to  which  they  may 
(not  inaptly)  be  considered  as  blood  rela¬ 
tions.  The  records  of  medical  science  abound 
with  examples  of  cyanosis  thus  produced. 

Other  cases  there  are,  in  which  the  fora¬ 
men  ovale  remains  permanently  open  with¬ 
out  producing  cyanosis ;  and  certain  it  is 
(let  the  explanation  be  as  it  may)  that  a  pa¬ 
tent  condition  of  the  aperture  in  question  is 
compatible  with  a  long  life,  and  with  a 
healthy  condition  of  the  circulatory  and  re¬ 
spiratory  functions. 

Much  ingenuity  has  been  displayed  by 


writers,  particularly  those  of  the  French 
school,  in  attempting  to  explain  such  dissi¬ 
milar  results  from  one  and  the  same  organic 
lesion.  In  many  instances,  where  an  open 
foramen  ovale  produces  no  disturbance  of 
function,  the  valvular  disposition  of  the 
aperture,  or  its  small  size,  prevents  any  in¬ 
terchange  of  the  venous  and  arterial  blood; 
and  in  others,  the  ventricles,  the  auriculo- 
ventricular,  the  pulmonary,  and  the  aortic 
orifices,  retain  their  proper  dimensions,  and 
the  auricles  their  just  proportions,  so  that 
the  blood  at  either  side  of  the  septum  flows 
onwards  in  its  natural  course,  without  im¬ 
pediment,  and  consequently  no  intermixture 
arises. 

There  is  still,  however,  a  third  class  of 
cases  of  the  same  malformation.  In  these, 
arterial  blood  passes  from  the  left  side  of  the 
heart  into  the  right,  through  the  open  fora¬ 
men  ovale,  and  thus  a  mixture  of  arterial 
with  venous  blood  taking  place  in  the  right 
auricle,  the  current  transmitted  to  the  lungs 
for  aeration  is  a  mixed  fluid,  consisting 
partly  of  venous  and  partly  of  arterial  blood. 
This  deviation  from  the  natural  course  of  the 
circulation  is  the  converse  of  that  already 
described  as  producing  cyanosis  ;  in  the  one, 
the  current  flows  from  the  right  auricle  into 
the  left,  depriving  the  lungs  of  a  portion  of 
the  blood  which  ought  to  circulate  through 
them,  and  supplying  the  system  at  large 
with  a  mixed  fluid,  partly  venous  and  partly 
arterial,  thus  causing  cyanosis  ;  whilst  in  the 
other,  the  current  flows  from  the  left  auricle 
into  the  right,  depriving  the  system  at  large 
of  a  portion  of  the  blood  which  ought  to 
supply  it,  and  transmitting  to  the  lungs  a 
mixed  fluid,  partly  venous  and  partly  arte¬ 
rial. —  Dublin  Quarterly  Journal. 


adaptation  -of  the  eye  to  vision  at 

different  distances.  action  of 

THE  IRIS. 

In  addition  to  the  many  proof  s  already 
afforded  that  the  action  of  the  iris  is  not 
the  force  concerned  in  adapting  the  eye 
to  various  distances  of  vision,  and  that 
alterations  in  the  width  of  the  pupil  may 
take  place  without  any  corresponding  change 
in  the  distinctness  of  objects  under  view, 
Hueck  states  that  without  altering  the 
direction  of  the  axes  of  his  eyes  or  the 
quantity  of  light  admitted,  but  merely  by 
fixing  his  attention  on  a  side  object,  he  was 
able  to  widen  his  pupils  as  much  as  one  half 
more  than  their  former  diameter,  without 
there  ensuing  any  indistinctness  of  the  object 
towards  which  the  eyes  were  directed.  He 
observes  also  that  the  inefficiency  of  the  iris, 
in  this  respect,  is  demonstrated  by  the  fact, 
that  individuals  in  whom  the  iris  is  wholly 
wanting,  have  usually  perfect  vision  for  near 
as  well  as  distant  objects. — Baly  and 
Kirkes’s  Recent  Advances  in  Physiology. 


478  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY,  ETC 


MODE  OF  EXAMINING  THE  SKIN. 

At  a  late  meeting  of  the  Paris  Academy  of 
Sciences,  M.  Flourens  exhibited  a  portion  of 
human  skin,  prepared  and  presented  by  M. 
Retzius.  It  was  taken  from  the  axilla,  and 
was  said  to  show  very  beautifully  the  seba¬ 
ceous  glands,  and,  in  the  deeper  texture,  the 
large  sudoriferous  glands.  Both  were  dis¬ 
tinctly  visible  to  the  naked  eye,  and  with 
a  simple  lens,  their  general  structure,  and 
the  coots  of  the  sweat-glands,  were  very  per¬ 
ceptible.  The  preparation  was  made  by 
macerating  the  skin  in  sulphuric  ether,  which 
rendered  its  texture  transparent. 


METEOROLOGICAL  SUMMARY. 


Mean  Height  of  Barometer .  29-88 

“  “  Thermometer3  . .  61 '2 

Self-registermg  do.b  ....  max.  92‘3  min.  38'2 
“  in  the  Thames  water  —  63‘5  —  61'5 

a  From  12  observations  daily.  i>  Sun. 


Rain,  in  inches,  0  7:  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological. — The  mean  temperature  of  the 
week  was  3°.4  above  the  mean  of  the  month 
(57°  .8). 


BIRTHS  &  DEATHS  in  the  Metropolis 


During  the  week  ending  Saturday ,  Sept.  2. 


Births. 

Deaths. 

Av.  of  5  Sum. 

Males....  688 

Males....  526 

Males. . . 

495 

Females. .  649 

Females..  494 

Females. 

477 

1337 

1020 

972 

"West— Kensington;  Chelsea;  St.  George, 
Hanover  Square;  Westminster;  St.  Martin 
in  the  Fields;  St.  James  ..  (Pop.  301,326)  150 
North  —  St.  Marylebone  ;  St.  Pancras  ; 
Islington  ;  Hackney . (Pop.  366,303)  189 

Central — St.  Giles  and  St.  George;  Strand; 
Holborn;  Clerkenwell;  St.  Luke;  East 
London ;  West  London ;  the  City  of 
London  . (Pop.  374,759)  187 

East— Shoreditch ;  Bethnal  Green  ;  White¬ 
chapel  ;  St.  George  in  the  East ;  Stepney ; 
Poplar . (Pop.  393,247)  230 

.South  —  St.  Saviour  ;  St.  Olave  ;  Ber¬ 
mondsey  ;  St.  George,  Southwark ; 
Newington;  Lambeth;  Wandsworth  and 
Clapham  ;  Camberwell ;  Rotherhithe  ; 
Greenwich . (Pop.  479,469)  264 

Total .  1020 


Causes  of  Death. 

All  Causes . 

Specified  Causes . 

1.  ^j/»io(ic(orEpidemic,Endemic, 

Contagious)  Diseases . . 
Sporadic  Diseases,  viz. — 

2.  Dropsy,  Cancer,  &c.  of  uncer¬ 

tain  seat  . 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  . 

4.  Lungs  and  other  Organs  of 

Respiration . 

5.  Heart  and  Bloodvessels  . 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion  . 

7.  Diseases  of  the  Kidneys,  &c... 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c . 

9.  Rhematism,  Diseases  of  the 

Bones,  Joints,  &c . 

10.  Skin,  Cellular  Tissue,  &c . 


11.  Old  Age 


Intemperance 


| 

Av.  of 
5  Sum. 

1020 

972 

1018 

968 

00 

fH 

T* 

257 

31 

45 

102 

120 

86 

80 

32 

28 

55 

79 

12 

8 

11 

10 

9 

7 

7 

1 

34 

50 

22 

8 

The  following  is  a  selection  of  the  numbers  of 
Deaths  from  the  most  important  special  causes: 


Small-pox  . 

.  38 

Measles  . 

Scarlatina  . 

.  144 

Hooping-cough. 

.  26 

Diarrhoea  . 

.  61 

Cholera  . 

.  7 

Typhus  . 

.  89 

Dropsy . 

.  22 

Sudden  deaths  . 

.  1 

Paralysis .  11 

Convulsions  ....  40 

Bronchitis .  28 

Pneumonia .  35 

Phthisis . 117 

Dis.  of  Lungs,  &c.  6 

Teething .  4 

Dis.  Stomach,  &c.  6 
Dis.  of  Liver,  &c.  9 


Hydrocephalus..  26  Childbirth .  8 

Apoplexy .  18  Dis.ofUterus,&c.  3 


Remarks. — The  total  number  of  deaths  was 
48  above  the  weekly  summer  average.  There  is 
a  slight  increase  on  the  preceding  week  in  the 
mortality  from  scarlet  fever,  which  appears  to  be 
at  the  present  time  more  prevalent  and  fatal  than 
it  has  been  for  some  years.  The  deaths  from  this 
disease  were  144,  to  a  weekly  average  of  only  37. 
Of  these  140  were  among  infants. 


BOOKS  received  during  THE  WEEK. 
(The  List  will  be  given  next  week.) 

NOTICES  to  CORRESPONDENTS. 

The  communications  of  Dr.  Mayo  and  Mr. 
Jennette  will  be  inserted  in  the  following 
number. 

Mr.  Craig’s  letter  on  Chloroform  has  been  re¬ 
ceived. 

Received.— Mr.  Rumsey  ;  Mr.  W.  F.  Barlow ; 
An  Apothecary. 


THE  GENERAL  INDEX. 

We  have  to  announce  to  our  Subscribers  that  a  General 
Index  to  the  first  40  Volumes  of  the  London  Medical  Gazette 
will,  it  is  calculated,  form  a  large  Volume  of  about  700  pages. 
The  cost  of  the  Index  Volume,  respecting  which  many  inquiries 
have  been  made,  will  be  Twenty-four  Shillings ;  and  it  is  proposed 
to  commence  it  so  soon  as  the  Names  of  Five  Hundred  Subscribers 
have  been  obtained. — The  printers,  Messrs.  Wilson  and  OgilvY; 
57,  Skinner  Street,  will  receive  the  Names  of  Subscribers# 


479 


itonflon  iHciJtcal  Ca^mr. 


EettUttS. 


CLINICAL  LECTURE 

ON 

PARALYSIS, 

Delivered  at  King's  College  Hospital, 

By  R.  B.  Todd,  M.D.  F.R.S. 

Physician  to  the  Hospital. 
(Reported  by  Mr.  S.  J.  A.  Salter,  A.K.C.) 


Lecture  IV. 

Gentlemen, — The  case  upon  which  I  pro¬ 
pose  to  comment  to-day  is  one  of  not 
uncommon  occurrence — a  form  of  paralysis 
of  the  face  dependent  on  the  loss  of  power 
of  the  facial  portion  of  the  seventh  pair  of 
nerves. 

As  every  form  of  palsy  has  a  formidable 
appearance,  and  is  apt  to  create  much  alarm 
in  the  minds  of  the  patient  and  his  friends  ; 
and  as  this  is  particularly  the  case  when  the 
face  is  affected,  and  the  more  so  in  propor¬ 
tion  to  the  greater  distortion  of  the  counte¬ 
nance,  I  advise  you  to  make  yourselves  well 
acquainted  with  the  various  kinds  of  palsy 
that  affect  the  face.  The  alarm  which  a  loss 
of  power  in  one  side  of  the  face,  and  a  dis¬ 
tortion  of  the  balance  of  the  features,  occa¬ 
sion  to  the  patients  or  their  friends  is  very 
great — and  naturally  so.  Paralysis  is  a  for¬ 
midable  symptom;  and  on  its  first  appear¬ 
ance  it  is  apt  to  be  looked  upon  as  a 
sign  of  the  break-up  of  the  patient’s  con¬ 
stitution — an  indication  that  his  doom  is 
sealed.  It  is  very  important  that,  under 
such  circumstances,  the  medical  attendant 
should  display  a  perfect  acquaintance  with 
the  real  state  of  the  case,  and  be  able  to 
allay  the  patient’s  or  his  friends’  fears,  when 
the  nature  of  the  case  admits  of  his  being 
able  to  do  so.  As  in  the  generality  of  palsies, 
such  as  the  patient  now  in  the  hospital 
suffers  from,  you  may  speak  with  confi¬ 
dence  as  to  the  ultimate  result,  at  least  as 
regards  the  patient’s  life  ;  and  as  your  prog¬ 
nosis  should  rarely  or  never  be  otherwise 
than  favourable,  you  ought  to  possess  a 
thorough  knowledge  of  the  signs  and  the 
symptoms  of  this  malady,  so  as  to  enable 
you  to  recognise  it  readily  and  confidently 
whenever  it  comes  before  you. 

The  subject  of  this  case  is  John  Garrey  ; 
he  is  in  Fisk  ward,  and  you  can  scarcely 
fail  to  recognise  him  by  the  peculiar  ex¬ 
pression  of  his  countenance  ;  for  on  one  side 
his  look  is  most  doleful  and  melancholy, 
while  on  the  other  it  is  very  much  the 
reverse. 

He  is  39  years  of  age,  and  was  admitted 
xlii. — 1086.  Sept.  22,  1848. 


j  into  the  hospital  on  the  6th  of  January  : 
the  report  in  the  case-book  of  that  date  goes 
on  to  say  that  “  he  is  a  native  of  Ireland, 
but  has  lived  in  London  ever  since  he  was 
nine  or  ten  years  of  age :  is  a  married  man, 
a  carpenter  by  trade ;  temperate,  and  has 
always  had  good  general  health  until  a  week 
ago,  when,  after  keeping  in-doors  for  a  fort- 
night,  in  consequence  of  having  a  bad  leg, 
he  was  obliged  to  go  out  in  search  of  work, 
and  was  exposed  all  day  to  very  cold 
weather :  in  the  evening  he  had  an  attack 
of  shivering,  and  twitching  in  the  under  lip 
on  the  right  side ;  after  supper,  he  found 
his  lip  drawn  to  the  left  side,  but  it  was  free 
from  pain.  About  four  days  after  this  he  was 
seized  with  a  severe  pain  behind  the  right 
ear,  which  still  continues,  as  do  the  dis¬ 
tortion  of  the  face  and  inability  to  close  the 
eye  on  the  right  side,  even  during  sleep  ;  he 
cannot  whistle,  and  he  frowns  only  on  the 
left  side.  Upon  trying  to  shut  the  eye  he 
carries  the  ball  upwards  and  inwards,  but 
does  not  bring  the  lid  down  over  it,  except¬ 
ing  a  very  little.  He  protrudes  the  tongue 
in  the  median  line.” 

The  leading  character  of  these  cases  of 
facial  palsy  is  the  inability  to  close  the  eye¬ 
lids,  from  paralysis  of  the  orbicularis  palpe¬ 
brarum  muscle :  this  is  the  pathognomonic 
sign  which  determines  the  peculiar  nature  of 
the  palsy,  and  distinguishes  it  from  the  more 
serious  form  of  facial  palsy  which  is  depen¬ 
dent  on  disease  of  the  brain  and  palsy  of  the 
fifth  nerve.  It  is  remarkable  how  seldom 
the  seventh  pair  of  nerves  is  affected  by 
disease  of  the  brain.  I  cannot  say  that  I 
ever  saw  a  single  instance  of  paralysis  of  the 
orbicular  muscle  of  the  eyelids  due  distinctly 
to  diseased  brain  ;  and  I  have  only  seen  a 
few  in  which  the  power  of  the  muscle  ap¬ 
peared  to  be  enfeebled  from  that  cause. 
Thus  we  have  a  point  favourable  and  conso¬ 
latory  to  a  patient  afflicted  with  portio  dura 
paralysis  ;  namely,  that  the  affection  being 
seated  in  that  nerve  affords  a  strong  proba¬ 
bility  that  he  is  free  from  disease  of  the 
brain;  for  diseased  brain  would  give  rise  to 
a  different  form  of  facial  palsy,  and  very 
rarely,  if  ever,  causes  this. 

You  have  only  to  examine  this  patient 
with  care,  and  you  will  find  that  he  has 
almost  every  sign  which  indicates  that  the 
paralysis  has  its  seat  in  the  portio  dura 
nerve.  He  cannot  close  his  right  eyelids ; 
in  making  the  attempt,  however,  he  seems 
not  to  have  lost  the  power  altogether,  for 
the  upper  lid  is  slightly  depressed ;  yet  if 
you  put  your  finger  on  the  orbicular  muscle 
you  do  not  find  the  slightest  contraction  of 
it.  How,  then,  is  this  slight  depression  of 
the  upper  lid  produced  t  Watch  him 
closely  while  he  shuts  the  left  eye  and 
attempts  to  do  the  same  with  the  right,  and 
you  will  perceive  that  at  the  moment  the 


480 


DR.  TODD’S  CLINICAL  LECTURE  ON  PARALYSIS. 


left  eye  is  closed,  the  right  eyeball  turns 
upwards  and  inwards  to  such  an  extent  that 
the  cornea  is  nearly  or  wholly  concealed  by 
the  upper  lid,  and  by  this  upward  movement 
of  the  ball  the  upper  lid  is  slightly  depressed. 
The  same  upward  movement  of  the  eyeball 
takes  place  on  the  sound  side  at  the  moment 
of  the  forcible  contraction  of  the  orbicular 
muscle.  It  is  a  very  curious  instance  of  an 
involuntary  movement  which  cannot  be  con¬ 
trolled,  accompanying  a  forcible  action  of 
another  kind ;  and  no  doubt  has  reference 
to  the  complete  protection  of  the  eyeball 
against  all  those  sources  of  injury  which 
would  occasion  the  forcible  closure  of  the 
eyelids. 

Sir  Charles  Bell,  to  whom  we  are  so  much 
indebted  for  our  improved  knowledge  of  the 
paralytic  affections  of  the  face,  dwelt  much 
on  this  upward  movement  of  the  eyeball. 
He  affirmed  that  it  took  place  in  sleep,  and 
that  during  sleep  the  eyeball  retained  this 
position.  I  doubt  much  the  correctness  of 
this  assertion.  I  have  had  many  opportu¬ 
nities  of  satisfying  myself  that  in  perfectly 
tranquil  sleep  the  eyeball  is  directed  for¬ 
wards,  and  seems  suspended  in  the  orbit, 
being  equipoised  among  its  muscles.  Close 
the  eyelids  slowly  and  without  force,  and 
the  eyeball  remains  quiescent, — contract  the 
orbicular  muscle  forcibly,  instantly  the  eye¬ 
ball  turns  upwards  and  inwards.  When 
the  orbicular  muscle  is  made  to  contract 
strongly  as  a  reflex  action,  as  when  you  try 
to  push  any  object  into  the  eye,  the  upward 
movement  takes  place.  But  in  ordinary 
winking  you  have  none  of  it.  This  move¬ 
ment  of  the  eyeball,  then,  accompanies  only 
forced  contraction  of  the  orbicular  muscle  of 
the  eyeball. 

If  you  will  take  the  pains  to  watch  persons 
sleeping,  whenever  you  have  the  opportunity, 
you  will  find  that  in  sound  and  tranquil 
sleep  there  is  no  indication  of  active  con¬ 
traction  of  the  orbicular  muscle:  there  are 
no  wrinkles  of  the  eyelid,  and  no  depression 
of  the  brow,  as  when  that  muscle  is  in  strong 
contraction  ; — if,  with  the  greatest  care  and 
gentleness,  you  raise  the  upper  lid,  you 
will  find  the  eyeball  directed  forwards, 
maintained  in  this  position  by  the  equili¬ 
brium  of  its  muscles.  Should  your  at¬ 
tempt  to  raise  the  lid  give  rise  to  a 
reflex  action,  you  will  encounter  a  distinct 
resistance  from  the  contraction  of  the  orbicu¬ 
lar  muscle,  and  the  eyeball  will  be  turned 
"upwards  and  inwards,  more  or  less  forcibly 
in  proportion  to  the  force  of  the  reflex 
action.  I  think,  therefore,  we  are  justified 
in  asserting,  that  in  sound  sleep  the  position 
of  the  eyeball  is  one  of  quiescence,  that  it  is 
maintained  in  that  position  by  the  passive 
contraction  of  all  its  muscles,  and  that  the 
eyelids  are  kept  closed  by  the  passive  con¬ 
traction  of  their  orbicular  muscle,  and  that 


there  is  no  effort  or  influence  of  the  nervous 
system  directed  upon  any  of  these  muscles. 
It  is  only  when  sleep  is  disturbed,  when  the 
mind  is  more  or  less  active,  as  in  dreaming, 
that  you  will  find  active  contraction  of  the 
orbicular  muscle  of  the  eyelid. 

Our  patient  is  unable  to  frown  on  the 
right  side,  while  he  does  so  distinctly  on  the 
left ;  neither  can  he  move  his  scalp  on  the 
right  side  :  the  corrugator  supercilii,  and  the 
frontal  portion  of  the  occipito-frontalis  mus¬ 
cles,  are  paralysed — and  hence  these  move¬ 
ments  cannot  be  effected.  The  levatores  alae 
nasi,  and  the  zygomatic  muscles,  are  like¬ 
wise  paralysed  on  the  right  side,  and  there¬ 
fore  the  right  nostril  is  motionless,  and  the 
angle  of  the  mouth  hangs  on  that  side.  The 
orbicularis  oris  muscle  is  paralysed  as  to  its 
right  half :  the  patient  is  consequently  unable 
to  purse  up  his  mouth,  and  if  you  ask  him 
to  whistle,  he  will  afford  you  indications  of 
his  inability  to  perform  this  as  well  as  other 
actions.  In  making  the  attempt  to  whistle, 
you  may  perceive  that  he  contracts  the  orbi¬ 
cular  muscle  of  the  mouth  on  the  left,  but 
not  at  all  on  the  right,  and  so  he  is  quite 
unable  to  get  his  lip  into  the  position  neces- 
.sary  for  the  production  of  sound  ;  and,  while 
trying  to  adapt  his  mouth  for  this  purpose, 
he  smiles  or  laughs,  as  is  so  often  the  case 
when  you  ask  a  person  to  whistle,  and  you 
are  thus  enabled  to  see  how  completely  the 
action  of  the  features  is  confined  to  the  left 
side.  The  act  of  smiling  or  laughing  is  ex¬ 
aggerated  on  the  left  side,  and  the  reason  is 
because  the  left  muscles  have  lost  completely 
the  resistance  of  those  of  the  right  side, 
which  remain  perfectly  motionless,  and 
which  from  disease  have  lost  their  tone,  and 
have  suffered  much  in  their  nutrition.  For  the 
same  reason  all  the  movements  of  the 
features  which  act  in  symmetry,  and  which 
at  the  same  time  counterbalance  each  other, 
are  found  to  take  place  to  an  exaggerated 
extent  on  the  healthy  side.  Hence,  in  smil¬ 
ing,  laughing,  and  speaking,  the  face  is 
drawn  more  or  less  to  the  right  side :  the 
distortion  takes  places  on  the  healthy  side, 
the  paralysed  side  remaining  unmoved.  The 
popular  notion,  in  cases  of  this  kind,  is  that 
the  disease  is  on  the  side  to  which  the  mouth 
is  drawn.  No  medical  man,  however,  can 
fall  into  this  mistake  if  he  be  at  all  ac¬ 
quainted  with  the  real  condition  of  the  pa¬ 
tient. 

Another  muscle  which  is  paralysed  in  this 
case,  and  in  all  cases  of  the  same  kind,  is 
the  buccinator.  Hence  the  cheek  hangs 
loose,  and,  as  the  patient  speaks,  it  flaps  to 
and  fro.  This  extreme  looseness  of  the 
cheek  is  not  an  early  symptom  of  this  form 
of  paralysis ;  it  manifests  itself  more  and 
more,  the  longer  the  duration  of  the  disease, 
and  ultimately  becomes  the  cause  of  symp¬ 
toms  very  troublesome  to  the  patient.  It 


481. 


DR.  todd’s  clinical  lecture  on  paralysis. 


interferes  not  only  with  articulation,  from 
its  looseness  and  the  flapping  movement 
while  the  patient  is  speaking,  but  with  mas¬ 
tication  likewise.  The  palsied  muscle  allows 
the  food  to  accumulate  between  the  teeth 
and  the  jaw,  and  fails  in  its  function  of 
supplying  the  mill  with  its  proper  amount  of 
material  to  be  ground.  After  a  little  time, 
patients  learn  to  remedy  the  defect  of  ar¬ 
ticulation  which  the  paralytic  condition  of 
•the  buccinator  muscle  causes,  by  supporting 
the  cheek  with  the  hand ;  and  a  similar 
kind  of  support  helps  to  remove  the  incon¬ 
veniences  of  mastication. 

You  will  observe  that  all  the  muscles  para¬ 
lysed  in  this  affection  are  superficial :  they 
are  all  muscles  more  or  less  concerned  in  the 
expression  of  the  countenance.  The  deep- 
seated  muscles  are  not  affected — these  are 
muscles  of  mastication— the  only  muscle 
paralysed,  which  is  concerned  in  mastica¬ 
tion,  being  the  buccinator,  which  is,  however, 
only  accessory  to  that  function,  and  is  as 
much  or  more  a  muscle  of  expression. 

And  now  we  come  to  a  most  important 
question — what  is  the  exact  nature  of  this 
disease  ?  is  it  a  disease  of  certain  muscles  ? 
■or  of  a  certain  nerve  or  nerves  ?  or  is  it 
an  affection  of  the  brain  ?  Its  one-sided 
character  would  denote  its  being  a  cerebral 
.affection :  it  may,  however,  occur  simulta¬ 
neously  on  both  sides,  and  I  know  of  one 
instance  of  this  kind.  Experience,  however, 
as  I  have  already  told  you,  assures  us  that  it 
very  rarely  indeed  accompanies  cerebral 
disease;  sometimes  it  occurs  as  the  result 
-of  intm-cranial  disease,  but  rarely,  if 
ever*,  from  lesion  of  the  brain  itself. 
’Wibat,  then,  is  its  nature  ?  Sir  C.  Bell 
Nearly  pointed  this  out  long  ago,  and  to 
him  we  are  especially  indebted  for  our 
knowledge  of  the  precise  nature  of  the  dis¬ 
ease  ;  so  much  so,  that  some  designate 
the  disease  Bell’s  paralysis  of  the  face.  Not 
that  I  should  recommend  you  to  adopt  this 
name  ;  for  I  must  say  that  I  cannot  regard 
it  as  any  compliment  to  the  great  names  of 
our  profession,  to  attach  them  to  any  of  the 
numerous  ills  to  which  our  flesh  is  heir. 

Sir  C.  Bell  first  pointed  out  the  true 
nature  of  this  palsy,  because  he  was  the 
first  to  unravel  the  intricacy  of  the  nerves  of 
the  face.  He  showed  that  one  nerve,  and 
one  nerve  only,  was  at  fault  in  this  disease, 
and  that  it  was  strictly  a  local  paralysis,  due 
to  a  destruction  of  the  nervous  force  in  some 
part  of  the  course  of  this  nerve.  The  affected 
nerve  is  the  portio  dura  of  the  seventh  pair  : 
the  proper  facial  nerve  which  supplies  all 
the  muscles  paralysed  in  this  affection,  and 
is  the  only  nerve  which  supplies  them.  The 
fifth  pair  is  not  affected,  because  the  muscles 
of  mastication  are  free,  and  because  the 
sensibility  of  the  face  remains  intact.  Some, 
times  the  patient  cpmplaips  of  slight  pains 


in  the  face,  which  may  probably  be  due  to  a 
slight  affection  of  the  filaments  of  the  fifth, 
which  anastomose  with  the  portio  dura. 

There  is,  however,  one  muscle  paralysed  in 
this  affection,  which  does  receive  a  supply 
from  the  fifth — namely,  the  buccinator. 
This  muscle  has  two  motor  nerves — a  branch 
of  the  facial,  and  the  long  buccal  nerve  from 
the  fifth  :  the  former  may  be  regarded  as  its 
nerve  of  expression ;  the  latter  as  its  nerve 
of  mastication.  How  comes  it,  then,  that 
if  the  first  be  paralysed  and  the  muscle 
ceases  to  act  in  expression,  it  likewise 
ceases  to  act  in  mastication  ?  The  two 
nerves  are  distinct ;  and  the  buccal  nerve  is 
one  of  considerable  size,  and  to  all  appear¬ 
ance  would  seem  perfectly  adequate  to  the 
maintenance  of  a  different  action  indepen¬ 
dent  pf  the  portio  dura.  It  is  not  easy  to 
find  an  explanation  of  this  curious  fact, 
which  is  equally  true  if  the  nerve  first  pal¬ 
sied  be  the  fifth — as  in  cases  of  hemiplegia, 
in  which  the  hanging  of  the  cheek  is  due 
to  paralysis  of  the  buccal  nerve,  and  of  the 
buccinator  muscle.  The  advocates  of  Dr. 
Hall’s  views  would  doubtless  explain  it  by- 
assigning  to  the  facial  nerve  a  specially  spinal 
character,  and  to  the  fifth  a  cerebral.  The 
palsy  of  the  facial  nerve  would,  according  to 
these  views,  not  only  destroy  the  influence  of 
the  will  over  the  muscle,  but  also  cut  off  its 
supply  of  irritability.  Without  going  into 
other  serious  and  fatal  objections  to  this  ex¬ 
planation,  it  is  quite  enough  to  state  that  it 
is  inadequate  to  explain  the  complete  palsy 
of  the  buccinator  muscle  when  the  fifth  is 
the  only  nerve  affected,  as  in  common  hemi¬ 
plegia. 

In  some  instances  the  velum  of  the  palate 
participates  in  the  paralysis  ;  and  when  you 
look  into  the  patient’s  throat,  you  find  the 
uvula  inclining  away  from  the  paralysed 
side,  and  the  velum  drawn  to  the  sound  side. 
It  is  probable  that  the  portio  dura  exercises 
some  influence  on  the  muscles  of  the  palate 
through  the  greater  superficial  petrosal  nerve 
of  Arnold,  which  arises  from  the  knee¬ 
shaped  ganglion  that  is  formed  upon  the 
trunk  of  the  portio  dura  in  the  aqueduct  of 
Fallopius,  and  communicates  with  Meckel’s 
ganglion,  whence  the  palate-muscles  derive 
their  nerves.  Possibly  this  influence  may 
be  more  direct  in  some  cases  than  in  others. 

As  this  is  a  purely  local  palsy,  its  causes 
are  generally  strictly  local.  Thus  a  com¬ 
mon  cause  of  it.  and  especially  in  strumous 
children,  is  otitis,  and  the  subsequent  caries 
of  the  petrous  portion  of  the  temporal  bone. 
In  such  cases  the  paralysis  is  generally  very 
complete  :  it  is  caused  by  inflammatory  or 
destructive  disease  of  the  nerve  in  the 
Fallopian  aqueduct,  and  it  is  often  associated 
with  a  discharge  from  the  ear,  and  with 
deafness.  Injury  to  the  trunk  of  the  nerve 
may  give  rise  to  this  form  of  palsy  i  hence 


482 


DR.  TODD’S  CLINICAL  LECTURE  ON  PARALYSIS. 


it  often  follows  surgical  operations  on  the 
face,  and  accidental  wounds  in  the  parotid 
region;  and  formerly,  before  the  true  function 
of  the  facial  nerve  was  known,  when  sur¬ 
geons  used  to  divide  this  nerve  for  tic  dou¬ 
loureux ,  this  form  of  paralysis  used  to  be 
regularly  manufactured  by  chirurgical  skill. 

A  very  common  cause  of  this  palsy  is 
exposure  to  cold  ;  as  by  exposure  at  an  open 
window  in  a  coach  or  railway  carriage  to  a 
current  of  cold  air.  The  case  under  our 
consideration  was  one  of  this  description,  the 
patient  having  been  exposed  the  whole  day 
to  a  cold  atmosphere  while  in  search  of 
work.  These  are  instances  of  what  has  been 
called  “ peripheral  paralysis — cold  acting 
directly  on  the  peripheral  ramifications  of 
the  nerve. 

Sometimes  you  meet  with  cases  which  can¬ 
not  be  satisfactorily  traced  to  exposure  to 
cold  :  the  patients,  however,  will  be  found  to 
be  out  of  health,  and  to  have  had  pains  about 
the  face  and  neck  for  some  days.  It  is  pro¬ 
bable  that  in  all  cases  which  have  not  a 
traumatic  origin,  or  are  not  caused  by  dis¬ 
ease  of  the  petrous  bone,  there  may  be  some 
constitutional  fault  which  may  shew  itself  in 
this  local  malady,  just  as  painful  affections 
of  sentient  nerves — the  fifth,  for  instance — 
are  undoubtedly  generally  of  constitutional 
origin. 

Mr.  Bowman  tells  me  he  has  met  with 
several  cases  of  distinctly  rheumatic  para¬ 
lysis  of  the  portio  dura  among  the  patients 
at  the  Ophthalmic  Hospital,  Moorfields. 

Very  lately  I  have  met  with  a  well-marked 
case  of  palsy  of  the  portio  dura  which  was 
rheumatic  in  its  origin.  A  man  had  severe 
rheumatism  of  some  of  the  intercostal 
muscles  of  the  left  side.  This  got  well,  and 
then  the  muscles  of  the  hip  became  affected, 
and  he  was  completely  lamed  in  consequence. 
As  these  were  getting  better,  he  found  his 
face  to  become  suddenly  paralysed  on  one 
side,  with  all  the  symptoms  of  palsy  of  the 
portio  dura. 

Periodical  neuralgic  affections  are,  I  be¬ 
lieve,  generally  due  to  the  determination  of 
some  poison  to  a  particular  nerve — as  the 
paludal  poison,  or  some  matter  generated  in 
the  system,  gouty  or  rheumatic.  There  is 
no  reason  why  such  morbid  matters  should 
not  affect  a  motor  nerve  as  they  affect  a  sensi¬ 
tive  nerve,  causing  paralysis  in  the  one  case, 
and  neuralgia  in  the  other. 

The  cause  of  the  palsy,  in  the  case  under 
our  consideration,  appears  to  have  been  the 
direct: influence  of  cold.  This  view  is  con¬ 
firmed  by  the  pain  which  the  patient  suf¬ 
fered  at  first  in  the  neighbourhood  of  the 
ear  ;  as  if  the  ear  itself  and  the  nerves  about 
it  were  chilled,  and  some  degree  of  inflam¬ 
mation  excited  in  them  in  consequence. 

The  duration  of  this  palsy  varies  con¬ 
siderably  :  it  rarely,  if  ever,  lasts  a  shorter 


time  than  ten  days,  whilst  it  very  often 
extends  to  as  many  weeks  :  perhaps  three  or 
four  weeks  may  be  assigned  as  an  average 
duration  for  the  non-traumatic  cases. 

The  prognosis  in  cases  of  this  kind  should 
always  be  founded  upon  the  cause.  When 
the  paralysis  has  been  caused  by  mechanical 
injury,  your  prognosis  must  generally  be 
unfavourable,  more  especially  if  any  distinct 
solution  of  continuity  have  taken  place  in 
the  nerve.  Nerve-substance  is  very  slow  of 
regeneration ;  and  when  it  is  reproduced, 
the  new  fibres  do  not  adapt  themselves  with 
precision  to  the  old  ones,  and  so  they  form 
very  imperfect  conductors  of  the  nervous 
force.  But  if  the  paralysis  is  due  to  cold  or 
to  some  constitutional  cause,  it  almost  in¬ 
variably  gets  well.  But  you  should  bear  in 
mind  that  even  in  cases  which  are  incurable 
by  reason  of  the  solution  of  continuity  of 
the  nerve,  there  is  little  in  this  form  of 
paralysis  tending  to  shorten  life,  or  calcu¬ 
lated  to  prove  otherwise  than  inconvenient, 
by  causing  imperfection  of  speech,  mastica¬ 
tion,  and  vision,  and  sometimes  of  deglu¬ 
tition. 

In  Garrey’s  case  I  have  given  a  favourable 
prognosis,  believing  that  no  serious  mischief 
has  been  done  to  the  nerve,  and  that  it  has 
not  been  the  subject  of  destructive  disease. 
He  begins  to  gain  some  power  over  the 
orbicular  muscle  of  the  eyelids,  and  the  dis¬ 
tortion  of  the  face  is  somewhat  less.  The 
duration  of  the  palsy  has  already  been  quite 
three  weeks,  and  it  seems  probable  that  the 
patient’s  recovery  will  not  be  rapid,  as  so 
little  amendment  has  as  yet  shewn  itself.  I 
have  observed  that  when  they  begin  to  mend 
early — that  is,  within  a  week — complete 
recovery  takes  place  very  rapidly  ;  but  if  the 
first  signs  of  improvement  show  themselves 
late,  the  recovery  is  slow,  or  only  partial. 

You  will  likewise  find  it  necessary  to  be 
guided  by  the  cause  of  the  palsy  as  to  the 
course  you  will  pursue  in  its  treatment.  If 
otitis  be  its  cause,  and  the  inflammation  be 
of  recent  occurrence,  it  will  be  necessary  for 
you  to  have  recourse  to  the  usual  antiphlo¬ 
gistic  measures  for  its  suppression  ;  and  in 
such  a  case  it  may  be  desirable  to  carry  the 
use  of  mercury  to  ptyalism.  In  the  palsy 
from  division  of  the  nerve,  all  medical  treat¬ 
ment  is  useless  ;  and  when  the  disease  has 
been  caused  by  cold,  or  has  arisen  from  any 
constitutional  cause,  much  medical  inter¬ 
ference  is  not  requisite.  If  there  be  pain  of 
the  face,  warm  fomentations  will  prove 
useful.  Sometimes  a  few  leeches  at  the 
angle  of  the  jaw,  or  over  the  parotid  space, 
or  behind  the  ear,  may  be  tried,  ora  blister, 
or  iodine  paint.  I  cannot  say  that  I  have 
ever  known  clear  and  distinct  benefit  pro¬ 
duced  by  any  of  these  remedies  in  shorten¬ 
ing  the  duration  of  the  palsy. 

In  the  use  of  internal  remedies  you  must 


DR.  MAYO’S  OUTLINES  OF  MEDICAL  PROOF. 


483 


be  guided  by  the  diathesis,  and  the  existing 
condition  of  your  patient.  Mild  purgatives 
are  generally  useful,  and  sometimes  alkalies 
and  sudorifics,  and  I  have  seen  decided 
benefit  from  the  use  of  the  iodide  of  potas¬ 
sium.  I  cannot  name  to  you  any  remedy 
which  will  act  specifically  on  the  palsied 
nerve.  Strychnine  is  of  no  use  in  such  cases. 

As  to  local  remedies,  I  advise  you  to 
abstain  from  the  use  of  them,  if  possible. 
Blisters  are  open  to  this  objection,  that 
they  sometimes  cause  enlargement  of  the 
neighbouring  glands  of  the  neck,  which,  by 
their  pressure,  may  increase  the  evil  we  wish 
to  remove.  Galvanism,  used  carefully,  may 
be  useful, — always  remembering,  in  the  use 
of  it,  to  vary  the  direction  of  the  current, 
and  never  to  carry  it  on  so  long  as  to  ex¬ 
haust  any  small  amount  of  nervous  force 
which  the  nerve  may  be  capable  of  gene¬ 
rating. 

Our  patient,  Garrey,  has  been  treated 
chiefly  by  leeching  and  fomenting,  and 
purging,  in  the  first  instance,  and  afterwards 
by  the  iodide  of  potassium.  He  has  been 
completely  relieved  of  pain,  and  his  mus¬ 
cular  power  is  beginning  to  return.  I  pro¬ 
pose  shortly  to  try  the  effects  of  galvanism 
with  him. 

Garrey  suffers  from  a  very  troublesome 
symptom,  of  constant  occurrence  in  these 
cases,  and  which  is  very  difficult  to  deal  with — 
I  mean  irritation  of  the  conjunctiva,  occasion¬ 
ing  free  lacrymation  and  soreness  of  the  eye. 
This  is  obviously  due  to  the  constant  expo¬ 
sure  of  the  eye,  occasioned  by  the  loss  of 
the  power  of  winking  ;  and  it  can  only  be 
obviated  by  attention  on  the  part  of  the 
patient  to  the  protection  of  the  eye,  or 
by  his  wearing  a  shade  to  cover  it. 


ANALYSIS  OF  WROUGHT  IRON  PRODUCED 
BY  CEMENTATION  FROM  CAST  IRON.  BY 
PROF.  MILLER. 

It  is  to  be  noticed,  that  a  considerable 
change  in  specific  gravity  occurs  in  iron 
after  cementation.  Wfsen  forged,  it  was 
found  to  have  increased  in  density;  the 
brittle  iron  had  a  specific  gravity  of  7' 684, 
the  malleable  7*718.  The  results  of  analy¬ 
sis  were  briefly  these  : — the  quantity,  both 
of  carbon  and  silicon,  are  materially  dimi¬ 
nished  by  the  cementation,  though  still  the 
proportion  of  both  is  materially  greater  than 
in  good  bar-iron.  It  also  appears  that  the 
proportion  of  the  carbon  which  is  insoluble  in 
acids,  is  nearly  the  same  both  before  and 
after  the  iron  has  been  rendered  malleable, 
the  diminution  being  confined  almost  to 
that  portion  of  carbon  which  was  chemically 
combined  with  the  metal,  and  which,  there¬ 
fore,  would  be  in  a  state  for  propagation 
through  the  mass  more  readily  by  cemen¬ 
tation.  —  British  Association ,  Athenaeum 
report. 


(Drtgtnal  i^ommumcatton*. 


OUTLINES  of  MEDICAL  PROOF. 

By  Thomas  Mayo,  M.D.  F.R.S. 
Physician  to  the  Infirmary  of  St.  Marylebone. 
[Continued  from  p.  62.] 


During  the  last  winter,  in  the  able 
lecture  delivered  by  Dr.  Whewell  at 
the  Royal  Institution,  it  was  maintained 
that  false  theory  had  proved  more  ad¬ 
vantageous  to  science  than  the  absence 
of  theory  :  in  other  words,  agreeably 
to  Lord  Verulam,  that  “truth  more 
readily  emerges  out  of  error  than  out 
of  confusion.”  I  am  not  disposed  to 
contest  with  Dr.  Whewell  his  general 
proposition  ;  but  it  deserves  to  be  very 
attentively  considered  in  its  bearings 
on  medical  science,  so  far  as  it  may 
there  be  accepted  as  a  basis  of  reason, 
ing.  The  value,  indeed,  of  that  em¬ 
pirical  procedure  which  1  explained  in 
my  last  paper,  derives  additional  evi¬ 
dence  from  the  very  peculiar  nature  of 
the  curative  operations  which  are  con¬ 
stantly  proceeding  in  some  diseases 
irrespectively  of  our  plans,  except  so 
far  that  they  may  be  suspended  or  pre¬ 
vented  by  our  interference.  The  pro¬ 
gression  of  some  disorders  to  a  success¬ 
ful  issue,  if  left  absolutely  to  their  own 
course,— of  others,  again,  if  the  critical 
efforts  of  the  system  are  modified  and 
called  out  by  art,— while,  of  other  dis¬ 
orders,  the  course  is  altogether  and 
uniformly  mischievous,  if  left  to  itself, 

• — impose  very  varying  duties  upon  the 
physician  in  respect  to  boldness  of 
pathological  and  therapeutical  hypo¬ 
thesis.  Now  it,  is  somewhat  remarka¬ 
ble,  that  precisely  that  class  of  diseases 
in  which  nature,  unassisted  by  art, 
seems  most  powerful  to  cure,  has  been 
the  very  class  in  which  theory  or  hy¬ 
pothesis  has  been  most  active,  and,  I 
may  add,  most  intrusive.  I  allude  to 
fever ;  the  ordinary  forms  of  which 
certainly  afford  instances  of  a  morbid 
procedure  tending  to  a  spontaneous 
cure.  Now,  if  this  be  the  case,  it  may 
appear  not  unreasonable  if  I  select  that 
class  of  disorders,  as  affording  appro¬ 
priate  subject-matter  for  some  more 
extended  inquiry  into  the  uses  and 
abuses  of  theory.  To  this  point  I  shall 
devote  the  following  remarks. 


4*4 


DK.  MAYO  S  OUTLINES  OF  MEDICAL  PROOF 


I  must  refer  to  the  general  account 
which  1  have  given  in  t lie  “  Outlines,” 
of  the  relation  of  hypothesis  to  proof 
in  our  pathological  and  therapeutical 
deductions.  Its  foundation,  I  have 
there  admitted,  can  rarely  be  laid  in 
experiment;  it.  must  depend  mainly 
u(or  observation.  I  may  add,  that, 
in  its  legitimate  form,  it  may  be  said 
to  spring  out  of  observation,  and  to 
serve  as  a  systematising  principle, 
through  which  subsequentobservations 
arc  arranged.  It  may  thus  be  consi 
dered  the  result  of  an  empirical  induc¬ 
tion,  and  the  basis  of  a  scientific  in¬ 
duction,  between  which  processes  it 
thus  holds  a  kind  of  middle  place, 
derived  from  the  one,  and  occasioning 
the  growth  of  the  other.  In  its  less 
legitimate  form,  which  I  have  termed 
gratuitous,  it  is  to  be  found  classifying 
observed  facts  in  reference  to  some 
principle  presumed  to  pervade  them  : 
I  say  presumed,  because  its  existence 
is  taken  for  granted,  on  the  ground 
that  it  offers  an  explanation  of  the 
reference  of  the  facts  to  each  other. 
Now  the  gratuitous  hypothesis  has 
been  extensively  applied  to  fever  ;  that 
is  to  say,  where  the  nature  of  the 
disease,  in  its  relation  to  the  vis  medi- 
catrix,  is  most  marked,  we  have  un¬ 
happily  considered  ourselves  most  at 
liberty  to  siray  out  of  the  region  of 
fact.  I  have  noticed  in  the  “  Outlines” 
the  glaring  deviations  in  this  direc¬ 
tion  of  the  Brunonian  theory.  But  it 
must  be  remembered  that  a  barren 
theory  may  be  nearly  as  mischevious 
as  one  which  at  once  suggests  wrong 
practice.  Those  into  whom  it  is  in¬ 
stilled  may,  in  fact,  not  be  aware  of  its 
sterility,  or  content  with  inaction.  The 
wordy  and  unsubstantial  nature  of  the 
hypothesis  of  >pasm,  as  the  cause  of 
fever,  is  sufficiently  shown  in  the  readi¬ 
ness  with  which  it  takes  any  form 
which  the  imagination  of  its  employers 
has  been  disposed  to  give  it.  Thus, 
while  the  first  stage  in  the  febrile 
paroxysm  is  assumed,  both  by  Cullen 
and  Sauvages,  to  consist  in  spasm, 
according  to  Sauvages  this  hypothe¬ 
tical  state  involves  a  constrictive 
force,  whereby  the  blood  is  propelled 
so  as  to  conquer  a  stasis  or  obstruc¬ 
tion  :  Cullen,  on  the  other  hand,  hav¬ 
ing  borrowed  spasm  from  Sauvages, 
himself  assigns  it  two  functions.  It 
is,  according  to  him,  both  the  source 
of  the  obstruction  and  the  agent  in  the 


removal  of  the  obstruction — that  is,  of 
itself.  Now,  whichever  of  these  views 
we  adopt,  it  is  obvious  that  we  must 
regard  it  as  having  no  proved  objective 
sense,  through  which  the  therapeutics 
may  be  determined.  Yet  will  this  hy¬ 
pothesis  of  spasm  lend  itself,  with  dan¬ 
gerous  readiness,  to  many  views,  which 
a  sober  empiricism  would  discard  from 
the  treatment  of  the  disease.  Thus 
we  find  Cullen,  Aph.  127,  obliged,  by 
the  terms  of  his  theory,  to  admit  the 
use  of  antispasmodics  as  a  method  of 
taking  off'  the  spasm  of  the  extreme 
vessels,  which  appears  to  be  the  chief 
cau.se  of  violent  reaction.  And  thus 
the  cautious  and  moderate  Dr.  Cullen 
might  place  the  fever  patient  as 
mischievously  under  a  hot  regimen,  as 
his  ignorant  and  conceited  pupil  Dr. 
Brown. 

If,  in  the  absence  of  that  inductive 
hypothesis  which  assigns  causes  on 
proof  being  afforded  of  their  reality, 
we  must,  for  convenience,  sometimes 
adopt  the  gratuitous  hypothesis  which 
assigns  causes  on  proof  being  af¬ 
forded  of  their  suitableness,  let  us 
do  so  in  the  discreet  manner  of  our 
great  teacher,  Sydenham.  Speaking  of 
the  terms  ebullition  and  fermentation 
as  of  frequent  use  with  physicians  of 
his  day,  he  observes,  that  he  has  him¬ 
self  no  objection  occasionally  to  use 
this  language,  provided  it  be  perfectly 
understood  that  these  (hypothetical) 
expressions  “  have  no  other  purpose  in 
his  treatise  than  a  more  vivid  illustra¬ 
tion  of  his  ideas.”  We  may,  indeed, 
permit  the  natural  philosopher  to  help 
himself  freely  out  of  the  treasures  of 
his  imagination  :  his  aim  and  object 
is  discovery  :  while  the  physician,  in 
those  diseases  at  least  which  tend  to  a 
spontaneous  cure,  is  in  an  analogous 
position  to  him  only  when  the  vis  me- 
dicatrix  is  failing;  up  to  that  time  he 
has  to  watch  and  pilot  the  patient  on  a 
theory  as  empirical  and  as  unpresum¬ 
ing  as  he  can  devise.  Again,  the  hy¬ 
potheses  of  the  natural  philosopher 
may  be  comparatively  innocent,  even 
while  they  are  illusory,  for  they  can 
be  tested  before  they  are  applied  to 
human  use,  while  the  discoveries  of 
pathology  and  therapeutics  can  be 
tested  only  by  application  to  man. 

Between  the  nominalism,  if  I  may 
use  this  term,  of  the  gratuitous  hypo¬ 
thesis,  and  the  realism  of  the  inductive 
hypothesis,  as  applied  to  fever,  we  may 


DR.  MAYO’S  OUTLINES  OF  MEDICAL  PROOF. 


485 


assign  a  place  to  a  kind  of  hypothesis 
which  we  meet  with,  in  which  really 
existing  conditions  are  assumed  as  its 
basis;  but  the  connection  between 
these  conditions  and  the  disease  of 
which  they  are  predicated  is  vague  and 
illusory.  Such,  in  some  of  its  heads, 
is  the  hypothesis  of  fevers  laid  down 
by  Pinel.  Thus,  in  the  mucous  or 
pituitous  fever  and  the  gastric  fever, 
the  specific  relation  between  states  of 
the  mucous  or  pituitous  secretion  in 
the  one  and  gastic  irritation  in  the 
other,  to  the  fevers  ranged  under  these 
heads,  is  eminently  unsatisfactory.  If, 
however,  terms  of  this  import  and  this 
relation  to  their  subject-matter  are 
rightly  appreciated — not  as  explaining 
diseases,  but  as  directing  inquirers  into 
modes  of  investigation,  I  have  no 
disparaging  remark  to  make  against 
them. 

But  our  hypotheses,  even  where  they 
deserve  the  epithet  inductive,  have 
not  always  maintained  that  caution 
which  befits  us  in  dealing  with  a 
disease  whose  course  will  generally  be 
more  favourable  in  the  absence  of  all 
hypotheses,  than  under  the  guidance 
of  any  other  than  the  most  carefully 
selected.  The  safest  hypothesis,  in 
fact,  which  we  can  apply  to  this  sub¬ 
ject  is  one  which  we  may  glean  from 
the  history  of  fevers  transmitted  to  us 
bv  Sydenham.  His  observations  ena¬ 
ble  him  to  establish  the  general  fact  of 
a  change  of  their  type  occurring  in 
successive  periods,  and  in  this  way 
authorise  us  to  expect  a  corresponding 
variation  in  treatment. 

It  is  much  to  be  regretted  that  the 
admitted  value  of  this  hypothesis  has 
not  made  it  more  influential  in  the  in¬ 
quiries  of  subsequent  pathologists.  In 
our  own  day,  two  hypotheses,  each 
utterly  irrespective  of  the  principle  thus 
suggested  by  Sydenham  in  respect  to 
fever,  have  widely  influenced  the 
practice  of  this  country  ;  each  of  them 
far  removed  from  the  gratuitous  hypo¬ 
thesis  in  their  obvious  reference  to  ob¬ 
served  facts  as  their  bases,  one  of  them 
distinguished  in  the  highest  degree  by 
inductive  precision.  I  allude  to  those 
of  Dr.  Armstrong  and  Dr.  Louis.  The 
debt  of  gratitude  which  we  certainly 
owe  to  Dr.  Armstrong  for  establishing 
a  form  of  fever,  congestive  in  its  first 
stage,  as  requiring  certain  depletory 
measures,  would  have  been  more  freely 
paid  him,  and  his  memory  would  have 


commanded  a  larger  share  of  fame,  had 
he  imitated  the  circumspection  of  the 
pathologist,*  who  immediately  pre¬ 
ceded  him  in  these  views.  It  is  true 
that  the  chemical  inquiries,  which 
have  been  carried  out  since  the  publi¬ 
cation  of  Dr.  Armstrong’s  works,  into 
the  constitution  of  the  blood,  have  given 
to  the  symptoms,  by  which  he  recog¬ 
nised  congestion  in  the  above  sense,  a 
new  significancy  by  suggesting  causes 
of  those  symptoms,  which  connect  them 
with  crasis  rather  than  quantity  of 
blood  ;  and  ir  is  equally  true,  that  these 
practical  difficulties  in  the  application 
of  his  views,  arising  from  this  branch 
of  science,  would  have  been  remedied 
had  he  left  on  record  cases  illustrating 
his  practice  under  his  theory  of  con¬ 
gestion.  For  the  naked  results  of 
practice  contain  a  source  of  information 
quite  independent  of  the  theory  on 
which  it  may  here  have  been  founded. 
I  am, indeed,  the  more  desirous  to  attract 
attention  to  the  views  of  Dr.  Armstrong, 
because  his  want  of  precision,  and  the 
undue  extent  which  he  at  first  gave  to 
his  views,  which  no  subsequent  mitiga¬ 
tion  could  undo  in  public  opinion,  have 
left  them  in  abeyance.  Cases  are  fre¬ 
quently  occurring  of  well-marked 
typhus,  in  which  depletion  taking  place 
at  an  early  period,  has  obviously  tended 
to  give  a  successful  termination.  Other 
similar  cases  occur,  in  which  a  similar 
measure  would  probably  prove  equally 
successful,  if  the  principle  on  whicn  it 
may  be  carried  out,  were  more  definitely 
laid  dowrn.  Still,  in  the  absence  of  this 
practical  character  from  Dr.  Armstrong’s 
speculations  on  congestive  fever,  l  be¬ 
lieve  that  his  merits  are  truly  and  faith¬ 
fully  set  forth  by  his  friend  and  candid 
admirer,  Dr.  Booth  “  1 1  was  commonly 
supposed,”  says  Dr.  Boott,  “on  the 
prevalent  authority  of  Dr.  Cullen,  that 
the  stage  of  oppression  always  attends 
fever,  and  that  this  was  uniformly  suc¬ 
ceeded  by  one  of  reaction  ;  fever,  in 
fact,  being  made  toconsist  inanincrease 
of  the  heart’s  action  and  of  the  animal 
heat,  excluding,  therefore,  the  unmixed 
congestive  form  entirely.  But  Dr. 
Armstrong  has  proved,  that  in  many 
cases  there  is  no  congestion,  and  in 
others  that  there  is  no  reaction  ;  and  he 
has  moreexplicitly  shewn  how  the  state 
of  excitement  arises  ;  that  it  is  some- 

*  I  allude  to  Dr.  Rush.  That  Sydenham  of 
America  never  fails  to  record  the  epidemic  periods 
to  which  his  views  relate. 


486 


DR.  MAYO’S  OUTLINES  OF  MEDICAL  PROOF. 


times  direct  or  indirect  in  its  origin,  as 
well  as  the  cause,  and  occasionally  the 
effect,  of  inflammation.”* 

Conformably  with  the  French  system 
of  pathological  inquiry,  which  has  be¬ 
come  perhaps  too  popular  among  our¬ 
selves,  Dr.  Louis  prefers  the  localised 
to  the  dynamical  view  of  fever,  and  has 
based  his  hypothesis  of  the  cause  of 
typhus  on  the  ulceration  of  Peyer  and 
Brunner’s  glands.  In  common  with  Dr. 
Armstrong,  he  has  neglected  the  ex- 
ampleof  Sydenham, and  conceived  him¬ 
self  to  embrace  the  entire  disease,  when 
he  has  made  good  the  phenomena  of  one 
epidemic  period.  Accordingly",  we  find 
him  committing  the  errors  which  belong 
to  unripe  generalisation,  and  assuming 
that  the  debility  of  typhus  is  the  effect 
of  the  glandular  ulceration,  while  it 
can,  in  fact,  exist  in  its  highest  degree 
in  cases  of  which  this  symptom  forms 
no  part.  If  the  views  of  Dr.  Louis, 
contrasted  wTith  those  of  Dr.  Armstrong, 
in  being  less  dynamical,  are  less  com¬ 
prehensive,  and  so  far  less  philosophi¬ 
cal,  they  far  exceed  bothDr.  Armstrong, 
and  almost  every  other  pathologist,  in 
inductive  precision.  Both,  however,  of 
these  writers  are,  as  I  have  observed, 
of  the  right  kind,  in  obtaining  re¬ 
spectively  their  hypotheses  from  real 
grounds,  and  affirming,  as  such,  truths, 
not  plausibilities. 

If  comprehensiveness  of  views  and 
careful  observation  are  requisite  to  the 
framing  a  sound  hypothesis,  judgment 
and  discretion  are  often  requisite 
in  a  high  degree  for  its  just  appli¬ 
cation.  Thus  an  hypothesis  may 
be  framed  to  meet  circumstances,  under 
which  its  truth  has  to  be  assumed,  not 
as  having  been  proved,  but  as  having 
became  more  probable  than  the  con¬ 
trary  supposition ;  yet,  under  which 
some  hypothesis  had  become  very  de¬ 
sirable.  In  short,  circumstances  may 
have  arrived,  in  which  the  risk  of 
confusion  without  an  hypothesis  has 
become  a  greater  evil  than  the  risk  of 
error  with  one.  But  the  hypothesis 
selected  on  these  grounds  may  involve 
much  practical  mischief  if  taken  un¬ 
reservedly.  Such  would  be  the  work¬ 
ing-such,  indeed,  I  may  say,  has  been 
the  working  of  the  hypotheses  framed 
to  meet  questions  of  epidemic  or  con¬ 
tagious  fever.  That  in  a  particular 
place,  at  a  particular  time,  fevers  spread 


through  a  population,  circumscribed  by 
local  limits,  which  they  do  not  pass  by 
conveyance  through  infected  persons, 
is  apparently  most  true.  That  there 
are  other  fevers,  and  generally  other 
forms  of  pyrexia,  which  recognise  no 
such  circumscription,  and  which  occur 
so  frequently  on  an  infected  person 
being  brought  near  some  one  else,  who 
thus  appears  to  receive  the  fever  from 
him,  as  to  imply  transmission,  is  equally 
true.  And  if  we  let  these  two  con¬ 
siderations  serve  as  broad  statements 
of  a  general  probability,  we  use  them 
discreetly  according  to  the  present 
state  of  our  knowlege. 

Now,  it  is  perhaps  theoretically  right 
to  assign  to  typhus,  as  some  do,  the 
first  of  these  two  descriptions.  We 
perhaps  cannot  generalise  on  the  sub¬ 
ject  of  its  spread  with  as  much  truth 
in  any  other  way.  Yet  we  may  find 
reason  to  doubt  our  selection  of  this 
hypothesis,  when  we  see  cases  of 
typhus,  which  had  before  been  ende- 
mically  circumscribed,  spreading  from 
bed  to  bed  when  admitted  into  hospitals. 
Still,  the  usefulness  of  the  theoretical 
distinction  is  not  in  the  least  impaired 
by  these  qualifications,  if  rightly  un¬ 
derstood;  but  a  great  misdirection  of 
reasoning  is  averted  :  this  usefulness 
consists  in  its  tendency  to  solve  the 
practical  question, — the  general  distinc¬ 
tion  between  epidemic  and  contagious 
influence  being  assumed, — how  far,  and 
in  what  instances,  should  the  precau¬ 
tions  demanded  on  the  second  assump¬ 
tion  be  extended  to  cases  mainly  of 
the  first  kind. 

In  these  last  remarks,  I  am  aware 
that  I  am  only  unfolding  and  exem¬ 
plifying  principles  wffiich  our  best 
physicians  have  been  for  some  time 
carrying  out.  But,  though  they  have 
arrived  at  this  point,  it  is  right  in  our 
speculations  on  medical  reasoning,  to 
consider  through  what  perils  men  have 
passed  while  unenlightened  by  these 
sounder  views,  and  to  record  them  for 
the  benefit  of  others.  Thus  we  have 
been  in  danger  of  a  removal  of  quaran¬ 
tine  in  reference  to  plague,1  while  it  wras 
considered  unphilosophical  to  admit 
the  existence  of  contagion,  where  an 
epidemic  influence  had  been  demon¬ 
strated.  The  fallacy  on  wffiich  such 
reasoning  proceeds  is  indeed  still  in¬ 
fluential,  or  has  been  so  to  a  recent 
date.  Speaking  of  the  poison  of  typhus, 
as  “  either  at  all  times  diffused  in  the  at- 


*  Life  of  Dr.  Armstrong,  vol.  i.  p.  124. 


SYMPTOMS,  TREATMENT,  AND  INFECTIOUS  NATURE  OF  CHOLERA.  487 


mosphere  of  some  regions,  or  capable 
of  being  spontaneously  generated  in 
the  human  frame,”  the  late  Dr. 
Williams  observes  that,  if  it  be  an- 
philosophical  to  admit  the  agency  of  two 
causes  in  the  explanation  of  the  same 
phenomena,  the  theory  of  a  spontaneous 
generation  of  the  poison  is  negatived.* 
Now  I  quote  this  passage  not  in  its  re¬ 
lation  to  the  doctrine  which  it  conveys 
on  the  poison  of  typhus,  but  in  relation 
to  the  logical  principle  conveyed  in  the 
terms  quoted  by  me  in  italics.  The  ex¬ 
cellent  and  learned  writer  of  this  pas¬ 
sage  should  have  remembered  with 
what  meaning  we  must  often  be  con¬ 
tent,  in  our  imperfect  science,  to  use 
the  word  cause,  if  we  choose  to  use  it, 
as  he  has  applied  it  in  that  passage. 
The  rare  and  singular  merit  of  being 
the  vera  causa  in  the  scientific  accep¬ 
tation  of  the  term,  in  which  it  is  pre¬ 
sumed  to  contain  all  the  essential  an¬ 
tecedents  to  the  effect,  can  rarely  be 
challenged  by  medical  causes,  except, 
as  has  been  observed  in  the  Outlines  of 
Medical  Proof,  when  they  have  been 
obtained  through  experiment ;  and  I 
have  endeavoured  there  to  prove  that 
our  inductions  are  mainly  those  of  ob¬ 
servation. 

[To  be  continued.] 


REMARKS  ON  THE 

SYMPTOMS,  TREATMENT,  AND  IN¬ 
FECTIOUS  NATURE  OF  ASIATIC 
CHOLERA. 

By  Matthew  Jennette,  M.R.C.S.,  &c. 

Hon.  Surgeon  to  the  Birkenhead  Infirmary,  and 
Surgeon  to  the  Police  Force. 


My  intention  in  writing  the  following 
observations  on  Asiatic  Cholera,  is  not 
to  pretend  to  give  a  full  or  complete 
account  of  that  disease,  but  simply 
(having  had  an  opportunity  of  seeing 
it  in  Dublin  in  1832  and  1834)  to  give 
them  as  my  mite  to  the  general  fund  of 
knowledge  on  the  subject,  and  which, 
although  trifling,  may,  with  the  con¬ 
tributed  experience  of  others,  do  some¬ 
thing  towards  our  profession  coming 
to  an  agreement  as  to  what  is  best  to 
do  should  that  direful  visitation  reach 
our  shores.  I  am  the  more  induced  to 
do  so,  as,  notwithstanding  the  melan¬ 


choly  experience  that  many  of  our 
brethren  in  the  profession  have  had  of 
the  disease,  doubts  and  uncertainty 
still  hang  over  the  medical  horizon  as 
to  the  treatment  best  calculated  for  the 
patient.  At  present,  for  instance, 
naphtha,  chloroform,  &c.,  are  stated  to 
be  almost  certain  cures,  just  as  cajeput 
oil  in  1832  was  considered  so  indispen¬ 
sable,  that  its  name  was  in  every  one’s 
mouth,  and  it  was  hoarded  up  by  many 
as  a  precious  panacea,  lest  the  market 
might  be  exhausted,  and  thus  the  last 
hope  of  recovery  be  annihilated  ;  but 
to  what  use,  we  will  see  in  the  sequel. 

In  describing  the  course  of  the  dis¬ 
ease,  distinct  stages  are  usually  pointed 
out,  which  are  wrell  enough  for  its  con¬ 
venient  portraiture,  but  the  practitioner 
will  find  by  experience  no  such  regular 
succession  of  symptoms ;  as  the  greatest 
irregularity  prevails  in  their  duration 
and  severity,  each  may  have  priority  or 
be  absent,  or  all  may  attack  together. 
Although  an  individual  may  from  ap¬ 
parent  health  pass  through  all  the 
stages  to  death  in  two  hours,  the  dis¬ 
ease  may  linger  for  two  or  three  days 
before  anything  occurs  to  produce  suffi¬ 
cient  alarm  in  the  patient  to  cause  him 
to  seek  for  advice ;  some  complain 
most  of  cramps,  others  of  vomiting,  and 
so  on.  On  questioning  patients,  it  will 
be  found  that  many  have  suffered  from 
slight  diarrhoea  for  some  days,  during 
which  time  they  may  be  considered  as 
it  were  on  the  brink  of  a  precipice, — for 
unexpectedly,  generally  at  night,  a  sud¬ 
den  pain  in  the  abdomen  seizes  them  : 
this  is  often  confined  to  the  pit  of  the 
stomach,  or  the  course  of  the  transverse 
arch  of  the  colon  ;  the  contents  of  the 
stomach  are  now  rejected,  and  inordi¬ 
nate  thirst  is  complained  of;  soon  the 
bowels  are  moved,  and  a  dark  offensive 
motion  is  passed,  not  unlike  a  linseed- 
meal  poultice  in  appearance :  the 
strength  becomes  prostrated;  the  fingers 
and  back  of  the  hands  assume  a  dirty 
hue;  the  thirst  is  insatiable,  and  each 
indulgence  in  drink  excites  vomiting 
of  a  wheyish  fluid,  much  larger  in 
quantity  than  the  beverage  swallowed, 
which  is  ejected  with  force  :  so  uncon¬ 
trollable  is  the  desire  of  patients  to 
empty  their  stomach,  that  after  drink¬ 
ing  you  will  often  observe  them  tickle 
their  fauces  to  produce  that  effect,  and 
the  next  moment  implore  as  earnestly 
for  more  drink,  to  be  again  ejected  by 
the  same  means  ;  a  sensation  of  burn- 


*  Elements  of  Medicine,  vol.  i.  p.  33. 


488 


MR.  JENNETTE  ON  THE  SYMPTOMS,  TREATMENT,  AND 


ing  is  felt  at  the  stomach,  and  the 
drink  craved,  (which  is  generally  cold 
water),  is  solicited  in  order,  as  the  pa¬ 
tient  will  tell  you,  to  cool  his  inside. 
After  each  fit  of  vomiting,  a  quiet,  dozy 
state  supervenes,  with  eyes  so  upturned 
as  to  expose  only  the  white  part 
through  the  half-closed  lids :  this  ap¬ 
pearance  often  continues  some  time 
after  convalescence — an  indication  of 
the  sufferings  endured  and  the  dangers 
escaped.  The  face,  extremities,  and 
abdomen,  become  cold  ;  the  chest  not 
so  much  so  ;  and  often  when  the  rest 
of  the  body  is  as  cold  as  marble,  the 
scalp  is  in  its  natural  state,  or  preter- 
naturally  hot;  and  it  is  extraordinary, 
that  while  the  surface  is  so  cold,  com¬ 
plaints  of  oppressive  heat  are  made  : 
the  bed-clothes  are  constantly  dis¬ 
placed,  and  external  heat,  however  ap¬ 
plied,  produces  discomfort  to  the  pa¬ 
tient,  and  although  bottles  of  hot  water, 
or  bags  of  heated  salt,  may  be  tolerated 
for  a  while,  if  applied  to  his  death-like 
feet,  (as  he  sometimes  fancies  cramps 
are  so  relieved),  it  is  necessary  to  watch 
constantly  to  prevent  his  kicking  them 
from  him.  The  features  become  sharp; 
the  face  apparently  diminished  in  size  ; 
theeyesarequitehollow  in  their  sockets; 
the  expression  of  countenance  is  com¬ 
pletely  altered,  and  characteristic  of 
alarm.  The  secretion  of  urine  is 
stopped,  although  very  often  there  is 
an  urgent  desire  as  if  to  pass  it. 

The  alvine  evacuations  become  fre¬ 
quent,  and  are  ejected  like  those  of  the 
stomach,  forcibly,  but  without  pain, 
and  are  of  a  rice-water  or  wheyish 
character.  The  pulse  is  at  first  irre¬ 
gular  and  fluttering:  it  soon  becomes 
small,  quick,  and  easily  compressible. 
In  three  or  four  hours  the  blueness  of 
the  hands  becomes  intense,  particu¬ 
larly  under  the  nails,  and  their  skin  is 
shrivelled :  the  insteps  also  become 
blue,  but  not  so  much  so  as  the  hands  ; 
the  face  assumes  more  of  a  leaden  than 
a  blue  appearance;  pressure  fora  while 
on  a  blue  part  restores  the  natural 
colour,  but  it  soon  recovers  its  diseased 
appearance.  The  respiration  becomes 
laboured,  and  the  patient  complains  of 
a  great  weight  and  oppression  about 
the  chest.  The  vomiting  and  thirst 
continues,  while  the  purging  often  sub¬ 
sides  after  three  or  four  rice-coloured 
stools.  With  the  increase  of  weakness 
is  the  recession  of  the  pulse,  until  it  is 
lost  in  the  wrist  and  instep,  but  for 


some  time  after  may  be  felt  in  the  tem¬ 
poral  or  carotid  arteries.  It  generally 
beats  from  100  to  130  in  the  minute. 
Shortly  after  the  beginning  of  the  at¬ 
tack,  cramps  in  the  great  extensors  of 
one  or  both  feet  become  constant,  and 
produce  great  agony.  The  fingers, 
though  not  often,  are  also  sometimes 
affected.  Spasms  of  other  muscles  are 
not  common.  The  tongue  generally  at 
first  is  natural  in  appearance,  but  soon 
becomes  coated  with  a  white  fur,  is 
moist,  large,  flat,  and  soon,  as  well  as 
the  breath,  becomes  deadly  cold  : 
these  characters  it  retains  to  the  end, 
if  it  is  unfavourable  ;  if  otherwise,  the 
white  becomes  broken  up  into  patches 
on  a  florid  red  ground.  The  voice  the 
while  subsides  into  a  whisper;  the 
words,  nearly  inaudible,  are  enunciated 
with  an  effort  with  a  pause  between 
each,  and  are  blown  out  rather  than 
spoken.  Life  is  now  fast  ebbing  ;  drink 
is  no  longer  called  for,  but  if  given  it 
apparently  produces  comfort.  Cramps 
and  vomiting  cease;  perhaps  there  is 
some  involuntary  discharge  from  the 
rectum,  (often  indeed  considerable), 
even  although  purging  had  ceased  for 
some  time.  The  respiration  becomes 
inaudible  and  thoracic:  the  abdomen 
falls  in  at  each  inspiration,  and  does 
not  swell  out  again  until  the  last 
moment  of  expiration,  when  an  effort 
is  made  to  exhaust  the  lungs  to  the 
utmost.  After  an  uncertain  time  death 
occurs  quietly,  without  convulsions, and 
generally  without  the  tracheal  rattle. 
The  eye  retains  its  brilliancy,  the  skin 
often  becoming  as  pale  before  death 
as  if  it  was  produced  by  haemorrhage. 
Singular,  all  through  this  scene  the 
patient  retains  his  consciousness,  and 
whilst  there  is  the  stamp  of  death  upon 
his  features,  and  its  cold  grasp  is 
upon  him,  and  his  appearance  alto¬ 
gether  of  the  most  unearthly  kind,  as 
long  as  he  retains  the  power  of  ex¬ 
pressing  his  sensations,  he  does  so,  to 
those  about  him,  with  minuteness. 
The  transition  from  life  to  death  is 
sometimes  hardly  perceptible,  and  in 
many  cases  persons  have  been  sup¬ 
posed  dead  before  they  were  really  so. 
It  is  strange,  but  bodies  after  death 
sometimes  recover  some  warmth,  and 
are  even  affected  with  cramps  and 
spasmodic  contractions  of  the  limbs. 
This  no  doubt  is  owing  to  spasmodic 
irritation  of  the  excito-motory  system. 
The  different  parts  die  quickly  after 


INFECTIOUS  NATURE  OF  ASIATIC  CHOLERA. 


489 


each  other  in  ordinary  death,  and  the 
excito-motory  system,  though  the  last 
to  die,  does  so  nearly  at  the  same  period 
as  the  others  :  but  here  there  is  a  vio- 
lence  done  to  the  animal  functions,  an 
interruption  to  the  circulation,  that 
even  anticipates  the  death  of  the  or¬ 
ganic  functions  ;  and  consequently, 
when  the  latter  actually  takes  place,  a 
change  occurs,  which  partially  restores 
the  circulation,  and  gives  a  little  irrita¬ 
bility  and  excitability  to  the  true 
spinal  system.  The  symptoms,  al¬ 
though  generally  as  1  have  described, 
are  sometimes  very  different :  in  some 
cases  equally  malignant  as  in  the  blue 
variety,  the  skin  retains  its  natural 
pale  appearance ;  sometimes  there  is 
neither  vomiting  or  purging,  or  either 
is  absent  ;  in  some  the  secretion  of 
urine  is  only  diminished;  sometimes 
for  some  hours  there  is  considerable 
fever,  with  warm  moist  skin,  quick  full 
pulse,  &c.,  subsiding  afterwards  into 
the  to-be-dreaded  state  of  collapse,  &c. 

If  the  individual  is  to  recover,  the 
amendment  is  generally  very  quick  : 
the  pulse  gradually  returns,  and  re¬ 
covers  its  tone;  heat  returns  to  the 
skin,  and  the  appearance  of  anything 
from  the  stomach  or  bowels  other  than 
the  rice- coloured  discharge  is  favoura¬ 
ble,  but  bile  most  so  :  indeed,  when  it 
is  seen,  the  disease  may  be  said  to  have 
lost  its  malignity.  Hiccough  follow¬ 
ing  the  first  appearance  of  reaction  is 
not  a  bad  sign ;  the  return  of  the  se¬ 
cretion  of  urine  is  also  favourable. 
The  alteration  in  the  character  of  the 
countenance  is  perhaps  the  best  indi¬ 
cation  of  recovery,  accompanied  with 
heat  of  skin,  returning  without  external 
agency,  and  a  pulse  palpable  at  the 
wrist.  In  passing,  we  may  remark 
how  inappropriate  the  name  cholera, 
derived  as  it  is  from  bilis,  and 

pew,  fluo,  is,  inasmuch  as  that,  instead 
of  a  flow  of  bile,  there  is  a  suppression 
of  that  secretion  in  the  disease.  Cop¬ 
land  proposes  to  call  it  asphyxia  pesti- 
lentia ;  but,  as  there  is  not  much  in  a 
name,  we  may  be  content  with  the 
usual  one  of  algide  or  Asiatic  cholera. 

On  examination  after  death,  the  in¬ 
testine  is  generally  found  to  contain 
a  ricewater-like  fluid,  like  what  was 
discharged  during  life;  the  abdominal 
viscera  are  much  congested.  With 
this  state  of  engorgement  there  is  also 
ecchymosis  in  the  intestines,  and  some¬ 
times  under  the  peritoneum,  &c.  The 


urinary  bladder  is  empty,  and  the  gall¬ 
bladder  generally  distended  :  it  is  un¬ 
certain  whether  bile  is  secreted  during 
this  disease ;  however,  none  is  dis¬ 
charged  ;  the  serous  membranes  are 
generally  dry.  Rayer  says,  the  most 
constant  and  the  most  persistent  intes¬ 
tinal  lesion  in  cholera  is  the  develop¬ 
ment  of  the  follicles  met  with  as  well 
in  the  algide  period  as  in  that  of  re¬ 
action;  but  the  most  remarkable  thing 
to  be  observed  is  the  state  of  the  blood: 
it  is  found  in  the  great  vessels,  and 
sometimes  even  in  the  smaller  ones, 
very  black  and  grumous,  and  in  the 
heart  and  large  vessels  there  may  be 
large  fibrinous  masses  reaching  far 
into  them,  and  partially  blocking  them 
up.  This  is  evidently  a  cause  of  inter¬ 
ruption  to  the  circulation,  and  is  a 
common  cause  of  asphyxia  in  blue 
cholera.  The  blood  has  lost  its  serum 
and  saline  contents  to  form  the  charac¬ 
teristic  discharge  of  the  disease  :  it  is 
therefore  thicker  than  usual,  and  unfit 
for  circulation.  This  is  the  immediate 
cause  of  death,  and  patients  have 
sometimes  been  restored  by  injecting 
alkaline  solutions  into  the  veins.  The 
altered  state  of  the  blood,  and  the  im¬ 
pediment  to  the  circulation,  explain 
the  blueness  and  coldness  of  the  skin, 
and  the  general  collapse. 

Much  has  been  written  and  specu¬ 
lated  as  to  the  cause  of  cholera.  I  do 
not  pretend  to  be  able  to  elucidate  so 
difficult  a  point;  but  I  believe  it  is 
liable  at  all  times  and  places  to  occur, 
if  not  as  a  pestilence,  in  isolated  cases. 
For  instance,  I  attended  a  well-marked 
case,  a  man  named  Lattan,  about  four 
years  since,  in  William  Street,  in 
this  town,  and  about  six  years  since, 
a  family  of  five,  who  took  the  disease 
in  succession,  in  Castle  Buildings. 
But  to  render  it  pestiferous  as  it  has 
been  in  India  since  it  first  appeared  in 
the  Delta  of  the  Ganges  in  1818,  or  as 
it  is  now  in  the  east  of  Europe,  certain 
conditions  of  the  atmosphere,  of  which 
we  as  yet  know  little,  are  required; 
but  this  atmospheric  condition,  even 
although  the  disease  is  raging  in  a 
district,  will  not  produce  the  disease 
without  communicating  so  with  the 
affected  as  to  inspire  into  the  lungs  the 
infectious  matter  which  they  generate 
and  diffuse.  This  was  beautifully 
illustrated  at  Sunderland,  the  first  place 
in  England  affected  in  1831.  The  82d 
Regiment  was  quartered  there  then, » 


490 


MR.  JENNETTE  ON  THE  SYMPTOMS,  TREATMENT,  AND 


and  its  surgeon,  Mr.  Kell,  being  con¬ 
vinced,  from  his  own  experience  of  the 
disease  in  the  East,  and  the  published 
statements  of  others,  of  the  successful 
exclusion  of  cholera  from  populous 
places  by  prohibiting  intercourse  be¬ 
tween  those  in  health  and  the  affected, 
determined  recommending  to  the  com¬ 
manding-officer  the  closing  of  the 
barrack-gates,  and  the  detention  of 
the  troops  in  quarters.  On  the  1st  of 
November,  the  existence  of  the  disease 
in  the  town  being  universally  admitted, 
the  barrack- gates  were  closed  the  next 
day,  and  no  one  allowed  to  enter  except 
on  urgent  business.  The  disease  was 
soon  raging  outside  the  walls :  roll- 
calls  were  frequently  ordered,  and  each 
individual  in  the  barrack  was  daily 
examined :  and,  to  enliven  the  dull 
months  of  November,  December,  and 
January,  amusements,  such  as  cricket, 
foot-ball,  &c.,  were  patronised  and  en¬ 
couraged  by  the  officers,  and  theatrical 
performances  were  had  two  or  three 
times  a  week;  and  the  men  on  guard 
at  night,  on  account  of  cholera  attack¬ 
ing  generally  at  that  time,  were  re¬ 
lieved  after  half  the  usual  time  of 
duty.  It  was  not  until  the  1st  of 
February  that  the  gates  were  thrown 
open,  at  that  time  the  town  being 
declared  free  from  the  disease,  which 
destroyed  many  within  a  few  yards  of 
the  military  quarters :  thus  affording 
an  irresistible  proof  of  the  salutary 
effects  of  the  measures  adopted;  for 
among  the  400  inmates  of  the  barrack 
there  was  not  a  single  case.  The 
question  of  infection  and  contagion, 
as  regards  cholera,  is  still,  however, 
one  about  which  much  may  be  said 
pro  and  con.  In  the  great  cholera 
hospital  in  Dublin,  for  instance,  very 
few  indeed  of  the  numerous  nurses  and 
attendants  had  the  disease,  although, 
when  exhausted  with  fatigue,  they 
would  often  throw  themselves  on  the 
pallet  with  a  collapsed  patient.  The 
Sisters  of  Charity,  whose  practical 
works  of  mercy  were  unceasing,  sus¬ 
tained  no  injury,  neither  did  the  Pro¬ 
testant  clergymen  who  prayed  in  the 
wards,  nor  the  Catholic  priest,  wdtose 
duties  obliged  him  to  sit  at  the  bed¬ 
side  with  his  face  often  in  actual 
contact  with  that  of  the  patient;  nor 
did  the  medical  attendants  suffer; 
(however,  on  this  point  I  must  remark 
that  I  myself  suffered  from  the  disease 
acquired  by  attendance  on  the  sick). 


In  favour  of  its  .non-infectious  nature, 
it  is  stated  that  its  progress  is  too  uni¬ 
form  to  depend  on  infection ;  that 
troops  affected  by  it  have  passed 
through  a  country  and  left  it  free  from 
it  (this  argument,  however,  tells  both 
wrays);  and,  again,  the  disease  wears 
itself  out  wherever  it  appears,  and  yet 
shews  itself  with  renewed  vigour  in  a 
new  quarter,  where,  however,  it  is 
after  a  while  rendered  impotent  as 
before.  Its  infectious  character  is  sup¬ 
ported  by  the  fact  of  its  spreading  over 
countries  differing  in  climate,  soil, 
elevation,  and  population,  from  those 
where  it  first  broke  out  :  its  progress 
is  uniform  and  progressive,  and  often 
opposed  to  strong  winds ;  ships  arriv¬ 
ing  from  a  healthy  place  have  never 
suffered  until  reaching  the  shore.  In 
its  progress,  cholera  has  travelled 
chiefly  by  the  great  roads,  affecting 
places  at  either  side,  without  extending 
to  those  at  a  distance,  &c.  Although  I 
have  thus  stated  some  of  the  arguments 
for  and  against  the  infectious  nature 
of  cholera,  and  am  myself  disposed  to 
consider  it  very  infectious,  although 
perhaps  not  contagious,  yet  I  do  not 
feel  myself  justified  in  deciding  the 
point,  nor  do  I  think  it  could  be  done 
unless  we  knew  all  about  the  localities, 
habits,  police  regulations,  &c.,  of  those 
places  which  have  and  have  not  suf¬ 
fered  from  the  ravages  of  the  disease. 
Fear  of  the  disease — filth  — bad  and 
defective  food — fatigue— intemperance 
— the  depressing  passions,  &c.,  are 
powerful  predispositions  to  the  pesti¬ 
lence  ;  whilst  the  opposites  not  only 
act  as  prophylactics,  but  very  probably 
as  antidotes.  On  this  account,  and  to 
give  public  confidence,  it  is  very  likely 
many  declared  themselves  to  be  non- 
contagionists,  or  even  non-infectionists, 
in  opposition  to  their  own  convictions. 
As  to  diagnosis :  in  severe  forms  of 
bilious  cholera,  the  powers  of  life  are 
often  very  much  deranged ;  but  the 
dark,  ropy  appearance  of  the  blood — 
the  cold,  wet,  shrivelled  surface,  and 
its  blue  colour — the  absence  of  pulse 
from  the  wrist — marked  and  rapidly' 
increasing  collapse, .  and  earthy  odour 
of  the  body,  even  during  life  —  the 
burning:  sensation  between  the  scrobi- 
cuius  cordis  and  umbilicus — the  com¬ 
plete  arrest  of  glandular  secretions — 
and  the  coldness  of  the  respired  air, 
are  entirely  absent.  Some  poisons,  as 
tobacco,  occasion  symptoms  in  some 


INFECTIOUS  NATURE  OF  ASIATIC  CHOLERA. 


491 


respect  resembling  Asiatic  cholera  ; 
but  the  history  of  the  case,  and  the 
characters  distinguishing  it  from  severe 
bilious  cholera,  are  enough  to  point 
out  the  difference.  As  regards  treat¬ 
ment,  the  most  opposite  plans  have 
been  adopted,  with  perfect  failure  in 
some  cases,  and  as  complete  apparent 
success  in  others.  It  is  remarkable 
that  where  this  scourge  has  been  most 
severe,  its  disappearance  has  left  us 
in  the  same  uncertainty  as  to  its  treat¬ 
ment  in  which  it  previously  found  us. 
Its  appearance  in  1832  had  the  effect 
of  reviving  the  analysis  of  the  blood  as 
a  basis  for  medical  practice,  and  various 
proposals  have  in  consequence  been 
made  ;  for  instance,  it  was  found  to 
contain  more  carbon  than  it  ought,  and 
the  inhalation  of  oxygen  and  protoxide 
of  azote  was  tried  in  Dublin  ;  but 
the  effect  was  unsatisfactory.  Dr. 
O’Shaughnessy  proposed  supplying  the 
deficiency  of  fluid  and  saline  matter  in 
the  blood  by  injecting  into  the  veins 
water  containing  muriate  and  carbo¬ 
nate  of  soda,  in  the  proportion  of  4  oz. 
of  the  former  and  9iv.  of  the  latter  to 
10  pounds  of  wafer,  at  a  temperature 
of  from  104°  to  118°;  but,  as  far  as  I 
can  learn,  this  plan  has  not  been  very 
successful  in  ultimately  saving  life, 
although  it  has  had  a  wonderful  effect 
in  many  collapsed  patients  by  restoring 
the  circulation,  warmth,  &c.,  and  re¬ 
moving,  in  fact,  all  bad  symptoms  for 
a  time ;  but  unfortunately,  generally 
they  soon  relapse  and  die.  But  here 
an  important  consideration  is  sug¬ 
gested — to  wit,  that,  although  a  patient 
may  be  incurable,  he  may,  neverthe¬ 
less,  by  this  means  be  restored,  at  least 
long  enough  to  settle  his  worldly 
affairs.  Then  there  has  been  Dr. 
Stevens’s  plan  of  supplying  those 
salts  to  the  blood  by  the  intestinal  ab¬ 
sorbents,  a  proceeding  which  1  believe 
has  not  stood  the  test  of  experience: 
he  gave  a  powder  containing  jss.  Carb. 
Soda,  £)j.  Mur.  Soda,  and  gr.  vij.  Oxym. 
Pot.,  every  hour,  in  a  glass  of  toast 
water,  till  reaction  set  in,  and  then  at 
longer  intervals  ; — he  applied  mustard 
poultices,  kept  the  apartment  warm, 
and  gave  injections  of  a  pint  of  warm 
water,  containing  in  solution  a  table¬ 
spoonful  of  common  salt  and  two  of 
sugar.  M.  Levacher,  of  Paris,  observ¬ 
ing  the  blood  of  cholera  patients  to  be 
deficient  in  albumen,  treated  them 
with  white  of  egg  beat  up  and  mixed 


with  cold  sugar  and  water;  this  he 
gave  both  by  injection  and  the 
mouth,  and  he  stated  that  his  success 
was  wonderful.  I  am  not  aware  whe¬ 
ther  this  treatment  was  tested  in  this 
country. 

A  certain  gentleman  in  Dublin  pro¬ 
posed  to  remove,  as  he  expressed  it, 
“  a  few  tons”  of  atmospheric  pressure 
off  the  surface  by  means  of  a  sort  of 
air-tight  body  case,  having  a  hole  for 
the  head,  with  an  air-pump  attached: 
but  this  is  too  absurd  to  dwell  upon. 

Mr.  Spilsbury,  a  surgeon  of  Walsal, 
recommended  in  some  journal  during 
the  epidemic  of  1832,  cold  affusions,  to 
the  exclusion  of  other  treatment;  but 
although  1  would  be  afraid  to  try  this 
plan,  I  have  an  idea  that  the  sweating 
plan  of  the  hydropathist  might  be 
useful.  While  I  think  so,  let  it  not  be 
for  a  moment  inferred  that  I  am  a 
follower  of  Priessnitz. 

To  discuss  this  treatment  properly 
we  may  consider  three  types  or  forms  of 
cholera:  —  1st,  where  there  are  well- 
marked  premonitory  symptoms,  parti¬ 
cularly  diarrhoea,  for  a  time,  varying 
from  a  few  hours  to  three  or  four  days, 
and  then,  if  neglected,  passing  into  the 
characteristic  blue  stage ;  2nd,  where 
the  premonitory  symptoms  are  of  very 
short  duration,  and  consist  principally 
of  giddiness,  noise  in  the  ears,  a  sense 
of  oppression  in  the  chest,  weight  in 
the  epigastrium,  &c.,  rapidly  passing 
into  the  usual  state  of  collapse  ;  and 
3rd,  where  there  are  no  premonitory 
symptoms,  but  the  patient’s  vital 
powers  are  suddenly  laid  prostrate — 
sudden  discharges  of  serous  fluid  take 
place  from  the  stomach  and  bowels, 
with  cramp  and  spasms — the  pulse  not 
to  be  found  at  the  wrist,  and  his 
breathing  laborious — all  the  marked 
characters  of  collapse  being  present. 
This  lust  form  is  generally  beyond  the 
reach  of  medical  aid,  as  the  first  is  the 
most  manageable.  We  also  find  the 
first  variety  more  frequently  with  the 
young,  and  the  latter  in  old  subjects  ; 
but  we  will  meet  with  bad  cases  in 
every  age,  from  childhood  upwards. 
We  may  also  divide  the  disease  into 
four  stages:  the  premonitory — that  of 
collapse — the  stage  of  reaction — and 
lastly,  of  vital  exhaustion.  We  are 
not  to  expect  in  every  case  those  four 
stages, — very  often  we  have  only  the 
second  and  last,  with  perhaps  no  at¬ 
tempt  to  get  up  the  third  or  reactionary 


492 


MR.  JENNETTR  ON  THE  SYMPTOMS,  TREATMENT,  AND 


stage.  Much  has  been  said  and  written 
about  the  consecutive  fever  of  malig¬ 
nant  cholera;  but  the  result  of  the  ex¬ 
perience  of  the  disease  in  Dublin  led 
practitioners  there  to  believe  that  the 
supervention  of  fever,  with  or  without 
inflammatory  engagement  of  the  cra¬ 
nial,  thoracic,  abdominal,  or  other 
viscera,  on  reaction  coming  on,  is  not  a 
legitimate  consequence  of  the  disease  ; 
but  that,  should  the  treatment  by  sti¬ 
mulants  be  adopted,  great  care  and 
watching  will  be  necessary  ;  for  if  you 
allow  the  moment  reaction  commences 
to  pass  unobserved,  and  push  them 
further,  febrile  disturbance  will  surely 
occur :  this  often  happened,  but  there 
appeared  nothing  specific,  it  having 
only  the  characters  which  follow  the 
abuse  of  opium,  brandy,  &c.,  and  ap¬ 
peared  more  manageable. 

The  public  ought  to  be  wTarned  to 
send  for  advice  on  the  first  advent  of 
gastro-intestinal  symptoms;  for,  un¬ 
fortunately,  the  distress  and  diarrhoea 
is  often  so  trifling,  that  many  do  not 
apply  for  relief  until  the  awful  collapse 
sets  in.  Persons  thus  affected  often 
go  about  and  attend  to  their  ordinary 
business,  but  the  bilious  diuretic  stools 
glide  gradually  into  the  characteristic 
discharge.  Castor  oil,  Gregory’s  pow¬ 
der,  &c.,  have  been  suggested  for  this, 
but  very  improperly ;  Sydenham,  long 
ago,  compared  this  practice  to  extin¬ 
guishing  fire  with  oil :  no,  we  must 
check  the  purging,  which  may  easily 
be  done  by  the  vegetable  astringents, 
such  as  kino,  catechu,  &c.,  chalk  mix¬ 
ture,  small  quantities  of  opium,  pil. 
hyd.,  &c. ;  or  we  may  administer  as  an 
injection  from  ten  to  twenty  grains  of 
acet.  plumbi,  dissolved  by  a  few  minims 
of  distilled  vinegar,  in  8  oz.  of  water ; 
and  this  salt  may  also  be  given  by  the 
mouth,  in  pills  containing  2  grs.,  with 
§■  gr.  of  opium,  every  second,  third,  or 
fourth  hour,  as  the  case  may  require. 
Often-repeated  small  doses  of  a  strong 
infusion  ofbuchu  havealsobeen  strongly 
recommended.  In  fact,  a  person  thus 
affected  is  in  so  recoverable  a  state, 
that  I  think  if  a  fatal  case  occurs  it 
must  be  from  mismanagement  or  ne¬ 
glect.  Such  cannot  be  said  of  the  next 
stage,  that  of  collapse,  or  the  blue 
condition ;  and  I  fear  that,  although 
however  much  we  may  flatter  ourselves 
with  understanding  the  disease,  and 
however  much  we  may  at  present  rely 
on  the  assertions  of  others,  we  will  be 


doomed  often  to  disappointment  in  its 
treatment. 

When  we  see  a  patient  cold,  pulse¬ 
less,  powerless,  with  difficulty  of  breath¬ 
ing,  stagnant  circulation,  purging,  vo¬ 
miting,  and  cramps,  it  appears  obvious 
enough  that  artificial  heat  must  be 
applied,  stimulants  given,  bleeding  or 
antispasmodics  employed,  opiates  and 
astringents  had  recourse  to ;  and  this, 
with  of  course  considerable  variety  of 
detail,  form  the  majority  of  the  recorded 
practice.  However,  medical  efforts  form 
a  melancholy  restrospect  in  this  disease ; 
it  has  reversed  judgment  and  confound¬ 
ed  experience. 

Before  its  appearance  in  Ireland, 
medical  men  very  generally  considered, 
from  all  they  had  read,  and  from  the 
confident  tone  in  which  authors  recom¬ 
mended  certain  treatments,  that  they 
were  quite  ready  to  meet  the  enemy 
face  to  face,  and  keep  him  at  bay  :  but 
soon  were  they  disappointed.  Opium, 
for  instance,  did  in  many  cases  great 
mischief,  producing  its  poisonous  effects 
without  answering  the  purpose  for 
which  it  was  given.  Stimulants,  as 
brandy,  capsicum,  cajeput  oil,  ammonia, 
&c.,  appeared  to  produce,  in  some  cases, 
no  more  effect  than  if  thrown  into  a 
vessel  at  the  bed  side  ;  and  in  many 
were  decidedly  prejudicial.  If  they  are 
used,  it  is  a  mistake  to  increase  their 
potency  to  the  intensity  of  the  collapse : 
patients,  whose  cases  seem  to  indicate 
the  need  of  stimulants,  almost  always 
after  the  first  dose  express  a  repugnance 
to  swallow  them  ;  even  dram  drinkers 
will  refuse  ardent  spirits.  In  fact,  sti¬ 
muli  often  depress  rather  than  elevate 
the  pulse.  General  bleeding  was  found 
decidedly  improper — possibly  cupping 
at  the  epigastrium,  or  a  few  leeches  to 
the  anus,  may  be  useful. 

One  of  the  strongest  prejudices  at 
first,  in  Dublin,  was  against  the  use  of 
cold  water  as  a  drink,  it  having  been 
asserted  by  some  writer  in  India  that 
its  use  was  fatal ;  however,  it  got  into 
general  use  by  a  patient  (a  hopeless 
case)  in  the  hospital,  surreptitiously 
getting  it,  and  recovering.  There  are 
some  severe  cases  where  there  is  no 
vomiting  ;  in  these,  to  rouse  the  powers 
of  life  an  emetic  may  be  useful,  and  I 
believe  3  ij-  of  powder  mustard,  repeated 
in  ten  minutes  if  necessary,  is  the  best. 
In  ordinary  cases,  although  some  prac¬ 
titioners  do  notdislikeseeing  the  patient 
vomit,  yet  it  is  by  most  desired  to  arrest 


INFECTIOUS  NATURE  OF  ASIATIC  CHOLERA.  I  U3 


that  discharge ;  infusion  of  coffee,  not 
the  decoction,  often  succeeds.  Should 
the  vomiting  be  accompanied  with 
spasms, sinapisms  to  the  spine  orepigas- 
trium,  and  nit.  arg.  may  he  g  ven,  in  a 
dose  of  from  3  to  5  grains,  in  8  oz.  dis¬ 
tilled  water;  if  this  fails,  grs.  v.  of  the 
subnit.  bismuth  given  first,  and  3  grs. 
every  hour  until  5SS*  *s  used,  or  the 
ox.  zmci  may  be  tried  in  the  same  way  ; 
but  when  the  vomiting  is  unattended 
with  spasms,  particularly  when  the  dis¬ 
charge  is  acid,  alkaline  solutions,  or 
aq.  calcis,  are  best.  A  table-spoonful  of 
a  solution  of  about  1^  oz.  of  common 
salttoaquart  of  water,  given  every  three 
or  four  minutes,  sometimes  allays  thirst 
and  relieves  vomiting,  and  so  enables 
active  medicines  to  rest  on  the  stomach. 
As  to  very  warm  clothing  md  artificial 
heat,  contrivances  were  arranged  in  the 
Dublin  hospital  to  throw  hot  air  over 
the  patient,  the  bed-clothes  being  lifted 
off’ the  body  by  means  of  bed  cradles. 
The  patient  would  cry  out  to  be  let  to 
die  ;  that  he  could  not  bear  it.  Patients 
in  collapse  will  not  suffer  anything  of 
of  the  kind  ;  but  where  heat  is  naturally 
returning  to  the  surface,  a  patient  will 
then  be  desirous  to  be  covered,  as  much 
as  he  was  before  to  strip  himself.  Bags 
of  moderately-heated  salt  or  sand  to  the 
feet,  often  are  useful  to  relieve  cramps  ; 
but  hand  friction  or  compression  over 
the  swollen  muscles  answer,  I  think, 
better.  Sinapisms  are  sometimes  useful, 
after  leeching,  to  the  epigastrium,  but 
give  great  pain  afterwards.  Let  it  never 
be  forgotten,  that  when  a  person  is 
seized  with  cholera,  he  should  at  once 
be  placed  in  tne  horizontal  position,  and 
if  he  is  to  be  carried  to  another  bed¬ 
room  he  must  be  removed  as  much  as 
possible  in  the  recumbent  position,  and 
not  suffered  to  walk. 

Having  now  given,  as  far  as  I  am 
able,  a  sketch  of  the  experience  of 
medical  men  in  Dublin,  until  i  he  disease 
arrived  at  its  acme,  I  will  now  shortly 
describe  two  plans  which  then  began  to 
be  adopted  there,  both  of  which  having 
many  admirers,  and,  I  believe,  great  suc- 
cess — the  calomel  and  the  acet.  plumbi 
treatment.  Mr.  M‘Coy,  one  of  the  sur¬ 
geon-  to  the  cholera  hospital,  gave 
calomel  in  large  doses,  to  the  exclusion 
of  all  s  imulants,  dry  with  a  little  sugar, 
in  doses  of  10,  15,  or  even  20  grs.,  fol¬ 
lowed  by  a  little  cold  water,  eveiy  hour 
or  half  hour,  as  the  urgency  of  the  case 
demanded,  with  great  success  in  cold 


i  pulseless  ease*  :  one  had  440  grs.  i  .  63 
hours;  anoi  her  360  grs.  in  84  hour-; 
276  grs.  to  anoihei  patient  m  13  hoars, 
and  soon.  He  only  foun  1  this  practice 
of  no  avail  in  cases  of  the  third  type, 
where  the  individual  is  suddenly  i  .  d 
"prostrate,  without  vomiting,  &e.  Th  -.e 
large  doses  of  cato  nel,  it  i-  said,  d  >  mi 
produce  any  of  ;  he  ili  co  (sequences  oe 
casionally  resulting  from  mercury.  I'ne 
soreness  of  the  mouth  g  tier  illy  apt>  rs 
in  from  40  to  70  hours,  rind  soon  p  .  -es 
away.  in  a  few  cases  there  vwi  i 
troublesome  hiccough  alter  reaction  : 
gr.xx.ofacid  sulp.dll.  i  <  >  ater  evert 
hour  relieved  it.  i'ne  fi  si  stool,  .fi  r 
the  rice-water  discharge  cea-e-,  uu  .er 
this  treatment,  is  greyish;  the  «iU  or 
31  shows  bile;  cola  wmei  is  given  a-, 
a  drink,  and  afterwards  w  ak  oeei-tea, 
with  the  fat  carefully  removed  :  re¬ 
covery  is  perfect  m  two  to  our  day-. 

The  treatment  of  eholer ;  with  acet. 
plumbi  was  proposed  by  Dupuytreu  in 
Feb.  1832:  it  is  advocated  strohgl.  hy 
Dr.  Craw  hell  in  his  work  on  cooler.; 
he  had  a  most  extensive  experie..  e  of 
its  use  in  the  Grange  Gorman  Ho-p.  it 
of  Dublin,  and  gave  it  on  n  uy  eiie.naia 
and  hy  the  month.  H  co. unities  <n  - 
salt,  if  the  patient  is  losing  grouu 
with  stimuli,  camphor,  ammonia,  &c  r 
or  if  the  stomach  will  noi  hear  loose, 
with  lime  v\ater,  either  a.one  or  who 
a  little  good  whisky .  Dr  Gr.vesspe.K 
highly,  al-o,  of  the  use  ot  acet.  plum  n 
in  cholera,  in  doses  of  two  gis.  anno 
eighth  of  opium,  every  hall  hour.  Jr. 
Williams,  ol  University  College,  and 
several  others,  speak  favourab.y  ot  this 
plan. 

Having  considerably  exceeded  tile 
limits  l  marked  out  for  myself.  1  iind 
now  conclude,  although  I  am  luny 
aware  my  essay  is  very  imperleet;  how¬ 
ever,  if  by  writing  it  l  succeed  in  >  i 
mutating  others  to  exertion  m  the  .>iu  ty 
of  the  disease  and  its  treatment,  l  wilt 
have  accomplished  what  1  had  in  view 
by  so  doing. 

Birkenhead,  6th  Sept.,  1848. 


ORITUARY. 

O  v  the  19th  ot  J uue,  at  New  York,  wait  .er 
ue  had  gone  for  the  recovery  ot'  his  nealth, 
John  Butur,  Esq.,  surgeon  ot  tne  Colonial 
Hospital  at  Trinidad,  and  formerly  oi 
Bristol,  aged  42. 


494:  MR.  CRAIG  ON  THE  DANGERS  TO  BE  APPREHENDED  FROM  THE 


ON  THE 

DANGERS  TO  BE  APPREHENDED 
FROM  the  USE  of  CHLOROFORM 
IN  MIDWIFERY. 

By  John  Craig,  Esq.,  Surgeon, 
Paisley. 


In  the  Medical  Gazette  for  May  5, 
1848,  it  is  reported  that  Mr.  Brown 
read  a  paper  on  the  Employment  of 
Chloroform  in  Midwifery.  This  paper, 
with  its  accompanying  remarks,  ren¬ 
ders  it,  in  my  view,  a  very  interesting 
document  on  the  use  of  chloroform  — 
interesting,  because  it  shews  that  up 
to  this  date  the  conscientious  accou¬ 
cheur  had  nothing  to  guide  him  on 
which  he  could  consistently  depend  in 
the  use  of  this  agent  in  the  practice 
of  midwifery.  Some  practitioners  extol 
it  as  a  means  of  great  utility  and  safety 
in  facilitating  the  expulsion  of  the 
child;  others,  with  more  caution  and 
some  doubt,  hesitate  to  receive  all  the 
marvellous  but  ill-digested  accounts 
which  have  been  published  on  this 
subject.  It  is  truly  surprising  that 
none  of  the  principal  supporters  of  the 
use  of  chloroform  in  midwifery-prac¬ 
tice,  in  which  the  well-being  and 
the  lives  of  two  human  beings  are 
at  stake,  should  neither  have  taken 
into  consideration  the  nature  of  the 
cases  in  which  the  vapour  has  been 
employed,  nor  the  various  powers  and 
effects  of  the  chloroform  itself;  conse¬ 
quently  such  an  empirical  and  so  blind 
a  mode  of  procedure  must  have  given 
rise  to  the  reported  dangerous  and 
fatal  results  which  have  occurred. 
At  page  777*,  Dr.  Moffat,  of  Edin¬ 
burgh,  is  reported  to  have  said  that 
“parturient  pains  consist  of  two  dis¬ 
tinct  elements :  first,  the  muscular 
contractions  ;  and,  secondly,  the  sensa¬ 
tions  of  pain  to  which  they  give  rise; 
the  latter  (the  sensation  of  pain)  being 
in  no  degree  requisite  for  the  perfect 
performance  of  the  former  (the  mus¬ 
cular  contractions) ;  that  these  two 
things  are  quite  different ;  and  that  one 
of  them  (the  sensation  of  pain)  may  be 
removed  by  anaesthetic  means,  whilst 
the  other  (the  muscular  contractions) 
are  allowed  to  remain  unabated;  the 


former  being  unnecessary,  the  latter 
necessary,  for  the  active  process  of 
parturition.”  This  statement  of  Dr. 
Moffat’s  is  so  far  true ;  for  some  wo¬ 
men,  without  the  aid  of  anaesthetic 
means,  bear  children  without  almost 
any  pain,  in  which  cases  the  labour  is 
short, — shewing  clearly  that  the  latter 
element,  pain,  is  one  of  the  causes  of 
protraction  in  labour :  thus  showing, 
that  when  a  morbid  condition  of  the 
expulsive  organs  is  present,  such  as 
excess  of  pain,  inflammation,  &c.,  the 
duration  of  labour  will  be  long,  and 
the  pain  severe.  But,  on  the  other 
hand,  in  the  great  majority  of  severe 
and  obstinate  cases  of  protracted  la¬ 
bour  with  which  we  most  frequentlyr 
meet,  the  subduing  of  the  pains  by 
aneesthetic  means  does  not  generally 
accelerate  the  expulsion  of  the  child: 
thus  exhibiting  that  the  severity  of  the 
pain  has  but  a  minor  share,  in  most 
cases,  in  arresting  delivery.  The 
cases,  then,  in  midwifery  practice,  in 
which  chloroform  will  either  be  really 
necessary,  useful,  or  safe,  will  be  very 
few  in  number.  Besides,  from  what 
has  been  repeatedly  reported,  chloro¬ 
form  appears  neither  to  be  a  suitable 
nor  a  safe  remedy  in  child-bed  cases ; 
and  we  are  informed  that  much  of  the 
mischief  resulting  from  its  use  is  not 
reported.  Thus  the  conscientious  and 
responsible  practitioner,  from  all  that 
has  yet  been  advanced  on  the  use  of 
chloroform  in  midwifery,  will  infer 
that  it  should  seldom  or  never  be 
employed  in  obstetric  practice,  espe¬ 
cially  when  much  more  certain  and 
much  more  safe  means  have  been 
repeatedly  laid  before  the  profession. 
(See  Med.  Gaz.,  Jan.  6,  1848,  p.  31.) 
In  this  number  it  is  noticed  that  the 
Medical  Gazette  takes  precedence  of 
every  other  medical  work  in  this  or 
any  other  age,  of  having  promulgated  a 
consistent,  safe,  and  natural  mode  of 
treatment  by  metropolitan  practitioners 
in  reference  to  that  form  of  protracted 
labour  which  arises  from  a  morbid 
state  of  the  expulsive  organs  them¬ 
selves.  It  is  proper  to  state,  for  the 
honour  of  the  responsible  accoucheur, 
— for  the  safety  and  well-being  of  the 
parturient  woman  and  her  child, — that, 
whatever  may  be  the  means  used  to 
alleviate  her  sufferings,  which  always 
arise  from  a  disturbed  condition  of  the 
expelling  organs  in  such  labours,  the 
principles  by  which  the  accoucheur  is 


„*  See  our  last  volume. 


USE  OF  CHLOROFORM  IN  MIDWIFERY 


495 


actuated,  in  order  to  success,  must  i  appear  that  many  practitioners  never 
always  be  the  same, — not  at  once  to  take  into  consideration  the  awful  re¬ 
stupefy  his  patient  by  any  means,  but  sponsibility  they  lie  under  by  persever- 
to  ascertain  the  real  causes  of  her  un-  ing  in  the  use  of  what  they  consider 
natural  suffering  and  unnecessarily  remedial  means,  without  possessing  a 
prolonged  labour,  and,  in  a  scientific  knowledge  either  of  the  nature  or  mode 
and  consistent  manner,  apply  the  of  operation  of  the  medicine,  or  whe- 
means  of  relief  according  as  each  pro-  therit  be  really  suitable  for  the  removal  of 
tracting  cause  may  indicate,  in  order  to  the  complaint  it  is  intended  to  remedy, 
its  removal.  It  may  unhesitatingly  be  A  sufficient  proof  of  this  statement,  I 
said  that  almost  all  the  severe  pro-  think,  is  noticed  in  a  contemporary 
traded  labours  are  of  the  above  de-  periodical,  when  speaking  of  chloro- 
scription,  and  may  be  speedily  con-  form.  The  writer  says,  “  I  would  ear- 
verted  into  a  labour  sufficiently  natural  nestly  wish  all  parties, both  in  favour  of, 
so  as  to  expel  the  child  in  a  few  hours  and  against  chloroform  (and  the  remark 


by  the  efforts  of  the  mother. 

In  my  immediate  neighbourhood  a 
woman  died  ten  or  twelve  days  after 
having  borne  a  child,  and  in  her  case 
chloroform  had  been  employed.  It  was 


will  bear  on  many  other  points),  not  to 
allow  themselves  to  confound  the  post 
hoc  with  the  propter  hoc.  I  refer,” 
he  says,  “  to  the  ergot  of  rye,  which 
many  obstetricians  condemn  on  account 


considered  by  the  medical  attendants  j  of  its  fancied  injurious  effects  upon  the 
that  the  woman’s  death  was  occasioned  I  foetus.  This  imputation  I  do  not  be- 
by  peritoneal  inflammation,  yet  no  par-  lieve  to  be  based  on  solid  grounds.” 
ticular  alarming  symptom  appeared  Other  accoucheurs  of  extensive  expe- 
until  the  day  previous  to  her  death,  rience,  with  whom  I  have  conversed 
Chloroform,  seemingly,  has  been  used  on  this  subject,  and  who  hold  the  same 
by  many  practitioners  in  midwifery,  views  with  the  above  author,  hesitate 


in  a  similar  manner  to  what  ergot  of 
rye  was  employed;  for  in  almost  every 
case  that  appeared  to  be  tedious,  the 
obstetrician  used  ergot  of  rye,  without 
taking  into  consideration  either  the 


not  to  acknowledge  that  previous  to 
administering  the  ergot  the  children 
were  alive,  yet  they  were  born  dead ; 
and  it  is  no  uncommon  occurrence  that 
when  the  pains  of  labour  are  severe, 


nature  of  the  obstructing  causes  to  de-  but  producing  little  effect  in  advancing 
livery,  or  the  properties  or  powers  of  the  child,  those  who  hold  the  above 
the  means  used  for  facilitating  the  ex-  favourable  views  of  ergot  administer  it 
pulsion  of  the  child :  the  consequence  a  few  hours  after  the  commencement 
was,  that  in  many  instances  the  action  of  labour,  and  the  child  is  unexpectedly 
of  the  uterus  was  greatly  increased,  born  dead:  thus  showing  that  neither 
but  still  not  sufficiently  so  to  overcome  a  knowledge  of  the  effects  of  the  opera- 
tlie  obstruction ;  and  thus  the  child  tion  of  the  means  employed,  nor  a 
was  born  dead  from  compression  on  knowledge  of  the  nature  of  the  case  in 
the  umbilical  cord.  Had  the  ob-  which  the  means  were  used,  are  at  all 
struction  in  a  great  measure  been  re-  understood  by  the  practitioner, 
moved  previous  to  the  administration  of  At  page  77 8  of  the  same  number  of 
the  ergot,  either  it  would  not  have  been  the  Medical  Gazette,  Dr.  Barnes 
required,  or  if  employed  it  would  have  asks,  when  speaking  of  the  employ- 
been  harmless.  These  fatal  results, 
arising  from  the  indiscriminate  use  of 
ergot  of  rye,  have,  so  far  as  my  know¬ 
ledge  extends,  greatly  lessened  the 
frequency  of  its  employment.  And, 
from  the  very  commencement  of  the 
exhibition  of  anaesthetic  means  in 
child-bed  cases,  the  same  blind  and 
resolute  mode  of  procedure  has  been 
followed  as  with  ergot  of  rye;  and  it 
appears  that  nothing  but  the  same  kind 
of  mischievous  results  will  operate  in 
arresting  the  hand  of  the  undeliberalive 
administrator  of  chloroform.  It  would 


ment  of  chloroform  in  midwifery, 
Why  interfere  with  a  natural  pro¬ 
cess?”  If  Dr.  Barnes  mean  by  this 
query  that  there  is  no  propriety  in  in¬ 
terfering  with  a  labour  going  on  with¬ 
out  any  unfavourable  symptoms,  either 
as  regards  the  position  of  the  child  or 
the  state  of  the  pelvis,  even  although 
the  labour  may  continue  long  and  se¬ 
vere,  yet  the  child  be  ultimately  ex¬ 
pelled  by  the  efforts  of  the  mother,  it 
is  evident  such  a  procedure  cannot  be 
“  a  natural  process.”  It  has  been  al¬ 
ready  stated  that  every  purely  natural 


496  MR.  CRAIG  ON  '’'HE  DANGER  TO  BE  APPREHENDED  FROM  THE 


labour  will  terminate  in  a  few  hours, 
and  will  be  effected  without  much  con¬ 
tinued  pain  ;  but  those  labours  which 
may  also  terminate  naturally,  although 
of  long  duration,  ought  to  be  distin¬ 
guished  by  some  epithet — as  protracted 
natural  labour;  for  by  this  distinction 
the  mind  is  at  once  led  to  inquire  re 
garding  the  nature  of  the  protracting 
cause,  and  how  it  should  be  removed, 
as  well  as  by  what  means. 

Now,  by  making  a  correct  physiolo¬ 
gical  and  pathological  inquiry  into  the 
nature  of  labours  speedry  terminated, 
as  well  as  into  the  causes  of  pro 
traded  labours,  it  must  occur  to  the 
careful  inquirer  that  the  nature  of  the 
causes  which  arrest  the  completion  of 
a  labour  to  perhaps  two  or  three  days, 
must  be  of  a  morbid  description;  and 
then  the  tedious  struggle  before  deli¬ 
very  is  effected  could  not  have  been  ‘‘  a 
natural  process.”  In  a  labour  so  sever 
and  so  extended,  then,  the  long-con¬ 
tinued  process  before  delivery  is  com¬ 
pleted,  is  one  of  an  unn  dural  descrip¬ 
tion,  arising  from  disease  of  the  ex¬ 
pulsive  organs  ;  and  when  such  disease 
is  removed  by  sui  able  means,  as  already 
noticed  in  a  former  number  of  the 
Medical  Gazette,  the  restriction  aid¬ 
ing  from  disease  will  be  so  far  removed 
that  delivery  will  be  effected  in  a  iew 
hours.  The  same  remarks  may  justly 
apply  to  a  statement  made  by  Dr. 
Meigs,  Professor  of  Midwifery  in  Je 
ferson  College, in  his  co  municalion  to 
Dr.  Simpson,  Professor  of  Midwifery 
in  Edinburgh,  on  the  subject  of  the  use 
of  chloroform  in  the  practice  of  mid¬ 
wifery,  as  reported  in  the  Philadelphia 
Med.  Examiner,  March  1848,  and  no 
ticed  in  the  Medical  Gazette,  July 
1848.  Dr.  Meigs  states,  “  1  have  been 
accustomed  to  look  upon  the  sensation 
of  pain  in  labour  as  a  physiologi  al  re¬ 
lative  of  the  power  of  lorce;  I  have 
always  regarded  a  labour- [  ain  as  a  most 
desirable,  salutary,  and  conservative 
manifestation  of  life-force.”  Again, 
the  Dr.  says,  “there  is,  in  natural  la 
hour,  no  element  of  disease.”  In  this 
way  of  expressing  themselves  it  is  verv 
evident  that  these  two  observing  prac¬ 
titioners  have  declared  their  views  re¬ 
garding  natural  labours  either  ob- 
curely  or  altogether  in  an  inapplicable 
manner  respecting  those  forms  of  la¬ 
bour  in  which  the  long  and  severe 
suffering  arises  from  a  diseased  condi¬ 


tion  of  the  organs  of  propulsion  only.. 
In  this  last  form  of  labour,  then,  the 
sensation  of  pain  cannot  be  a  physiolo¬ 
gical  relative,  but  really  a  pathological 
relative,  indicating  a  diseased  state  of 
the  parts  concerned  in  the  propulsion, 
of  the  child  ;  and  when  this  state  is  re¬ 
moved,  by  the  means  suited  for  that 
purpose,  the  labour  is  speedily  converted 
into  a  “  natural  process,”  and  the  deli¬ 
very  is  effected  in  a  few  hours,  instead 
of  extending  for  two  or  sometimes  to 
three  days.  To  say  that  “  there  is  in 
prolonged  natural  labour  no  element  of 
disease,  or  that  it  is  a  natural  process, 
i*  quite  untenable.” 

The  following  remark,  expressed  by 
Dr.  Meigs  in  the  same  letter,  appears 
io  me  most  worthy  of  notice,  as  it 
proves  him  to  be  a  practitioner  of  a 
correctly  cultivated  mind.  He  says, 
“  but  should  I  exhibit  the  remedy 
[chlorofoim]  for  pain  to  a  thousand 
patients  in  labour,  merely  to  prevent 
i  he  physiological  pain,  and  for  no  other 
motive,  and  if  1  were  in  consequence  to 
destroy  one  of  them,  I  should  feel  dis¬ 
posed  to  clothe  me  in  sackcloth,  and 
cast  ashes  on  my  head  for  theremainder 
of  my  days.”  Sentiments  thus  ex¬ 
pressed  by  so  accomplished  a  practi¬ 
tioner  as  Professor  Meigs,  should  be 
riveted  henceforth  on  the  minds  of  ac¬ 
coucheurs,  in  order  to  remind  them  of 
the  dread  responsibility  they  lie  under 
by  their  employment  of  dangerous 
means  of  relief  in  that  delicate  and  peri¬ 
lous  condition  in  which  parturient 
women  should  always  be  considered  to 
be  until  recovery  has  iaken  place.  For 
it  is  very  clear,  that  from  the  commence¬ 
ment  of  the  use  of  anaesthetic  means  in 
child  bed  cases,  that  the  prescribers 
neither  had  any  correct  knowledge  of 
i he  nature  of  the  causes  requiring  the 
employment  of  means  of  relief,  nor  of 
the  powers  and  properties  of  the  means 
used.  In  the  Medical  Gazette  for 
August  1 1,  1848,  page  252,  one  of  your 
correspondents  states,  that  he  is  still 
favourable  to  further  proceedings  with 
chloroform  in  child-bed  cases.  I  have 
only  to  hope  and  advise,  that  he 
will,  as  a  responsible  practitioner,  con¬ 
sider  well  the  sage  remarks  of  Dr. 
Meigs  on  this  subject,  namely,  that 
the  employment  of  doubtful  and  dan¬ 
gerous  means,  unnecessarily,  in  ob¬ 
stetric  practice,  to  the  destruction  of 
life,  is  a  sin  which  would  seem  bind- 


USE  OF  CHLOROFORM  IN  MIDWIFERY. 


497 


ing  on  the  obstetrician  ever  afterwards 
to  clothe  him  in  sackcloth,  and  cast 
ashes  on  his  head. 

The  same  author,  as  well  as  others, 
seems  to  consider  that  opium  and  other 
curative  means  might  be  objected  to  in 
child-bed  cases,  on  similar  grounds 
with  chloroform  ;  for  it  has  been  ascer¬ 
tained  that  in  operative  surgery  great 
advantage  has  been  obtained  by  the 
employment  of  chloroform  ;  and  why 
should  it  be  withheld  in  severe  labours  ? 
Such  views,  however,  are  quite  value¬ 
less  ;  for  the  two  cases  are  entirely 
different :  the  surgeon  in  amputating  a 
leg,  is  desirous  to  save  the  patient  the 
pain  incurred  by  his  cutting  instru¬ 
ments,  and  he  uses  chloroform,  not  for 
the  purpose  of  removing  the  leg,  but  to 
subdue  pain  during  the  operation. 
Thus  the  surgeon  is  convinced  from 
what  he  knows  of  chloroform,  that  by 
its  use  he  will  subdue  the  pain,  and 
that  by  his  instruments  he  will  ampu¬ 
tate  the  leg.  In  this  way  we  see  the 
surgeon  is  well  acquainted  with  every 
particular  which  he  purposes  to 
accomplish,  which  enables  him  to 
anticipate  a  favourabl  eresult ;  whereas 
the  accoucheur  seems  to  be  totally 
unacquainted  with  the  nature  of 
his  case  of  severe  labour,  for  the  relief 
of  which  he  deems  the  use  of  chloro¬ 
form  requisite,  thus  showing  that  he 
is  equally  unacquainted  with  the 
powers  and  properties  of  the  means  of 
relief.  The  skilful  surgeon  uses  chlo¬ 
roform  to  subdue  pain  arising  from  the 
operation  necessary  for  the  removal  of 
a  diseased  portion  of  the  body ;  but  the 
accoucheur  uses  chloroform  to  subdue 
pain  arising  from  a  diseased  condition 
of  the  uterine  organs,  destined  for  the 
expulsion  of  the  child :  thus  by  his 
procedure  he  subdues  the  pain,  but  the 
disease  remains,  and  on  suspending  the 
employment  of  the  means  of  relief,  the 
pain  returns  in  all  its  violence.  Thus 
we  see  the  wide  difference  between 
the  surgeon’s  case,  and  his  views  and 
intentions,  and  those  of  the  accou¬ 
cheur’s.  The  great  object  of  the  sur¬ 
geon  is  to  save  pain,  while  he  removes 
the  disease ;  whereas  the  accoucheur 
being  unacquainted  with  the  nature  of 
the  disease  of  the  propelling  organs 
which  causes  the  pain,  the  latter  is 
subdued  by  chloroform,  while  the  dis¬ 
eased  condition  of  the  organs  of  pro¬ 
pulsion,  the  true  obstructing  cause  to 
delivery,  is  allowed  to  remain,  so  that 


dose  after  dose  of  the  deleterious  vapour 
is  repeated,  until  occasionally  injurious 
effects  are  sustained  by  the  mother 
and  not  un.frequently,  as  reported,  bv 
the  child  also.  J 

Now  the  skilful  obstetrician,  who  is 
acquainted  with  the  nature  of  the  ob¬ 
structing  causes  of  protracted  labours, 
employs  the  well-known  means  for 
their  removal— -viz.  opium,  venesection, 
&c.,  according  as  each  obstructing 
cause  indicates  :  and  thus  by  banishing 
from  his  mind  that  remorseless  and 
blind  mode  of  procedure  by  chloro¬ 
form,  he  speedily  and  safely,  scientifi¬ 
cally  and  naturally,  removes  the  dis¬ 
eased  obstructing  causes  to  the  delivery 
of  the  mother. 

Such  is  the  whole  secret,  if  secret  it 
may  be  called,  in  the  treatment  of  the 
great  proportion  of  protracted  labours 
with  which  the  accoucheur  is  concerned ; 
and  no  other  mode  of  treatment  is  it  at 
all  probable  will  ever  be  advanced  so 
effectually  to  limit  the  duration  of  such 
labours,  and  at  the  same  time  with  any 
thing  like  the  same  degree  of  safety  to 
the  mother  and  her  child.  The  causes, 
and  the  nature  of  the  causes,  which 
arrest  the  progressive  and  speedy  ad¬ 
vancement  of  the  child  must  be  known, 
and  as  these  are  connected  with  in¬ 
flammation,  congestion,  excessive  mor¬ 
bid  sensibility  of  the  uterine  organs, 
and  a  constipated  or  loaded  state  of 
the  bowels,  any  ordinary  observer,  by 
careful  examination,  may  make  himself 
sufficiently  acquainted  with  them  ;  and 
the  means  for  the  removal  of  such  ail¬ 
ments  have  been  so  well  known  for 
hundreds  of  years,  that  neither  doubt 
nor  difficulty  can  well  happen  to  their 
safe  and  successful  employment.  From 
the  consideration  that  these  facts  may 
be  easily  put  to  the  test  of  experiment 
with  all  manner  of  safety,  one’s  mind 
recoils  from  the  very  idea  that  there 
are  to  be  found  rational  and  responsible 
individuals  trifling  away  their  time  in 
uselessly  experimenting  with  a  delete¬ 
rious  and  poisonous  drug,  at  the  risk, 
and  even  the  cost  of  life,  and  at  the 
same  time  selecting  for  their  victims 
the  wives  of  their  bosoms. 

Paisley,  Sept.  9,  1848. 


498  EXPENSES  INCURRED  FOR  POOR-LAW  MEDICAL  RELIEF. 


MEDICAL  GAZETTE. 


FRIDAY,  SEPTEMBER  22,  1848. 


The  Medical  Officers  of  Poor-Law 
Unions  should  not  lose  sight  of  the 
fact  that,  towards  the  close  of  the  late 
session  of  Parliament,  an  objection  was 
taken  to  the  amount  expended  in  me¬ 
dical  relief,  by  one  of  the  sturdy  re¬ 
formers  of  the  day  !  Mr.  Hume,  who 
complained  that  this  charge,  which 
was  £40,000  in  1846,  had  been  actually 
increased  to  £85,000,  can  be  but  little 
acquainted  with  the  services  rendered 
by  the  medical  officers  of  Unions,  or 
with  the  loud  and  just  complaints  of 
the  inadequacy  of  the  present  scale  of 
remuneration.  His  objection  to  the 
estimate  arises  from  his  contemplat¬ 
ing  the  amount  in  the  aggregate, 
and  probably  from  his  supposing  that 
the  House  of  Commons  had  gone 
far  enough  in  1846  in  paying  these 
hard-working  members  of  the  profes¬ 
sion  at  the  lowest  possible  rate.  He 
would  have  shewn  himself  a  better 
friend  to  the  profession  and  to  the 
poor,  if  he  had  not  placed  these  two 
sums  in  contrast  without  stating  that 
there  was  still  room  for  an  increased 
remuneration.  Economical  reformers 
are,  however,  very  apt  to  take  figures 
without  reference  to  facts,  and  this 
appears  to  have  been  Mr.  Hume’s  plan 
on  the  present  occasion.  It  is  satis¬ 
factory  to  know  that  the  hon.  member 
took  nothing  by  his  suggestion.  Lord 
Ebrington  reminded  the  Committee 
that  the  subject  of  Poor-law  medical 
relief  had  been  already  under  the  con¬ 
sideration  of  the  House  of  Commons. 
He  stated  truly  that  the  greatest  com¬ 
plaints  had  been  made  of  the  inade¬ 
quate  remuneration  afforded  to  the 
medical  officers  of  Unions ;  and,  as 
only  one-half  of  the  charge  for  such 


officers  was  borne  by  the  State,  an 
increase  of  the  estimate  proved  that  a 
corresponding  charge  had  been  made 
on  the  rate-payers  themselves.  These 
little  occurrences  serve  to  shewr  that 
men  wdio  are  called  Liberals,  do  not 
always  take  a  liberal  viewr  of  questions 
intimately  connected  with  the  interests 
of  the  medical  profession. 

As  we  are  upon  the  subject  of  Poor- 
law  medical  relief,  we  invite  our  readers 
to  consider  the  appeal  made  by  Mr. 
Martin,  at  p.  435  of  the  last  number  of 
our  journal. 


Among  the  various  aspects  in  which  the 
Slave-trade  question  may  be  viewed, 
there  is  one  in  which  it  is  of  some 
interest  to  the  medical  profession,  as  it 
closely  concerns  the  value  and  impor¬ 
tance  of  Medical  Statistics.  We  allude 
to  the  alleged  increase  in  the  rate  of 
mortality  among  the  crew's  of  English 
vessels  stationed  off  the  pestilential 
coast  of  Africa.  According  to  one  set 
of  statisticians,  the  increased  mortality 
is  frightful  ;  while,  according  to  the 
inferences  of  another  set,  the  deaths 
are  not  more  numerous  than  among  an. 
equal  number  of  men  engaged  in  the 
Channel  service  !  Such  a  difference  of 
opinion  among  men  w?ho  contend  that 
they  derive  their  information  from 
official  and  other  authentic  documents, 
is  a  strong  confirmation  of  the  assertion 
of  Dr.  Johnson,  that  there  is  nothing 
so  difficult  to  ascertain  as  “  a  fact.’* 
This  question  should  be  entirely  dis¬ 
severed  from  the  political  bearings  of 
the  slave-trade,  and  it  is  in  this  point 
of  view  that  w-e  propose  to  consider  it. 
It  is  unfortunate  that  it  cannot  be  dis¬ 
cussed  in  either  House  of  Parliament 
without  becoming  mixed  up  with  nu¬ 
merous  irrelevant  subjects,  and  a  plain 
medical  fact  is  thus  distorted  to  serve 
the  purposes  of  two  opposite  parties. 

In  an  early  part  of  the  year,  certain 
returns  on  the  state  of  health  of  the 


ALLEGED  SALUBRITY  OF  THE  CLIMATE  OF  THE  AFRICAN  COAST.  499 


squadron  employed  off  the  coast  of 
Africa  were  laid  before  the  House  of 
Lords ;  and,  in  reference  to  these,  Lord 
Aberdeen  remarked — 

“  With  respect  to  the  health  of  our 
squadron,  there  is  no  doubt  that  on 
this  subject  the  greatest  exaggeration 
and  misrepresentations  have  taken 
place.  Undoubtedly  the  climate  and 
swamps  on  the  coast  of  Africa  are  in¬ 
jurious  to  health  and  life,  but  with 
due  precautions  the  climate  on  the 
coast  of  Africa  is  not  at  all  more  un¬ 
healthy  than  any  other  tropical  cli¬ 
mate.  The  return  on  your  lordships' 
table  shows  that  the  loss  of  life  has 
been  exaggerated  to  a  degree  scarcely 
credible  ;  and,  if  due  precautions  are 
taken,  the  amount  of  deaths  occurring 
is  not  greater,  as  I  have  before  stated, 
than  might  be  expected  in  any  other 
tropical  climate.  Taking  the  year 
1847,  if  the  last  six  months  should 
not  prove  more  fatal  than  the  first 
six  months  (the  returns  for  the  latter 
period  being  the  latest  received),  the 
loss  in  the  squadron  in  the  course  of 
the  year  would  be  considerably  less  than 
two  per  cent,  for  the  year  (we  under¬ 
stood).  This  is  not  such  a  loss  as 
should  make  the  country  abandon 
efforts  having  so  important  an  object  in 
view.  I  may  mention  that,  from  the 
account  of  a  vessel  employed  in  this 
service,  which  has  recently  arrived  in 
our  ports,  it  appears  that  the  health  of 
the  squadron  off  the  coast  of  Africa  is 
such  as  need  not  give  rise  to  uneasi¬ 
ness.  The  noble  earl  here  read  the 
following  account,  dated  the  14th  of 
November,  from  Portsmouth  : — ‘  The 
Waterwitch,  8,  Commander  T.  Francis 
Birch,  arrived  at  Spithead  yesterday 
morning  from  the  west  coast  of  Africa 
station,  where  she  has  been  engaged 
in  the  suppression  of  the  slave  trade, 
chiefly  on  the  Kabenda  station.  The 
squadron  generally  were  exceedingly 
healthy.  The  Waterwitch  has  been 
very  healthy  all  the  time  she  has  been 
out,  having  lost  only  one  man  by  sick¬ 
ness  on  board.’  The  loss  of  only  one 
man  through  sickness  on  board  during 
a  period  of  three  years,  can,  I  think, 
give  rise  to  no  great  uneasiness.  With¬ 
out  due  precaution  being  taken,  a 
similar  loss  might  occur  in  the  Channel; 
but,  if  such  sickness  can  be  prevented 
by  due  precautions,  we  have  a  right  to 


expect  that  they  will  be  adopted. 
Therefore  I  contend,  both  from  the 
return  on  your  lordships’  table  and 
from  general  information  of  the  state 
of  the  squadron  off  the  coast  of  Africa, 
that  there  is  nothing  serious  to  be  appre¬ 
hended  on  the  score  of  unhealthiness  of  the 
climate.  Before  the  squadron  was  aug¬ 
mented  to  the  present  amount,  I  ap¬ 
plied  to  officers  the  most  experienced, 
and  the  best  entitled  to  give  an  opinion 
to  carry  weight  with  the  Government, 
for  information  on  the  subject,  and 
every  one  of  them  to  a  man  declared 
that,  with  due  precaution,  no  appre¬ 
hension  need  exist  with  respect  to  the 
health  of  the  squadron.  It  is  true  that 
an  unfortunate  epidemic  occurred  on 
board  of  a  single  vessel ;  but  it  was 
confined  there,  and  did  not  extend  to 
other  ships  of  the  squadron ;  conse¬ 
quently,  it  could  not  be  held  that  the 
squadron  generally  was  unhealthy  be¬ 
cause  of  that  single  instance  of  an 
epidemic  prevailing  in  one  vessel.” 

This  statement  was  confirmed  by 
Lord  Auckland,  who  said — 

“  The  last  return  from  the  comman¬ 
der  on  that  (the  African)  station  ex¬ 
hibited  fewer  deaths,  fewer  cases  of 
disease,  and  more  captures  than  in  any 
former  year.  The  success  that  had 
attended  this  increased  attention  to  the 
health  of  the  men  proved  that,  what¬ 
ever  might  be  the  unhealthiness  of  the 
mouths  and  banks  of  the  rivers,  the  sea 
on  the  coast  of  Africa  was  not  more 
unhealthy  than  any  other  sea  in  a  tro¬ 
pical  climate.  The  deaths  had  been 
reduced  from  five  per  cent,  in  1846  to 
two  per  cent,  in  the  past  year,  and  the 
number  of  invalids  had  decreased  from 
ten  per  cent,  in  1845  and  1846  to  five 
per  cent,  in  1847  ;  by  a  recent  order  of 
the  Admiralty,  no  ship  was  now  allow¬ 
ed  to  remain  on  the  African  station  for 
more  than  two  years  ” 

The  inference  to  be  drawn  from 
these  statements  is,  that  the  coast 
of  Africa,  contrary  to  what  is  gene¬ 
rally  believed,  is  a  very  healthy  cli¬ 
mate.  The  mortality  among  the  crews 
of  our  vessels  is  very  little  greater 
than  among  civilians  at  home  !  It 
would  appear,  however,  that  in  order 
to  ensure  this  salubrity,  certain  precau- 


500  ALLEGED  SALUBRITY  OF  THE 

tions  are  required ;  and  although  one 
ship  is  stated  by  Lord  Aberdeen  to 
have  lost  only  one  man  in  three  years, 
we  are  informed  by  another  noble  lord 
that,  by  a  recent  order  of  the  Admi¬ 
ralty,  no  ship  is  now  allowed  to  remain 
on  the  African  station  for  more  than 
two  years.  We  are  at  a  loss  to  recon¬ 
cile  these  conflicting  statements,  or  to 
comprehend  why,  when  the  annual 
deaths  are  considerably  less  than  tivo 
per  cent.,  the  crews  are  to  be  ordered 
home  from  these  salubrious  waters  to 
die  at  a  higher  figure  of  mortality  in 
the  pestilential  atmosphere  of  Great 
Britain  !  The  first  idea  which  occurs 
to  us  is,  that  the  advocates  of  the 
healthiness  of  the  African  coast  prove 
too  much,  and  that  they  have  probably 
been  misled  by  some  trifling  mistake 
in  the  figures.  A  great  statesman  has 
said  that  there  is  nothing  so  fallacious 
as  figures,  except  facts  ;  and  daily  expe¬ 
rience  as  to  the  mode  in  which  medical 
statistics  are  handled  by  men  whose 
minds  can  grasp  only  a  few  of  the 
elements  which  are  necessary  to  a  cor¬ 
rect  calculation,  proves  that  there  is 
much  truth  in  this  saying.  The 
stoutest  controversialist  is  sometimes 
knocked  down  by  a  decimal  fraction, 
and  he  does  not  recover  himself,  or 
perceive  the  incorrectness  or  irrele¬ 
vancy  of  the  arithmetical  argument, 
until  it  is  too  late  to  confute  his  adver¬ 
sary. 

We  need  hardly  say  that  general  ex¬ 
perience  is  most  decidedly  against  this 
attempt  to  prove  that  the  climate  of 
the  African  coast  is  less  fatal  to  human 
life  than  that  of  England :  and  the 
order  of  the  Admiralty  as  to  the  limited 
service,  is  a  sufficient  proof  that  the 
argument  respecting  its  alleged  salu¬ 
brity  must  be  unsound.  The  fact  is,  a 
question  of  this  kind  cannot  be  deter¬ 
mined  by  taking  the  mortality  in  one 
ship  for  three  years,  or  in  half  a  dozen 
ships  for  six  months.  In  this  way  we 


CLIMATE  OF  THE  AFRICAN  COAST. 

may  deduce  the  most  erroneous  conclu¬ 
sions,  and  mislead  those  who  are  in¬ 
clined  to  take  ready-made  statements 
in  preference  to  analysing  the  facts  for 
themselves.  In  the  forcible  language 
of  a  contemporary,*  it  is  necessary  to 
remember  “  that  the  average  ratio  of 
mortality  on  the  coast  is  produced  in 
part  by  violent  and  sudden  epidemics, 
which  do  the  work  of  death  with  such 
rapid  destructiveness  as  to  compensate 
the  comparative  impunity  of  a  whole 
season.  Precisely,  the  same  sanguine 
conclusion  as  that  drawn  by  Lord  Aber¬ 
deen  was  actually  expressed  by  a  Lord 
of  the  Admiralty  on  a  similar  occasion 
three  years  ago,  when,  in  a  few  short 
weeks,  came  the  fatal  plague  of  the 
Eclair,  which  carried  off  74  lives  in 
a  single  vessel  at  a  blow  !  The  ratio 
of  mortality  was  similarly  affected  in 
1830,  1837,  and  1841  :  thus  proving  that 
at  any  moment  a  Waterwitch  may  be¬ 
come  an  Eden,  and  that  the  insidious 
venom  of  the  coast  is  incessantly  at 
hand  to  destroy,  by  an  hour’s  blight, 
the  successful  caution  of  the  year. 
This,  too,  is  the  identical  peril  which 
cannot  be  lessened,  like  every-day 
hazards,  by  the  exertions  of  science 
and  prudence.  To  ascertain  the  actual 
facts  in  such  a  case  as  this,  the  obvious 
course  is  to  take  an  average  of  years; 
and  this  we  are  enabled  to  offer,  toge¬ 
ther  with  a  comparative  statement  of 
the  mortality  on  the  other  stations  re¬ 
ferred  to,  in  a  form  so  plain,  palpable, 
and  authentic,  that  its  evidence  must 
surely  set  at  rest  all  such  deductions 
and  inquiries  as  those  laid  before  the 
House  of  Lords.  It  is  from  a  formal 
report,  compiled  from  official  sources, 
and  by  authority,  and  the  table  will  be 
found  in  its  177th  page.f  From  the 
year  1825  to  the  year  1845  the  average 
annual  ratio  of  mortality,  from  disease 


*  Times,  February  24th,  1848. 
t  Report  on  the  Climate  and  Diseases  of  th* 
African  Station. 


ON  THE  DEFECTS  IN  THE  ACT  FOR  THE  REGISTRATION  OF  DEATHS.  501 


alone,  on  the  African  station,  was  58*4 
per  1,000  of  the  mean  force  employed  ; 
a  fact  which  will  be  better  compre¬ 
hended  by  looking  at  it  in  juxtaposi¬ 
tion  with  the  returns  from  other  sta¬ 
tions  of  various  degrees  of  salubrity, 
computed  on  the  same  principle. 


South  America  .  . 

.  7-7 

Mediterranean  .  . 

.  9-3 

Home . 

.  9-8 

East  Indies  .  .  . 

.  15T 

West  Indies  .  .  . 

.  18*1 

Coast  of  Africa  .  . 

.  58*4 

When  we  add,  in  the  words  of  the  re¬ 
port,  that  even  this  return  is  not  to  be 
supposed  as  conveying  “  any  adequate 
idea  of  the  permanent  loss  of  health,” 
we  conceive  this  part  of  the  question 
may  be  taken  as  beyond  dispute. 

It  would  require  some  courage  to  call 
this  plain  statement  of  facts,  based  on 
an  authentic  report,  a  great  exaggera¬ 
tion  and  misrepresentation  ;  and  unless 
the  facts  be  denied,  the  salubrity  of  the 
African  coast  may  be  treated  as  a  mi¬ 
nisterial  phantasmagoria.  All  expe¬ 
rience  tends  to  show  that  the  crews  of 
our  vessels  are  there  yearly  decimated ; 
and  it  has  become  a  serious  question 
whether,  by  the  maintenance  of  the 
system,  we  do  not  lose  more  valuable 
lives  among  our  own  men  than  we 
rescue  from  the  hands  of  the  slave- 
dealers. 


We  have  repeatedly  called  the  atten¬ 
tion  of  those  in  authority  to  the  very 
defective  working  of  the  Act  for  the 
Registration  of  Deaths.  When  the 
cause  of  death  is  not  determined,  it  is 
clear  that  the  real  object  of  the  Regis¬ 
tration  Act,  which  is  to  register  the 
causes,  and  not  the  mere  number,  of 
deaths,  is  practically  defeated.  The 
system  has  been  tried  for  some  years, 
and  is  proved  to  be  an  utter  failure. 
To  say  that  it  is  better  than  no  regis¬ 


tration,  is  no  excuse  for  the  perpetua¬ 
tion  of  defects  which  a  vigilant  super¬ 
intendence  might  remove.  The  ma¬ 
chinery  of  the  new  Public  Health  Act 
might  be  easily  brought  into  operation 
for  improving  the  Registration  Act; 
and  the  work  which  is  now  so  negli¬ 
gently  performed  by  coroners  and  non¬ 
professional  registrars  might  be  trans¬ 
ferred  to  the  Officers  of  Health.  Without 
some  alteration  in  the  present  system, 
there  can  be  no  security  to  life:  the 
criminal,  as  it  has  been  proved  by 
recent  disclosures,  may  perpetrate  his 
crime  in  secresy,  and  murder  by  poison 
may  be  registered  as  death  from  na¬ 
tural  causes.  We  have  already  endea¬ 
voured  to  show  that  the  remedy  for 
the  prevention  of  secret  murder  lies 
not  in  increasing  the  number  of  coro¬ 
ners’  inquests,  but  in  rendering  the 
inquiries  more  efficient.  So  long  as 
deaths  can  be  registered  without  me¬ 
dical  certificates,  and  so  long  as,  in 
cases  of  sudden  death,  medical  certifi¬ 
cates  are  granted  without  a  post¬ 
mortem  examination  of  the  body,  the 
Registration  Act  is  reduced  to  a  nullity. 
We  are  glad  to  have  the  corroborative 
testimony  of  so  able  an  inquirer  as  Mr. 
Rumsey,  of  Gloucester,  in  support  of 
our  views  on  the  necessity  for  an  im¬ 
proved  system  of  registration  and  of 
conducting  inquests  before  coroners. 
We  have  elsewhere  reprinted  extracts 
from  his  recent  report  to  the  Registrar- 
General*;  but  we  reserve  for  this  place 
his  remarks  on  the  defects  in  the  Re¬ 
gistration  Act,  and  on  the  mode  of 
conducting  coroners’  inquests. 

“  I  beg  leave  to  remark  on  the  large 
proportion  of  deaths  registered  in  this 
district  without  any  medical  certificate. 
The  following  table  shews  the  numbers 
of  certified  and  non-certified  deaths, 
and  of  coroners’  inquests,  in  the 
Gloucester  districts  during  the  year 
1847 : — 


*  See  page  513. 


502  ON  THE  DEFECTS  IN  THE  ACT  FOR  THE  REGISTRATION  OF  DEATHS. 


Certi- 

Non 

Ver- 

tied. 

Certi¬ 

fied. 

diets. 

Total. 

City  &  Suburbs 

353 

156 

27 

536 

Rural  Parishes 

27 

88 

6 

121 

380 

244 

33 

Public  Insti- ") 
tutions  .  .  ) 

94 

16 

110 

767 

“  Setting  aside  the  public  institutions 
(where  the  cause  of  death  is  certified  by 
the  medical  officers),  and  the  coroners’ 
inquests,  no  fewer  than  244  out  of  624, 
or  39  per  cent,  of  the  deaths ,  are  regis¬ 
tered  on  the  mere  authority  of  survivors 
or  nurses.  Hence  we  find  deaths  re¬ 
ported  as  from  ‘  stricture  in  the  wind¬ 
pipe,’  and  ‘  rheumatism  in  the  bowels.’ 
It  is  needless  to  observe  that  such 
returns  convey  no  authentic  informa¬ 
tion,  and  afford  no  valid  security  to 
the  public. 

“The  results  even  of  coroners1  in¬ 
quests  are  scarcely  more  satisfactory. 
Setting  aside,  as  before,  those  held  in 
public  institutions,  where  the  cause  of 
death  is  duly  explained  to  the  coroner 
and  jury  by  a  competent  medical 
officer,  it  appears  that  in  13  out  of  33 
(39  per  cent,  again )  the  verdict  was 
either  ‘  died  by  the  visitation  of  God,’ 
or  ‘  died  from  natural  causes,’ — a  rude 
method  of  settling  a  difficult  question 
which  judge  and  jury  were  alike  in¬ 
competent  to  solve,  and  unwilling  to 
refer  to  medical  authority.  Notwith¬ 
standing  all  that  has  been  urged  about 
the  invaluable  protection  afforded  to 
the  community  by  the  ancient  institu¬ 
tion  of  coroners’  inquests,  it  appears 
that  of  the  deaths  subject  to  this  mode 
of  investigation  (and  these  requiring, 
from  their  suddenness,  or  seclusion,  or 
violence,  the  most  accurate  and  scien¬ 
tific  inquiry),  an  equal  proportion  re¬ 
mained  in  this  district  without  any 
satisfactory  information  respecting  the 
cause  of  death,  as  of  ordinary  cases 
reported  only  by  the  District  Regis¬ 
trars. 

“  In  at  least  two  ?2on-certified  deaths, 
it  is  obvious  that  either  an  inquest  or 
medical  evidence  was  most  necessary: 
one  stated  to  have  been  from  ‘  inflam¬ 
mation  caused  by  a  scald,’  another 
from  ‘natural  causes,’  on  the  mere 


information  of  an  individual,  without 
the  verdict  of  a  jury. 

“  The  extreme  importance  of  not 
depending  on  the  unauthorised  state¬ 
ments  of  parties,  who  may  have  an 
object  in  concealing  or  mis-stating 
facts,  has  been  urged  to  me  by  one  of 
the  District  Registrars,  who  assures  me 
that  he  discovered  two  instances  last 
year  in  which  the  deaths  of  infants, 
born  alive,  were  represented  to  him  as 
‘  still  births.’  In  crowded  and  ne¬ 
glected  localities,  where  life  is  at 
a  low  value,  the  consequences  of  the 
non- requirement  of  medical  certificates 
may  be  readily  imagined.  The  accu¬ 
mulation,  from  all  quarters,  of  facts 
and  arguments,  proving  the  necessity 
for  a  competent  inquiry  and  report,  in 
every  instance ,  as  to  the  fact  and  cause 
of  death,  will,  I  trust,  under  your  ma¬ 
nagement  of  this  department,  aided  by 
the  operation  of  the  Public  Health  Bill, 
lead  to  the  adoption  of  an  improved 
system.” 

Such  a  statement  requires  no  com¬ 
ment  ;  it  is  based  on  incontrovertible 
facts,  and  it  most  strongly  confirms 
the  remarks  which  we  had  recently 
occasion  to  make  on  the  letter  of  a 
metropolitan  coroner,  in  which  it  was 
proposed  to  increase  the  number  of 
inquests,  when  it  is  proved  that  a  very 
large  proportion  of  those  which  are  at 
present  held  leave  the  cause  of  death  en¬ 
tirely  unexplained  !  In  our  view,  the 
registration  of  deaths  should  take  place 
only  under  the  supervision  of  the  Offi¬ 
cer  of  Health,  to  be  appointed  under 
the  new  act.  It  should  also  rest  en¬ 
tirely  with  this  functionary  to  deter¬ 
mine  in  what  cases  a  post-mortem 
inspection  should  be  made,  and  when 
an  inquiry  should  take  place  before  the 
coroner.  Some  objections  might  be 
taken  to  the  efficient  working  of  this 
plan,  but  with  a  conscientious  and 
well-qualified  Officer  of  Health,  we 
should  not  have  to  complain  of  the 
gross  abuses  which  are  daily  brought 
to  light  under  the  present  system. 


dr.  Copland’s  dictionary  of  practical  medicine. 


503 


Iftebtefos. 


A  Dictionary  of  Practical  Medicine  ; 
comprising  General  Pathology ,  the 
Nature  and  Treatment  of  Diseases, 
Morbid  Structures ,  fyc.  By  James 
Copland,  M.D.  F.R.S.  &c.  Part 
XIII.  London :  Longmans.  1848. 

The  publication  of  another  part  of  this 
excellent  work,  after  a  comparatively 
short  interval,  is  a  most  favourable 
augury  for  its  early  completion.  This 
part,  which  is  the  fourth  of  the  third 
volume,  extends  from  Poisons  to  Ra¬ 
bies,  and  comprises  numerous  subjects 
of  great  practical  interest.  There  are 
several  circumstances  connected  with 
a  work  of  this  magnitude  and  extent, 
which  cannot  fail  to  attract  the  notice 
of  a  reader.  The  first  of  these  is,  that 
any  single,  unassisted  author  should 
be  able  to  write  so  well  upon  subjects 
differing  so  widely  from  each  other  as 
those  contained  in  this  Cyclopaedia ; 
the  second  is,  that  the  space  assigned 
to  each  subject  should  be  so  fairly  pro¬ 
portioned  ;  and  the  third,  that  the 
author  should  contrive  to  keep  his  ob¬ 
ject — namely,  practical  medicine — con¬ 
stantly  in  view,  so  that  no  reader  can 
justly  complain  that  the  work  does  not 
strictly  correspond  to  its  title. 

Of  the  article  on  Poisons  we  had 
occasion  to  speak  in  our  notice  of 
Part  XII.  The  few  pages  here  de¬ 
voted  to  its  completion,  include  chiefly 
a  description  of  the  animal  poisons. 
In  reference  to  the  poison  of  the  viper, 
Dr.  Copland  says — 

“The  activity  of  the  poison  of  the  viper, 
and  indeed  of  all  serpents,  depends  upon  a 
variety  of  circumstances.  When  long  con¬ 
fined,  or  after  the  animal  has  bitten  frequently 
in  rapid  succession,  and  during  cold  seasons, 
when  it  loses  its  activity,  the  poison  also 
loses  its  virulence  more  or  less,  owing  either 
to  a  scantier,  or  a  weaker,  or  an  exhausted 
secretion.  Serpents  are  most  poisonous  in 
warm,  humid,  and  malarious  climates,  and 
are  there  most  numerous.  In  those  parts  of 
Africa,  which  were  chiefly  of  this  description 
that  I  visited,  accidents  from  them  were  very 
frequent ;  but,  owing  to  my  residence  at  any 
place  being  short,  I  did  not  succeed  in  ob¬ 
taining  any  of  the  poisonous  species.  The 
most  dangerous  bites  are  inflicted  on  naked, 
or  imperfectly  covered  parts,  particularly 
the  extremities ;  and  the  more  severe  and 
virulent,  the  more  rapidly  are  the  symptoms 


i  developed.  The  poisonous  properties  of  the 
fluid  contained  in  the  reservoir  do  not  cease 
with  the  animal’s  life  ;  but  may  continue, 
like  some  other  poisonous  fluids,  as  that  of 
small- pox,  &c.,  even  when  the  fluid  is  dried 
and  kept  for  some  time.  Professor  Mangili 
has  demonstrated  that  it  may  be  swallowed 
without  injury.  The  fetish-men ,  or  native 
doctors  in  Africa,  have  in  my  presence,  when 
sucking  the  wound  made  by  a  poisonous 
serpent,  swallowed  the  fluids  thus  drawn 
from  the  wound  to  show  their  powers  and 
invulnerability.”  (p.  435-436.) 

Dr.  Copland,  as  we  have  already 
stated,  has  proposed  a  new  classifica¬ 
tion  of  poisons  ;  and  a  summary  of  the 
poisons  belonging  to  the  various  classes 
on  his  arrangement  is  appended  to  the 
article.  The  principal  objection  to  it 
is,  that  it  is  not  sufficiently  simple,  and 
some  of  the  classes  so  merge  into  others 
that  the  boundary  between  them  is  in¬ 
distinct.  The  bibliography  of  medical 
literature,  in  reference  to  poisons,  covers 
nearly  two  pages  of  very  small  type, 
and  will  be  found  a  most  valuable 
source  of  reference  by  toxicologists. 

In  treating  of  Pregnancy,  the  author 
thus  discusses  the  debated  question  of 
menstruation  occurring  during  preg¬ 
nancy  :  — 

‘  ‘  Menstruation  during  pregnancy ,  or  rather 
a  periodical  discharge  of  a  sanguineous  fluid 
from  the  vagina,  has  been  occasionally  ob¬ 
served.  This  discharge  may  occur  once  or 
oftener  during  utero-gestation,  and  after 
irregular  intervals,  but  it  most  frequently 
takes  place  at  the  menstrual  periods,  and,  in 
some  instances,  it  returns  for  three,  four, 
five,  or  six  months,  or  even  for  the  whole 
period  of  pregnancy.  Drs.  Denman  and 
Hamilton  have  doubted  the  occurrence  of 
these  discharges — a  scepticism  the  more  re¬ 
markable  considering  the  great  experience  of 
these  physicians,  and  the  frequency  of  the 
phenomenon  according  to  the  observation  of 
very  eminent  practitioners.  Although  I 
have  never  been  engaged  in  the  practice  of 
midwifery,  yet  I  have  been  consulted  in  two 
cases,  in  which  this  discharge  was  stated  to 
have  occurred  regularly  during  four  or  five 
successive  menstrual  periods  ;  and  not  in  one 
pregnancy  only,  but  in  each  of  several  occa¬ 
sions  of  utero-gestation.  Neither  of  these 
patients  had  ever  had  an  abortion.  The 
discharge  was  represented  to  have  continued 
from  three  to  four  days,  to  have  become 
paLy  than  usual  after  the  second  day,  and  to 
Wltfiassed  into  a  moderate  leucorrhoea.  It 
does',clot  appear  to  be  attended  with  any  in¬ 
convenience  to  the  patient  beyond  increas¬ 
ing  aching  of  the  back  and  loins.  The 
growth  of  the  child  is  not  affected  by  it; 


504 


dr.  Copland’s  dictionary  of  practical  medicine. 


although,  judging  from  the  instances  which 
I  have  seen,  the  constitution  is  rendered 
more  delicate ;  so  that  the  aphorism  of  Hip¬ 
pocrates,  “  that  the  children  of  women  who 
menstruate  during  pregnancy  cannot  he 
healthy,”  appears  partly  true.  The  dis¬ 
charge  probably  proceeds  from  the  vessels  of 
the  cervix  uteri  and  vagina,  in  consequence 
of  the  more  than  usual  vascular  determina¬ 
tion  to  the  uterine  organs  during  pregnancy, 
the  periodic  recurrence  being  the  con¬ 
sequence  either  of  ovarian  excitement  and 
influence,  or  of  habit,  (p.  450.) 

A  very  large  space  is  given  in  this 
part  to  diseases  of  the  puerperal  state, 
especially  to  Puerperal  fevers.  The 
connection  between  puerperal  fever 
and  erysipelas  calls  for  especial  notice. 

11  Dr.  Holmes  notices,  in  his  instructive  me¬ 
moir,  that  Dr.  S.  Jackson  went  from  a  case 
of  gangrenous  erysipelas  which  he  had  been 
dressing,  to  the  first  of  the  series  of  cases 
which  took  place  in  his  practice ;  and  that  a 
Dr.  C.,  who  delivered  seven  women  in  suc¬ 
cession,  who  were  all  seized  with  puerperal 
fever,  had  made,  on  the  19th.  of  March,  the 
autopsy  of  a  man  who  died  after  a  very 
short  illness,  from  oedema  of  the  leg  and 
thigh  followed  by  gangrene,  and  the  first  of 
these  seven  cases  was  delivered  by  him  on 
the  20th,  the  following  day.  When  making 
the  autopsy  on  the  19th,  Dr.  C.  wounded  his 
hand,  and  was  confined  to  his  house,  after 
delivering  the  first  case  on  the  20th,  until 
the  3d  of  April,  and  on  April  the  9th  he 
attended  the  second  case  of  fever.  Several 
cases  of  erysipelas  occurred  very  soon  after¬ 
wards  in  the  house  where  the  autopsy  of  the 
man  just  mentioned  took  place.  There 
were  also  many  cases  of  erysipelas  in 
town  at  the  time  of  the  puerperal  cases. 
The  nurse  who  laid  out  the  body  of  the  third 
puerperal  patient  was  taken  on  the  evening 
of  the  same  day  with  sore  throat  and  erysi¬ 
pelas,  and  died  in  ten  days.  The  nurse  who 
laid  out  the  body  of  the  fourth  case  of  puer¬ 
peral  fever  was  seized  on  the  day  following 
with  symptoms  like  those  of  that  case,  and 
died  in  a  week,  without  any  external  marks 
of  erysipelas. 

“  Another  physician,  who  had  a  series  of 
five  successive  cases  of  puerperal  fever,  states, 
in  a  letter  to  Dr.  Holmes,  that  for  two  weeks 
previously  to  the  first  case  of  puerperal 
fever,  he  had  been  attending  a  severe  case  of 
erysipelas,  and  the  infection  may  have  been 
conveyed  through  him  to  the  patient,  as  he 
admits  ;  but,  he  asks,  4  Wherefore  does  tHs 
not  occur  to  other  physicians,  or  to  e 
at  other  times ;  for  he  has  since  had 
more  inveterate  case  of  erysipelas,  but  A  has 
had  no  disease  in  any  of  his  midwifery  cayes  ?’ 
It  would  be  culpable  in  him  to  make  the  ex¬ 
periment,  or  to  repeat  the  risk,  without  due 


precautions.  Inoculation  with  the  matter 
of  small-pox  or  cow-pox  does  not  always 
communicate  the  disease;  indeed,  it  often 
fails  of  doing  so ;  but  no  one  now  disputes 
the  contagious  nature  of  the  virus  inoculated. 
Dr.  Merriman,  an  able  and  cautious  practi¬ 
tioner,  mentioned  ( Lancet ,  2d  May,  1840), 
that  he  was  at  the  examination  of  a  case  of 
puerperal  fever  at  2  p.m.  He  took  care  not 
to  touch  the  body.  At  9  o’clock  the  same 
evening  he  attended  a  woman  in  labour ;  she 
was  so  nearly  delivered  that  he  had  scarcely 
anything  to  do.  The  next  morning  she  had 
rigors,  and  died  in  forty-eight  hours.  Her 
infant  had  erysipelas,  and  died  in  two  days. 
A  patient  whom  I  was  attending  in  the  hos¬ 
pital,  in  1828,  was  seen  by  a  lady  ;  and, 
whilst  listening  to  her  faint  voice,  her  breath 
was  felt  by  the  lady,  who  was  stooping  over 
her.  This  lady  was  the  following  day  at¬ 
tacked  with  erysipelas  in  the  face.”  (p.  509.) 

These  facts  deserve  the  serious  atten¬ 
tion  of  practitioners.  That  there  is 
some  close  connection  between  the 
malignant  form  of  puerperal  fever  and 
erysipelas,  appears  to  be  now  esta¬ 
blished  on  indisputable  evidence.  Our 
author  considers  it  to  be  clearly  proved 
that  some  of  the  series  of  cases  of  the 
more  malignant  states  of  puerperal 
fever  have  been  produced  by  an  infec¬ 
tion  originating  in  the  effluvia  proceed¬ 
ing  from  erysipelas,  or  by  the  contagion 
of  the  matter,  or  contaminating  mate¬ 
rial  produced  by  erysipelas.  From  the 
opportunities  which  Dr.  Copland  has 
had  of  observing  this  disease,  during  a 
period  of  nearly  forty  years,  he  draws 
the  following  inferences,  and  suggests 
certain  precautions  :  — 

44  That  lying-in  hospitals  and  wards  have 
been  established  and  supported  on  mistaken 
views  as  to  the  benefits  they  confer  on  in¬ 
dividuals  and  the  community  ;  that  the 
charity  would  be  bestowed  more  safely  to 
the  objects  themselves,  and  to  others  con¬ 
tingently,  if  it  were  so  administered  as  to 
afford  the  required  aid,  to  increase  the  com¬ 
forts,  and  to  improve  the  sanitary  conditions 
of  females  in  the  puerperal  states  at  their 
own  places  of  residence. 

44  If  these  institutions  be  still  continued 
and  supported,  as  introductions  to  midwifery 
practice,  or  for  the  doubtful  benefit  of  the 
recipients  of  a  certain  kind  of  charity,  the 
obstetric  physicians  and  surgeons  attached 
to  them  ought  not  to  attend  those  cases  of 
puerperal  fever,  or  of  erysipelas,  which  so 
frequently  break  out  in  the  wards  of  such 
institutions  ;  for,  by  doing  so,  they  convey 
the  poison  from  one  patient  to  another,  both 
within  and  without  the  institution.  In  all 


dr.  Copland’s  dictionary  of  practical  medicine. 


505 


such  circumstances,  the  consulting  physician 
or  surgeon  to  the  institution,  who,  as  in  my 
own  case,  should  not  be  engaged  in  the 
practice  of  midwifery,  ought  to  take  charge 
of  these  cases,  which  should,  immediately 
upon  their  attack,  be  removed,  with  due  care 
and  precaution,  into  a  separate  ward,  provided 
for  the  reception  of  such  cases,  and  situated 
without  the  walls  of  the  hospital,  but  apart 
from  other  houses. 

“  A  physician  or  surgeon  engaged  in  obste¬ 
tric  practice,  upon  the  occurrence  of  puer¬ 
peral  fever  in  any  of  his  cases,  should  either 
explain  the  matter  to  her  friends,  and  call  in 
a  physician  not  engaged  in  this  practice,  to 
whose  care  she  ought  to  be  committed  ;  or 
he  should  relinquish  the  care  of  puerperal 
females  during  his  attendance  on  cases  of 
this  fever,  and  even  of  erysipelas  ;  or  he 
should  change  all  his  clothes,  and  carefully 
wash  his  hands,  after  seeing  cases  of  either  of 
these  maladies,  before  proceeding  to  a  puer¬ 
peral  female. 

‘  ‘An  obstetric  practitioner  should  not  make 
an  autopsy  of  a  case  of  puerperal  fever,  or  of 
erysipelas,  or  of  peritonitis,  or  of  diffusive  in¬ 
flammation  of  the  cellular  tissue,  or  of  the 
disease  occasioned  by  the  necroscopic  poison, 
nor  even  attend,  or  dress,  or  visit  any  of  such 
cases,  without  immediately  afterwards  ob¬ 
serving  the  precautions  just  stated,  and  allow¬ 
ing  two  or  three  days  to  elapse  between  such 
attendance  and  midwifery  engagements,  or 
visits  to  puerperal  females. 

“  It  is  the  duty  of  obstetric  practitioners  at¬ 
tached  to  public  institutions  to  prevent,  as 
far  as  possible,  the  spread  of  this  pestilence 
by  midwives,  nurses,  or  other  assistants ; 
and,  as  soon  as  two  or  three  cases  occur  in 
succession,  or  other  causes  of  suspicion  pre¬ 
sent  themselves,  to  take  the  most  decided 
measures  against  the  extension  of  contagion. 
Whatever  indulgence  may  have  heretofore 
been  extended  to  those  who  have  been  the 
ignorant  causes  of  the  misery  disclosed  by 
the  above  statements — which  convey  but  a 
small  part  of  what  has  occurred  in  recent 
times — cannot  now  be  expected,  and  ought 
not  to  be  granted  ;  for  the  practitioner  is  now 
too  well  informed,  or,  at  least,  the  sources  of 
information  as  to  this  matter  are  too  open  for 
him  to  be  longer  ignorant,  that  this  most 
deadly  of  our  domestic  pestilences  is 
conveyed  from  the  infected  to  the  healthy 
chiefly  and  most  frequently  by  the  accoucheur, 
when  it  occurs  without  the  walls  of  a  lying-in 
hospital;  and  that  ignorance  of,  or  inattention 
to,  this  fact,  already  not  unknown  to  the 
well-informed  part  of  the  community, — this 
flagrant  neglect  of  what  we  owe  to  those  who 
confide  in  us,  and  to  society  in  general,  to 
whom  we  must  look  for  consideration  and 
esteem,  will  be  no  longer  viewed  as  a  mis¬ 
fortune,  but  will  be  more  justly  considered  a 
erirne  of  no  small  magnitude.”  (p.  509-510.) 


We  need  hardly  say  that  these  sug¬ 
gestions  have  a  very  important  bearing 
on  practice.  The  whole  of  this  article 
appears  to  us  to  have  been  most  care¬ 
fully  prepared. 

The  part  concludes  with  an  essay  on 
Rabies,  which,  however,  is  not  com¬ 
pleted  in  the  present  number.  We 
shall  select  from  this  one  or  two  ex¬ 
tracts  on  subjects  which  have  formed, 
and  still  form,  qucestiones  vexatce  among 
veterinary  pathologists  and  physio¬ 
logists.  The  first  refers  to  the  stage  of 
incubation  of  the  poison  of  Rabies. 

“  Stage  of  incubation — the  latent  period. 
— In  this,  the  first  stage,  the  symptoms  of 
disorder  may  be  either  wanting,  or  so  slight 
as  to  escape  observation.  The  wound,  by 
which  the  distemper  is  usually  inoculated, 
whether  dressed  or  neglected,  generally  heals 
up  as  kindly  as  similar  injuries  ;  if  indeed 
not  more  rapidly  than  they,  leaving  a  cicatrix 
which  differs  in  no  respects  from  those  usu¬ 
ally  following  such  injuries.  In  some  cases, 
however,  pain  has  been  felt  in  the  cicatrix  a 
considerable  time  after  the  accident,  and  in 
a  few  a  slight  fever,  or  a  rapid  pulse,  has  been 
remarked  to  continue  from  the  receipt  of  the 
injury  to  the  outbreak  of  the  distemper.  The 
duration  of  this  period  is  seldom  shorter 
than  forty  days,  or  longer  than  two  years. 
Undoubted  instances  have,  however,  been 
adduced  by  M.  Trolliet,  whose  experience  of 
this  disease  has  been  most  extensive,  in  which 
the  characteristic  symptoms  sppeared  as  early 
as  the  eighth  day,  and  he  even  quotes  in¬ 
stances  of  their  occurrence  as  early  as  the  day 
following  the  injury.  That  the  duration  of 
this  period  sometimes  extends  to  six  or  nine 
months  has  been  satisfactorily  proved.  Ap¬ 
parently  authentic  cases  have  been  adduced 
of  a  much  longer  time.  J.  Hunter,  R. 
Hamilton,  and  S.  Bardsley,  have  endeavoured 
to  show  that  all  credible  cases  on  record  have 
occurred  before  the  eighteenth  month;  whilst 
other  authors  have  contended  for  even  a  longer 
period.  Dr.  Urban  states  confidently  that 
he  has  known  cases  to  occur  as  late  as  twenty 
months,  and  four  years  after  the  injury  ;  and 
similar  prolonged  periods  have  been  adduced 
by  others.  In  these,  the  question  is,  whe¬ 
ther  the  disease  has  been  actually  inoculated 
at  a  period  so  far  back,  or  has  there  occurred 
a  re-inoculation  at  some  intervening  period  ? 
The  solution  of  the  doubt  as  to  the  possible 
duration  of  this  period  is  one  of  some  im¬ 
portance  as  respects  the  fears  of  a  person  who 
has  sustained  this  most  distressing  injury. 

“  Tne  circumstances  which,  in  man  espe¬ 
cially,  seem  to  shorten  the  duration  of  this 
period  on  the  one  hand,  and  to  prolong  it  on 
the  other,  have  not  been  fully  inquired  into. 
It  is  not  improbable  that  a  small  dose  of  the 
poison  communicated  to  the  wound,  will  take 


506 


dr.  Copland’s  dictionary  of  practical  medicine. 


a  longer  time  to  produce  its  effects  upon  the 
constitution  of  the  injured  person,  than  a 
stronger  or  larger  dose — that  the  rapidity  of 
the  effect  will  have  some  relation  to  the  viru¬ 
lence  or  quantity  of  the  inoculated  poison, 
and  the  constitutional  powers  of  the  subject. 
In  cases,  however,  where  symptoms  of  hy¬ 
drophobia,  with  spasms,  &c.  follow  imme¬ 
diately  or  very  soon  after  a  bite,  a  question 
suggests  itself,  are  the  symptoms  actually 
those  of  inoculated  rabies,  or  are  they  merely 
induced  by  the  nature  of  the  local  injury,  by 
the  laceration  of  a  nerve,  by  the  puncture  of 
a  tendon,  or  by  the  fright  or  mental  anxiety 
consequent  upon  the  accident  ?  This  topic 
require :•  only  to  be  kept  in  recollection  in 
relation  to  this  part  of  the  subject :  fuller 
consideration  will  be  given  to  it  in  the  sequel. 
The  causes  which  more  especially  tend  to 
hasten  the  development  of  the  distemper  after 
inoculation,  are  debility  of  constitution,  pre¬ 
vious  ill-health,  the  fright  experienced  at  the 
time,  the  fear  and  anxiety  afterwards  enter¬ 
tained,  the  depressing  passions,  venereal  ex¬ 
cesses,  exposure  to  the  sun’s  rays,  and  in¬ 
juries  received  on  the  cicatrices.  Whilst,  on 
the  other  hand,  a  vigorous  constitution,  and 
absence  of  all  dread,  and  of  all  causes  of 
mental  depression  or  of  bodily  exhaustion, 
probably  either  prolong  the  period  of  incu¬ 
bation,  or  successfully  resist  the  influence  of 
the  poison,  especially  when  the  quantity 
inoculated  has  been  small.”  (p.  566.) 

In  another  paragraph  we  have  an 
analysis  of  the  disputed  question  whe¬ 
ther  rabies  does  or  does  not  appear  in 
a  sporadic  form  in  the  animals  subject 
to  it.  Our  author  is  inclined  to  the 
opinion  that  the  disease  only  appears 
in  animals  as  a  result  of  transmission 
by  inoculation  ;  but  he  candidly  admits 
that  its  origin  is  still  involved  in  much 
obscurity. 

u  Are  certain  species  of  the  canine  and 
feline  races,  as  the  dog,  the  wolf,  <SfC.,  capa¬ 
ble  of  generating  the  malady  de  novo,  with¬ 
out  previous  inoculation  or  infection,  and  of 
communicating  it  afterwards  ?  The  genera¬ 
tion  of  this  disease  de  novo  by  the  animals 
which  appear  to  be  most  frequently  affected 
by  it  has  been  believed  in  by  the  great  ma¬ 
jority  of  writers,  yet  I  do  not  consider  the 
matter  to  be  at  all  determined.  Experiments 
have  been  made  by  Dupuytren,  Breschet, 
Magendie,  Bourgelat,  and  others,  on  dogs  and 
cats,  these  animals  being  placed  in  those  cir¬ 
cumstances  in  which  they  have  been  said  to 
originate  rabies,  without  this  disease  having 
appeared  in  a  single  instance  among  them. 
This  point  is  most  difficult  to  be  determined  ; 
and  probably  a  just  conclusion  respecting  it 
will  be  more  likely  to  be  arrived  at  by  careful 
observation  of  facts  and  by  extensive  expe¬ 


rience,  than  by  experiments,  the  failure  of 
which  can  prove  nothing,  whilst  what  may 
appear  as  a  conclusive  result  will  admit  of 
cavil.  The  late  Mr.  Youatt,  a  well-educated, 
able,  and  candid  observer,  and  possessed  of 
the  greatest  experience,  remarked  to  me  that 
he  believed  that  the  disease  rarely,  or  perhaps 
never,  originated  de  novo,  but  in  contagion. 
It  has  certainly  not  existed  for  ages  in  cer¬ 
tain  insulated  or  secluded  places,  until  intro¬ 
duced  by  inoculation  on  well-ascertained  oc¬ 
casions,  whilst  it  has  never  been  observed  in 
other  places  similarly  circumstanced.  The 
matter  deserves  further  investigation,  as 
serving  to  arrest  the  propagation  of  this  dis¬ 
tressing  malady. 

“  Those  who  believe  that  rabies  may  occur 
spontaneously  in  the  dog,  wolf,  or  cat,  fur¬ 
nish  no  precise  information  on  the  subject ; 
and  it  certainly  cannot  be  proved  that,  when 
it  does  appear  in  one  of  these  animals,  it  is 
not  the  consequence  of  inoculation  or  infec¬ 
tion  at  some  previous  period.  The  long  time 
often  required  for  the  development  of  the 
disease,  after  undoubted  inoculation,  and  the 
possibility  of  its  being  communicated  other¬ 
wise  than  by  inoculation — by  the  contact  of 
the  virus  with  a  mucous  surface — serve  to 
render  the  proof  of  actual  communication 
by  contagion  a  matter  of  difficulty.  Those 
who  contend  for  the  spontaneous  origin  of 
the  disease,  suppose  that  pr  tracted  thirst  or 
hunger,  extreme  heat,  violent  excitement  of 
anger,  the  sexual  heat,  &c.,  severally,  or 
variously  associated,  may  develope  the 
malady,  independently  of  contagion.  Still 
these  are  merely  suppositions,  and  are  un¬ 
supported  by  positive  evidence.  M.  Trolliet 
states  that  the  months  of  J anuary  and  August, 
the  coldest  and  the  warmest,  furnish  the 
fewest  instances  of  rabies  ;  and  that  in  March 
and  April  the  greatest  number  of  wolves  are 
rabid  ;  and  that  in  May  and  September  the 
greater  number  of  dogs.  Several  writers 
have  contended  that  the  malady  is  very  rare 
in  very  hot  and  very  cold  climates,  whilst  it 
is  most  frequent  in  temperate  countries  ;  but 
much  uncertainty  and  even  obscurity,  en¬ 
velope  the  subject  of  the  spontaneous  origin 
of  this  terrible  distemper.”  (p.  575.) 

The  same  question  has  been  raised 
with  regard  to  the  specific  diseases  of 
infancy— namely,  small-pox,  measles, 
scarlet-fever,  and  hooping-cough;  as 
well  as  with  respect  to  syphilis.  It 
cannot  be  supposed  that  these  diseases 
have  existed  ab  origine  mundi ;  and  if 
they  have  had  an  origin  from  terrestrial 
causes,  coupled  with  morbific  states  of 
the  body,  there  is  nothing  to  prevent 
the  recurrence  of  these  conditions. 
Admitting  it  as  proved  that  no  dog  now 
becomes  affected  with  rabies  except  by 
inoculation  from  another  dog  labouring 


THE  PERIODOSCOPE - ITS  APPLICATION  TO  OBSTETRIC  CALCULATIONS.  507 


under  the  disease,  we  cannot  deny  the 
possibility  of  a  sporadic  origin,  unless 
we  are  prepared  to  assert,  either  that 
the  disease  was  imparted  to  the  canine 
species  at  its  creation,  or  that  the  (un¬ 
known)  conditions  which  once  contri¬ 
buted  to  its  production  can  never  by 
possibility  recur.  The  first  of  these 
two  propositions  will  hardly  be  main¬ 
tained,  and  we  know  of  no  reasonable 
ground  by  which  the  second  can  be 
supported.  We  are,  therefore,  inclined 
to  infer,  that  what  has  once  probably 
had  a  sporadic  origin  may  again  have 
a  similar  origin. 

Tile  subscribers  to  this  work  will 
find  that  they  have  in  this  number 
another  valuable  addition  to  their 
libraries,  and  we  hope  before  long  to 
have  occasion  to  announce  the  publi¬ 
cation  of  another  part  of  this  most 
useful  Dictionary. 


The  Periodoscope,  with  its  application 
to  .  bstetric  Calculations,  and  the 
Periodicities  of  the  Sex.  By  W. 
Tyler  Smith,  M.  B.  Lond.  Obstetric 
Lecturer  in  the  Hunterian  School  of 
Medicine.  8vo.  pp.  47.  London  : 
Churchill,  1848. 

Any  detailed  description  of  the  inge¬ 
nious  instrument  here  devised  by  Dr. 
Tyh  r  Smith,  for  determining  numerous 
important  questions  connected  with 
pregnancy  and  parturition,  is  unneces¬ 
sary,  because  we  feelquitesurethatit  will 
be  sooner  or  later  in  the  hands  of  most 
obstetric  practitioners.  The  object  of 
the  printed  diagram  is  to  save  the 
practitioner  the  trouble  of  making  cal¬ 
culations  based  upon  rules  w  hich  are 
for  the  most  part  conflicting  with  each 
other ;  and  Dr.  Smith  has  so  well 
managed  his  periodoscope,  and  the  ac¬ 
companying  explanation,  that  it  will 
be  equally  serviceable  to  all  practi¬ 
tioners,  whatever  views  they  may  en¬ 
tertain  respecting  menstruation,  con¬ 
ception,  and  the  duration  of  pregnancy. 
The  few  pages  which  accompany  the 
periodoscope  are  explanatory  of  its  use. 
The  instrument  plainly  sets  forth, 
without  any  preliminary  arithmetical 
calculation,  t lie  period  at  which  abor¬ 
tion  and  premature  labour  may  take 
place,  and  the  dates  to  which  gestation 
may  be  protracted.  One  singular  fea¬ 
ture  is,  that  the  study  of  the  periodo¬ 
scope  will  be  as  serviceable  to  pregnant 
females  as  to  their  medical  attendants. 


It  will  teach  the  former  the  necessity 
of  observing,  at  certain  epochs,  hy¬ 
gienic  rules,  which  the  latter  often  en¬ 
deavour  in  vain  to  enforce.  In  legal 
medicine  this  little  work  will  have  a 
most  useful  application  in  reference  to 
suits  of  contested  legitimacy.  The 
periodoscope  will  serve  to  correct  im¬ 
mediately  those  blunders  which  are  so 
liable  to  occur  from  mixing  up  calendar 
with  lunar  months  ;  and  it  will  enable 
a  barrister  to  test  the  accuracy  of  the 
calculation  made  by  a  medical  witness 
respecting  the  duration  of  pregnancy. 
We  anticipate  for  the  work  that  which 
it  deserves  for  its  novelty,  ingenuity, 
and  utility— -namely,  a  wide  circulation. 
It  should  be  in  the  hands  of  all  medi¬ 
cal  men  who  practise  midwifery;  of 
those  married  females  who  are  desirous 
of  avoiding  the  perils  which,  through 
incaution  and  imprudence,  often  attend 
the  pregnant  state  ;  and  of  all  lawyers, 
who  are  likely  to  be  engaged  in  suits 
involving  questions  relative  to  legiti¬ 
macy,  paternity,  affiliation,  and  adul¬ 
terine  bastardy.  Like  the  other  medi¬ 
cal  publications  of  Mr.  Churchill,  this 
work  is  most  creditably  got  up.  In 
another  edition,  the  only  point  which 
we  would  suggest  is,  whether  it  might 
not  be  published  in  a  small  pocket 
form. 


The  Hand  phre  nologic  ally  considered  ; 
being  a  Glimpse  at  the  relation  of  the 
Mind  with  the  Organization  of  the 
Body.  8vo.  pp.  78.  London.  1848. 

This  is  a  strange  attempt  to  make 
something  out  of  nothing.  To  endea¬ 
vour  to  revise  chiroscopy  in  the  nine¬ 
teenth  century  required  a  large  amount 
of  courage;  accordingly  the  author  of 
this  new  revelation  has  contented  him¬ 
self  with  some  vague  generalities  re¬ 
specting  variations  in  the  form  and 
structure  of  the  hand,  as  affected  by 
age,  sex,  temperament,  mental  tendency , 
and  habits.  Two-thirds  of  the  book 
have  really  very  little  reference  to  the 
title.  It  is  only  at  page  54  that  the 
author  begins  his  subject ;  and  we  are 
soon  plunged  into  a  mass  of  assump¬ 
tions,  which  daily  experience  enables 
us  to  contradict.  It  is  not  to  be  denied 
that  the  hand,  like  other  parts  of  the 
bodily  structure,  is  modified  by  the 
habits  and  occupation  of  the  individual; 
but  the  phrenological  relations  have  ye  t 
to  be  proved.  The  writer  appears  to 


508  THE  RIGHTS  OF  PHYSICIANS  AND  GENERAL  PRACTITIONERS. 


take  these  for  granted.  Hands,  like 
noses,  are  subject  to  infinite  variation  ; 
and  in  our  opinion  it  would  be  just  as 
reasonable  to  base  phrenology  on  naso- 
logy  as  on  chirology.  Indeed,  if  we 
mistake  not,  one  ingenious  writer  has 
lately  made  out  a  better  plea  for  the 
nose,  as  indicative  of  intellectual  quali¬ 
fications,  than  the  compiler  of  this 
essay  has  for  the  hand.  The  ears  and 
feet  are  still  left  open  to  any  ambitious 
candidate  who  is  desirous  of  acquiring 
some  notoriety  by  working  out  the  re¬ 
lation  of  the  mind  with  the  organization 
of  these  useful  appendages. 


<2'ou,esponticntr. 


THE  RIGHTS  OF  PHYSICIANS  AND  GENERAL 
PRACTITIONERS. 

Sir, — Having  read  the  Report  of  the 
Council  of  the  National  Institute  on  the 
medical  reform  question,  I  request  permis¬ 
sion  to  offer  a  few  remaiks  on  that  produc¬ 
tion. 

It  is  truly  stated  in  the  preface  (p.  5)  that 
“  the  most  important  feature  in  the  recent 
proceedings  in  medical  affairs  is  unquestiona¬ 
bly  the  calling  of  a  conference,  composed 
of  representatives  of  the  Royal  College  of 
Physicians,  the  Royal  College  of  Surgeons, 
the  Society  of  Apothecaries,  and  on  the  part 
of  the  General  Practitioners  of  the  National 
Institute  of  Medicine,  Surgery,  and  Mid¬ 
wifery.  ” 

Mr.  Guthrie  professes  not  to  know  what 
a  general  practitioner  is  ;  I  am  in  the  same 
predicament  Is  it  a  person  who  practises 
homoeopathy ,  hydropathy,  mesmerism,  phre¬ 
nology,  astrology,  and  other  curious  arts? 

Medical  practitioners  must  be  either 
physicians,  surgeons,  or  apothecaries ;  if 
they  practise  the  two  latter  branches  con¬ 
jointly  they  are  surgeon  apothecaries,  and 
under  this  name  should  they  be  incorporated, 
if  they  have  a  charter  at  all,  which  is  per¬ 
fectly  unnecessary.  Most  of  these  gentle¬ 
men,  if  not  all  of  them,  already  belong  to, 
or  are  members  of,  a  chartered  body  :  what 
they  ought  to  aim  at  is,  surely,  a  reforma¬ 
tion  of  their  respective  bodies. 

Whatever  may  be  said  of  the  matter,  the 
National  Institute  is  a  self-constituted  body, 
without  legal  recognition,  who  are  attempt¬ 
ing,  seemingly,  to  obtain  the  sole  power  of 
medical  legislation,  and  endeavouring  to 
subject  to  their  domination  practitioners  of 
higher  professional  rank  than  themselves. 

As  to  the  conference  itself,  there  is  some¬ 
thing  ludicrous  in  it.  It  consisted  of  the 
heads  of  three  legally  recognised  bodies, 


with  the  addition  of  a  fourth  party  sent  there 
by  certain  individuals  who  already  formed 
integral  parts  of  two  out  of  the  three  recog¬ 
nised  bodies.  These  last  gentlemen,  there¬ 
fore,  must  have  had  a  three-fold  preponder¬ 
ance  in  the  conference.  As  surgeons,  they 
were  represented  by  Mr.  Travers  ;  as  apo¬ 
thecaries,  they  were  represented  by  Mr. 
Bean  ;  and  Mr.  Pennington  was  deputed  to 
act  as  a  principal  in  the  conference.  It 
would  appear  strange  if,  in  the  House  of 
Peers,  Lord  A.  should  give  his  vote  perso¬ 
nally,  and  also  have  another  vote  for  the 
proxy  which  he  had  deposited  with  Lord  B. 

Before  any  step  is  taken  in  medical  legis¬ 
lation,  the  precise  grievances  it  is  sought  to 
remedy  should  be  pointed  out,  and  the 
methods  enumerated  by  which  they  are  to  be 
remedied. 

What  has  the  apothecary  to  complain  of  ? 
Has  he  not  the  power  of  undertaking  the 
sole  management  of  diseases,  to  the  entire 
exclusion  of  the  physician,  for  as  long  a 
time,  and  to  as  great  an  extent,  as  the  patient 
will  consent  ?  Has  he  not  the  power  to  set 
broken  bones  and  reduce  dislocations,  without 
any  interference  of  the  College  of  Surgeons, 
even  if  he  does  not  possess  their  diploma? 
Can  he  not  dispense  medicines  to  his  own 
patients,  and  sell  them  to  those  who  are  not 
his  own  patients  ?  Have  not  the  apotheca¬ 
ries  unlimited  power  of  practising  every 
branch  of  the  profession,  with  the  additional 
advantage  (optional,  of  course,)  of  joining 
with  it  a  trade,  and  of  being  entitled  to  ob¬ 
tain  payment  of  their  bill  of  articles  supplied 
as  “IP'  invoice  ?”  Is  anything  more  re¬ 
quired  ?  Yes  ;  the  power  of  the  associated 
members  to  legislate  for  all  the  various 
grades  of  the  profession,  and  to  subject  every 
individual  of  it  to  their  exclusive  domina¬ 
tion  ! 

It  appears  to  me  that  if  any  party  has 
grievances  to  complain  of,  it  is  the  physician. 
He  is  encroached  upon  by  the  apothecary, 
who  professing,  and  perhaps  truly,  to  be 
better  educated  than  his  predecessors,  thinks 
a  physician  a  perfectly  useless  appendage  in 
a  sick  room.  The  pure  surgeon  hesitates 
not  to  undertake- the  management  of  purely 
medical  cases,  not  requiring  in  the  least  de¬ 
gree  whatever,  surgical  aid.  Whilst  thus 
pressed  upon  on  every  side,  he  never  retaliates 
by  setting  a  broken  bone  or  reducing  a  dis¬ 
location,  or  by  dispensing  medicines  even  to 
his  own  patients.  He  remains  a  quiet  suf¬ 
ferer.  I  see  no  remedy  proposed  in  the  con¬ 
templated  charter  for  his  grievances. 

It  is  stated  in  the  preface,  p.  8  (21),  that 
the  College  of  Physicians  had  “  assented  not 
only  to  the  formation  of  the  new  body,  but 
to  every  measure  which,  in  the  opinion  of 
the  Conference,  is  calculated  to  insure  its 
efficiency  and  permanency,  reserving  to  itself 
its  own  rights  only  as  respects  the  title  of 


PROGRESS  OF  THE  CHOLERA  ON  THE  CONTINENT. 


509 

"T"  *  *  1  '  1  ""  ■  —  ■  . .  ■  ■  ■  -  .  . . .  ..  , 


Doctor  in  Medicine."  Yes,  and  a  barren 
title  it  will  be,  when,  as  must  necessarily 
happen  if  the  charter  is  obtained,  the  sphere 
of  the  physician  is  so  greatly  curtailed,  or, 
more  properly  speaking,  annihilated. 

If  a  person  registers  as  a  physician,  he  is 
allowed  to  practise  in  his  own  department 
of  the  profession  ;  if  he  registers  as  a  general 
practitioner,  he  may  practise  in  every  de¬ 
partment. 

To  enable  any  one  to  register  as  a  physi¬ 
cian,  he  is  to  be  examined  by  the  president 
and  censors  of  the  College  of  Physicians,  but 
it  must  be  in  the  presence  of  a  person  de¬ 
puted  by  the  apothecaries,  if  they  choose  to 
send  one. 

largos. 

September  1848. 

***  Our  correspondent  is,  we  think,  a 
little  premature  in  his  anticipation  of  the 
injury  likely  to  be  inflicted  on  physicians  by 
the  incorporation  of  the  general  practitioners. 
He  must  take  the  rights  and  privileges  of 
physicians  from  their  charter,  the  terms  of 
which  are  not  yet  finally  settled.  The  de¬ 
signation  of  general  practitioner  is,  we  ad¬ 
mit,  most  unfortunately  chosen.  It  has 
nothing  professional  about  it,  and  might, 
with  equal  reason,  be  applied  to  attorneys 
who  practise  in  all  the  courts. 


JMctucal  Ihudlt^enrc. 


THE  CHOLERA  IN  SYRIA. 

Aleppo. —  Letters  from  Damascus,  of  the 
2d  August,  announce  that  the  ravages  of 
the  cholera  at  Aleppo  have  been  very  severe. 
It  is  alleged  that  one-fourth  of  the  popula¬ 
tion  of  the  city  has  been  cut  off  by  the  dis¬ 
ease.  The  streets  are  deserted  :  the  bazaars 
closed,  and  those  of  the  inhabitants  who  had 
the  power  have  fled  into  the  adjoining 
country.  "When  the  cholera  first  appeared, 
the  deaths  were  from  300  to  350  daily. 
The  attacks  are  now  reduced  to  about  40 
daily,  and  the  recoveries  are  numerous. 
This  scourge  appears  to  leave  one  city  only 
to  break  out  in  another.  When  it  had 
abated  at  Aleppo,  it  broke  out  at  Hama, 
where  the  deaths  are  now  20  a  day.  Its 
appearance  in  Damascus  is  expected  daily, 
and  there  is  a  general  panic  among  the  in¬ 
habitants. 

PROGRESS  OF  THE  CHOLERA  ON  THE 
CONTINENT. 

The  German  papers  contain  returns  of  cases 
of  cholera  from  the  following  places  : — Ber¬ 
lin,  the  8th  inst. ;  Stettin,  the  5th;  Magde¬ 
burg,  the  9th ;  Vienna,  the  8th  ;  Moscow, 
the  26th  of  August;  St.  Petersburgh,  the 


1st  of  September;  and  Warsaw,  the  5th. 
Up  to  the  8th  inst.  there  had  been  784  cases 
of  cholera  in  Berlin,  484  of  which  had  termi¬ 
nated  fatally  ;  205  patients  are  still  under 
medical  treatment,  and  the  remaining  95  are 
reported  as  having  terminated  favourably. 
At  Stettin,  on  the  6th,  32  new  cases  had 
occurred,  and  7  had  died.  The  cases  from 
the  8th  of  August  to  the  5th  of  September 
were  652,  of  which  433  had  terminated 
fatally,  110  had  recovered,  and  109  remained 
ill.  At  Magdeburg,  up  to  the  6th  inst., 
there  had  been  79  cases,  of  which  35  had 
terminated  fatally  ;  from  the  6th  to  the  7th  4 
new  cases  had  occurred,  and  5  had  died, 
making  83  cases,  out  of  which  40  deaths  ; 
from  the  7th  to  the  8th  104  cases  and  46 
deaths  ;  and  from  the  8th  to  the  9th  17  new 
cases  and  10  deaths.  At  Vienna  the  cholera 
had  already  broken  out,  and  2  deaths  had 
occurred.  A  St.  Petersburgh  letter  of  the 
3d  states  that  the  cholera,  which  had  been 
gradually  diminishing  in  virulence,  was  again 
slightly  increasing.  On  the  1st  there  were 
53  new  cases,  20  deaths,  and  35  cures,  being 
an  increase  of  14  cases  and  10  deaths  upon 
the  numbers  of  the  preceding  days.  On 
the  morning  of  the  2d  there  were  380  cho¬ 
lera  patients  under  treatment.  At  Moscow, 
on  the  25th  ult.,  there  were  25  new  cases 
and  16  deaths  ;  and  on  the  26th  there  were 
25  new  cases,  but  only  11  deaths.  In  the 
other  provinces  of  Russia  afflicted  with  this 
disease  it  is  making  great  ravages ;  in  some 
of  them  as  many  as  between  5,000  and  6,000 
persons  are  carried  off  by  it  weekly.  At 
Warsaw,  from  the  1st  to  the  4th  of  Septem¬ 
ber,  214  cases,  of  which  53  cured  and  58 
deaths.  At  Posen,  also,  the  cholera  had 
broken  out. 

Trieste,  September  8th. — It  is  reported 
that  the  Asiatic  cholera  has  broken  out  in 
this  seaport.  It  appears  that  a  vessel 
had  recently  arrived  from  Constantinople, 
the  crew  of  which  had  been  affected  by 
cholera.  The  ship  had  been  put  into  quaran¬ 
tine,  but  the  captain  having  subsequently 
been  seized  with  illness,  attended  by  cholera 
symptoms,  much  alarm  was  temporarily 
created  for  the  health  of  the  place.  His 
speedy  recovery,  however,  eventually  re¬ 
stored  some  confidence. 

Should  this  report  be  proved  to  be 
correct,  we  have  no  doubt  that  some 
busy  theorists  will  immediately  under¬ 
take  to  prove  that  the  arrival  of  the 
ship  from  Constantinople  had  nothing  what¬ 
ever  to  do  with  the  irruption  of  the  disease. 
A  peccant  cesspool  or  dust-bin  will  be 
found,  the  emanations  from  which  will 
doubtless  suffice  to  explain  all  the  symp¬ 
toms  !  It  is  strange  that  the  cholera  will 
always  appear  at  some  sea-port  having 
commercial  intercourse  with  a  country  in 
which  it  prevails,  as  if  constantly  to  tax  the 


510 


INFALLIBLE  REMEDIES  FOR  ASIATIC  CHOLERA. 


ingenuity  of  those  who,  like  our  Sanitary 
Commissioners,  maintain  that  the  disease  is 
not  communicable  in  any  manner  whatso¬ 
ever. 

Hamburgh ,  Sept.  15. — The  Asiatic  cho¬ 
lera  made  its  appearance  in  this  town  at  the 
beginning  of  the  month.  There  have  been 
about  280  cases  within  a  period  of  fourteen 
days.  About  half  of  this  number  are  now 
convalescent. 

INFALLIBLE  REMEDIES  AND  SPECIFICS  FOR 
ASIATIC  CHOLERA. 

One  of  the  marked  features  of  the  advent 
of  Asiatic  cholera  is  that  many  quasi¬ 
medical  practitioners,  send  letters  to  the 
daily  journals  on  the  “  advice  gratis”  prin¬ 
ciple,  recommending  the  use  of  particular 
medicines  which  ihey  have  never  known  to 
fail  in  curing  cholera.  We  have  assigned  a 
portion  of  our  space  this  week  to  a  long 
letter  upon  an  alleged  cholera  specific  ;  be¬ 
cause  it  appeared  to  have  a  sort  of  official 
character,  and  all  that  is  official  in  medical 
bulletins  must  be  productive  either  of  much 
harm  or  good.  In  either  case,  it  is  the  duty 
of  medical  journalists  to  make  the  facts 
known,  so  that  the  public  may  not  be  in- 
dused  to  poison  themselves  without  due 
warning.  A  Dr.  Kruger  Hansen  has  re¬ 
cently  rushed  into  print  with  two  remedies, 
one  of  which  we  are  unable  to  decipher,  and 
the  other  appears  to  fall  under  the  “  chip 
and  porridge”  variety  of  prescriptions.  We 
give  the  doctor’s  account  of  his  remedies  as 
they  appeared  in  the  Times. 

“  The  remedies  in  question  contain  nothing 
that  can  possibly  operate  injuriously — not 
even  if  the  symptoms  be  mistaken — no 
matter  whether  the  disease  be  Mecklenburgh 
or  Asiatic  cholera :  the  utmost  effect  that 
can  be  produced  upon  sensitive  and  suscep¬ 
tible  patients  would  amount  to  no  more 
than  that  of  one  glass  of  wine  beyond  the 
usual  allowance  taken  after  dinner.  Not 
only  were  the  x-emedies  found  most  beneficial 
in  the  year  1832,  but  I  have  even  during 
the  last  few  weeks  had  many  opportunities 
of  seeing  that  cholera — advanced  to  the 
well-known  ‘  Asiatic’  stage  —  was  trans¬ 
formed,  after  a  few  doses,  into  a  reactionary 
state,  and  that  even  then  the  patient  became 
convalescent,  after  the  administration  of  re¬ 
storative  balsam  (I ebens -balsam)  or  tincture 
of  Angelica  and  wine. 

“  The  two  remedies  which  I  have  hitherto 
found  so  efficacious  are  the  following  : — 

“  1.  R  Mixtura  Pyro  Tartarica,  drachms  ij. 

Tinctura  Opii  Simplex,  drachm  /3. 

“  N.B.  About  20  drops  for  a  grown 
person. 

“2.  Rec.  Cort.  Cascarill,  gr.  xij. 

Pulv.  Aromat.  gr.  iv. 

Alum.  crud.  gr.  ij. 

Op.  pur.  gr.  i. 


“  N.B.  Det.  pro  dosi  the  quantity  deemed 
requisite.  {Vide  No.  1  powder.) 

“  If  watery  evacuations  supervened  during 
the  epidemic,  with  or  without  rumblings  in 
the  bowels,  I  at  once  administered  to  adults 
the  above  powder  mixed  with  any  liquid  at 
hand,  and  invariably  after  its  operation, 
from  the  fourth  to  the  eighth  hour,  adminis¬ 
tered  half  of  one  or  more,  until  the  watery 
evacuations  ceased.  When  vomitings  pre¬ 
ceded  or  accompanied  the  watery  evacuations, 
I  first  administered  a  dose  of  the  drops 
mixed  with  water  or  wine,  repeating  it  every 
hour.  When  early  administered,  the  symp¬ 
toms  subsided  after  three  or  four  doses,  an 
additional  dose  only  having  been  adminis¬ 
tered  in  rare  cases,  in  consequence  of  a  con¬ 
tinuance  of  rumblings  in  the  intestines.  If, 
in  the  state  or  reaction  there  still  con¬ 
tinued  an  inclination  to  watery  evacuations, 
I  did  not  regard  this,  as  so  many  physicians 
do,  as  a  favourable  symptom  ;  but  on  the 
contrary,  endeavoured  to  stop  them  by 
smaller  doses  of  the  powder,  and  the  avoid¬ 
ance  of  all  acids  and  vegetable  substances, 
except  potatoes  and  farinaceous  preparations. 
It  need  hardly  be  remarked  that  the  doses 
were  smaller  in  proportion  when  adminis¬ 
tered  to  patients  of  tender  age.” 

It  will  be  perceived  that  the  Doctor’s 
directions  are  sufficiently  vague,  and  his 
pyrotartaric  mixture  is  to  us  a  perfect  mys¬ 
tery.  We  might  have  conjectured  that  he 
intended  by  it  pyrotartaric  acid,  but  that 
in  his  instructions  he  recommends  the  scru¬ 
pulous  avoidance  of  all  acids  and  vegetable 
substances.  Owing  to  this  obscurity,  we  do 
not  think  that  Dr.  Kruger  Hansen’s  specific 
will  do  much  harm. 

In  the  same  journal  there  appears  a  letter 
from  “  a  retired  practitioner,”  who  recom¬ 
mends,  every  half  hour ,  five  grains  of 
calomel  with  one  grain  and  a  half  of  opium, 
and  the  same,  or  even  a  larger,  dose  of 
black  pepper.  He  did  not  find  that  assa- 
foetida  had  any  marked  effect  on  the  disease. 
The  objection  to  this  mode  of  treatment  is, 
that  three  grains  of  opium  per  hour  are  too 
large  a  dose  to  be  administered  indiscrimi¬ 
nately  with  safety.  The  symptoms  of  cho¬ 
lera  may  be  arrested,  but  the  unlucky  patient 
may  die  from  the  effects  of  the  opium.  We 
admit  that  in  certain  diseases  larger  doses  of 
opium  may  be  borne  than  in  health.  We 
are  not  satisfied,  however,  that  the  safety 
of  large  doses  of  narcotics  frequently  re¬ 
peated  has  been  clearly  proved  in  reference 
to  Asiatic  cholera,  and  wre  feel  certain  that 
on  the  last  invasion  of  the  epidemic  many 
were  poisoned  by  the  too  free  use  of  this 
drug.  They  might,  it  is  true,  have  died 
from  cholera ;  but  the  opium  accelerated 
death,  and,  by  so  doing,  destroyed  all  hope 
of  recovery.  The  public  should  learn  from 
the  many  and  conflicting  plans  of  treatment 


ALLEGED  REMEDY  FOR  ASIATIC  CHOLERA. 


511 


recommended  by  newspaper-writers,  that 
these  “  advice  gratis”  cures  for  cholera  have 
about  as  much  claim  to  their  reasonable 
consideration  as  the  wonderful  restoration  of 
limbs,  &c.  produced  by  the  use  of  a  single 
pot  of  Professor  Holloway’s  ointment ! 

ALLEGED  REMEDY  FOR  ASIATIC  CHOLERA. 

[As  it  is  our  desire  to  collect  information 
from  all  sources  respecting  the  treatment  of 
this  formidable  disease,  we  here  reprint  an 
article  which  has  appeared  in  the  public 
journals,  in  which  the  writer  speaks  very 
confidently  of  the  great  success  which  has 
attended  the  use  of  a  mixture  of  stimulants 
and  antispasmodies.  The  document  has  a 
quasi-official  authority,  as  it  is  represented 
to  be  the  subject  of  a  report  to  the  Govern¬ 
ment  Board  of  Health.  We  must  confess 
that  we  put  very  little  confidence  in  the 
alleged  remedy,  notwithstanding  its  vaunted 
success.  Most  professional  men  know  what 
is  meant  by  the  success  of  remedies  :  in  nine 
cases  cut  of  ten  where  disease  is  found  to  be 
unmanageable  under  every  form  of  treat¬ 
ment,  the  good  effects  are  based  upon  a  mere 
post  hoc  propter  hoc  inference.  Opium, 
in  all  doses,  has  been  repeatedly  tried,  and 
failed.  Stimulants  as  powerful  as  black 
pepper  have  also  been  tried  and  failed  ;  and 
our  knowledge  of  the  properties  of  assafoetida 
is  not  such  as  to  justify  any  sanguine  expec¬ 
tation  of  marvellous  results  from  its  employ¬ 
ment.  The  plan  of  mechanically  confining 
the  circulation  of  the  blood  to  the  trunk  is 
novel.  It  would  have  been  more  satisfactory 
if  the  gentleman  giving  the  information  to 
the  Board  of  Health  had  given  some  definite 
statement  as  to  the  number  of  cases  treated, 
date  of  attack,  age,  Sec.  As  it  is,  there  is  a 
shadowy  vagueness  throughout  the  document 
on  these  important  particulars.  It  is  well 
known  that  on  the  decline  of  the  disease  in 
a  locality,  all  kinds  of  treatment,  which  at 
first  failed,  appear  to  succeed.] 

Memorandum  of  the  Arabian  Prescription 

of  Assafoetida,  Opium,  tyc.in  Cholera. 

Several  years  before  the  cholera  appeared 
in  India,  in  the  course  of  my  oriental  pur¬ 
suits,  I  was  in  the  habit  of  reading  oriental 
works  on  medicine  with  a  learned  native 
physician,  who  had  been  regularly  educated 
as  a  pupil  of  the  principal  Hakeem  (physi¬ 
cian)  of  the  old  Nawab  of  Oude.  In  my 
course  of  reading  in  an  Arabic  work  of  great 
antiquity  on  medicine,  I  met  with  an  account 
of  a  disease  which  struck  me  as  being  ex¬ 
tremely  formidable,  which  I  had  never  heard 
of,  and  which  my  learned  friend  had  never 
know  n  except  in  books.  I  took  a  note  of  it, 
and  of  the  remedies  prescribed  for  its  cure. 

W  hen  the  cholera  broke  out  in  Bengal  in 
1817,  it  did  not,  till  after  some  time,  strike 
me  that  it  was  the  same  disease  of  which  I 


had  read,  and  the  faith  I  had  in  oriental  me¬ 
dicine  did  not  shake  my  confidence  in  the 
remedies  prescribed  by  our  own  medical 
men.  But  I  was  at  length  undeceived  ;  and 
after  long  and  very  extensive  experience  I 
became  fully  impressed  with  the  conviction 
that  no  remedy  had  been  discovered  worthy 
of  reliance,  having  tried  everything  that  had 
been  favourably  spoken  of,  not  always  in¬ 
deed  without  success,  but  in  the  main  with 
signal  failure ;  so  much  so,  that  when  a  case 
was  brought  to  me,  my  experience  justified 
no  hope,  but,  on  the  contrary,  complete  des¬ 
pair.  I  was  now  convinced  it  was  the  same 
disease  of  which  I  had  so  long  ago  read,  and 
I  determined  to  try  the  remedy  prescribed 
by  the  Arabian  physicians.  I  recollected 
two  of  the  ingredients,  but  I  forgot  the  third. 
The  note  I  had  made  was  not  to  be  found  ; 
but  a  third*  ingredient  came  into  my  mind, 
with  the  conviction  that  it  was  the  right  one  : 
and  I  determined  to  try  the  prescription  I 
had  thus  formed.  But  the  quantities  for  the 
dose  I  had  still  more  entirely  forgotten ; 
and  this  I  likewise  supplied  by  considering 
what  might  be  a  dose  of  each  separate  ingre¬ 
dient.  The  first  case  was  not  a  very  bad 
one  :  the  medicine  was  given,  and  it  was 
cured  with  complete  success.  Other  cases 
were  brought,  some  bad  cases,  and  some 
otherwise  ;  they  all  terminated  favourably, 
not  a  man  was  lost.  One  shocking  case  ap¬ 
peared  of  collapse  after  violent  suffering,  the 
patient  evidently  sinking,  having  more  the 
appearance  of  a  skeleton  covered  with  skin 
than  a  living  being  ;  the  pulse  gone.  Here  I 
had  no  hope,  but  I  administered  the  medi¬ 
cine  in  the  way  hereafter  described,  and  per¬ 
severed,  being  thankful  for  the  smallest  sign 
of  its  effect.  I  still  persevered,  and  at  length 
the  poor  creature  was  restored,  I  may  almost 
say  to  life,  and  completely  cured.  This  gave 
us  great  confidence,  the  more  especially  as 
all  the  while  a  native  doctor  whom  I  em¬ 
ployed  to  administer  the  medicine  among 
the  surrounding  inhabitants  reported  to  me 
daily  equal  success.  No  one  who  has  wit¬ 
nessed  such  scenes  as  those  to  which  I  have 
alluded  will  be  surprised  at  the  joy  and 
thankfulness  which  arose  in  my  mind  on 
being  thus  able  to  combat  so  formidable  a 
disease. 

This  ancient  remedy  for  the  most  destruc¬ 
tive  disease  of  either  ancient  or  modern 
times  does  not  consist  of  rare  or  numerous 
ingredients.  They  are  articles  in  common 
use  by  all  Asiatics,  and  found  in  every 


*  The  third  ingredient  is  black  pepper,  which 
I  have  used ;  but  the  Arabian  prescription,  1 
found  on  recovering  the  note  I  had  mislaid,  was 
the  powder  of  the  root  of  the  “  Asclepias  Gigan- 
tea,”  which  is  a  powerful  stimulant  and  febri¬ 
fuge  ;  but  it  is  a  rare  plant,  and  as  the  pepper 
answered  so  well  I  have  never  tried  the  ASsclepias 
Gigantea.  The  other  two  ingredients,,  assafoe¬ 
tida  and  opium,  were  correct, 


512 


ALLEGED  REMEDY  FOR  ASIATIC  CHOLERA. 


bazaar  (market)  in  Asia — namely,  assafoetida- 
opium,  black  pepper  (pulverized).  I  con¬ 
tinued  the  use  of  this  medicine  for  years, 
during  my  residence  in  India,  with  the 
greatest  success,  the  extent  of  which  will  be 
best  understood  when  I  say  that,  instead  of 
despair,  as  formerly  when  a  case  of  cholera 
was  brought  to  me,  I  learned  to  feel  con¬ 
fident  that  if  the  patient  was  not  so  far  gone 
that  the  vital  powers  were  well  nigh  extinct, 
his  life  might  be  saved.  In  the  meantime  I 
had,  through  the  medium  of  the  Calcutta 
newspapers,  made  known  the  remedy  and 
its  success ;  and  seeing  its  extreme  value, 
and  also  that  the  ingredients  were  such  as 
would  be  acceptable  even  to  the  most  fasti¬ 
dious  Hindoo,  I  suggested  to  the  Govern¬ 
ment  of  India  to  make  it  known  to  the 
people  throughout  the  country  by  means  of 
the  village  officers  and  the  different  police 
thanas  (stations),  enjoining  them  to  keep 
supplies  of  the  medicine  for  general  use ; 
and  thus  it  was  proclaimed  throughout  the 
Bengal  Presidency.  And  soon  thereafter 
many  letters  from  benevolent  individuals  at 
different  stations  appeared  in  the  public 
papers  recommending  it,  and  giving  the 
most  favourable  account  of  its  success.  The 
author,  or  rather  the  revivor,  of  it  was  not 
made  known  (for  not  being  a  medical  man 
my  name  could  add  no  weight  to  the  pre¬ 
scription).  I,  however,  made  a  point  of 
recommending  it  to  all  our  own  medical 
officers  of  whom  I  had  any  knowledge,  and 
many  of  them  throughout  the  country  then 
relied  upon  it,  although  from  the  ravages 
which  the  disease  is  stated  to  have  made  of 
late  years  in  many  parts  of  India,  I  much 
fear  that  this  powerful  medicine  has  in  the 
course  of  time,  and  by  the  constant  change 
of  men,  been  greatly  forgotten. 

I  have,  however,  since  my  return  to  Eng¬ 
land  heard  from  several  medical  men  in 
India  of  the  success  with  which  they  con¬ 
tinued  to  use  it.  Of  these  I  have  particu¬ 
larly  to  mention  a  gentleman  who  was 
among  the  first  to  whom  I  recommended 
the  medicine,  and  who  has  constantly  used 
it  ever  since — that  is,  for  nearly  25  years. 
I  mean  Dr.  Wise,  now  principal  of  the 
College  of  Dakkah,  in  Bengal,  a  man  of 
great  science  and  knowledge  of  his  profes¬ 
sion,  and  an  author  both  in  oriental  litera¬ 
ture  and  in  medicine  ancient  and  modern. 
This  is  happily  confirmed  by  a  letter  which 
I  have  lately  received  from  Dr.  Wise.  The 
communication  is  so  important  that  I  can¬ 
not  suppress  the  following  extract  from  it 
without  omitting  a  striking  proof  of  the 
value  of  the  remedy  I  desire  universally  to 
recommend : — 

Extract  of  a  Letter  from  Mr.  Thomas 

Wise,  M.D.,  dated  Dakkah,  April  2, 
1847. 

“  Many  years  ago  you  asked  me  my  opi¬ 


nio  n  of  your  prescription  (the  assafoetid 
and  opium  pills  in  cholera).  My  repor^ 
was  then  favourable,  and  I  think  you  will 
be  pleased  to  know  the  result  of  my  further 
experience.  I  am  happy  to  say  it  is  still 
very  favourable  :  indeed,  so  much  so,  that 
when  they  (the  pills)  are  given  in  an  early 
stage  of  the  disease,  they  almost  always  ac¬ 
complish  a  cure.  So  much  is  this  the  case 
that  I  always  use  them  ;  and  since  Septem¬ 
ber  last,  during  the  prevalence  of  a  preva¬ 
lent  epidemic,  I  find  I  have  distributed 
20,600  pills.  Almost  every  turning  in  the 
city  of  Dakkah  had  boards  indicating  where 
the  pills  were  to  be  got.  When  the  patients 
were  brought  to  the  hospital,  or  when  I  see 
them  first  in  a  collapsed  state  of  cholera,  I 
give  a  pill  broken  down  (bruised  in  a  spoon¬ 
ful  of  brandy  and  water),  and  repeat  it ;  and 
I  apply  the  tourniquet  to  the  four  extremi¬ 
ties.  This  throws  several  pounds  of  blood 
into  the  trunk,  and  disturbs  and  removes 
the  morbid  action  ;  and  thus  patients  are 
jpured  when  there  is  no  chance  with  any 
other  remedies.” 

The  tourniquet  is  a  recent  application,  to 
which  Dr.  Wise  attaches  considerable  im¬ 
portance. 

Mode  of  using  the  medicine. 

Ingredients  for  one  dose  for  an  adult. — 
Assafoetida,  opium,  black  pepper  (pul¬ 
verized),  of  each  two  grains  made  into  a 
pill. 

N.B. — Should  two  grains  of  opium  be 
thought  too  large  a  dose  (which  if  very  pure 
opium  be  used  it  may  be)  lg  grains  may  be 
tried . 

These  pills  may  be  made  up  and  kept  for 
use  in  a  phial,  the  mouth  of  it  being  well 
closed.  When  used  the  pills  should  be 
broken  down  and  bruised  and  taken  in  a 
table-spoonful  of  brandy  and  water,  and 
washed  down  with  a  small  quantity  of  the 
same.  (It  would  be  still  better  to  chew  the 
pill  and  swallow  it,  washed  down  in  the  same 
manner.)  But  the  pills  should  not  be  swal¬ 
lowed  whole,  as  they  would  not  act  so 
promptly,  and  might  be  brought  up  by  vo¬ 
miting.  The  dose  should  be  repeated  every 
half-hour*  or  hour,  according  to  the  urgency 
of  the  case,  until  the  symptoms  be  subdued. 
Two  or  three  doses  are  generally  sufficient, 
but  five  or  more  have  been  given  before  the 
disease  has  been  arrested,  giving  half  or 
quarter  doses  at  shorter  intervals ;  and  in 
cases  of  great  prostration  and  protracted 
disease  I  have,  as  an  additional  stimulant, 
substituted  red  pepper  for  the  black  pepper 
occasionally. 

Friction,  with  hot  and  stimulating  sub- 


*  Two  grains  of  opium  every  half-hour,  to  the 
extent  of  five  doses,  would  be  heroic  practice. 
The  patient  may  recover  from  the  disease,  but 
die  from  the  treatment. — Ed.  Gaz. 


MORTALITY  OF  THE  GLOUCESTER  DISTRICTS  IN  1847. 


513 


stances,  over  the  stomach  and  abdomen, 
should  also  be  used.  The  limbs  also  should 
be  well  rubbed  in  the  same  way ;  and  if  the 
patient  has  complained  of  more  than  usual 
pain  in  the  stomach  1  have  sometimes  given 
10  grains  of  calomel — although  I  cannot  say 
that  l  have  observed  much  benefit  from  it, 
unless  where  there  has  been  congestion  of 
liver ;  or  indeed  from  anything  taken  inter¬ 
nally  except  this  medicine.  If  there  be  much 
thirst,  as  generally  there  is,  a  few  spoonfuls 
of  brandy  and  water  may  be  given. 

In  cases  of  collapse  the  same  course  must 
be  pursued  and  continued,  the  medicine  being 
repeated  at  intervals  of  longer  or  shorter 
duration,  according  to  the  state  of  the  patient. 
And  as  Dr.  Wise  has  recommended  the  ap¬ 
plication  of  the  tourniquet  to  the  arms  and 
legs  in  order  to  husband  as  it  were  the  vital 
power  by  limiting  the  extent  of  circulation, 
this  may  be  tried  by  applying  a  ligature  of 
tape  or  other  substances  to  the  upper  arm 
and  thigh  if  the  tourniquet  be  not  available. 

Cure  for  the  Cholera. 

Ingredients. — Assafoetida,  opium,  black 
pepper  pulverized.  These  ingredients,  more 
or  less  pure,  will  be  found  in  every  town  and 
village. 

The  dose  for  an  adult  is  from  a  grain  and 
a  half  to  two  grains  of  each,  made  into  a 
pill.* 

The  medicine  should  be  made  up  into  pills 
of  one  dose  each,  and  kept  for  use  in  a  phial 
well  closed,  as  it  is  of  great  importance  to 
check  the  disease  the  instant  of  its  attack. 

The  best  mode  of  administering  the  pill  is 
not  by  swallowing  it  whole,  lest  it  be  rejected 
in  that  state,  but  by  chewing  it  and  swallow¬ 
ing  it  with  the  moisture  of  the  mouth,  and  a 
very  little  brandy-and-water  to  wash  it  down. 
The  next  best  way  of  administering  the  me¬ 
dicine  is  by  bruising  the  pill  in  a  spoonful  of 
brandy  and- water,  and  then  swallowing  it. 

Much  liquid  must  not  be  given;  but  to 
relieve  the  thirst,  which  is  great,  brandy-and- 
water  by  spoonfuls  occasionally,  is  the  best 
mode. 

The  dose  should  be  repeated  every  half  or 
three-quarters  of  an  hour  according  to  the 
urgency  of  the  symptoms  until  they  have 
been  subdued.  From  three  to  five  doses 
have  generally  been  sufficient  for  this,  al¬ 
though  as  many  as  eight  have  been  given 
before  health  has  been  restored  in  bad  cases. 

Should  great  prostration  of  strength  pre¬ 
vail,  with  spasm  or  without  spasm,  alter  the 
other  symptoms  (vomiting,  purging,  &c.) 
have  been  subdued,  the  medicine  must  not 
be  wholly  lei t  off,  but  given  in  half  or  quarter 
doses  so  as  to  keep  up  the  strength  and 
restore  the  pulse. 


*  This  according  as  the  ingredients  are  pure  or 
otherwise.  If  pure,  grains  will  suffice. 


Friction,  with  stimulating  liniment  o^ 
some  kind,  ought  to  be  applied  carefully  to 
the  stomach,  abdomen,  legs,  and  arms  ;  and 
when  pain  in  the  stomach  has  been  severe, 
and  there  was  reason  to  fear  congestion  of 
the  liver,  eight  or  ten  grains  of  calomel  have 
been  given  with  good  effect. 

In  cases  of  collapse  and  great  prostration 
of  strength  the  application  of  the  tourniquet 
to  the  arms  and  legs  has  been  recommended, 
in  order,  as  it  were,  to  husband  the  vital 
j  power  by  limiting  the  extent  of  the  circula¬ 
tion.  This  may  be  tried,  using  a  ligature  of 
tape  or  other  substance,  if  the  tourniquet  be 
not  available. 

The  favourable  symptoms  of  recovery  are 
restoration  of  the  pulse,  returning  warmth 
of  the  body,  and  sleep  ;  and  after  being  re¬ 
freshed  by  sleep,  the  recovery  being  com¬ 
plete,  a  dose  of  castor  oil  may  be  given. 

REPORT  TO  THE  REGISTRAR  GENERAL  ON 

THE  MORTALITY  OF  THE  GLOUCESTER 

DISTRICTS  IN  1847.  BY  H.  W.  RUMSEY, 

ESQ. 

[We  have  great  pleasure  in  giving  insertion 
to  the  subjoined  Report,  w'hich  has  been  ably 
drawn  up  by  a  gentleman  in  every  way  quali¬ 
fied  for  the  task,  and  whose  name  is  well 
known  to  our  readers  by  his  former  contri¬ 
butions  to  this  journal.  We  have  selected 
for  insertion  those  parts  of  the  Report  which 
appeared  to  be  of  general  interest,  omitting 
details  of  a  purely  local  character.  We  trust 
that  Mr.  Rumsey’s  example,  in  furnishing 
correct  scientific  reports  of  the  rate  of  mor¬ 
tality  in  the  Gloucester  districts,  will  serve 
to  stimulate  practitioners  in  other  provincial 
districts,  and  induce  them  to  come  forward 
in  aid  of  the  great  objects  of  sanitary  reform.] 
The  addition  to  the  population  of  the  city 
of  Gloucester  and  its  suburbs  averaged  2‘41 
per  cent,  annually  between  1831  and  1841  : 
the  addition  to  the  rural  parishes  alone  about 
1  per  cent.  This  different  ratio  of  increase 
in  town  and  country  is  strikingly  illustrative 
of  the  great  fact  of  the  age ;  that  is,  the 
rapid  concentration  of  large  masses  of  the 
people  in  towns  and  crowded  districts. 
Whatever  may  be  the  causes  for  this  altered 
distribution  of  the  population,  it  is  impossi¬ 
ble  to  watch  without  anxiety  the  progress  of 
a  change  which  is  so  plainly  and  incontesti- 
bly  accompanied  by  moral  and  physical  dete¬ 
rioration  of  the  people, — by  shortened  life, 
prolonged  sickness,  and  growing  distress, 
disaffection,  and  crime. 

The  population  of  the  whole  Superinten¬ 
dent  Registrar’s  district  (viz.  the  Gloucester 
Union  and  one  extra-parochial  place)  was 
in  1831,  22,312;  in  1841,  26,815. 

The  increase,  4503,  averages  two  per  cent, 
annually,  a  rate  nearly  double  that  for  Eng¬ 
land  and  Wales  in  the  same  period.  Sup¬ 
posing  the  same  rate  of  increase  to  have 


514 


REPORT  TO  THE  REGISTRAR-GENERAL  ON  THE 


continued  since  1841,  3,217  persons  would 
have  been  added  in  six  years,  and  the  popu¬ 
lation  in  1847  would  have  amounted  to 
30,032. 

The  total  number  of  deaths  in  the  year 
was  767  ;  but  at  least  46  of  these  were  of 
persons  coming  from  beyond  the  limits  of 
the  Union  into  the  Asylum,  Infirmary,  and 
Prison.  The  average  number  of  immigrants 
constantly  inhabiting  these  institutions  may 
be  estimated  at  440  last  year.  Deducting 
this  number  from  the  assumed  population, 
and  the  46  deaths  from  the  total  mortality 
of  the  year,  it  appears  that  721  deaths  oc¬ 
curred  among  nearly  29,600  inhabitants,  or 
1  in  41,  or  2 '43  per  cent. 

In  order  to  distribute  the  estimated  addi¬ 
tion  to  the  population  since  1841  among  the 


Thus,  eight  in  every  thousand,  or  176  per¬ 
sons  in  the  city  and  suburbs,  died  in  1847, 
beyond  the  number  which  would  have  died 
had  the  ratio  been  the  same  as  in  the  sur¬ 
rounding  country  parishes.  Even  supposing 
the  city  mortality,  instead  of  being  reduced 
to  1  in  54g  annually  (the  country  rate),  had 
been  1  in  50,  which  has  been  stated  on  high 
authority  as  “  a  fair  standard  rate  of  mor¬ 
tality  for  all  towns  and  populous  places, ” 
the  excess  of  deaths  would  amount  to  141  : 
say  140  deaths,  involving  2,800  cases  of 
sickness  in  the  year,  or  280  persons  con¬ 
stantly  ill,  over  and  above  the  natural  pro¬ 
portion  of  mortality  and  sickness  !  The 
sanatory  reformers  of  Gloucester  could  not 
produce  a  stronger  argument,  nor  plead  a 
more  ample  justification  for  their  labours. 
I  do  not  admit  that  the  year  1847  was  un¬ 
favourably  distinguished  for  disease  and 
death  in  this  place.  The  rate  of  mortality 
which  I  have  now  deduced,  is  below  that 
stated  in  Mr.  Slanev’s  Report  of  Gloucester 
as  the  average  of  three  years  and  eleven 
months,  which  appears  to  have  been  2'76, 
or  1  in  every  36  inhabitants. 

The  preceding  estimate  of  extra  or  pre¬ 
ventive  sickness  is  based  upon  extended 
statistical  observations  of  the  relation  sub¬ 
sisting  between  sickness  and  mortality,  which 
has  been  assumed  to  be  uniform  throughout 


three  proposed  divisions  of  the  whole  district, 
we  may  suppose  that  the  rural  parishes, 
which  in  1841  contained  7028  persons,  in¬ 
creased  (as  before)  six  per  cent,  in  the  six 
years.  Their  population  accordingly  would 
have  amounted  to  7450  in  1847,  leaving  for 
the  city  and  suburbs  22,150.  Now,  in 
1841  the  suburbs  did  not  contain  half  the 
number  of  the  city  inhabitants  (6,125  to 
12,832)  ;  but  considering  the  more  rapid 
increase  of  the  former,  their  population  might, 
in  1847,  be  safely  assumed  to  be  7,380,  or 
half  that  belonging  to  the  city  proper — 
14,760  ;  thus  making  up  the  total  calculated 
population  for  that  year. 

The  following  table  shows  the  ratio  of 
mortality  in  these  three  divisions  of  the 
Union : — 


the  kingdom,  so  that,  the  latter  being  given, 
the  former  may  be  found,  in  any  locality  or 
among  any  class  of  persons.  It  would,  how¬ 
ever,  be  much  more  satisfactory  if  the  pre¬ 
valence  of  sickness  cQuld  be  determined  by  a 
separate  observation  in  each  district.  There 
is  reason  to  believe  that  the  above  ratio  (two 
years  of  sickness,  or  twenty  cases  to  one 
death )  is  far  from  being  constant ;  and  that 
as  the  habits  and  occupations  of  the  people 
vary,  as  the  average  age  of  the  living  is  higher 
or  lower,  as  epidemic  and  contagious  diseases 
are  more  or  less  prevalent,  as  sanatory  pre¬ 
cautions  are  more  or  less  observed,  and  as 
medical  care  is  more  or  less  liberally  bestowed 
on  the  poor, — the  proportion  between  sick¬ 
ness  and  death  varies  very  greatly.  But  I 
had  no  other  means  of  estimating  the  general 
amount  of  sickness  ;  for,  as  I  reported  to  the 
Health  of  Town  Commissioners,  the  records 
of  our  public  medical  establishments  are 
either  defective  or  inaccessible,  and  a  vast 
number  of  cases  among  the  poor  do  not  come 
at  all  under  medical  observation  or  treatment. 
The  only  certain  method  of  obtaining  au¬ 
thentic  information  as  to  the  prevalence  of 
sickness  in  the  town  generally,  and  in  the 
worst-conditioned  localities  especially,  would 
be  for  the  municipal  authorities  to  require 
periodical  returns  of  the  sanatory  condition 
of  single  streets  and  courts. 


MORTALITY 

Estimated 

In  pub- 

Tn 

One 

Deaths 

population 

licinsti- 

houses. 

Total. 

death  in 

per  cent. 

in  1847. 

tutions. 

City  Proper  . 

• 

14,767 

32 

355 

387 

38'15 

Suburbs  .  . 

• 

7,388 

16 

181 

197 

37*3 

22,150 

48 

536 

584 

38 

2*64 

Rural  Parishes 

• 

7,450 

16 

121 

137 

54*4 

1'84 

29,600 

64 

657 

721 

41 

Difference  in  the 

m 

ortality  per  cent,  of  Town  and  Country 

0'8 

. 

MORTALITY  OF  THE  GLOUCESTER  DISTRICTS  IN  1847 


515 


In  estimating  the  comparative  mortality 
of  different  parts  of  the  city,  with  reference 
to  population,  the  last  census  is  adopted  as 
the  basis  of  calculation  ;  while  to  compensate 
for  not  taking  into  account  the  probable  in¬ 
crease  of  population,  the  deaths  occurring  in 
public  institutions  are  also  omitted. 

From  a  table  on  the  rate  of  mortality  in 
certain  parishes  and  districts  in  1847,  as  well 
as  from  conclusions  previously  drawn,  it  ap¬ 
pears  that,  on  the  whole,  the  suburbs  of 
Gloucester  were,  in  1847,  more  unfavourable 
to  health  and  life  than  either  the  city  or  the 
rural  parishes.  The  hamlet  of  Kingsholm 
(St.  Mary)  suffered  the  highest  mortality  of 
all  the  parochial  divisions;  while  St.  Michael, 
a  parish  in  the  very  centre  of  the  old  city, 
experienced  the  lowest  proportion  of  deaths. 
It  is  worthy  of  notice  that  the  parishes  and 
places  which  show  the  higher  rates  of  mor¬ 
tality,  and  the  greater  proportion  of  death 
from  fever  and  other  epidemic  diseases,  in 
1847,  were  generally  those  in  which  the 
Asiatic  cholera  raged  most  fearfully  in  1832. 
This  remark  applies  especially  to  “  the 
Island,”  and  the  courts  and  lanes  adjoining 
Westgate  Street,  in  the  two  last-named 
parishes.  These,  notwithstanding  the  recent 
sanatory  measures  of  the  Town  Council,  and 
the  zealous  efforts  of  their  inspector  of  nui¬ 
sances,  still  remain  in  an  unsatisfactory  con¬ 


Here,  then,  these  divisions  appear  still  in 
the  same  order,  the  rural  parishes  showing 
the  lowest  infant  mortality,  the  suburbs  the 
highest ;  the  former  containing  the  greatest 
proportion  of  persons  dying  above  60,  the 
suburbs  the  smallest.  From  all  these  ob¬ 
servations,  coinciding  so  remarkably  as  they 
do,  though  not  extending  beyond  the  year 
1847,  we  may  fairly  conclude  that  the 
suburbs  of  Gloucester  contain  a  population 
more  subject  to  disease  and  death  than  the 
other  divisions  of  the  union. 

It  would  be  unsuitable  to  trouble  you  with 
lengthened  remarks  on  the  causes  of  the 
lower  sanitary  condition  of  the  suburbs,  but 
I  may  be  allowed  to  mention,  as  a  main 
source  of  atmospheric  pollution,  the  open 
ditches  which  surround  the  town  in  all 
directions.  Laden  with  the  decomposing 
impurities  of  the  place,  these  trail  their  slow 
and  loathsome  courses  through  meadow's  and 
open  places  in  the  immediate  vicinity  of  the 
city,  which  would  otherwise  prove  highly 
beneficial  to  the  inhabitants,  both  for  health 
and  recreation,  but  which,  in  their  present 
condition,  are  worse  than  useless.  The 
hamlet  of  Kingsholm  St.  Mary,  already 


dition,  and  must  continue  so  until  the  adop¬ 
tion  of  a  comprehensive  system  of  sewerage, 
combined  with  a  constant  supply  of  water 
(at  high  pressure)  to  each  dwelling,  and  an 
improved  street  and  house  ventilation. 

Not  having  before  me  the  apes  of  the  in¬ 
habitants  at  the  last  census,  I  cannot  deter¬ 
mine  the  vital  strength  of  the  Gloucester 
population  by  the  surest  test — namely,  the 
mean  duration  of  life  ;  but  something  may 
be  learnt  from  the  average  age  at  death, 
which,  in  1847,  was  32-71  years  in  the  rural 
districts;  2  7’ 73  in  the  city  proper  ;  and  only 
25-56  in  the  suburbs.  In  London  (1841) 
this  was  29  ;  in  Surrey,  34  years.  I  would 
not  infer  from  this  single  observation  of 
facts,  that  our  city  and  rural  residents  are 
respectively  shorter  lived  than  the  inhabi¬ 
tants  of  London  and  Surrey.  An  increasing 
population,  like  ours,  is  generally  composed 
of  comparatively  young  persons,  and  the  low- 
average  age  at  death  may  depend  on  the  ex¬ 
cess  of  children,  for  immigration  takes  place 
but  to  a  very  small  extent  in  Gloucester. 
The  calculation  of  the  mean  age  of  death  in 
this  place  is  therefore  chiefly  of  importance 
as  a  means  of  comparing  the  different  parts 
of  the  district  among  themselves. 

The  proportion  dying  at  different  ages  in 
the  three  divisions  differs  as  follows  : — 


mentioned  as  the  most  fatal  locality  last 
year,  contains  a  nest  of  small,  ill-conditioned 
streets,  one  of  which  is  named  Sweet  Briar , 
(the  “  lucus  a  non  lucendo”  of  Gloucester), 
probably  from  its  displaying  a  most  foul  and 
pestilential  ditch,  which  conveys  or  rather 
arrests  the  drainage  of  the  northern  and 
eastern  suburbs.  No  partial  measures  will 
be  of  any  avail  in  such  a  case.  No  plan  of 
drainage  and  cleansing  which  does  not  extend 
for  a  mile  from  the  centre  of  the  city  on  all 
sides  will  remove  these  evils,  or  diminish 
the  destruction  of  health  and  life  which  I 
have  shown  to  prevail  beyond  the  olden 
limits  of  Gloucester. 

In  reference  to  the  monthly  progress  of 
mortality  during  the  year,  together  with 
the  diseases  registered  as  the  causes  of  death, 
it  may  be  observed  that  the  first  quarter  ex¬ 
hibited  the  highest  mortality  of  the  year,  and 
that  January  was  the  most  fatal  month.  The 
second  quarter  ranks  next  to  the  first  in  its 
number  of  deaths ;  and  the  month  of  May 
next  to  January.  The  excess  of  deaths  in  these 
quarters  and  months  is  mainly  attributable 
to  diseases  of  the  respiratory  organs.  May 
was  most  fatal  to  consumptive  patients,  and 


Deaths 

Proportion 

under  5 

above  60 

Total. 

under  5 

above  60 

Rural  Parishes 

46 

34 

121 

1  in  2’63 

1  in  3'56 

City  •  •  •  •  • 

155 

67 

335 

- 2-29 

5-30 

Suburbs  .... 

87 

34 

181 

2-08 

5-32 

516  MORTALITY  OF  THE  GLOUCESTER  DISTRICTS  IN  1847. 


January  to  old  persons.  Deaths  from  dis¬ 
orders  of  the  brain  and  nervous  system  were 
also  inexcessdaring  the  firstfive  monthsof  the 
year,  and  April  shows  an  extraordinary  mor¬ 
tality  among  diseases  of  this  class.  Dis¬ 
orders  of  the  digestive  organs  proved  more 
than  usually  destructive  in  June.  Measles 
was  epidemic  from  February  to  June,  caus¬ 
ing  25  deaths.  Fever  succeeded  measles, 
and  carried  off  29  in  the  last  two  quarters. 
Scarlatina  prevailed  during  September, 
October,  and  November.  On  the  whole, 
the  zymotic  (epidemic,  endemic,  and  con¬ 
tagious)  class  of  diseases  distinguished  the 
mortality  of  the  last  four  months.  The  in¬ 
fluenza  of  December  destroyed  ten  persons, 
and  the  same  number  died  of  this  epidemic 
in  the  preceding  January.  The  last  quarter, 
however,  presented  a  total  mortality  rather 
below  the  average,  and  in  this  respect  it 
contrasts  strongly  with  the  117  districts  re¬ 
ported  quarterly  from  the  General  Register 
office.  The  third  quarter  of  the  year  was 
here  the  most  favourable  to  life  of  all,  the 


If  it  should  at  first  sight  appear  that  the 
ratio  of  deaths  from  fever  and  lung  diseases 
was  rather  higher  in  Gloucester  last  year 
than  in  the  whole  country  at  the  former 
quinquennial  period,  it  should  be  borne  in 
mind  that  a  much  smaller  proportion  of 
deaths,  from  causes  not  specified,  occurred 
in  Gloucester  than  in  England  and  Wales. 
It  deserves  notice  that  while  the  deaths  at¬ 
tributed  to  “  debility"  were  4  per  cent,  in 
England,  “  debility  from  birth"  alone  is  re¬ 
ported  to  have  carried  off  5  per  cent,  in  the 
Gloucester  districts.  Diseases  of  the  brain 
and  nervous  system  alone  shew  a  somewhat 
higher  mortality  here,  but  this  is  fully  ac¬ 
counted  for  from  our  possessing  an  admirably- 
conducted  Lunatic  Asylum,  which  receives 
patients  from  the  whole  of  this  and  other 
counties. 

The  extra  mortality,  therefore,  which  has 
been  proved  to  exist  in  Gloucester,  cannot 
be  attributed  to  the  unusual  prevalence  of 
any  particular  disease,  or  class  of  diseases, 
but  to  the  excess  of  all  sorts  of  sickness,  and 
a  consequent  general  increase  of  deaths. 
There  is  every  ground  to  believe  that  this 
excess  may  have  arisen  from  removable 
causes. 


deaths  being  only  three-fifths  of  those  in  the 
first  quarter. 

With  regard  to  the  relative  prevalence  of 
different  classes  of  disease,  it  may  be  ob¬ 
served  that  in  the  city  and  suburbs,  deaths 
from  zymotic  diseases  were  nearly  23  per 
cent,  of  the  whole  number,  while  in  the 
table  appended  to  Mr.  Slaney's  Report, 
they  seem  to  have  been  33  per  cent.  The 
following  table  shews  that,  notwithstanding 
the  great  prevalence  of  influenza  in  the 
metropolis,  the  total  deaths  from  zymotic 
diseases  were  scarcely  in  a  higher  ratio  there 
than  in  Gloucester,  while,  from  diseases  of 
the  respiratory  organs,  the  metropolis  ratio 
of  mortality  was  higher,  and  from  fever 
lower  : — 

Between  the  whole  Gloucester  Union  in 
1847,  and  the  average  of  England  and  Wales 
in  the  five  years  1838-42,  there  also  exists 
a  remarkable  similarity  in  the  relative  pro¬ 
portion  of  deaths  from  the  above-mentioned 
causes. 


INCREASED  SALE  OF  OPIUM. 

The  monthly  returns  of  the  Board  of  Trade 
continue  to  shew  a  great  increase  in  the  im¬ 
portation  of  this  drug,  and  in  the  quantity 
taken  for  home  consumption.  In  the  month 
ending  Aug.  5,  1847,  the  quantity  of  opium 
imported  is  stated  to  have  been  only  14  lbs., 
and  the  quantity  taken  for  home  consump¬ 
tion  was  6134  lbs.  In  the  same  monthly 
period  in  1848,  the  quantity  imported  was 
1744  lbs.,  and  that  taken  for  home  con¬ 
sumption  was  6802  lbs.  It  would  be  de¬ 
sirable  to  know  for  what  purposes  so  large 
a  consumption  of  this  drug  is  required. 

preparation  of  collodion,  or  solution 

of  gun-cotton,  as  an  adhesive 

MATERIAL  FOR  SURGICAL  PURPOSES. 

M.  Malgaigne  has  recently  communicated 
to  the  French  medical  journals  some  remarks 
on  the  preparation  of  gun-cotton  for  surgical 
purposes.  Several  French  chemists,  at 
the  suggestion  of  M.  Malgaigne,  attempted 
to  make  an  ethereal  solution  of  this  com¬ 
pound  by  pursuing  the  process  recommended 
by  Mr.  Maynard  in  the  American  Journal 
of  Medical  Sciences ;  but  they  failed  in  pro¬ 
curing  the  cotton  in  a  state  in  which  it 


DEATHS  FROM 


Per 

cent. 

Per 

cent. 

ltespira- 

All 

Causes. 

Zymotic 

Diseases. 

Fever. 

tory 

i  Organs. 

Per 

cent. 

Metropolis,  1847  .  .  . 

60,442 

13,887 

23 

3,184 

5-2 

18,460 

30-5 

Gloucester,  1847 

England  &  Wales  1838-42, 

536 

123 

22-9 

35 

6’5 

158 

92* 

Annual  average  .  .  . 

346,887 

67,375 

19*4 

16,533 

4*7 

91,093 

26*2 

Gloucester  Union,  1847  . 

767 

146 

19* 

43 

5-6  1 

1 

206 

26*9 

COLLODION  AS  AN  ADHESIVE  MATERIAL  FOR  SURGICAL  PURPOSES.  517 


could  be  dissolved  by  ether.  It  appears 
that  these  experimentalists  had  employed  a 
mixture  of  nitric  and  sulphuric  acids ;  but 
M.  Mialhe  ascertained,  after  many  trials, 
that  the  collodion,  in  a  state  fitted  for  solu¬ 
tion,  was  much  more  easily  procured  by 
using  a  mixture  of  nitrate  of  potash  and 
sulphuric  acid. 

For  the  information  of  our  readers  who 
may  be  disposed  to  try  this  new  adhesive 
material,  we  here  give  a  description  of  M. 
Mialhe’s  process  for  its  preparation.  It 
appears,  from  the  results  obtained  by  this 
chemist,  that  cotton,  in  its  most  explosive 
form,  is  not  the  best  fitted  for  making  the 
ethereal  solution  : — 

Parts 
by  weight. 

Finely  powdered  nitrate  of  potash  .  40 

Concentrated  sulphuric  acid*  .  .  60 

Carded  cotton . 2 

Mix  the  nitre  with  the  sulphuric  acid  in  a 
porcelain  vessel,  then  add  the  cotton,  and 
agitate  the  mass  for  three  minutes  by  the 
aid  of  two  glass  rods.  Wash  the  cotton, 
without  first  pressing  it,  in  a  large  quantity 
of  water,  and,  when  all  acidity  is  removed 
(indicated  by  litmus  paper),  press  it  firmly 
in  a  cloth.  Pull  it  out  into  a  loose  mass, 
and  dry  it  in  a  stove  at  a  moderate  heat. 

The  compound  thus  obtained  is  not  pure 
fulminating  cotton :  it  always  retains  a 
small  quantity  of  sulphuric  acid,  is  less  in¬ 
flammable  than  gun-cotton,  and  it  leaves  a 
carbonaceous  residue  after  explosion.  It 
has,  however,  in  a  remarkable  degree,  the 
property  of  solubility  in  ether,  especially 
when  mixed  with  a  little  alcohol,  and  it 
forms  therewith  a  very  adhesive  solution,  to 
which  the  name  of  Collodion  has  been 
applied. 

Preparation  of  Collodion. 

Prepared  Cotton  ...  8  parts  by  weight. 

Rectified  sulphuric  ether  125  “ 

Rectified  alcohol  .  .  8  “ 

Put  the  cotton  with  the  ether  into  a  well- 
stopped  bottle,  and  shake  the  mixture  for 
some  minutes.  Then  add  the  alcohol  by 
degrees,  and  continue  to  shake  until  the 
whole  of  the  liquid  acquires  a  syrupy  con¬ 
sistency.  It  may  be  then  passed  through  a 
cloth,  the  residue  strongly  pressed,  and  the 
liquid  kept  in  a  well-secured  bottle. 

Collodion  thus  prepared  possesses  re¬ 
markably  adhesive  properties.  A  piece  of 
linen  or  cotton  cloth  covered  with  it,  and 
made  to  adhere  by  evaporation  to  the  palm 
of  the  hand,  will  support,  after  a  few  mi¬ 
nutes,  without  giving  way,  a  weight  of  from 
twenty  to  thirty  pounds.  Its  adhesive  power 
is  so  great,  that  the  cloth  will  commonly  be 

*  The  common  commercial  acid  will  answer. 
When  very  weak,  a  longer  immersion  of  the 
cotton  is  required. 


torn  before  it  gives  way.  The  collodion 
cannot  be  regarded  as  a  perfect  solution  of 
the  cotton.  It  contains,  suspended  and 
floating  in  it,  a  quantity  of  the  vegetable 
fibre  which  has  escaped  the  solvent  action  of 
the  ether.  The  liquid  portion  may  be  sepa¬ 
rated  from  these  fibres  by  a  filter,  but  it  is 
doubtful  whether  this  is  an  advantage.  In 
the  evaporation  of  the  liquid,  these  undis¬ 
solved  fibres,  by  felting  with  each  other,  ap¬ 
pear  to  give  a  greater  degree  of  tenacity  and 
resistance  to  the  dried  mass. 

In  the  preparation  of  collodion  it  is  in¬ 
dispensable  to  avoid  the  presence  of  water , 
as  this  renders  it  less  adhesive:  hence  the 
ether,  as  well  as  the  alcohol,  should  be  pure 
and  rectified.  The  parts  to  which  the  col¬ 
lodion  is  applied  should  be  first  thoroughly 
dried ,  and  no  water  allowed  to  come  in  con¬ 
tact  with  them  until  all  the  ether  is  evapo¬ 
rated. 

INCREASE  OF  SUICIDE  IN  FRANCE. 

According  to  some  statistical  tables  for  the 
year  1846,  recently  published  in  France,  it 
appears  that  suicide  has  been  for  some  years 
progressively  on  the  increase  in  that  country  ; 
and  as  we  infer  from  the  report  to  an 
amount  greater  than  would  be  indicated  by 


the  increase  of  population, 
suicides  amounted  in 

The  number  of 

1841  to  .  .  . 

.  2814 

1842  to  .  .  . 

.  2886 

1845  to  .  .  . 

.  3084 

1846  to  .  .  . 

.  3102 

Amongst  the  suicides  in 

1846,  were  27 

children  from  10  to  15  years  of  age,  139 
between  16  and  21  years,  443  from  21  to  30 
years,  1,214  from  30  to  50  years,  513  from 
50  to  60  years,  403  from  60  to  70  years,  209 
from  70  to  80  years,  and  51  above  80  years. 
Suicides  are  more  frequent  in  spring  and 
summer  than  in  winter  and  autumn.  The 
months  of  June,  July,  and  August,  produced 
940.  Those  of  March,  April,  and  May, 
904.  Those  of  September,  October,  and 
November,  654 ;  and  those  of  December, 
January,  and  February,  604.  Strangula¬ 
tion  and  suspension  were  the  means  most 
frequently  employed  by  the  suicides  of  1846 
to  terminate  their  existence  ;  1,077  had  re¬ 
course  to  it;  1,036  drowned  themselves; 
222  suffocated  themselves  with  charcoal, 
and  429  used  firearms.  Amongst  the  suicides 
recorded  in  the  year  1846,  more  than  a 
quarter,  viz.  888,  were  caused  by  insanity. 
The  other  cases  arose  from  various  causes. 
Physical  sufferings  and  domestic  unhappi¬ 
ness,  pecuniary  embarrassment,  and  the  fear 
of  distress,  are  the  most  frequent. 

It  further  appears  that  the  number  of 
accidental  deaths  during  the  year  1846, 
amounted  to  7,558  :  of  which  3,861  were 
caused  by  drowning,  624  were  crushed  to 
death  by  carriages,  and  45  were  caused  by 
railroad  accidents. 


518  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY,  ETC 


BIRTHS  &  DEATHS  in  the  Metropolis 


During  the  week  ending  Saturday ,  Sept.  9. 


Births. 
Males....  657 
Females. .  645 


1302 


Deaths. 
Males....  484 
Females. .  442 

926 


Av.  of  5  Sum. 
Males....  495 
Females..  477 


972 


Causes  of  Death. 

All  Causes . . 

Specified  Causes . 

1.  Zymotic{or'E\)\demic, Endemic, 

Contagious)  Diseases . . 
Sporadic  Diseases,  viz. — 

2.  Dropsy,  Cancer,  &c.  of  uncer¬ 

tain  seat  . 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  . 

4.  Lungs  and  other  Organs  of 

Respiration . 

5.  Heart  and  Bloodvessels  . 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion  . 

7.  Diseases  of  the  Kidneys,  &c... 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c . 

9.  Rhematism,  Diseases  of  the 
Bones,  Joints,  &c . 

10.  Shin,  Cellular  Tissue,  &c . 

11.  Old  Age . 

12.  Violence,  Privation,  Cold,  and 

Intemperance . 


1 

I 

Av.  of 
5  Sum. 

926' 

972 

925 

968 

374 

257 

41 

45 

90 

120 

70; 

80 

22 

28 

74 

79 

6 

8 

9 

10 

5 

7 

0 

1 

29 

50 

29 

8 

The  following  is  a  selection  of  the  numbers  of 
Deaths  from  the  most  important  special  causes : 


Small-pox  . 

36 

Paralysis . 

15 

Measles  . 

16 

Convulsions  .... 

28 

Scarlatina  . 

145 

Bronchitis . 

26 

Hooping-cough. . 

33 

Pneumonia . 

29 

Diarrhoea  . 

42 

Phthisis . 100 

Cholera  . 

6 

Dis.  of  Lungs,  &c. 

7 

Typhus  . 

63 

Teething . 

12 

Dropsy . 

20 

Dis.  Stomach,  &c. 

4 

Sudden  deaths  . . 

4 

Dis.  of  Liver,  &c. 

12 

Hydrocephalus . . 

18 

Childbirth . 

7 

Apoplexv . 

19 

Dis.  of  Uterus,&c. 

2 

Remarks.— The  total  number  of  deaths  was 
46  below  the  weekly  summer  average.  The 
deaths  from  diarrhoea  are  one-third  less  than 
the  average  at  this  season  (66)  Of  cholera  there 
were  only  six  fatal  cases,  while  the  average 
weekly  number  is  seven.  Notwithstandingthese 
favourable  circumstances,  the  continued  increase 
in  the  fatality  of  scarlet  fever  among  the  infan¬ 
tile  population  is  most  alarming.  The  deaths 
were  no  less  than  145  to  a  weekly  summer  average 
of  37. 


METEOROLOGICAL  SUMMARY. 


Mean  Height  of  Barometer .  30  08 

“  “  Thermometer1  .  52  3 

Self-registering  do.b _ max.  90  8  min.  23* 

“  in  the  Thames  water  —  61*5  —  55*8 

a  From  12  observations  daily.  b  Sun. 


Rain,  in  inches,  *33:  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological. — The  mean  temperature  of  the 
week  was  5°.5  below  the  mean  of  the  month. 


BOOKS  &  PERIODICALS  RECEIVED. 

Report  of  the  Medical  Officers  of  the  Lancaster 
Lunatic  Asylum. 

Sanitary  Questions  on  the  Wolverton  Well  Water, 
by  G.  Corfe,  Esq. 

A  Treatise  on  the  Advantages  and  Necessity  of 
Frequent  Bathing. 

Comptes  Rendus,  Nos.  7  and  8,  14  and  21  AoQt. 

British  Record  of  Obstetric  Medicine,  Sept.  1848. 

A  few  Thoughts  on  Cholera,  by  M.  T.  Sadler. 

The  Periodoscope,  by  W.  Tyler  Smith,  M.B.  &c. 

On  the  Employment  of  Chloroform  in  Dental 
Surgery,  by  F.  B.  Imlach,  Dentist. 

Taschen-Encyclopadie  der  rnedicinischen  Wis- 
senschaften,  11  Bandchen. 

Pliysiologie  des  Menschen,  von  Dr.  M.  Flankel. 
Erlangen,  1847. 

School  Chemistry,  by  Dr.  R.  D.  Thomson, 
Lecturer  on  Chemistry,  University  of  Glasgow. 

Works  of  the  Cavendish  Society.  —  Chemical 
Reports  and  Memoirs.  Edited  by  Thomas 
Graham,  Esq.  V.P.R.S.  L. 

Medicinische  Jahrbiicher  des  K.  K.  osterrei- 
chischen  Staates.  Februar,  Marz,  April,  Mai. 

Oesterreichische  Medicinische  Woclienschrift 
(for  the  same  months). 

The  January  numbers  of  these  journals  have 
not  been  received. 

The  Water-Cure  Journal,  No.  14,  Sept.  1848. 

Todd’s  Cyclopaedia  of  Anatomv  and  Physiology, 
Part  XXXIH. 


NOTICE, S  to  CORRESPONDENTS. 

The  letter  of  an  Apothecary  should  be  addressed 
to  the  Editor  of  the  Medical  Directory. 

The  communications  of  Mr.  Barlow  and  Mr. 
Smith  will  be  inserted  in  the  following  number. 

Mr.  J.  Jackson’s  paper  has  been  received. 

Medical  Prize  Essays.  —  A  note  is  left  with 
Messrs.  Wilson  and  Ogilvy,  Skinner  Street, 
for  our  correspondent  C.  S. 

K. — The  communication  will  be  inserted.  We 
shall  be  happy  to  receive  a  short  abstract  such 
as  that  to  which  our  correspondent  alludes  as 
a  specimen. 

The  continuation  papers  of  Dr.  Snow,  Dr.  An¬ 
drew  Clark,  and  Mr.  J.  D.  Macdonald,  have 
been  received,  and  will  have  early  insertion. 

Received.— Sir  B.  C.  Brodie. 


THE  GENERAL  INDEX. 

We  have  to  announce  to  our  Subscribers  that  a  General 
Index  to  the  first  40  Volumes  of  the  London  Medical  Gazette 
will,  it  is  calculated,  form  a  large  Yolume  of  about  700  pages. 
The  cost  of  the  Index  Yolume,  respecting  which  many  inquiries 
have  been  made,  will  be  Twenty-four  Shillings ;  and  it  is  proposed 
o  commence  it  so  soon  as  the  Names  of  Five  Hundred  Subscribers 
have  been  obtained. — The  printers,  Messrs.  Wilson  and  Ogilvy, 
5  7,  Skinner  Street,  will  receive  the  Names  of  Subscribers. 


519 


a.0ttfcou  JMcbtcal  (ia^ctte. 


lectures* 

COURSE  OF  SURGERY, 
Delivered  in  the  years  1846  and  1847, 

By  Bransby  B.  Cooper,  F.R.S. 

Surgeon,  and  Lecturer  on  Surgery  at  Guy’s 
Hospital. 


Lecture  XXXVIII. 

Direct  inguinal  hernia  or  internal  inguinal 
hernia — difficulty  in  diagnosis — Anatomy 
of —operation  for  direct  inguinal  hernia 
— Case — Small  size  of  direct  hernia . 
Femoral  hernia — peculiarities  of— diagno¬ 
sis —  coverings  —  conditions  of — taxis — 
direction  of— operation — division  of  stric¬ 
ture — variation  in  the  course  of  the  epigas¬ 
tric  artery — precaution — cause  of  stric¬ 
ture  —  Case  — favourable  prognosis  — 
after-treatment — difficulties  which  may 
present  themselves  during  the  operation — 
Cases. 

Umbilical  hernia  —  its  characters — opera¬ 
tion — Mr.  Key's  plan — modification  of — 
Cases — after-treatment.  Ventral  hernia 

— situation  of — Steatomata  may  be  mis¬ 
taken  for  ventral  hernia — operation  of 
strangulated  hernia  —  prognosis  unfa¬ 
vourable. 

Direct  inguinal  hernia. — A  scrotal  hernia 
does  not  necessarily  pass  through  the  inter¬ 
nal  abdominal  ring,  but  may  protrude  at 
once  from  the  cavity  of  the  abdomen  through 
the  external  ring :  this  is  called  a  direct  in - 
guinal  hernia,  or,  from  being  placed  on  the 
inner  side  of  the  epigastric  artery,  is  some¬ 
times  termed  an  internal  inguinal  hernia  : 
the  former  term,  however,  is,  I  think,  the 
most  appropriate.  It  is  very  difficult  to 
distinguish  a  direct  from  an  oblique  inguinal 
hernia  during  life  :  this  difficulty  arises  from 
the  descent  of  the  internal  ring  in  the  oblique 
hernia,  so  that  all  obvious  obliquity  in  the 
direction  of  the  swelling  is  lost :  usually, 
however,  a  direct  hernia  may  be  recog¬ 
nised  from  the  absence  of  the  pyramidal 
form,  and  from  being  the  part  which  should 
form  the  neck  enlarged  into  a  broad  base 
above  the  external  ring,  and  being  placed 
immediately  on  the  outer  side  of  the  sper¬ 
matic  cord,  which  in  an  oblique  inguinal 
hernia  is  covered  by  the  tumor.  The  want 
of  a  correct  diagnosis  is  not,  however,  im¬ 
portant  as  to  treatment,  for  the  direction  of 
the  taxis  in  either  kind  of  scrotal  hernia  must 
of  course  be  towards  the  external  ring  ;  and 
if  it  be  oblique  hernia,  the  proximity  of  the 
two  rings  would  do  away  with  any  necessity 
for  obliquity  in  the  direction  of  the  force 
employed  for  the  reduction.  A  direct  in- 

xlii. — 1087.  Sept.  29,  1848. 


guinal  hernia  pushes  before  it,  through  the 
external  ring,  the  united  tendon  of  the  in¬ 
ternal  oblique  and  transversalis  muscles, 
which  tendon  forms  the  posterior  wall  of  the 
inguinal  canal,  and  strengthens  the  abdomi¬ 
nal  parietes  immediately  behind  the  external 
ring.  The  posterior  surface  of  the  tendon 
is  covered  by  the  internal  abdominal  fascia, 
as  it  takes  its  course  downwards  behind 
Poupart’s  ligament  to  form  the  anterior  layer 
of  the  sheath  of  the  femoral  vessels.  The 
principal  anatomical  point  connected  with 
a  direct  inguinal  hernia,  is  the  position  of 
the  epigastric  artery,  which  lies  on  its  outer 
side,  and  that  of  the  spermatic  cord,  which 
is  somewhat  posterior  to  it,  and  also  placed 
on  its  iliac  side.  Should  the  attempt  to 
reduce  the  hernia  by  the  application  of  the 
taxis  fail,  the  operation  must  be  resorted 
to,  as  in  every  other  case  of  strangulated 
hernia. 

Operation  for  direct  inguinal  hernia.— 
The  parts  to  be  first  cut  through  in  this 
operation  are  the  skin,  external  spermatic 
fascia,  and  cremaster  muscle  ;  the  latter, 
however,  if  the  hernia  be  large,  would  pro¬ 
bably  only  cover  the  outer  portion  of  the 
tumor,  and  in  that  case  might  be  turned  off 
the  subjacent  coverings  without  requiring  the 
use  of  the  knife  :  the  tendinous  structure  of 
the  internal  oblique  and  transversalis  mus¬ 
cles  would  thus  be  exposed,  and  must  be 
divided,  and  with  it  (I  think  almost  un¬ 
avoidably)  the  internal  abdominal  fascia. 
When  these  various  tissues  are  cut  through, 
the  stricture  is  to  be  liberated  with  similar 
precautions  to  those  already  mentioned ;  but 
in  addition,  particular  care  must  be  taken 
not  to  give  any  outward  direction  to  the 
knife,  in  consequence  of  the  characteristic 
position  of  the  epigastric  artery.  If  the 
contents  of  the  sac  cannot  be  returned  when 
the  stricture  has  been  relieved,  the  sac  must 
be  laid  open,  as  in  the  operation  for  oblique 
inguinal  hernia. 

I  have  already  mentioned  that  there  is 
considerable  difficulty  in  distinguishing  a 
direct  from  an  oblique  inguinal  hernia,  and, 
indeed,  even  the  operation  may  not  solve 
this  difficulty ;  for  if  the  united  tendon  of 
the  internal  obiique  and  transversalis  muscles 
be  much  attenuated,  or  gives  only  a  partial 
covering  to  the  hernia,  it  may  escape  detec¬ 
tion,  and  no  specific  character  of  the  hernia 
would  then  present  itself. 

Among  the  numerous  operations  which  I 
have  performed  for  this  complaint,  I  have  on 
two  or  three  occasions  had  some  doubts,  both 
before  and  after  the  operation,  as  to  the  true 
nature  of  the  hernia ;  and  not  having  an  op¬ 
portunity  of  post-mortem  examination,  was 
unable  to  clear  up  the  point.  The  following 
case,  however,  seems  to  me  one  in  which 
there  can  be  little  question  as  to  the  course 
of  the  protruded  bowel : — 


520 


PECULIARITIES  OF  FEMORAL  HERNIA — DIAGNOSIS. 


A  patient  was  admitted  into  Luke’s  ward 
with  a  small  irreducible  scrotal  hernia 
on  the  right  side.  Mr.  Hilton  had  seen 
the  case,  and  had  given  it  as  his  opinion  that 
it  was  a  direct  inguinal  hernia.  After  the 
anatomical  lecture,  I  was  called  to  the  case, 
and  upon  examination  found  a  small  round 
firm  tumor,  scarcely  projecting  through  the 
right  external  ring,  and  not  in  the  least  ex¬ 
tending  outwards  into  the  inguinal  canal : 
as  the  patient  was  suffering  under  all  the 
symptoms  of  strangulated  hernia^  and  as  I 
was  unable  to  reduce  the  swelling,  I  proposed 
the  operation,  which  was  consented  to,  and 
immediately  performed.  On  cutting  through 
the  skin  and  superficial  fascia,  some  few 
fibres  of  the  cremaster  muscle  were  seen 
covering  the  outer  half  of  the  swelling ;  these 
were  easily  turned  downwards  and  outwards, 
without  the  aid  of  the  knife,  and  a  distinct 
tendinous  surface  exposed:  upon  dividing 
this,  the  sac  presented  itself  to  view,  and  1 
opened  it,  relieved  the  stricture,  and  easily 
reduced  the  hernia  :  the  patient  was  in  a  few 
days  convalescent.  I  have  no  doubt  in  this 
case  I  divided  the  internal  abdominal  fascia, 
the  fascia  transversalis  of  Sir  Astley  Cooper, 
at  the  same  time  I  cut  through  the  tendons 
of  the  internal  oblique  and  transversalis 
muscles. 

A  direct  inguinal  hernia  is  usually  very 
small,  owing  to  the  resistance  it  meets  from 
the  tendon  of  the  internal  oblique  and  trans¬ 
versalis  muscles,  and  this  resistance  is  so  great 
as  actually  to  prevent  the  protrusion  some¬ 
times  of  the  tumor  through  the  external  ring  ; 
in  a  few  cases  the  fibres  of  the  tendon  have 
given  way,  and  the  hernia  passed  between 
them  :  under  such  circumstances  there  would 
arise  still  greater  difficulty  in  recognising  the 
hernia  as  a  direct  one,  owing  to  its  appear¬ 
ing  without  its  characteristic  tendinous 
covering.  When  a  direct  hernia  increases 
to  a  large  size,  it  projects  below  the  free 
edge  of  the  tendon  of  the  internal  oblique 
and  transversalis  muscles,  so  that  only  the 
inner  and  upper  half  of  the  tumor  is  covered 
by  it,  but  the  partial  tendinous  covering  is 
sufficient  to  mark  the  direct  character  of  the 
hernia.  The  great  distinctive  peculiarity  of 
direct  inguinal  hernia  is,  however,  the  posi¬ 
tion  of  the  epigastric  artery ;  and  unless  the 
operator  be  well  acquainted  with  the  course 
of  that  vessel  in  relation  to  the  seat  of 
stricture,  he  would  be  very  likely  to  wound 
it :  and  it  is  to  avoid  doing  so,  that,  in  the 
operation,  the  incision  should  always  be 
made  directly  upwards. 

Femoral  hernia. — This  is  sometimes  also 
termed  a  merocele,  or  crural  hernia.  In 
femoral  hernia  the  protruding  viscus  passes 
down  behind  Poupart’s  ligament  into  the 
thigh,  and  it  may  easily  be  distinguished 
from  inguinal  hernia  if  the  swelling  be  of 


small  size,  as  it  is  seen  distinctly  below  Pou¬ 
part’s  ligament,  but  if  it  be  large  it  first 
projects  forwards  and  then  upwards  over 
Poupart’s  ligament,  acquiring  a  strong  re¬ 
semblance  to  an  inguinal  hernia  ;  as  it  can, 
however,  be  readily  pushed  down  completely 
into  the  thigh  to  the  outer  side  of,  and  below, 
the  spinous  process  of  the  pubes,  its  true 
nature  may  be  ascertained  with  certainty. 

The  opening  by  which  a  merocele  passes 
from  the  cavity  of  the  abdomen  to  the  thigh, 
is  that  through  which  the  femoral  vessels 
also  pass  ;  these  vessels  are  covered  by  the 
internal  abdominal  fascia,  which  tissue  fur¬ 
nishes  at  the  same  time  a  covering  to  the 
hernia.  The  protrusion,  as  you  will  per¬ 
ceive,  gentlemen,  has  nothing  to  do  with 
either  of  the  abdominal  rings,  going  directly 
to  the  thigh,  not  passing  through  but  under 
the  abdominal  parietes.  Its  coverings  are 
skin,  superficial  fascia,  internal  abdominal 
fascia,  and  peritoneum  :  it  does  not  obtain  a 
covering  from  the  fascia  lata,  as  it  protrudes 
through  the  opening  left  in  that  tissue  for 
the  ingress  of  the  saphena  major  vein. 
Sometimes,  however,  a  few  bands  of  fascia 
pass  across  from  the  iliac  to  the  pubic 
portion  of  the  fascia  lata,  and  may  perhaps 
be  considered  as  forming  somewhat  of  a 
covering  to  the  hernia,  but  they  would  offer 
no  obstacle  to  the  course  of  the  operation. 

Femoral,  as  well  as  every  other  kind  of 
hernia,  may  present  itself  under  one  of  the 
forms — reducible,  irreducible ,  or  strangu¬ 
lated.  In  order  to  discover  whether  the 
hernia  be  reducible,  the  taxis  must  be  ap¬ 
plied,  and  this  may  be  done  at  once,  unless 
there  exists  some  reason  for  first  submitting 
the  patient  to  the  warm  bath,  and  applying 
ice  to  the  swelling :  such  a  delay  would,  for 
instance,  be  advisable,  if  the  tumor  were 
tender,  and  the  skin  very  tense.  The  di¬ 
rection  in  which  the  taxis  must  be  applied 
is  quite  different  in  femoral  hernia  to  that 
required  in  inguinal ;  the  object  in  the  for¬ 
mer  is,  first  to  direct  the  tumor  into  the 
thigh,  and  then  press  it  backwards  through 
the  saphenous  opening,  and  it  is  not  until 
after  this  is  accomplished  that  any  attempt 
should  be  made  to  push  the  neck  of  the  sac 
upwards  behind  Poupart’s  ligament  into  the 
abdominal  cavity.  When  the  hernia  is 
reduced,  the  treatment  is  precisely  similar 
to  that  in  inguinal  hernia;  but  should  it 
remain  irreducible,  both  constitutional  and 
local  means  must  be  employed  to  prevent  it 
from  becoming  obstructed,  and  if  strangu¬ 
lated,  the  operation,  as  in  the  other  kinds  of 
hernia  already  spoken  of,  is  the  only  means 
of  giving  relief  to  the  patient.  The  operation 
in  this  case  differs,  however,  so  much  from 
that  in  inguinal  hernia,  as  to  demand  a  par¬ 
ticular  description. 

Operation  for  strangulated  femoral  her¬ 
nia. — The  first  step  in  this  operation  is  to 


OPERATION  FOR  STRANGULATED  FEMORAL  HERNIA. 


521 


make  a  horizontal  incision  through  the  base 
of  the  tumor,  and  a  vertical  one  from  the 
upper  part  of  the  tumor,  to  meet  the  first 
cnt  at  its  centre,  the  whole  incision  being  in 
the  form  of  an  inverted  T  (j,) :  and  being 
intended  to  divide  the  skin  only.  This  is  the 
form  of  incision  which  Sir  Astley  Cooper 
always  employed  in  femoral  hernia,  but  I  do 
not  urge  the  necessity  for  its  being  invariably 
adhered  to,  as  any  incision  through  the  skin 
which  affords  sufficienc  space  for  the  subse¬ 
quent  steps  in  the  operation,  may  be  found 
equally  efficient.  The  second  step  of  the 
operation  consists  in  dividing  the  superficial 
fascia  in  the  same  direction  as  that  of  the  in¬ 
cisions  through  the  skin  ;  and  if  any  of  the 
fibres  of  the  fascia  lata,  which  I  have  spoken 
of  as  sometimes  forming  a  partial  covering  to 
this  hernia,  be  seen,  they  must  be  carefully 
divided  so  as  to  ensure  the  complete  exposure 
of  the  internal  abdominal  fascia  (the  “  fascia 
propria’’  of  Sir  Astley  Cooper).  This  in¬ 
trinsic  covering  is  to  be  taken  up  by  the 
point  of  a  pair  of  forceps,  and  an  opening, 
only  just  large  enough  to  admit  of  the  pas¬ 
sage  of  a  director,  made  with  a  sharp-pointed 
knife;  the  fascia  may  then  be  more  completely 
laid  open,  when  a  quantity  of  fat  is  usually 
metwith :  this  must  not  be  mistakenfor  omen¬ 
tum,  which,  indeed,  it  cannot  be,  because 
the  hernial  sac  remains  yet  unopened.  The 
director  must  next  be  passed  between  the 
hernial  sac,  and  the  internal  abdominal  fascia, 
being  first  pushed  deeply  into  the  thigh,  and 
then  upwards  towards  Poupart's  ligament. 
In  its  upward  progress  a  degree  of  resistance 
■will  be  experienced,  in  proportion  to  the 
.tightness  of  the  stricture ;  the  director  must, 
however,  be  insinuated  beneath  the  point 
of  constriction,  and  the  hernial  knife  being 
passed  along  the  groove  into  the  cavity  of 
the  abdomen,  its  cutting  edge  is  turned  for¬ 
wards,  and  the  stricture  divided  by  giving 
-the  knife  an  upward  direction.  The  pre¬ 
caution.,  as  to  the  direction  in  which  the  cut 
is  made,  is  highly  necessary,  for  the  purpose 
of  avoiding  the  epigastric  artery,  which  lies 
ion  the  outer  side  of  the  stricture.  In 
the  normal  arrangement  of  the  parts,  the 
epigastric  artery  could  scarcely  be  considered 
in  danger  ;  but  it  sometimes  happens  that 
that  vessel  is  given  off  from  the  obturator 
artery,  and  when  -this  is  the  case,  it  must 
cross  exactly  over  the  part  of  the  tumor  sub¬ 
jected  to  constriction,  and  could  then  hardly 
escape  being  wounded  during  the  division 
of  the  stricture.  To  avoid  this  accident, 
I  therefore  always  pass  my  finger  along 
the  director,  while  that  instrument  is  under 
the  stricture,  to  seek  for  the  pulsation 
of  the  artery  before  I  use  the  knife.  If  I 
detected  the  presence  of  the  vessel,  I  should 
not  divide  the  stricture  by  the  knife,  but  by 
means  of  the  finger-nail,  or  some  blunt  in¬ 
strument  not  likely  to  wound  the  artery. 


The  internal  abdominal  fascia,  or  fascia  pro¬ 
pria,  is  always,  in  my  opinion,  the  seat  of  the 
constriction  in  femoral  hernia,  and  not  Pou- 
part’s  or  Gimbernat’s  ligament,  as  many 
surgeons  believe.  I  once  had  a  very  strong 
demonstration  of  this  fact ;  1  was  perform¬ 
ing  the  operation  for  femoral  hernia,  intend¬ 
ing  to  divide  the  stricture  external  to  the 
peritoneal  sac,  and  having,  as  I  believed, 
divided  the  stricture,  I  attempted  to  reduce 
the  hernia ;  I  could  not,  however,  suc¬ 
ceed,  but  still  felt  unwilling  to  open 
the  peritoneum,  and  therefore  divided  some 
fibres  of  Poupart’s  ligament,  and  afterwards 
Gimbernat’s  ligament,  but  both  without 
effect.  My  only  alternative  now  appeared  to 
lie  in  opening  the  sac,  and  incautiously  pro¬ 
ceeding  to  do  so  I  found  that  I  had  not  yet 
exposed  it,  the  fascia  propria  remaining  in¬ 
tact.  I  at  once  divided  that  tissue  at  the 
usual  point  of  stricture,  and  the  hernia  was 
directly  reduced ;  in  this  case,  at  any  rate, 
proving  that  the  seat  of  the  stricture  was  in 
the  internal  abdominal  fascia.  As  far  as  my 
experience  has  gone,  after  25  years’  practice 
at  Guy’s  Hospital,  I  should  say  that  the 
prognosis  in  femoral  hernia  is  more  favour¬ 
able  than  in  any  other  species,  particularly 
when  the  stricture  is  divided  internal  to  the 
peritoneal  sac ;  a  modification  of  the  opera¬ 
tion  which,  indeed,  I  have  found  more  easily 
effected  than  in  the  other  kinds  of  protrusion. 
The  after  treatment  of  femoral  hernia  does 
not  in  any  respect  differ  from  that  in  the  in¬ 
guinal;  you  must  not  employ  purgatives, 
but  leave  the  bowels  to  their  natural  action, 
as  the  peristaltic  motion  produced  by  ca¬ 
thartic  medicines  interrupts  the  progress  of 
the  reparation  set  up  by  nature  for  the  re¬ 
storation  of  the  parts. 

I  shall  describe  to  you,  gentlemen, 
some  of  the  difficulties  which  are  met  with 
in  cases  of  femoral  hernia,  and  do  my 
best  to  inform  you  of  the  means  which  are 
to  be  employed  to  avoid  and  overcome  them. 
In  the  first  place,  be  most  cautious  in  your 
diagnosis,  and,  however  certain  you  may  feel 
as  to  the  true  nature  of  the  tumor,  always 
commence  the  operation  rather  with  the  deli¬ 
beration  of  one  about  to  enter  upon  an  ex¬ 
ploration,  than  with  the  confidence  only  ad¬ 
missible  under  circumstances  of  indisputable 
certainty. 

Although  it  is  easier  to  distinguish  a 
femoral  than  it  is  an  inguinal  hernia,  yet  there 
are  abnormal  conditions  relating  to  the  seat 
of  femoral  hernia,  which  complicate  its 
diagnostic  marks.  An  enlarged  gland  in 
the  upper  part  of  the  thigh  concomitant  with 
sickness  and  obstruction  in  the  bowels, 
may  offer  great  difficulty  as  to  the  mode 
of  proceeding.  If,  under  these  circumstances, 
the  symptoms  be  of  recent  occurrence, 
and  delay,  therefore,  admissible,  internal  re¬ 
medies  may  be  first  had  recourse  to,  and  the 


522 


OPERATION  FOR  STRANGULATED  FEMORAL  HERNIA. 


taxis  employed ;  but  should  the  obstruction 
have  existed  for  a  considei  able  length  of  time, 
and  the  patient  be  consequently  in  danger, 
an  exploring  operation  should  be  no  further 
delayed.  Supposing  an  enlarged  gland  be 
exposed,  it  should  be  removed,  and  the  in¬ 
vestigation  continued  ;  for  it  is  very  probable 
that,  under  the  described  circumstances,  a 
hernial  tumor  may  yet  be  discovered  behind 
the  enlarged  gland.  Sir  Astley  Cooper 
mentions  a  case,  in  his  published  lectures,  of 
a  patient  being  admitted  into  Guy’s  Hospital, 
with  a  strangulated  femoral  hernia,  to  which 
he  had  had  a  poultice  applied  for  three  days, 
under  the  supposition  that  it  was  a  bubo. 
When  the  operation  was  performed,  the  in¬ 
testine  was  found  in  a  state  of  gangrene,  and 
the  patient  died.  Another  case  is  mentioned, 
in  which  a  surgeon  not  only  poulticed,  but 
also  opened  a  femoral  hernia,  believing  it  to 
be  abscess,  and  the  patient  died  two  days 
after.  I  witnessed  the  same  mistake  in 
Norwich,  several  years  ago,  but  in  that  case 
the  patient  survived,  and  the  artificial  anus 
proved  only  a  temporary  inconvenience. 

Psoas  abscess  and  femoral  hernia  may  co¬ 
exist,  and  should  exploration  be  necessary 
from  the  continuation  of  hernial  symptoms 
after  proper  remedies  had  been  ineffectually 
administered,  the  surgeon  is  not  only  justi¬ 
fied,  but  bound  to  investigate  the  nature  of 
the  swelling  by  surgical  exploration.  Varicose 
veins,  or  tumors  of  any  kind  in  this  region  of 
the  thigh,  may  lead  to  the  necessity  for 
similar  treatment  as  in  the  cases  alluded  to. 
I  must  again  also  caution  you,  gentlemen,  not 
to  confound  inguinal  with  femoral  hernia  ; 
for,  if  in  either  case  the  one  be  mistaken  for 
the  other,  neither  the  force  employed  in  the 
manipulation  by  the  taxis,  nor  the  surgical 
operation  for  the  division  of  the  stricture, 
will  be  applicable  to  either  indiscriminately. 

In  making  the  first  incision,  without  due 
caution  you  might  easily  wound  the  saphena 
major  vein  ;  you  should  therefore  always  pre¬ 
viously  ascertain  the  precise  position  of  that 
vessel.  Immediately  under  the  skin  you  may 
meet  with  some  difficulty,  in  consequence  of 
the  presence  of  enlarged  absorbent  glands, 
which  may  require  to  be  removed  to  enable 
you  to  prosecute  the  further  steps  of  the  ope¬ 
ration.  The  fascia  superficialis  you  will  also 
sometimes  find  much  thickened,  at  others 
much  attenuated,  and  you  should  be  pre¬ 
pared  for  this  variation,  or  you  may  in  some 
cases  hardly  recognize  the  structure  when 
exposed  to  view,  and  may  go  on  dividing  the 
fascia  into  several  layers,  so  as  to  complicate 
the  operation,  and  preclude  the  possibility 
of  knowing  how  far  you  have  proceeded.  The 
laying  open  the  sheath  of  the  femoral  vessels 
is  in  all  cases  a  difficult  part  of  the  opera¬ 
tion,  as  that  tissue  is  not  very  easily  distin¬ 
guished,  either  from  the  superficial  fascia, 
or  from  the  hernial  sac.  Usually,  however, 


a  large  vein  will  be  found  between  the  sheath 
and  the  superficial  fascia,  and  some  fat  be¬ 
tween  the  sheath  and  the  sac,  (the  peritoneum) 
but  where  neither  the  one  nor  the  other  be 
present,  great  caution  is  required.  The 
division  of  the  stricture  is  very  embarrassing 
to  a  young  operator,  from  the  great  depth  of 
the  constriction,  and  in  passing  the  director 
under  it,  it  must  be  pushed  deeply  back¬ 
wards  in  the  thigh,  before  it  is  directed  up¬ 
wards  under  Poupart’s  ligament.  In  femoral 
hernia  I  have  found  the  division  of  the 
stricture  external  to  the  sac  more  frequently 
effective  than  in  inguinal,  but  it  requires 
some  caution  in  pushing  the  contents  of  the 
sac  into  the  abdomen,  that  the  sac  and  con¬ 
tents  do  not  all  go  up  together,  (“  en  bloc”) 
and  thus  at  once  convert  an  external  into  an 
internal  hernia — a  result  which  would  most 
probably  terminate  fatally.  I  once  had  this 
misfortune  occur  to  me,  and  the  post-mortem 
examination  proved  the  fact, — even  in  the 
common  application  of  the  taxis  only,  it  has 
been  known  to  result.  If  compelled  to  open 
the  sac,  you  will  generally  find  that  a  con¬ 
siderable  quantity  of  fluid  escapes,  some¬ 
times  before,  but  more  frequently  after  the 
stricture  has  been  divided.  I  have  seen  so 
much  flow  out  as  to  give  rise  to  some  appre¬ 
hension  that  the  intestine  had  been  wounded 
— an  accident  more  likely  to  occur  in  femo¬ 
ral  than  in  any  other  species  of  hernia. 

Umbilical  hernia,  or  exomphalos ,  is  a  pro¬ 
trusion  of  a  portion  of  the  contents  of  the  ab¬ 
domen  through  the  umbilical  ring  :  it  is  sub¬ 
ject  to  exactly  the  same  conditions  as  other 
hernise — that  is  to  say,  it  may  be  either  re¬ 
ducible,  irreducible,  obstructed,  or  strangu¬ 
lated,  and  to  obstruction  it  is  more  especially 
liable.  If  common  precaution  be  exercised 
at  the  commencement  of  this  disease,  all  ill 
effect  may  easily  be  prevented  ;  for  it  is 
generally  reduced  with  great  facility,  and 
the  simplest  mechanical  means  is  sufficient 
to  retain  it  within  its  cavity.  Infants  are 
most  liable  to  this  hernia,  owing  to  the  large 
size  of  the  umbilicus  at  that  early  age,  and 
even  at  birth  umbilical  hernise  are  not  by 
any  means  unfrequent.  This  congenital 
tendency  may,  however,  be  easily  overcome 
by  judicious  management. 

The  parts  called  the  umbilicus  are  in  a 
different  condition  to  other  organs  of  the 
human  body  :  the  navel  is,  indeed,  merely  a 
cicatrix,  produced  by  the  healing  of  an  open¬ 
ing  through  which  in  foetal  life  an  apparatus 
had  passed,  for  the  purpose  of  maintaining  a 
communication  between  the  mother  and 
child.  At  the  time  of  birth,  this  medium  of 
connection  is  severed  close  to  the  infant,  and 
as  the  divided  part  heals  it  leaves  a  per¬ 
manent  cicatrix,  which  always  remains  a 
weak  point  in  the  parietes  of  the  abdomen. 
At  its  commencement  an  umbilical  hernia 


OPERATION  FOR  UMBILICAL  HERNIA - CASE. 


523 


usually  presents  a  rounded  projection  at  the 
navel,  but  in  thin  persons  soon  acquires  a 
pendulous  character.  The  neck  of  the  hernia 
is  usually  above  the  centre  of  the  umbilical 
ring,  and  consequently  also  above  the  re¬ 
mains  of  the  umbilical  vessels.  The  coverings 
of  this  hernia  are — skin,  superficial  fascia,  in¬ 
ternal  abdominal  fascia,  and  peritoneum  ; 
but  if  the  hernia  be  very  large,  and  have  ex¬ 
isted  for  some  length  of  time,  the  cicatrix  of 
both  the  superficial  fascia  and  internal  ab¬ 
dominal  fascia  may  have  become  completely 
absorbed ;  and  in  that  case  the  skin  and 
peritoneum  would  alone  be  left  as  the  hernial 
coverings :  hence,  it  is  obvious  that  the 
greatest  care  is  necessary  in  making  the  first 
incision  in  the  operation  for  strangulated 
umbilical  hernia. 

The  operation  is  commenced  by  making 
a  vertical  incision  two  and  a  half  or  three 
inches  in  length,  according  to  the  size  of  the 
tumor.  It  must  commence  above  the  tumor, 
about  one  half  its  length  being  in  the  linea 
alba,  penetrating  through  the  skin  and 
superficial  fascia,  and  the  other  half  extend¬ 
ing  across  the  tumor  itself,  dividing  the  skin 
over  the  protrusion.  When  this  is  accom¬ 
plished,  the  linea  alba  must  be  laid  bare  as 
far  as  the  upper  section  of  the  first  incision 
extends  :  the  tendon  must  be  carefully  per¬ 
forated,  and  the  director  passed  between  it 
and  the  internal  abdominal  fascia  down¬ 
wards  to  the  umbilical  ring.  The  hernial 
knife  is  then  introduced  along  the  groove  of 
the  director,  or  upon  the  finger,  which 
is  perhaps  the  safer  and  more  convenient 
method,  and  the  stricture  cautiously  di¬ 
vided.  When  the  constriction  is  thus  re¬ 
lieved,  the  sac  should,  if  possible,  be 
emptied  of  its  contents,  but  never  itself 
opened,  unless  in  cases  of  extreme  necessity. 
To  my  colleague,  Mr.  Key,  is  due  the 
credit  of  having  devised  the  plan  of  passing 
the  director  through  the  linea  alba  above 
the  hernia,  so  as  to  divide  the  stricture  by 
an  incision  made  from  above  downwards, 
instead  of  commencing  from  below :  by 
this  means  we  gain  the  important  advantage 
of  exposing  with  certainty  the  internal  ab¬ 
dominal  fascia,  and  securing  the  division  of 
the  stricture,  without  risk  of  injuring  the 
peritoneal  sac — an  accident  which  is  almost 
unavoidable  if  the  operation  be  performed 
in  the  usual  manner.  I  always  adopted 
the  plan  just  described  ;  but,  having  in  one 
instance  failed  in  endeavouring  to  empty  the 
sac  after  I  had  divided  the  stricture,  I  con¬ 
tinued  my  incision  upon  the  tumor,  intend¬ 
ing  to  open  the  sac  itself ;  but  as  soon  as  I 
had  exposed  it,  by  cutting  through  its 
fascial  covering,  it  suddenly  became  flaccid, 
and  the  contents  were  readily  returned. 
Since  this  case  I  have  so  far  modified  Mr. 
Key's  method  as  to  always  continue  my  inci¬ 
sion  along  the  upper  portion  of  the  tumor, 


and  I  believe  that  the  division  of  the  skin 
from  the  circumference  of  the  umbilical  ring 
facilitates  the  liberation  of  the  stricture, 
and  tends  also  to  set  free  the  neck  of 
the  hernial  sac :  at  any  rate,  I  should 
strongly  recommend,  that,  where  Mr.  Key's 
method  does  not  succeed,  the  effect  of  pro¬ 
longing  the  incision  should  always  be  tried 
before  the  sac  be  opened,  as  it  is  in  opening 
that  membrane  that  the  greatest  danger  is 
to  be  apprehended,  and  this  perhaps  more 
particularly  the  case  in  umbilical  than  in 
any  other  kind  of  hernia. 

Some  time  since  I  was  requested  by 
Dr.  Williams,  of  Tavistock  Square,  to 
visit  a  lady  about  60  years  of  age,  weigh¬ 
ing  at  least  20  stone,  who  was  the  sub¬ 
ject  of  a  large  umbilical  hernia  which, 
had  been  irreducible  for  many  years,  and 
had  become  either  strangulated  or  ob¬ 
structed  five  days  before.  The  case  was 
rendered  somewhat  complicated  by  the 
existence  of  a  large  inguinal  hernia  in  the 
right  side  ;  but  the  latter  was  reducible,  and 
free  from  pain  or  tension.  I  therefore  pro¬ 
posed  operating  on  the  umbilical  tumor, 
which  was  consented  to.  I  made  my  in¬ 
cision  in  the  course  of  the  linea  alba  an 
inch  and  a  half  long,  terminating  half  an 
inch  above  the  tumor,  and  easily  exposed 
the  internal  abdominal  fascia :  I  made  an 
opening  into  it,  and,  passing  my  finger 
between  it  and  the  peritoneum  downwards 
to  the  point  of  constriction,  divided  the 
stricture,  but  was  still  unable  to  empty  the 
sac.  I  therefore  continued  my  external  in¬ 
cision  through  the  skin  for  the  remaining 
half  inch,  and  also  for  an  inch  on  the  tumor 
itself ;  and  the  moment  I  had  divided  the 
abdominal  fascia  of  the  hernia,  the  sac  be¬ 
came  flaccid,  and  a  large  portion  of  its  con¬ 
tents  receded  into  the  abdomen.  Two 
hours  after  the  operation  the  patient  had  a 
copious  motion,  and  a  second  shortly  after, 
uninduced  by  purgatives  ;  but  on  the  third 
day  symptoms  of  sloughing  omentum  super¬ 
vened,  and  on  the  ninth  day  after  the  ope¬ 
ration  the  patient  died. 

Sept.  29,  1837,  I  operated  on  an  old 
woman,  aged  79,  at  Guy's,  for  strangulated 
umbilical  hernia,  of  which  she  had  been  the 
subject  for  fifty  years,  but,  three  days  pre¬ 
vious  to  her  admission,  a  fresh  portion  had 
descended  and  become  strangulated.  I  did 
not  open  the  sac,  and  could  not  relieve  the 
stricture  until  I  had  divided  the  abdominal 
fascia  covering  the  hernia  itself,  as  in  the 
last  case  ;  but  directly  this  was  effected,  the 
protruded  intestine  was  readily  pressed  back 
into  the  abdomen,  and  the  patient  reco¬ 
vered  without  a  single  bad  symptom. 

Some  years  ago  I  saw  Mr.  Callaway  ope¬ 
rate  for  umbilical  hernia  on  a  woman  aged 
55,  who  had  had  fifteen  children.  The 
tumor  was  of  very  large  size,  and  the 


524  VENTRAL  HERNIA - STEATOMATA  MAY  BE  MISTAKEN  FOR  IT. 


greater  part  of  it  had  existed  for  upwards  of 
twenty  years,  but  a  fresh  portion  had  de¬ 
scended  four  days  before  her  admission  into 
Guy’s.  The  swelling  felt  as  hard  as  if  it 
contained  some  solid  viscus,  and  was  so 
large  as  to  occupy  the  middle  third  of  the 
abdomen  :  the  upper  portion  was  soft,  and 
seemed  to  contain  the  newly  protruded  in¬ 
testine  ;  the  larger  and  harder  portion 
we  both  believed  to  contain  consolidated 
omentum.  We  considered  it  a  very  un¬ 
favourable  case  for  the  operation  ;  but  Mr. 
Callaway  felt  it  right  to  give  the  patient  the 
only  chance  there  was  of  saving  her  life.  He 
commenced  his  operation  by  making  an  in¬ 
cision  vertically  along  the  upper  third  of 
the  tumor  ;  and,  cutting  through  the  skin, 
an  inch  in  depth  of  fat,  and  the  superficial 
fascia,  he  was  enabled  to  raise  the  tumor 
sufficiently  to  expose  the  umbilical  opening 
and  the  neck  of  the  sac,  covered  by  the  in¬ 
ternal  abdominal  fascia.  Through  this 
fascia  he  made  a  small  opening  (leaving  the 
peritoneal  covering  intact),  and  then  divided 
the  stricture,  at  the  same  time  enlarging  the 
umbilical  ring  for  nearly  an  inch.  The 
hernial  sac,  however,  remained  as  tense  as 
before :  he  therefore  passed  the  probe- 
pointed  bistoury  again  between  the  sac  and 
the  internal  abdominal  fascia,  and,  cutting 
downwards  along  the  tumor,  freely  laid 
open  its  fascial  covering,  when  the  sac  be¬ 
came  at  once  relaxed — satisfactorily  proving 
that  the  stricture  resulted  as  much,  at  any 
rate,  from  the  fascial  covering  of  the  hernia 
as  from  the  fascia  of  the  ring  itself.  Al¬ 
though  this  patient  had  alvine  excretions 
she  sunk  the  next  day  ;  but  a  post-mortem 
examination  was  not  permitted. 

The  after-treatment  of  umbilical  hernia 
is  similar  to  that  which  is  followed  after  the 
removal  of  the  mechanical  cause  of  obstruc¬ 
tion  to  the  intestines  in  every  other  species 
of  hernia  :  the  patients,  however,  less  fre¬ 
quently  recover  from  the  operation. 

Ventral  hernia  may  occur  in  any  part  of 
the  abdomen,  but  more  generally  in  the 
tendinous  than  in  the  muscular  parietes. 
When  it  occurs  in  the  course  of  the  linea 
alba  above  the  umbilicus,  the  symptoms 
usually  indicate  interference  with  the  func¬ 
tions  of  the  stomach.  This  has  sometimes 
led  to  the  supposition  that  that  organ  was 
itself  protruded,  but  no  record  of  any  such 
phenomenon  is  to  be  found,  and  the  de¬ 
rangement  of  the  stomach  depends  upon  its 
proximity  to  the  protruded  viscus,  and  from 
the  dragging  action  of  the  omentum  upon  it 
when  either  that  structure  or  the  colon  con¬ 
stitute  the  contents  of  the  hernia.  The 
only  cases  in  which  I  have  known  the  sto¬ 
mach  to  be  the  subject  of  hernia  were 
where  there  existed  malformation  of  the 
diaphragm ;  and,  under  those  circumstances, 


I  have  seen  both  the  stomach  and  the  arch 
of  the  colon  within  the  chest.  Ventral 
hernise  sometimes  traverse  the  linea  semi- 
lunares,  and  are  placed  under  precisely  the 
same  conditions  as  when  they  perforate  the 
linea  alba,  the  disturbance  experienced  in 
the  functions  of  the  intestines  forming  the 
diagnostic  marks  in  both  cases.  It  some¬ 
times  happens,  however,  that  small  fatty 
tumors  (steatomata),  are  formed  in  different 
parts  of  the  abdominal  parietes,  and  these 
may  easily  be  mistaken  for  hernial  protru¬ 
sions,  especially  if  they  happen  to  be  con¬ 
comitant  with  any  interruption  to  the  func¬ 
tion  of  the  bowels  ;  and,  if  in  that  case 
the  medical  treatment  failed  to  restore  the 
bowels  to  their  healthy  condition,  it  would 
be  proper  to  cautiously  cut  down  upon  the 
tumor,  to  investigate  its  character.  It  is 
stated  that  steatomata  may  always  be  re¬ 
cognised  by  their  doughy  feel  and  lobulated 
form ;  but  the  existence  of  these  physical 
signs  ought  not  to  prevent  the  exploration 
of  the  tumor  under  the  circumstances  I 
have  mentioned  ;  for,  in  addition  to  the 
abnormal  formation  of  fat,  there  may  be 
protrusion  of  intestine  or  omentum,  and 
even  the  latter  may  cause  all  the  symptoms 
of  hernia. 

When  ventral  hernise  are  irreducible, 
bandages  or  trusses  must  be  worn  to  pre¬ 
vent  their  recurrence.  If  irreducible,  they 
require  some  mechanical  apparatus  to  pre¬ 
vent  further  protrusion,  and  to  defend  the 
parts  from  external  injury.  If  strangulated, 
they  require  to  be  relieved  by  operation ; 
similarly  indeed  to  every  kind  of  hernia. 
Ventral  hernise,  however,  differ  in  some  de¬ 
gree  from  other  abdominal  hernise  in  one 
respect :  instead  of  passing,  as  the  latter, 
through  large  natural  openings,  they  project 
through  small  perforations  normally  intended 
only  for  the  transmission  of  minute  vessels, 
and  which  become  sufficiently  enlarged,  from 
some  accidental  cause,  to  admit  of  visceral 
displacement.  Operations  for  ventral  hernise 
are  not  frequently  attended  by  a  successful 
result. 


RELATIVE  MORTALITY  FROM  AMPUTATIONS 
IN  THE  HOSPITALSOFENGLAND, FRANCE, 
AND  THE  UNITED  STATES. 

For  London  the  cases  amount  to  107,  and 
the  deaths  to  28,  or  26' 16  per  cent. 

For  Paris,  according  to  M.  Malgaigne, 
the  cases  amount  to  560,  the  deaths  to  299, 
or  53*39  per  cent. 

For  Philadelphia,  Boston,  and  New  York, 
according  to  Dr.  Buel,  the  cases  amount  to 
237,  the  deaths  to  53,  or  26*58  per  cent. — 
Dr.  Buel,  in  American  Journa.1  of  Med. 
Sciences,  July  1848. 


THE  MORBID  CONDITIONS  OF  THE  PULMONARY  ARTERY. 


525 


Original  ©ommnmcattons. 


A  COLLECTION  of  facts  illustrative  of 
THE 

MORBID  CONDITIONS  OF  THE 
PULMONARY  ARTERY. 

AS  BEARING  UPON  THE  TREATMENT  OF 
CARDIAC  AND  PULMONARY  DISEASES. 

By  Norman  Chevers,  M.D. 
Assistant  Surgeon,  Bengal  Army. 
[[Continued  from  p.  449.] 


Mr.  Curling,  of  the  London  Hospital, 
has  most  kindly  furnished  me  with  the  fol¬ 
lowing  highly  interesting  narrative  of  a  case  of 
traumatic  diffused  aneurism  of  the  right 
branch  of  the  pulmonary  artery.  The  pa¬ 
tient  was  admitted  under  the  care  of  Mr. 
Luke. 

“  Edmund  Taylor,  a  healthy  and  muscular 
young  man,  aged  23,  was  brought  to  the 
London  Hospital  about  5  in  the  morning, 
Sept.  30,  1838,  having  been  stabbed  in  the 
chest  with  a  long  clasp-knife  a  short  time 
previously.  The  wound  was  about  an  inch 
in  extent,  and  situated  at  the  front  and  upper 
part  of  the  right  side  of  the  chest,  near  the 
junction  of  the  cartilage  of  the  third  rib  with 
the  sternum.  I  was  informed  that  instantly 
after  its  infliction  there  was  a  profuse  hae¬ 
morrhage,  and  that  the  patient  coughed  up 
almost  immediately  a  considerable  quantity 
of  blood.  When  admitted  he  was  very 
faint,  and  there  was  a  slight  oozing  of  blood 
from  the  wound,  but  this  ceased  after  the 
edges  had  been  brought  together  with  adhe¬ 
sive  plaster.  His  breathing  continued  after¬ 
wards  to  be  much  oppressed,  and  for  two 
days  he  coughed  up  occasionally  a  small 
quantity  of  blood.  Pneumonia  supervened, 
but  it  was  checked  by  general  and  local 
blood-letting,  and  by  antimony  and  mercury 
exhibited  until  the  mouth  became  affected. 
He  appeared  to  be  going  on  tolerably  well, 
when,  on  the  eleventh  day  after  the  injury, 
he  was  seized  with  a  fit  of  coughing,  and 
upwards  of  sixteen  ounces  of  blood  suddenly 
gushed  out  from  the  wound.  From  this 
period  there  was  a  daily  haemorrhage,  vary¬ 
ing  in  quantity  from  one  or  two  ounces  to 
four  or  five  ;  and  he  frequently  expecto¬ 
rated  small  clots  of  blood.  The  blood  which 
issued  from  the  wound  was  thin,  and  some¬ 
times  mixed  with  matter  like  pus ;  and  air 
always  escaped  when  the  part  was  dressed. 
Digitalis,  the  acetate  of  lead,  and  other  re¬ 
medies,  were  given  to  check  the  haemorrhage, 
but  with  no  effect.  The  patient  got  gra¬ 
dually  weaker  ;  and  being  exhausted  by  the 


daily  losses  of  blood,  died  on  the  29th  day 
after  the  injury. 

“  The  body  was  examined  the  day  after 
death.  It  was  much  wasted  and  exsangui- 
neous.  The  knife  had  passed  in  an  oblique 
direction,  dividing  the  cartilage  of  the  third 
rib,  and  entering  the  chest  a  little  to  the 
right  side  of  the  anterior  mediastinum.  The 
whole  of  the  front  part  of  the  middle  lobe  of 
the  right  lung  was  converted  into  a  false 
aneurismal  sac.  There  was  a  large  irregular 
cavity,  filled  with  coagulated  blood,  part  of 
which  was  in  layers,  and  deprived  in  a  great 
degree  of  the  red  particles,  and  part  loose 
and  soft,  and  of  a  greyish -red  colour.  There 
was  also  a  small  quantity  of  coagulated  blood. 
At  the  bottom  of  this  cavity,  towards  the 
heart,  was  distinctly  perceived  an  opening  in 
a  large  vessel,  capable  of  admitting  a  full- 
sized  goose-quill ; — the  aperture  communi¬ 
cated  with  the  right  branch  of  the  pulmo¬ 
nary  artery  just  as  it  divides  into  several 
branches  for  distribution  throughout  the 
lung.  The  pulmonary  tissue  surrounding 
this  false  aneurism  was  hepatized  ;  and  there 
were  firm  pleuritic  adhesions  on  that  side  of 
the  chest.  The  pericardium  contained  about 
three  ounces  of  turbid  serum,  and  there  was 
a  thin  layer  of  loose  lymph  coating  a  great 
part  of  the  heart.  The  left  lung  and  the 
abdominal  viscera  were  sound.  The  mam¬ 
mary  artery  was  untouched,  but  the  small 
intercostal  vessel  communicating  with  it  was 
divided. 

“  It  will  perhaps  excite  some  surprise 
that  a  considerable  wound  of  one  of  the  two 
main  branches  of  an  artery  transmitting  the 
whole  of  the  circulating  fluid  of  the  body, 
should  not  have  been  attended  with  such  a 
loss  of  blood  as  to  have  destroyed  life  in  a 
short  period.  A  wound  of  the  same  extent 
in  the  arteria  innominata  or  common  iliac 
arteries,  less  in  size  than  the  vessel  wounded 
in  this  case,  would  no  doubt  have  proved 
fatal  in  a  few  minutes.  The  safety  of  the 
patient  may,  however,  be  ascribed  to  the 
inferior  power  of  the  right  ventricle  of  the 
heart  as  compared  with  that  of  the  left.  In 
the  collapse  which  resulted  from  the  profuse 
hsemorrhage  consequent  upon  the  wound,  we 
may  conclude  that  coagulation  took  place, — 
that  the  opening  in  the  right  branch  of  the 
pulmonary  artery  became  closed,  and  bleed¬ 
ing  arrested  for  a  time.  The  action  of  the 
right  ventricle,  reduced  by  the  hsemorrhage 
and  the  treatment  afterwards  pursued,  ap¬ 
pears  to  have  been  insufficient  to  disturb  the 
false  aneurism  which  had  formed  in  the  sub¬ 
stance  of  the  lung  ;  but  unfortunately  it  was 
subsequently  ruptured  in  a  violent  fit  of 
coughing.  Although  the  aneurismal  sac 
was  of  some  considerable  size  it  was  smaller 
than  might  have  been  expected,  considering 
the  magnitude  of  the  vessel  wounded, — its 
near  approximation  to  the  heart, — the  dura- 


626 


COLLECTION  OF  FACTS  ILLUSTRATIVE  OF 


tion  of  life  after  the  injury, — and  the  soft 
vascular  and  unresisting  nature  of  the  tissue 
which  formed  the  parietes.  But  this  cir¬ 
cumstance  may  perhaps  be  explained  by  the 
inferior  propulsive  power  of  the  right  ven¬ 
tricle.  A  false  aneurism  of  the  aorta,  under 
similar  conditions,  if  not  sooner  destructive 
to  life,  would,  I  think,  have  attained  in  the 
same  period  a  very  much  larger  size.  At 
the  time  that  the  bleeding  recurred,  eleven 
days  after  the  infliction  of  the  wound,  the 
lung  had  been  consolidated  by  inflammation. 
It  was  enabled,  therefore,  to  offer  conside¬ 
rable  resistance  to  the  effusion  of  blood  and 
the  extension  of  the  aneurism.’' 

It  is  singular  that,  while  so  much  has  been 
written  upon  the  subject  of  injuries  to  the 
lungs,  so  few  facts  should  have  been  hitherto 
elicited  with  regard  to  the  precise  manner  in 
which  lacerated  and  punctured  wounds  of 
branches  of  the  pulmonary  artery  heal.  It 
is  probable  that  their  closure  is  usually 
effected  by  the  gradual  infiltration  of  blood 
into  the  surrounding  tissue  of  the  lung,  as 
well  as  by  the  collapse  of  that  organ  conse¬ 
quent  upon  the  presence  of  blood  or  air 
within  the  pleura,  aided  by  the  depressed 
state  of  the  circulation  which  results  from 
the  haemorrhage,  and  from  the  depleting  plan 
of  treatment  which  is  usually  adopted.  In 
gun-shot  wounds,  the  closure  of  the  vessels 
is  doubtless  greatly  aided  by  the  contused 
condition  of  all  the  tissues. 

RUPTURE. 

Rupture  of  the  main  trunk  and  larger 
branches  of  the  artery  has  been  known  to 
occur  in  several  instances.  This  lesion  ap¬ 
pears  usually  to  result  from  a  diseased  con¬ 
dition  of  the  vessel,  and  is  afar  less  frequent 
consequence  of  severe  crushing  injuries  to 
the  chest,  than  is  rupture  of  the  thoracic 
aorta.  In  the  following  case,  however,  the 
laceration  appears  to  have  been  produced  by 
a  violence  of  this  description  : — 

A  healthy,  robust  youth,  setat.  22,  was, 
in  a  scuffle,  wounded  in  the  neck  ;  he  fell 
down  on  the  spot,  and  died  almost  directly. 
Very  little  blood  flowed  from  the  wound. 
On  dissection,  the  wound  was  found  to  have 
penetrated  two  inches  in  depth;  passing  be¬ 
tween  the  trachea  and  left  subclavian  vein, 
but  neither  these  or  any  other  important 
parts  were  injured.  Nearly  five  pounds  of 
black  coagulated  blood  were  found  in  the 
left  bag  of  the  pleura  ;  the  cavity  of  the  peri¬ 
cardium  also  contained  a  quart  of  clotted 
blood.  This  membrane  exhibited  an  irre¬ 
gular  rupture,  nearly  two  inches  in  length,  at 
the  point  corresponding  to  the  root  of  the 
left  lung  ;  the  'pulmonary  artery  was  found 
to  have  given  way  just  beneath  the  point 
where  the  pericardium  is  reflected  upon  this 


vessel  :  its  parietes  did  not,  howeve  -  eI- 
hibit  any  traces  of  morbid  change.* 

The  following  case  has  been  recorded  by 
Mr.  Wm.  Gunn,  R.N. : — f 

A  seaman,  setat.  46,  after  suffering  ft  urn 
pain  in  the  head,  extending  down  the  neck 
and  arm  to  the  hand,  which  was  benumbed, 
while  making  some  considerable  exertion, 
fell  back  without  speaking,  and  in  a  state  of 
exhaustion,  from  which  he  never  recovered. 
On  opening  the  chest,  the  left  side  was 
found  completely  full  of  blood,  the  lung 
being  collapsed  under  the  pressure.  A 
rupture  existed  in  the  pulmonary  artery 
about  half  an  inch  from  its  origin,  and  large 
enough  to  admit  the  point  of  the  little  finger. 
The  artery  was  diseased  at  the  point  where 
it  had  given  way. 

Two  highly  interesting  cases  of  rupture  of 
the  trunk  of  the  pulmonary  artery  have  been 
fully  detailed  by  M.  011ivier.| 

A  remarkable  instance  of  this  lesion  has 
also  been  recorded  by  Mr.  J.  Adam,  jun.§ 
The  patient  was  a  man  of  debilitated  con¬ 
stitution,  52  years  of  age,  who,  for  some 
time  previous  to  his  death,  had  been  subject 
to  various  uneasy  feelings,  referred  to  the 
region  of  the  stomach  and  head,  with  general 
derangement  of  the  digestive  functions,  and 
latterly  to  irregular  action  of  the  heart,  ac¬ 
companied  sometimes  with  a  sense  of  con¬ 
striction  across  the  chest,  increased  on  using 
any  corporeal  exertion,  or  too  frequent  in¬ 
dulgence  in  spirituous  liquors.  Latterly, 
when  the  fluttering  action  of  his  heart  became 
distressing,  he  was  obliged  to  have  recourse 
to  the  recumbent  posture  for  relief.  Death 
occurred  suddenly.  On  opening  the  thorax, 
a  large  quantity  of  dark  grumous  blood 
gushed  out  from  the  right  pleural  cavity, 
which  was  nearly  filled  with  the  effusion. 
Two  polypi  or  coagula  of  blood  were  found 
in  the  right  ventricle.  The  valves  of  the 
pulmonary  artery  were  in  a  state  of  ossifica¬ 
tion.  This  vessel  was  extremely  thin,  and 
enlarged  to  nearly  four  times  its  natural  size, 
being  not  less  than  seven  inches  in  circum¬ 
ference.  It  contained  an  organized  polypus, 
extending  from  the  semilunar  valves  about 
four  inches  along  the  artery.  A  rupture 
had  taken  place  in  the  “  middle”  of  the 
artery,  and  it  appeared  that  there  was  an 
opening  in  the  centre  of  the  polypus,  through 
which  the  blood  seemed  to  be  transmitted 
from  the  ventricle  to  the  lungs  and  aorta, 
and  other  large  vessels  issuing  from  its  arch 


*  Medico-Cliirurgical  Review,  July,  1848.  From 
the  Archives  G^ntirales. 

t  Edinburgh  Med.  and  Sur.  Journal,  January, 
1829,  and  London  Med.  Gazette,  Vol  iii.  p. 
545. 

T  Dictionnaire  de  Med. :  art.  Yaisseaux  Pulmo- 
naires. 

§  In  the  Calcutta  Medical  Transactions,  Vol. 
ij.  p.  115. 


THE  A 


CONDITIONS  OF  THE  PULMONARY  ARTERY.  527 


were  completely  ossified.  A  similar  condi¬ 
tion  of  disease  also  extended  .throughout  the 
remaining  portion  of  the  aorta.  There  was 
no  apparent  disease  of  the  lungs. 

Mr.  Fearn,  of  Derby,  has  publisheu  notes 
of  the  case  of  a  man,  setat.  63,  who  had  been1 
troubled  with  a  cough  for  a  long  time,  but 
in  whom  stethoscopic  examination  revealed 
nothing  beyond  the  evidences  of  general 
bronchitis.  The  patient  was  suddenly  seized 
with  a  tremendous  attack  of  hsemoptysis. 
The  bleeding,  however,  was  restrained  for 
a  while  by  appropriate  remedies,  but  it 
again  returned,  and  the  patient  died  from  ex¬ 
haustion,  nearly  four  days  after  the  first 
attack  of  haemorrhage.  On  examination 
after  death,  it  was  found  that  the  right  pul¬ 
monary  artery  was  ruptured,  just  at  its  en¬ 
trance  into  the  lung,  and  the  pulmonary 
tissue  was  broken  down  by  the  quantity  of 
blood  which  had  been  poured  into  it.  There 
were  no  tubercles,  nor  any  other  adventitious 
deposit,  in  either  lung.* 

A  case  of  sudden  death  from  rupture  of 
the  pulmonary  artery,  is  alluded  to  by  M. 
Devergie,  (Medecine  Legale,  t.  i.  p.  66).  And 
‘another,  occurring  in  a  man  54  years  of  age, 
is  noted  in  the  Sixth  Annual  Report  of  the 
Registrar-General  (p.  288.) 

Ulceration. 

The  coats  of  the  pulmonary  artery  occa¬ 
sionally  become  eroded  and  perforated  in 
cases  where  aneurismal  tumors  of  the  arch  of 
the  aorta  greatly  encroach  upon  this  vessel. 
A  similar  lesion  is  also  produced  in  certain 
cases  of  phthisical  disease  ;  and  sloughing 
of,  branches  of  the  artery  has  occurred, 
though  by  no  means  frequently,  in  cases 
of  pulmonary  gangrene  and  pneumonic 
abscess. 

In  cases  of  aneurism  of  the  arch  of  the 
aorta,  especially  where  the  dilatation  prin¬ 
cipally  affects  the  under  and  back  part  of 
the  vessel,  an  ulcerated  or  ruptured  com¬ 
munication  is  liable  to  be  formed  between 
the  pulmonary  and  systemic  arterial  trunks. 
The  lesion  is,  of  course,  by  no  means  one  of 
frequent  occurrence,  but  several  instances  of 
the  kind  are  upon  record,  of  which  the 
following  appear  to  be  most  characteris¬ 
tic  : — 

Dr.  Wells  relates  the  case  of  a  merchant, 
35  years  of  age,  who  had  suffered  from  ap¬ 
parent  premonitory  symptoms  of  phthisis, 
and  from  a  slight  attack  of  hemiplegia, 
which,  however,  had  passed  away  when  he 
consulted  Dr.  W.  He  then  suffered  from 
a  noise  in  his  ears,  flatulence,  and  pains  in 
his  hands  and  feet,  occasionally  attended 
with  slight  swelling  in  the  same  parts.  He 
did  not  complain  of  any  unusual  feelings  in 
his  chest.  After  considerable  fatigue  in 

*  Provincial  Medical  Journal,  and  Med,  Times, 
Nov.  15th,  1845. 


walking,  he  was  suddenly  seized,  between 
8  and  9  o’clock  p.m.,  while  playing  with  his 
children,  with  a  sense  of  great  oppression  in 
his  chest.  He  soon  after  became  sick,  and 
vomited  a  matter  streaked  with  blood.  The 
surface  was  cold.  Soon  after  midnight  he 
was  found  labouring  under  a  constant  desire 
to  cough,  and  was  continually  expectorating 
n  ucus  tinged  with  blood.  The  body  was 
moistened  with  a  cold  sweat,  and  his  pulse 
was  extremely  feeble :  sometimes  it  was 
scarcely  perceptible.  At  5  a.m.  his  pulse 
was  very  feeble  and  irregular ;  his  breathing 
difficult ;  skin,  pale,  cold,  and  covered  with 
a  clammy  sweat ;  and  he  frequently  tossed 
and  writhed  his  body  as  if  suffering  great 
pain  or  uneasiness.  The  faculties  of  the 
mind  seemed  unimpaired.  About  a  quarter 
of  an  hour  later  he  became  suddenly  worse, 
and  in  a  few  minutes  expired.  Almost  im¬ 
mediately  before  his  death,  he  complained 
much  of  heat  in  his  chest. 

Autopsy,  two  days  after  death. — The 
blood-vessels  of  the  lungs  were  very  much 
distended,  and  there  was  also  a  considerable 
quantity  of  blood  in  the  air-cells.  Each 
cavity  of  the  chest  contained  about  ten. 
ounces  of  a  fluid  highly  tinged  with  blood.? 
The  pericardium  contained  about  two 
ounces  of  a  fluid  similarly  tinged.  The 
tumor  adhered  to  the  pulmonary  artery  just 
before  its  division  into  the  right  and  left 
branches.  Within  the  circumference  of  this 
adhesion  there  was  a  narrow  hole,  by  means 
of  which  a  communication  was  formed  be¬ 
tween  the  two  arteries.  The  cavities  of  the 
heart  and  great  vessels  were  very  much  dis¬ 
tended  with  blood.* 

The  following  nearly  parallel  case  is  re¬ 
lated  by  Dr.  J.  Reid  : — 

A  gentleman,  aged  53  years,  who  had 
been  for  some  months  complaining  of  slight 
bronchitic  symptoms,  with  some  precordial 
uneasiness,  was  suddenly  seized  with  violent 
dyspnoea,  rapidly  followed  by  insensibility, 
and  in  about  four  minutes  from  the  com¬ 
mencement  of  the  attack  he  was  dead. 

On  examination  48  hours  after  death,  the 
heart  and  all  its  valves  wrere  found  healthy. 
That  portion  of  the  arch  of  the  aorta  between 
the  upper  part  of  the  sinuses  of  Valsalva 
and  the  origin  of  the  arteria  innominata 
was  dilated  into  an  aneurism  capable  of 
holding  the  fist.  The  dilatation  chiefly 
projected  to  the  left  side,  and  there  the 
coats  of  the  artery  were  not  only  irregularly 
thickened,  but  contained  numerous  yellow 
patches.  The  left  side  of  the  aneurism 
adhered  firmly  to  the  trunk  of  the  pulmo¬ 
nary  artery ,  and  a  ragged  irregular  fissure, 
nearly  an  inch  and  a  half  in  length,  formed 
a  communication  between  them.  The 

*  Trans,  of  a  Society  for  the  Improvement  of 
Med.  Chir.  Knowledge,  vol.  iii.  p.  85. 


528  THE  MORBID  CONDITIONS  OF  THE  PULMON 


-RTERY. 


aneurism  contained  only  a  few  small  clots  of 
fibrine.  The  lungs  contained  a  very  con¬ 
siderable  quantity  of  blood,  and  some 
serum.* 

Although  the  particulars  of  the  following 
case  are  detailed  at  considerable  length,  it  is 
difficult  to  learn,  from  the  description,  whe¬ 
ther  the  arterial  lesion  was  primarily  due,-  „o 
aneurism  of  the  vessel  or  to  erosion  of  its 
tunics.  The  rupture  of  so  large  an  artery 
could  scarcely  have  occurred  under  the  cir¬ 
cumstances. 

Mr. - ,  setat.  36,  of  a  consumptive 

family,  suffered  more  or  less  from  symp¬ 
toms  of  phthisis  from  the  autumn  of  1841  to 
November,  1842,  when  he  was  attacked 
with  active  haemoptysis.  The  blood  was 
coagulated,  and  expectorated  without  effort. 
At  the  end  of  a  month  he  sank  from  the 
exhausting  effects  of  the  haemorrhage. 

Examination. — There  were  adhesions  be¬ 
tween  the  pleura  of  the  left  side.  The 
pulmonary  pleurae  of  both  sides  presented 
the  peculiar  spotted  appearance  which  re¬ 
sults  from  strumous  deposit.  The  upper 
part  of  the  left  lung  was  entirely  occupied 
by  a  large  cavity  containing  about  half  a 
pint  of  grumous  and  coagulated  blood.  The 
walls  of  this  cavity  were  composed  of  the 
parenchymatous  structure  of  the  lung,  con¬ 
densed  and  solidified  by  pressure.  Upon 
careful  examination,  the  left  branch  of  the 
pulmonary  artery ,  at  the  distance  of  two 
inches  from  its  bifurcation,  was  found  to 
open  into  this  cavity  by  an  aperture  as  large 
as  a  crow-quill.  The  communication  of  the 
artery  with  the  abscess  was  considered  to  be 
the  result  of  the  coats  of  the  vessel  giving 
way,  rather  than  the  effect  of  the  ulceration 
of  the  abscess,  as  the  opening  from  the 
artery  was  funnel-shaped,  and  terminated  in 
the  smallest  possible  aperture.  The  trunk 
of  the  pulmonary  artery  was  so  large  as  at 
first  to  be  taken  for  the  aorta,  for  it  had  a 
complete  curvature  to  the  right  as  high  up 
as  the  left  clavicle.  It  was  thought  that 
this  dilatation  of  the  vessel  was  perhaps 
attributable  to  pressure  of  the  cyst  upon  one 
of  its  main  divisions.  The  patient  had 
suffered  from  difficulty  of  breathing  from 
childhood ;  but  it  is  not  mentioned  that 
marked  dyspnoea  was  one  of  his  later  symp¬ 
toms.  Indeed,  the  narrative  does  not 
clearly  prove  that  the  left  division  of  the 
artery  had  been  greatly  compressed  by  the 
abscess.f 

In  some  cases  of  congenital  defect,  where 
the  arterial  duct  remains  permanently  open, 
the  aorta  and  pulmonary  artery  are  found 
perfectly  in  apposition,  and  communicating 

by  a  wide  opening  of  somewhat  irregular 

« 

*  Edinburgh  Med.  and  Surgical  Journal,  vol. 
liv.  p.  114. 

f  Mr.  W.  Crowfoot,  Jun.,  of  Beccles ;  Med. 
Chir.  Transactions,  2d  Series,  vol.  viii. 


form.  In  distinguishing  such  cases,  it  will 
be  necessary  to  observe  whether  the  aorta  is 
dilated  at  that  spot,  and  especially  to  remark 
wb.fefcK'Vr  the  valves  and  trunk  of  the  pulmo¬ 
nary  artery  are  thickened  and  opaque  ;  as, 
where  a  communication  has  long  existed 
between  these  vessels,  the  pulmonary  artery 
usually  takes  upon  itself  much  of  the  func¬ 
tions  of  the  aorta,  while  its  structures  assume 
an  appearance  closely  resembling  those  of 
the  systemic  artery. 

In  addition  to  the  cases  mentioned  above, 
four  preparations  (numbered  14,  15,  87, 
102)  of  the  lesion  under  consideration  are 
stated  to  be  preserved  in  the  collection  at 
St.  Bartholomew’s  Hospital ;  and  one  (No. 
366)  in  the  Hunterian  Museum.  A  case  in 
which  an  aneurism  opened  into  the  pulmo¬ 
nary  artery  has  also  been  recorded  by  MM. 
Paven  and  Zeinck.*  Another  instance  has 
also  been  contributed  by  M.  Sue.f 

Dr.  Lee  observed  that,  in  a  case  where  a 
large  branch  of  the  pulmonary  artery  opened 
into  the  cavity  of  a  phthisical  abscess,  the 
vomica  was  not  lined  with  that  peculiar 
membranous  structure  which  usually  invests, 
the  walls  of  cavities  of  this  class. X 

It  is  not  usual  for  the  arterial  branches 
which  pass  upon  the  sides  of  pulmonary  vo¬ 
micae  to  become  occluded  by  coagula.  It  is 
probable  that  in  these  cases,  wherever 
haemorrhage  occurs  from  the  corrosion  of  a 
large  vessel  which  has  not  previously  become 
aneurismally  dilated,  the  perforation  of  the 
artery  is  due,  either  to  sloughing  of  the  in¬ 
terior  of  the  abscess,  a  not  unfrequent  oc¬ 
currence  in  phthisis,  or  to  the  absence  of 
that  solid  deposition  which  usually  lies  be¬ 
neath  the  pyogenic  membrane  of  phthisical 
cavities. 

I  was  present  at  the  examination  of  the 
body  of  a  man,  aetat.  58,  who  died,  February 
4th,  1845,  in  the  accident  ward  of  Guy’s 
Hospital,  from  the  secondary  effects  of  a 
fracture  of  the  elbow-joint.  He  had  suffered 
from  bronchitis,  with  foetid  expectoration, 
for  some  time  previous  to  his  death.  The 
walls  of  the  right  ventricle  were  rather  thin. 
Nearly  the  w?hole  of  the  postei’ior  portion  of 
the  right  lung  was  in  a  boggy  condition,  the 
result  of  a  low  form  of  pneumonia  ;  the  pul¬ 
monary  tissue  being  in  this  situation  gene¬ 
rally  infiltrated  wfith  abominably  foetid  sanies. 
This  portion  of  the  lung  contained  several 
cavities,  one  of  which  opened  into  a  circum¬ 
scribed  cavity  in  the  pleura ;  the  lung  sur¬ 
rounding  this  opening  was  in  a  sloughy  con¬ 
dition.  The  trunk  of  the  pulmonary  artery 
was  rather  wide,  and  decidedly  thin.  Its 
surface  was  free  from  stain  or  deposit,  but 
dull.  The  tissues  of  the  vessel  which  tra¬ 
versed  the  diseased  lung  were  generally 

*  Bulletin  de  la  Faculty  de  Mdd.,  1819. 

t  Journ.  de  Med.  Contin.  t.  24,  p.  124. 

i  Dublin  Medical  Journal,  vol.  xxv.  p.  168. 


ON  THE  ATROPHY  OF  PARALYSIS — THE  MEANS  OF  PREVENTING  IT.  529 


softened,  especially  in  the  inflamed  parts. 
Several  branches,  rather  larger  than  crow- 
quills,  were  more  or  less  obstructed  by  dark 
adherent  clots.  In  some  branches  these 
were  evidently  old,  and  nearly  absorbed, — the 
vessels  again  beginning  to  be  permeable  by 
blood  ;  in  others,  the  clots  produced  com¬ 
plete  obliteration,  and  were  adherent  to  the 
entire  circumference  of  the  arteries  which 
they  occupied.  Throughout  most  of  the  in¬ 
flamed  parts,  however,  many  branches  of  the 
vessel  remained  perfectly  free.  A  very  con¬ 
siderable  arterial  branch  was  almost  com 
pletely  obliterated  in  two  places  by  the  pres¬ 
sure  of  cavities  on  either  side.  At  each  of 
these  spots  the  vessel  scarcely  equalled  a 
whipcord  in  circumference.  The  contracted 
portion  which  was  most  distant  from  the 
heart,  was  partially  obstructed  by  some 
whitish  fibrine,  and  the  lining  membrane  of 
the  other  strait  was  vividly  and  deeply  red¬ 
dened,  evidently  by  an  intestritial  effusion  of 
blood.  This  vessel  may  have  been  capable 
of  transmitting  a  very  slender  current  of 
blood.  The  lesions  which  it  presented  did 
not  appear  to  be  particularly  recent,  being, 
in  all  probability,  of  several  days'  standing. 

Another  branch,  of  equal  size,  presented 
traces  of  severe  inflammatory  change,  at  a 
spot  where  it  lay  in  the  close  vicinity  of  a 
sloughy  cavity.  Here  the  interior  of  the 
vessel  bore  traces  of  circumscribed  thicken¬ 
ing  ;  its  lining  membrane  was  blackened,  as 
if  from  the  interstitial  effusion  of  blood 
which  had  become  partially  absorbed.  The 
centre  of  this  discolouration  presented  a 
raised  whitish  defined  spot,  where  the  tissues 
of  the  vessel  had  lost  their  cohesion  and  ap¬ 
peared  to  be  in  a  sloughing  condition ;  the 
diseased  tissue  was  not,  however,  sufficiently 
softened  and  detached  to  allow  of  haemorr¬ 
hage.  This  position  of  the  artery  was  not 
defended  by  adherent  coagulum :  a  small 
band  which  it  gave  oft’  appeared  to  have 
been  obliterated  by  fibrous  deposit ;  but, 
although  this  had  become  nearly  absorbed, 
the  vessel  still  remained  so  greatly  contracted 
as  to  be  almost  impervious. 

It  is  probable  that,  had  this  patient’s  life 
been  protracted  for  a  day  or  two,  or  had  the 
force  of  his  circulation  been  greater,  the 
separation  of  the  sloughy  portion  of  the 
artery  would  have  been  followed  by  fatal 
haemorrhage. 

[To  be  continued.] 


LATIN  EXAMINATION  AT  APOTHECARIES’ 
HALL. 

We  are  requested  to  announce  that  there 
will  be  a  preliminary  Latin  examination  at 
Apothecaries'  Hall  on  the  first  Thursday  in 
every  month.  Students  may  obtain  in¬ 
formation  on  application  at  the  Beadle's 
office. 


h 

ON  THE 

ATROPHY  OF  PARALYSIS, 

1  _i  and  the 

M  E  aant  S  OF  PREVENTINGIT. 
By  William  Frederick  Barlow, 
M.R.C.S. 

Mr.  Paget,  as  the  readers  of  ‘this 
journal  must  know,  has  directed  at¬ 
tention  to  the  atrophy  of  paralytic  limbs 
in  his  Lectures  delivered  in  the  Theatre 
of  the  Royal  College  of  Surgeons;  and 
very  ably  and  fully  insisted  on  the  good 
effects  which  would  result  from  forcing, 
by  some  mode  or  other,  the  paralysed 
parts  into  involuntary  action.  I  have 
endeavoured  to  call  attention  to  the 
same  subject  in  the  first  volume  of  Dr. 
Marshall  Hall’s  Observations  in  Medi¬ 
cine  ;  it  is  one,  as  too  many  shrunken 
limbs  will  testify,  of  no  inconsiderable 
moment. 

There  is  no  law  in  physiology  better 
known  than  that  of  the  existence  of 
the  nicest  possible  relation  between  the 
action  and  the  nutrition  of  muscles  ; 
and  everybody  knows  that  protracted 
rest  is  a  cause  of  their  atrophy ;  exer¬ 
cise,  of  their  nourishment;  over-action, 
of  their  hypertrophy.  And  this  law  is 
one  form  of  the  expression  of  the  truth, 
that  life  must,  to  be  perfect  and  fulfil 
all  that  it  can  accomplish,  be  a  busy 
and  energetic  life. 

No  one  has  more  explicitly  insisted 
on  the  benefit  derived  to  muscles  from 
their  action,  than  JohnHunter, — no  one 
more  interestingly ;  and  I  may  allude 
to  his  observations  on  the  “  colour  of 
muscles,  the  swelling  of  muscles,  and 
the  effects  of  habit  on  muscles.”* 
Painters  and  sculptors,  he  says,  know 
and  represent  the  effects  of  action,  and 
pourtray  Charon  and  Vulcan  with  large 
shoulders  and  brawny  arms.  But  the 
application  of  the  fact,  that  action  is  in¬ 
dispensable  to  healthy  nutrition,  re¬ 
mains  to  be  fully  made,  for  no  one  will 
deny  that  muscles  are  daily  permitted 
to  waste  from  disuse,  tvhich,  if  com¬ 
pelled  at  regular  and  proper  periods  to 
act  involuntarily,  would  either  not  waste 
at  all,  or  waste  to  an  incomparably  less 
extent.  Dr.  John  Reid  has  shown  how 
a  frog’s  muscles  may  be  nourished  by 
galvanism,  notwithstanding  their  being 

*  See  Works  of  Hunter  (Palmer’s  Edition.) 
Vol.  iv. 


530  ON  THE  ATROPHY  OF  PARALY'SIS - THE  M^'ANg  OF  PREVENTING  IT. 


cut  ofi'  from  the  nervous  centres.  I 
have  seen  cases  of  paralysis  (as  other  i 
must  have  done)  wherein  the  nutriei.it 
operation  of  this  powerful  agent  v  as 
extremely  marked.  This  ope.,.  *  )n, 
considered  by  itself \  would  suffice  to 
make  galvanism  of  the  greatest  value  in 
the  treatment  of  paralysis ;  but  galvan¬ 
ism  has  been  too  much  used  for  what 
it  cannot,  too  little  for  what  it  can ,  ac¬ 
complish.  It  is,  in  general,  the  best  of 
all  the  modes  of  producing  involuntary 
action ;  it  is  the  most  sure,  the  most 
manageable,  and  by  far  the  most  widely 
applicable,  since  it  acts  where  no  mo¬ 
tions  can  be  excited  otherwise.  It  was 
this  reflection  that  led  me  to  suggest 
that  it  should  be  used  for  the  express 
purpose  of  preventing  atrophy;  and  I 
think  the  reader  will  be  inclined  to 
agree  in  what  Mr.  Bowman  has  said  of 
its  power  to  do  so.*  But  where  and 
how  far  it  can  be  made  available  in  this 
respect  is,  strange  to  say,  a  matter  still 
in  need  of  close  inquiry. 

I  have  suggested  also  that  reflex  ac¬ 
tions  might  be  employed  to  preventatro- 
phy,fand,  since  then, have  had  occasion 
to  observe,  that  limbs  which  remained 
very  fairly  nourished  so  Jong  as  such 
motions  can  be  excited  in  them,  began 
to  waste  quickly  when  they  could  be 
provoked  no  longer.  But,  on  this  point, 
I  would  refer  to  a  case  in  which  Mr. 
Paget  (led  by  his  conclusions  from  Dr. 
Reid’s  experiments)  recommended  their 
excitement  with  the  direct  view  of 
causing  nutrition,  and,  apparently,  with 
good  result.  Though  far  less  generally 
applicable  than  galvanism,  they  may 
be  very  valuable  if  easily  to  be  excited, 
and  even  preferable  to  galvanism  in 
certain  cases,  as  in  that  of  a  child,  to 
whom  the  latter  gives  no  trifling  dis¬ 
tress  where  sensation  remains  in  the 
part  operated  on.  Direct  involuntary 
actions  tend  tonourish,  and  much  more, 
probably,  than  is  yet  suspected.  Cramp, 
if  it  happens  often,  may  greatly  influence 
the  size  of  a  limb,  as  has  been  lately 
proved  very  interestingly  by  a  writer  in 
the  April  number  of  the  British  and 
Foreign  Medico-Chirurgical  Review. 
Moreover,  as  Mr.  Bowman  shews,  by 
reference  to  the  disease  so  admirably 
described  by  Pott,  a  voluntary  muscle 
may  so  augment  through  involuntary 

See  article  “Muscular  Motion,”  in  Dr. 
Todd’s  Cyclopaedia  of  Anatomy  and  Physiology. 

f  Dr.  Marshall  Hall’s  Observations  in  Medi¬ 
cine,  vol.  i. 


^notion,  variously  caused,  as  to  “  appear 
hypertrophied.”  In  a  word,  it  is  use, 
not  the  manner  of  it,  which  nourishes 
a  muscle.  Emotion  may,  clearly,  sub¬ 
serve  nutrition  ;  and  I  have  lately  seen 
a  case  of  long-enduring  paralysis,  in 
which  the  paralytic  muscles  were  evi¬ 
dently  nourished  to  someextentthrough 
being  frequently  contracted  therewith. 
Nor  is  it  absurd  to  suppose  that  the 
aimless  movements  of  paralysis  agitans 
may,  in  some  severe  cases  of  the  affec¬ 
tion  (i literally  cases  of  paralysis  with 
agitation)  aid  considerably  in  checking 
atrophy. 

As  a  rule,  the  degree  of  atrophy  in 
paralysis  is  in  the  ratio  of  its  complete¬ 
ness  ;  but  the  most  complete  cerebral 
paralysis  which  can  occur,  may  not  be 
attended  by  any  loss  of  nourishment, 
because  of  the  frequently-occurring 
motions,  of  one  kind  or  other,  which 
are  dependent  on  the  spinal  marrow. 
Again,  injuries  of  the  cord  which  are 
attended  by  a  paralysis  in  which  spasms 
occur,  or  reflex  actions  can  be  excited, 
do  not  cause  the  same  wasting  of  parts 
as  those  accidents  which  effectually 
exclude  the  muscles  from  the  influence 
of  the  nervous  centres.  Dr.  Marshall 
Hall  has  shewn  that  irritability  may  be 
a  test  of  cerebral  paralysis,  as  distin¬ 
guished  from  spinal ;  and  I  have  had 
the  opportunity  of  seeing  him  employ 
it.  The  state  of  the  nutrition  of  the 
muscles  may,  as  it  seems  to  me,  also  help 
our  diagnosis.  For  instance,  if  in  a  case 
of  very  Z<m(/-standing  and  complete 
paralysis,  the  muscles  be  not  lax  and 
flabby,  but,  on  the  contrary,  well  nou¬ 
rished,  and  this  in  the  absence  of  any 
measures  having  been  taken  to  excite 
them  to  motion, — we  may  infer  that 
some  involuntary  action  must  have  oc¬ 
curred  from  time  to  time  to  prevent 
their  atrophy,  and  if  so,  the  paralysis 
is  cerebral  only.  But,  on  the  other 
hand,  muscles  may  greatly  waste,  and 
yet  be  connected  with  the  cord,  so 
that  atrophy  is  of  course  no  proof 
of  paralysis  being  spinal.  An  atro¬ 
phied  and  paralytic  muscle  may  be 
more  susceptible  of  the  galvanic  current 
than  its  healthy  fellow,  as  Dr.  Hall 
has  shewn.  But  the  most  favourable 
condition  of  all  for  excess  of  irritability 
is,  I  think,  that  in  which  the  muscles 
are  excluded  from  cerebral  influence, 
yet  still  connected  with  the  spinal  cord, 
and  have  enough  of  motion  to  nourish, 
too  little  to  exhaust  them.  This 


ON  THE  ATROPHY  OF  PARALYSIS — THE  MEANS  OF  PREVENTING  IT.  581 


opinion  is  in  no  wise  inconsistent  with 
the  fact  that,  under  opposite  circum¬ 
stances,  atrophied  muscles  may  be 
found  more  susceptible  of  galvanism 
than  those  that  are  well  nourished. 
The  matter  must  be  treated  as  a  whole. 
In  no  case  is  the  frog  more  irritable 
than  in  early  spring,  nor  ever  under  a 
happier  conjunction  of  circumstances 
for  the  manifestation  of  irritability  in 
the  extreme.  The  temperature  is 
favourable,  the  muscles  are  well  nou¬ 
rished,  and  yet  have  enjoyed  the  most 
protracted  repose;  and  it  seems  plain 
to  me,  that  most  irritability  is  to  be 
looked  for  in  that  state  in  which  the 
most  perfect  nutrition,  and  the  longest 
rest,  can  be  found  together. 

It  must  be  remembered  that  in  nou¬ 
rishing  a  muscle,  other  parts  are  nou¬ 
rished  also: — it  cannot  be  increased 
alone;  the  circulation  throughout  the 
whole  limb  is  benefited  ;  there  is  more 
demand  for  blood  ;  there  are  more  ele¬ 
ments  of  growth  eliminated ;  arteries, 
veins,  nerves,  the  hard  bones  even  share 
in  the  muscular  increase  ;  and  all  struc¬ 
tures  participate  in  its  waste.  In  some 
forms  of  paralysis  (as  Dr.  Gregory  says, 
if  my  memory  serves  me)  arterias  ipsce 
paralytica  sunt;  no  wonder  that  atro¬ 
phy  and  degeneration  shouldensue.Most 
true  it  is  that  we  cannot  rival  the  nor¬ 
mal  ways  whereby  growth  is  advanced 
and  nutrition  effected,  by  any  artificial 
proceeding,  however  ingeniously  it 
may  be  devised ;  but  we  may  in  some 
measure  compensate  a  voluntary  mus¬ 
cle,  for  the  atrophy  which  paralysis 
inflicts  upon  it  by  using  galvanism  re¬ 
peatedly  and  moderately,  not  seldom, 
and  to  excess.  Cases  there  will  be  in 
which  the  limb  may  be  hard  to  act 
upon  at  first,  but  the  muscles  will  at 
length  (as  I  have  found)  become  more 
irritable,  and  the  results  of  galvanism 
are  correspondingly  encouraging.  In¬ 
stances  of  partial  paralysis  there  are 
in  which  it  exists  in  a  double  sense  :  — 
it  contracts  both  by  virtue  of  its  own 
power,  and  forces  the  will  to  strong, 
successful  exercise.  I  have  known  a 
child  move  its  limbs  when  it  was  gal¬ 
vanised,  and  at  no  other  time.  The 
reason  was  plain  :  it  was  pained,  and 
used  energy  to  withdraw  the  part. 

There  are  cases  in  which  it  is  un¬ 
usually  important  to  attend  to  the  nu¬ 
trition  of  paralysed  limbs.  Generally 
speaking,  the  cases  of  the  young  more 
demand  such  attention  than  those  of 


the  aged ;  but  it  is  always  indicated 
wherever  there  is  wasting  and  a  chance 
of  recovery.  Let  me  point  to  what 
Mr.  Paget  has  said  upon  this  score, 
and  also  to  a  remark  of  Andral,  who 
observes  that  a  muscle,  from  long  im¬ 
mobility,  may  for  ever  lose  its  power 
of  contractility.  Whether  some  now 
hopeless  cases  of  paralysis  might  not 
have  been  classed  with  recoverable  mala¬ 
dies  had  but  the  nutrition  of  the  mus¬ 
cular  fibre  been  duly  cared  for,  is  a 
grave  but  plainly  an  expedient  ques¬ 
tion. 

Not  only  may  recovery  from  para¬ 
lysis  be  rendered  needlessly  slow  and 
tiresome,  by  allowing  muscles  to  waste 
away,  but  in  long-standing  cases  of 
this  affection,  absolutely  placed  beyond 
possibility.  There  may  be  no  efficient 
muscular  fibres  spared,  but*  only  use¬ 
less  remnants  of  them. 

But  in  reference  to  this  question  of 
providing  for  the  nutrition  of  paralysed 
limbs,  I  have  been  much  struck  by 
some  observations  in  Dr.  West’s  lec¬ 
tures  regarding  the  consequen6es  of 
paralysis  in  early  life.  There  is,  as 
he  proves  explicitly,  an  effect  of  para¬ 
lysis  peculiar  to  childhood, — “  arresta- 
tion  of  growth .”  Might  not  this,  as 
well  as  atrophy,  be  prevented  by  gal¬ 
vanism  ?  The  same  cause,  I  presume, 
which  leads  to  atrophy  in  the  adult, 
leads  both  to  atrophy  and  arrestation 
of  growth  in  the  child. 

Dr.  West’s  table  of  cases  is  very  in¬ 
structive;  he  mentions  no  less  than 
six  in  which  shortening  of  the  limb* 
took  place.*  Here  is  an  instance  :  a 
boy,  when  one  year  and  six  months  old, 
was  affected  with  paralysis  of  the  right 
leg.  Nothing  was  done  for  it;  and 
when  he  was  three  years  of  age,  it  wTas 
“wasted  and  shortened,  but  power  over 
it  was  on  the  increase.” 

Supposing  a  case  of  this  kind 
wherein  the  paralysis  is  completely 
cured,  can  anything  be  done  for  the 
lameness  consequent  on  the  shorten¬ 
ing  ?  A  trial  should  be  made  at  least ; 
and  I  think  it  would  be  right  to  advise 
that  the  affected  limb  should  be  used 
more  than  the  sound  one,  systematically 
and  perseveringly,  or  that  the  motions 
of  the  latter  should  be  purposely  pre¬ 
vented  at  certain  times  during  the  em¬ 
ployment  of  the  former  ;  for  perchance, 

*  Only  one  of  these  cases  appeared  to  have  been 
galvanised,  and  in  this  (Dr.  West  says)  galvanism 
“  was  tried  for  a  short  time.” 


552 


MR.  SMITH’S  CASE  OF  DISEASE  OF  THE  LARYNX. 


by  these  means  it  might  be  possible  to 
produce  an  inequality  of  growth  to  the 
advantage  of  the  shortened  member. 
Occasional  galvanism,  the  use  of  fric¬ 
tion,  and  the  sudden  application  of 
cold  now  and  then,  might  also  be  found 
useful. 

September,  1848. 


CASE  OF 

DISEASE  of  the  LARYNX. 

By  Henry  Smith,  M.R.C.S. 

Formerly  House-Surgeon  to  King’s  College 
Hospital. 


In  the  beginning  of  May,  I  was  con¬ 
sulted  by  Mrs.  P.,  a  married  woman, 
who  had  before  been  under  my  care 
for  secondary  syphilis.  She  now  com¬ 
plained  of  severe  pain  in  the  region  of 
the  larynx,  accompanied  with  difficulty 
of  breathing  and  harassing  cough. 
Her  voice  was  reduced  almost  to  a 
whisper,  and  it  was  evident  that  there 
was  some  serious  disease  in  the  vocal 
organ.  She  also  called  my  attention  to 
a  prominent  swelling  below  the  right 
scapula,  very  tender  on  pressure,  and 
painful  at  night.  She  was  very  weak 
and  pale,  and  presented  a  fair  specimen 
altogether  of  syphilitic  cachexy.  From 
the  knowledge  I  had  of  her  previous 
history  and  treatment,  I  had  no  doubt 
that  she  was  labouring  under  syphi¬ 
litic  ulceration  of  the  larynx,  and 
that  the  swelling  above  mentioned 
was  an  enormous  node  of  the  ribs, 
although  she  had  been  told  by  va¬ 
rious  medical  men  that  she  had  got 
tubercle,  and  that  she  would  not 
live  long.  I  carefully  examined  her 
lungs,  and  found  them  in  a  healthy 
condition,  and  gave  her  mild  doses  of 
calomel  with  opium,  and  quinine,  and 
five  grains  of  the  iodide  of  potassium 
twice  daily.  Her  mouth  became  gra¬ 
dually  affected  by  the  mercury,  but  no 
improvement  took  place ;  and  the  diffi¬ 
culty  of  breathing  was  so  great,  and 
her  voice  so  hoarse,  that  I  expected  I 
should  one  day  be  summoned  to  her 
for  the  purpose  of  ojSening  her  larynx. 

On  the  30th  of  May,  at  2  p.m.,  I  was 
hastily  called  by  her  husband,  who 
told  me  that  she  had  been  suddenly 
taken  very  ill  with  her  breathing,  and 
that  he  was  fearful  she  would  be  dead 
when  he  got  back.  I  immediately  at- 

♦ 


tended,  and  found  her  in  the  following 
condition: — She  was  lying  on  hei 
back  in  bed,  perfectly  unable  to  articu¬ 
late,  except  in  a  whisper,  placing  her 
hand  on  her  chest,  and  complaining  of 
great  sense  of  suffocation;  her  face  very 
anxious,  with  the  angles  of  the  mouth 
drawn  down,  depicting  a  state  of  great 
suffering.  Pulse  rapid  and  feeble; 
hands  cold.  It  appears  that  she  had 
been  sitting  up  in  the  morning,  more 
cheerful  than  usual,  but  had  suddenly 
become  affected  in  the  manner  de¬ 
scribed.  My  first  impulse  was  to 
open  the  larynx,  and  I  expressed  to 
her  friends  the  necessity  of  this  opera¬ 
tion,  to  which  they  perfectly  agreed, 
and  I  made  preparations  for  so  doing. 
Whilst,  however,  they  were  getting 
things  ready,  it  struck  me  that  there 
was  not  that  very  great  distress  which 
usually  exists  when  life  is  imminently 
in  danger  from  suffocation  ;  and,  more¬ 
over,  I  observed,  that  although  the 
face  was  very  anxious,  and  of  a  dusky 
colour,  yet  there  was  no  absolute  tur- 
gidity  of  the  vessels.  Under  these 
considerations,  I  hesitated,  and  poured 
a  glass  of  brandy  down  her  throat,  and 
determined  to  get  another  opinion. 
My  kind  and  honoured  friend,  Mr. 
Fergusson,  saw  her  with  me  in  less 
than  an  hour.  By  this  time  the  patient 
had  rallied  somewhat :  she  was  able  to 
speak  above  a  whisper,  and  there  was 
not  that  marked  distress  which  was  so 
apparent  at  first  sight.  Mr.  Fergusson 
expressed  his  opinion  that  the  symp¬ 
toms  were  not  so  much  due  to  an  ob¬ 
struction  in  her  breathing,  as  to  a  state 
of  syncope  ;  and  that,  on  that  account, 
the  operation  had  better  not  be  per¬ 
formed,  at  least  at  present ;  and  advised 
stimulants  and  carefu-l  watching.  She 
was  ordered  brandy  and  water  occa¬ 
sionally,  a  large  mustard  cataplasm  to 
be  applied  to  the  chest,  and  to  steam 
her  throat  with  hot  water.  In  the 
course  of  two  hours  she  was  again 
visited  by  me  :  she  continued  much  in 
the  same  condition,  but  had  improved 
somewhat  as  regards  her  breathing. 

At  10  p.m.  there  was  not  so  much  dis¬ 
tress  of  breathing,  although  since  I  last 
saw  her  she  had  suffered  one  or  two  sud¬ 
den  attacks  of  dyspnoea.  Shecomplained 
of  pain  and  uneasiness  in  the  region  of 
the  heart,  and  the  larynx  was  very 
painful ;  pulse  better.  Ordered — con¬ 
tinual  warm  fomentations  to  the  throat, 
outside  and  in  ;  a  large  sinapism  to  the 


ON  THE  HEPATIC  AFFERENT  VESSEL. 


533 


chest,  and  the  exhibition  of  nourishing 
broths,  &c. 

May  31st. — I  was  pleased  to  find 
this  poor  woman  considerably  better  : 
she  could  articulate  more  clearly ; 
pulse  better  ;  she  suffered  a  good  deal 
of  pain  in  her  throat;  breathing  tran¬ 
quil,  and  very  little  distress.  Four 
leeches  to  each  side  of  the  thyroid 
cartilage. — 1^  Calomel,  gr.  i.;  Pulv. 
Doveri,  gr.  v. ;  Quinae,  gr.  j .,  bis  die. 

June  1st. — Still  better;  can  breathe 
freely,  and  with  more  comfort ;  there 
is  still  much  tenderness  over  the 
larynx  ;  the  node  on  the  ribs  is  enor¬ 
mous,  and  exquisitely  painful. — To 
apply  four  more  leeches  to  larynx, 
and  take  five  grains  of  iodide  of  potas¬ 
sium  twice  daily. 

From  this  period  she  began  to  im¬ 
prove  steadily  ;  her  mouth  became 
affected  with  mercury,  and  her  symp¬ 
toms  gradually  gave  way  one  by  one, 
so  that  in  the  course  of  a  fortnight  she 
was  enabled  to  walk  up  to  my  resi¬ 
dence,  a  distance  of  nearly  a  mile. 
She  was,  however,  at  that  time  in  a 
very  weakly  condition,  and  was  ha¬ 
rassed  by  cough  ;  but,  under  the  use 
of  increased  doses  of  iodide  of  potas¬ 
sium,  sesquioxide  of  iron,  and  the 
external  application  of  iodine  paint  to 
the  larynx,  she  most  rapidly  improved  ; 
and  I  have  lately  seen  her  looking  ruddy 
and  fat ;  the  swelling  on  the  side  has 
disappeared,  and  she  can  speak  with 
tolerable  clearness,  although  some 
hoarseness  still  remains,  and,  I  think, 
will  ever  remain,  in  consequence  of 
the  structural  change  which  has  evi¬ 
dently  taken  place  in  her  vocal  organ. 

I  have  brought  this  case  before  the 
profession,  because  it  appears  to  me  to 
present  features  of  peculiar  interest, 
and  a  description  of  which  one  cannot 
easily  find  in  books;  moreover,  it  was 
so  instructive  to  myself,  that  I  am 
willing  that  it  should  prove,  if  possible, 
instructive  to  others ;  for  it  is  here 
shown  how  very  careful  we  should  be 
before  proceeding  to  any  extreme  mea¬ 
sure  in  a  difficult  and  doubtful  case. 
When  my  patient  was  seized  with  her 
sudden  attack,  my  first  impulse  (as  I 
before  said)  was  to  open  her  larynx, 
because  the  symptoms  appeared  to  me 
to  indicate  that  measure;  and  also, 
perhaps,  because  I  had  some  time  before 
been  expecting  to  be  called  to  her  in 
such  a  condition  ;  and  thus  my  mind 
was  somewhat  prejudiced  in  favour  of 


the  operation.  But  acting,  as  I  hope 
I  always  shall  do,  when  in  doubt  and 
uncertainty,  respecting  a  proceeding 
likely  to  involve  the  life  of  a  human 
being,  I  determined  to  have  the  opinion 
of  a  more  experienced  person,  and  thus 
was  prevented  from  committing  what 
(as  matters  turned  out)  at  least  would 
have  been  an  unnecessary  act,  and 
perhaps  a  serious  error;  as  it  is  well 
known — and  I  felt  this  at  the  time — 
that  the  operation  of  laryngotomy  is 
sometimes  attended  with  immediately 
fatal  results  :  nevertheless,  the  symp¬ 
toms  at  the  time  I  was  called,  taking 
into  consideration  the  history  of  the 
case,  were  sufficiently  urgent  to  induce 
many  persons  to  adopt  the  proceeding, 
and  appeared  to  warrant  one  in  doing 
so;  but  that  they  did  not  do  so  in  reality, 
is  evident  from  the  result  of  the  case. 

13,  Caroline  Street,  Bedford  Square, 
September,  1848. 


THE 

HEPATIC  AFFERENT  VESSEL. 

( From  a  Correspondent.) 

There  are  in  the  body  only  three 
afferent  vessels,  or  vessels  which  take 
blood  to  parts.  The  first  afferent 
vessel  is  the  hepatic ,  and  consists  of  the 
spleen  and  the  splenic  and  portal  vein 
and  its  branches.  The  second  afferent 
vessel  is  the  pulmonic ,  and  consists  of 
the  right  auricle  and  ventricle,  and 
the  pulmonary  artery  and  its  branches. 
The  third  afferent  vessel  is  the  systemic , 
and  consists  of  the  left  auricle  and 
ventricle,  and  the  aorta  and  its 
branches.  The  hepatic  veins  are  the 
hepatic  efferent  vessels,  and  take  the 
blood  from  the  liver.  The  pulmonary 
veins  are  the  pulmonic  efferent  vessels, 
and  take  the  blood  from  the  lungs. 
The  mesenteric  veins,  and  the  superior 
and  inferior  venae  cavae,  and  their  roots, 
are  the  systemic  efferent  vessels,  and 
take  the  blood  from  the  general  sji  stem. 
Intermediate  between  the  terminal 
branches  of  each  afferent  vessel  and 
the  primary  roots  of  the  corresponding 
efferent  vessels  are  the  capillaries, 
which  are  perferent  vessels — that  is, 
take  blood  through  parts.  All  blood¬ 
vessels,  therefore,  are  either  afferent, 
perferent,  or  efferent. 

Now  I  have  a  word  to  say  on  behalf 
of  the  hepatic  afferent  vessel,  the  most 


534 


ON  THE  HEPATLC  AFFERENT  VESSEL. 


neglected  of  all  vessels,  although  on 
Nature’s  list  it  is  marked  number  one — 
that  is,  it  is  the  first  of  the  three 
afferent  vessels.  It  is  simply  a  vein, 
with  a  spleen  for  its  commencement. 
The  pulmonic  afferent  vessel  is  an 
artery,  with  a  heart  for  its  commence¬ 
ment  ;  and  the  systemic  afferent  vessel 
is  also  an  artery,  with  a  heart  for  its 
commencement.  If  the  hepatic  afferent 
vessel  had  been  an  artery  too,  with  a 
heart  for  its  commencement,  in  the 
auricle  of  which  the  mesenteric  veins 
had  terminated,  the  three  afferent 
vessels  would  have  been  all  alike,  and 
then  the  function — that  is,  the  office 
and  action —of  the  first  would  have 
been  understood  simultaneously  with 
the  functions  of  the  other  two.  There 
would  have  been  no  difficulty  at  all  in 
the  matter  then;  nor  is  there  much,  if 
any,  now.  The  first  thing  necessary 
to  its  right  comprehension  is,  that  the 
hepatic  afferent  vessel  should  have  an 
admitted  existence  as  such,  which  at 
present  it  lias  not,  and  then  it  will  soon 
have  a  recognized  use.  Instead  of  re¬ 
garding  it  as  a  nonentity,  accord  to  it 
its  legitimate  rank  ; — let  it  be  acknow¬ 
ledged  to  be  an  afferent  vessel  as  well 
as  the  other  two :  and  then  it  will  be 
seen — Firstly,  that  it  receives  by  the 
mesenteric  veins  the  fluidified  or  di¬ 
gested  solids  and  the  fluids  ;  in  other 
words,  the  food  and  drink  from  the  ali¬ 
mentary  tube,  and  which  are  absorbed 
by  the  gastro-intestinal  capillaries  ;  and 
that  it  is  an  error,  and  a  very  absurd 
one  too,  to  suppose  that  an  out-of-the- 
way  vessel  like  the  left  subclavian 
vein,  receives  through  such  a  long  and 
narrow  tube  as  the  thoracic  duct  “  the 
fresh  nutritive  materials  derived  from 
the  digestive  process.”  Secondly,  that 
the  hepatic  afferent  vessel  propels  the 
blood  through  the  hepatic  capillaries 
or  liver, and  not,  as  isgenerally  believed, 
the  systemic  afferent  vessel ;  and 
thirdly,  that  the  reason  it  does  not  con¬ 
sist  of  a  heart  and  artery,  but  of  a  spleen 
and  vein  is,  because  a  different  kind  of 
motion  of  the  blood  is  required  through 
the  hepatic  capillaries  to  that  through 
either  the  pulmonic  or  systemic  capil¬ 
laries  ;  that  is,  an  intermittent  and  slow 
motion,  and  not  a  constant  and  rapid 
one.  If  a  constant  and  rapid,  instead 
©f  an  intermittent  and  slow,  motion  of 
the  blood  through  the  liver  had  been 
required,  then  the  hepatic  afferent  ves¬ 
sel,  like  the  pulmonic  and  systemic, 


would  have  consisted  of  an  auricle,  a 
ventricle,  and  an  artery,  and  the 
mesenteric  veins  would  have  terminated 
in  the  auricle.  On  the  other  hand,  if 
an  intermittent  and  slowr,  instead  of  a 
constant  and  rapid,  motion  of  the  blood 
through  the  lungs  had  been  necessary, 
the  right  auricle  and  ventricle  would 
have  been  a  spleen,  and  the  pulmonary 
artery  and  its  ramifications  a  vein,  like 
the  splenic  and  portal,  in  the  middle  of 
which  the  superior,  inferior,  and  hepatic 
cavse  would  have  terminated :  and 
again,  if  an  intermittent  and  slow,  in¬ 
stead  of  a  constant  and  rapid  motion 
of  the  blood  through  the  general  sys¬ 
tem  had  been  necessary,  the  left 
auricle  and  ventricle  would  have  been 
a  spleen,  and  the  aorta  and  its  ramifica¬ 
tions  a  vein,  like  the  splenic  andportal, 
in  the  middle  of  which  the  pulmonary 
veins  would  have  terminated.  For  the 
three  afferent  vessels  we  should  then 
have  had  one  heart  and  artery,  and 
two  spleens  and  veins,  and  not  as  now 
one  spleen  and  vein,  and  two  hearts 
and  arteries.  The  hepatic  afferent 
vessel,  by  slow  distension  and  contrac¬ 
tion,  produces  an  intermittent  and  slow 
motion  of  blood  ;  the  pulmonic  and 
systemic  afferent  vessels,  by  rapid  dis¬ 
tension  and  contraction,  produce  a  con¬ 
stant  and  rapid  motion  of  blood.  As 
I  have  said  elsewhere,  heart  and  spleen, 
and  artery  and  vein,  are  anatomical 
antitheses,  and  produce  opposite  phy¬ 
siological  effects  : — 

Heart  +  artery  =  constant  and  rapid 
motion  of  blood. 

Spleen  +  vein  =  intermittent  and  slow 
motion  of  blood. 

J.  J. 

Sept.  16,  1848. 

P.S.  The  spleen,  which  never  ought 
to  be  regarded  as  a  distinct  or  isolated 
organ,  but  as  the  commencement  or 
roots  of  the  hepatic  afferent  vessel, 
consists  essentially,  and  almost  wholly, 
of  the  branches  of  the  splenic  artery, 
and  of  the  roots  of  the  splenic  and 
portal  vein,  and  of  the  intermediate 
capillaries.  The  capillaries  are  for  the 
purpose  of  furnishing  points  of  origin 
for  the  venous  roots,  which  could  not 
originate  from  nothing,  or  from  any¬ 
thing  else  than  capillaries,  and  the 
artery  is  for  the  purpose  of  supplying 
material  for  the  formation  of  the 
capillaries.  Its  tortuosity  is  evidently 
to  minimise  the  quantity  of  blood  that 


DESCRIPTION  OF  A  TRUSS  TO  BE  WORN  IN  CONGENITAL  HERNIA.  535 


passes  through  it,  for  it  is  not  the  blood 
that  is  wanted,  but  only  the  blood¬ 
vessel.  The  elastic  capsule  of  the 
spleen,  and  its  prolongations  through 
the  interior  of  the  organ,  and  the 
splenic  nerves  and  lymphatics,  are  of 
secondary  importance,  and  in  this 
place  require  no  comment. 


DESCRIPTION  OF  A 

TRUSS  TO  BE  WORN  IN  CASES  OF 
CONGENITAL  HERNIA. 

By  William  Coates,  M.R.C.S. 

“  If  circumstances  will  admit  of  a  truss 
being  applied  and  worn,  in  cases  of 
congenital  hernia  in  young  subjects, 
there  will  be  considerable  chance  of  a 
radical  cure  being  effected.” — Sami. 
Cooper. 

From  this  passage  we  may  infer  that 
some  difficulty  is  to  be  encountered  in 
the  adjustment  of  a  truss  in  young  sub¬ 
jects  ;  and  there  are  few  surgeons,  I 
believe,  who  have  not  been  hampered 
in  the  management  of  hernia,  occurring 
in  very  young  infants,  either  from  the 
want  of  tact  in  nurses— the  impatience 
of  restraints — the  necessity  of  removing 
the  truss  during  washing  and  dressing, 
when  the  infant  usually  cries — the 
falling  which  frequently  occurs — or 
from  the  expense  of  a  constant  supply 
of  new  trusses,  occasioned  by  the  rot¬ 
ting  and  destroying  influence  of  urine, 
notwithstanding  the  coating  of  india- 
rubber,  japan,  or  any  other  varnish. 


The  subjoined  sketch  represents  a 
truss  employed  by  a  gudewife  in  my 
neighbourhood  j  and  its  excellence  is 


such  that  it  is  a  duty  to  make  it  gene¬ 
rally  known.  Horace  tells  us  not  to 
despise  the  teaching  of  the  unlearned, 
for — 

“  Interdum  vulgus  rectum  videt.”— Epist. 

I  have  given  this  truss  extensive  trials : 
the  result  has  uniformly  been  the  ra¬ 
dical  cure  of  the  disease.  It  consists, 
simply,  of  a  skein  of  lamb’s  wool  : 
for  infants, — Berlin  wool  is  prefera¬ 
ble :  this  encircles  the  pelvis,  one  end 
is  passed  through  the  other  at  a  point 
corresponding  with  the  inguinal  ring; 
the  free  end  is  carried  between  the 
thighs,  and  is  fastened,  behind  to  that 
portion  which  forms  the  cincture. 

This  simple  and  cheap  contrivance 
can  be  worn  during  the  morning  and 
evening  ablutions,  and  then  changed 
for  a  dry  one  ;  no  attention  is  required 
on  the  part  of  the  nurse,  except  at  the 
moment  of  changing.  With  ordinary 
care  in  drying  the  skin,  and  the  occa¬ 
sional  application  of  magnesia  or  other 
nursery  powders,  I  have  never  found 
the  skin  galled. 

In  cases  of  emergency  this  truss  may 
be  made  available  for  adults ;  or  rather, 
the  modification  of  two  silk  handker¬ 
chiefs  tied  in  a  ring,  which,  as  a  jt ris- 
alter ,  is  no  more  to  be  despised  than  is 
a  garter  and  stick  as  a  temporary  tour¬ 
niquet. 

Wrington,  Sept.  4,  1848. 


SATISFACTORY  INFORMATION  FOR  ENGLISH 
MEDICAL  AUTHORS. 

Our  Canadian  contemporary,  the  British 
American  Journal,  in  its  number  for  Sep¬ 
tember,  gives  a  short  notice  of  the  works  of 
Drs.  G.  O.  Rees,  Griffith,  and  Mr.  Mark- 
wick,  on  the  Blood  and  Urine,  and  it  sums 
up  with  the  following  very  satisfactory  an¬ 
nouncement  : — “  Like  most  American  re¬ 
prints,  it  contains  numerous  typographical 
errors  ;  but  we  must  overlook  this,  when,  we 
recollect  that  we  have  three  treatises  neatly 
hound  together,  and  well  printed  on  good 
paper,  for  less  than  the  English  copy  of  any 
one  of  them  would  cost.n 

It  is  with  regret  that  we  do  not  see  this 
dishonest  system  of  stealing  and  selling  other 
persons’  goods  strongly  denounced  by  our 
contemporary.  However  the  eighth  com¬ 
mandment  may  be  despised  at  Philadelphia — 
Canada  is  a  British  possession,  and  we  desire 
to  know  why  the  stolen  labours  of  English 
authors  are  allowed  to  be  sold  across  the 
border  so  that  three  volumes  are  to  be  had 
for  the  price  of  one  in  England.  Is  this  fair 
dealing  ? 


536 


COMMENCEMENT  OF  ANOTHER  MEDICAL  SESSION - 


MEDICAL  GAZETTE. 


FRIDAY,  SEPTEMBER  29,  1848. 


Before  another  number  of  our  journal 
appears,  the  medical  session  for  1848-9 
will  have  commenced.  The  Metropo¬ 
litan  and  Provincial  schools  have  under¬ 
gone  but  few  changes  during  the  sum¬ 
mer  vacation  :  we  still  recognise  among 
the  professors  and  lecturers,  the  names 
of  gentlemen  already  well  known  to  the 
profession,  and  the  same  routine  of 
study  is  marked  out  for  the  young  aspi¬ 
rants  to  professional  honours.  The 
principal  change,  so  far  as  the  metro¬ 
polis  is  concerned,  is  the  accession  of 
Mr.  Arnott  to  the  office  of  Surgeon  and 
Professor  of  Surgery  in  the  Medical 
School  of  University  College.  Some 
of  our  contemporaries  have  been  busy 
in  predicting  the  downfal  of  this  Col¬ 
lege  ;  and  have  described  the  new  ap¬ 
pointments  as  the  result  of  jobbery  and 
intrigue.  Of  the  existence  of  these 
influences  we  know  nothing ;  but  it 
appears  to  us  that  that  species  of  job¬ 
bery  which  succeeds  in  filling  the  Chairs 
of  Anatomy,  Surgery,  Midwifery,  Che¬ 
mistry,  and  Materia  Medica,  with  such 
men  as  now  hold  these  appointments 
in  the  school  of  University  College, 
cannot  be  reasonably  objected  to.  We 
do  not  believe  that  the  concours,  with 
its  noisy  but  unsound  professions  of 
fair  play,  would  have  succeeded  in  pro¬ 
curing  a  more  talented  or  a  more  highly- 
respected  body  of  professors  than  those 
who  are  now  attached  to  this  College. 
The  grievance,  if  any,  must  therefore 
be  regarded  as  one  of  a  sentimental 
kind.  Appointments  privately  made 
by  irresponsible  councils, may,  it  is  true, 
lead  to  the  creation  of  a  bad  class  of 
teachers ;  but  we  are  by  no  means  con¬ 
vinced  that  any  other  mode  of  election 
yet  devised  is  free  from  the  same  objec¬ 


tion.  In  the  meantime,  the  Council  of 
University  College  have  not  only  put  a 
stop  to  the  dissensions  which  existed 
in  the  school  at  the  close  of  the  last 
session,  but  have  succeeded  in  recruit¬ 
ing  their  medical  staff  in  a  most  efficient 
and  satisfactory  manner. 

Among  the  other  changes,  we  ought 
to  notice  that  Dr.  West,  whose  lec¬ 
tures,  as  recently  published  in  this 
journal,  have  deservedly  acquired  for 
him  a  high  reputation,  has  joined  the 
Medical  School  of  St.  Bartholomew’s 
Hospital  as  Professor  of  Midwifery.* 

It  is  not  our  practice  to  give  advice 
respecting  the  choice  of  schools.  There 
are,  probably,  fewr  students  who  have 
not  already,  under  the  guidance  of  pa¬ 
rents  or  medical  friends,  made  a  selec¬ 
tion  before  they  reach  the  metropolis. 
To  those  who  may  not  have  had  the 
good  fortune  to  be  thus  assisted  by  the 
mature  experience  of  others,  we  would 
only  say, — Look  to  the  means  for  im¬ 
parting  a  sound  knowledge  of  ■practical 
medicine  and  surgery  :  look  to  the  hos¬ 
pital  attached  to  the  school — the  op¬ 
portunities  afforded  for  clinical  study , 
and  the  facilities  thrown  out  by  the  aid 
of  a  museum  and  good  medical  library 
for  the  acquisition  of  professional  know¬ 
ledge.  Again,  we  would  say — Do  not 
look  to  those  “  Establishments,”  whe¬ 
ther  in  town  or  country,  the  principal 


*  We  think  the  time  has  arrived  when  theterm 
professor  should  be  substituted  for  that  of  lec¬ 
turer  in  the  appointments  held  in  our  medical 
schools.  Whoever  is  qualified  to  teach  m  a 
school  attached  to  a  metropolitan  or  provincial 
hospital  must,  virtute  officii,  be  a  professor.  The 
term  lecturer,  in  reference  to  medical  tuition,  is 
not  used  in  the  language  of  any  other  country  ; 
and  the  public  are  misled  by  supposing  it  to  be 
an  office  inferior  to  that  of  a  professor.  As  it 
strictly  implies  the  reader  of  a  discourse,  it 
is  more  applicable  to  members  of  the  cle¬ 
rical  than  of  the  medical  profession.  We  need 
hardly  say  that  there  is  no  assignable  difference 
in  qualification  or  professional  standing  between 
lecturers  and  professors  in  our  medical  schools ; 
and  there  appears  to  be  some  absurdity  in  retain¬ 
ing  the  use  of  a  term  which  is  apt  to  mislead  the 
public,  when  there  is  another  more  intelligible 
at  hand.  The  only  drawback  to  the  general 
adoption  of  the  title  that  we  know  of  is,  that  the 
shilling  dispensers  of  chemistry  and  natural  phi¬ 
losophy  at  Polytechnic  and  Mechanics’  Institu¬ 
tions  commonly  style  themelves  professors. 


ADVICE  TO  STUDENTS — CHEAP  MEDICAL  ESTABLISHMENTS.  537 


attractions  of  which  consist  in  unu¬ 
sually  low  fees  and  in  a  preponderance 
of  prizes  in  the  shape  of  books,  medals, 
&c.* 

In  medicine,  as  in  other  professions, 
the  parade  of  unprecedentedly  low 
fees  may  turn  out  to  be  a  hollow  de¬ 
ceit.  Men  know  what  it  is  to  buy  too 
cheaply :  they  soon  find  out  their  mis¬ 
take,  and  they  thus  often  acquire  use¬ 
ful  experience  at  a  small  cost.  In 
medical  education,  however,  the  evil  of 
an  unfortunate  selection  may  be  dis¬ 
covered  only  when  too  late,  and  an  un¬ 
wise  economy  in  the  beginning  may  thus 
prove  ruinous  in  the  end.  At  the 
close  of  a  session,  letters  have  been  ad¬ 
dressed  to  us  by  students,  complaining 
that  promises  had  not  been  performed ; 
that  lectures  had  been  delivered  with  ir¬ 
regularity;  the  means  of  illustrationwere 
wanting,  and  there  were  no  subjects  to 
be  had  for  dissection.  These  gentle¬ 
men  had  entirely  forgotten  that  they 
had  received  a  full  equivalent  for  their 
contributions  ;  and  that  it  was  most  un¬ 
reasonable  on  their  parts  to  expect,  that 
for  half  the  sum,  they  should  receive 
all  the  benefits  which  their  student- 


*  It  is  very  much  to  be  regretted,  that  in  the 
London  Hospital  Schools,  with  very  few  excep¬ 
tions,  the  dresserships,— those  important  offices 
which  lead  to  the  acquisition  of  a  greater 
amount  of  practical  instruction  in  a  few  weeks 
than  can  otherwise  be  gained  in  one  or  more 
years,  are  still  made  a  matter  of  bargain  and 
sale,  and  are  only  to  be  procured  by  the  payment 
of  heavy  fees.  This  system  should  be  entirely 
abolished,  as  it  allows  an  incompetent  man,  well 
provided  with  money,  to  occupy  a  most  responsi¬ 
ble  office,  while  the  poor,  but  industrious,  and 
perhaps  competent  student,  is  excluded,  merely 
because  he  lias  not  the  means  of  paying  the  fee. 
To  the  honour  of  the  governors  of  a  few  institu¬ 
tions  in  the  metropolis,  this  system  has  been 
abolished,  and  the  sole  qualifications  for  the  office, 
are  the  industry  and  ability  displayed  by  the 
student, and  certifiedby  the  professors.  Theseare 
the  real  prizes  to  which  a  student  should  look  ; 
he  will  find  one  of  these  appointments  far  more 
valuable  to  him  hereafter,  than  any  number  of 
gold  or  silver  medals  earned  by  the  closest  ap¬ 
plication  to  one  or  two  special  branches  of  medical 
science.  We  are  aware  that  the  sale  of  dresserships 
is  sometimes  justified  by  the  plea  that  the  insti¬ 
tution  is  in  want  of  funds  ;  but  the  real  question 
is, — should  money  be  raised  by  a  system  which 
cannot  ensure  that  attention  and  skill  which  the 
patients  in  public  hospitals  have  a  right  to  re¬ 
ceive,  and  which  makes  a  long  purse  the  only 
test  of  competency  in  the  medical  attendant. 


friends  had  derived  at  other  medical 
schools.  We  by  no  means  object  to 
competition  in  medical  education,  but 
it  must  be  a  wholesome  competition. 
No  single  branch  of  medicine  can  be 
efficiently  taught  without  certain  ex¬ 
penses  being  incurred;  and  it  would 
be  easy  to  prove  that  the  fees  in  some 
instances  could  not  have  been  adequate 
to  cover  these  necessary  expenses, — to 
furnish  the  prizes  (awarded  as  a  matter 
of  course),  and  to  leave  a  balance  in  the 
hands  of  the  professor!  The  name  of  one 
of  these  teachers  has  been  forwarded 
to  us,  with  the  representation  that  the 
students,  in  entering  to  his  courses,  are 
well  aware  that  they  are  paying  the 
fee  for  the  certificate  to  enable  them  to 
go  up  to  the  Hall  or  College,  and  that 
they  are  perfectly  willing  to  forego  the 
dubious  benefit  of  his  lectures.  For 
these  reasons  we  say  :  let  students  be¬ 
ware  of  these  tempting  inducements. 
The  fact  that  schools  and  private 
teachers  are  “  recognised,”  is  at  present 
no  criterion  of  the  efficiency  of  the  for¬ 
mer,  or  of  the  competency  of  the  latter. 

The  agitation  on  the  subject  of  me¬ 
dical  reform  has  created  some  uncer¬ 
tainty  among  those  who  are  about  to 
enter  the  profession,  as  to  the  course 
which  they  should  adopt.  The  yearly 
threatening  of  Medical  Education  and 
Practice  of  Physic  Acts,  has  unsettled 
the  minds  of  all  connected  with  the 
profession.  They  who  are  desirous  of 
joining  it  have,  however,  only  one  plain 
rule  to  follow — namely,  to  obey  the  laws 
as  they  are.  The  rules  of  the  Apothe¬ 
caries’  Society  and  of  the  College  of 
Surgeons, regarding  the  course  of  study, 
must  be  strictly  observed.  There  must 
be  no  omission,  on  the  hypothetical 
ground  that  a  medical  millennium  is  at 
hand,  or  that  the  medical  profession  in 
these  islands  is  about  to  undergo  a 
complete  regeneration  on  the  “  liberty, 
equality,  and  fraternity”  principle. 
Whatever  measure  may  be  passed,  the 


538  NEW  COURSE  OF  LECTURES.  THE  CAVENDISH  SOCIETY. 


rights  of  students  under  old  regu¬ 
lations  will  be  respected  ;  while  those 
who  fall  under  the  new  regulations 
must  be  prepared  for  a  larger  de¬ 
mand  being  made  on  them  as  to  the 
period  of  study,  the  subjects  to  be  stu¬ 
died,  and  the  mode  of  examination. 
The  improvement  of  the  profession 
will  assuredly  consist  not  in  making 
rules  more  lax,  but  in  making  them 
more  stringent. 

One  word  of  advice  in  conclusion. 
A  student  must  not  expect  too  much 
from  his  teachers.  Knowledge  cannot 
be  poured  into  the  mind  as  water  is  into 
a  vessel.  Hard  work,  close  study,  with 
industry  and  perseverance,  are  essen¬ 
tially  required.  With  these  a  man 
may  achieve  any  object :  without  them 
he  will  achieve  nothing. 


Our  readers  will,  we  are  sure,  be 
pleased  to  hear  that  in  addition  to  the 
valuable  series  of  lectures  which  have 
recently  appeared  in  this  journal,  we 
have  made  arrangements  to  publish  a 
Course  of  Lectures  on  Preternatural 
and  Complex  Labours,  and  on  certain 
Diseases  of  the  Parturient  State,  by 
Dr.  E.  W.  Murphy,  Professor  of  Mid¬ 
wifery,  &c.,  in  University  College.  The 
introductory  lecture  to  the  Course,  will 
be  inserted  in  the  following  number, 
and  the  remaining  lectures  will  appear 
on  alternate  weeks,  until  the  course  is 
completed.  These  lectures  will  in¬ 
clude  the  practical  consideration  of  the 
following  subjects  :  —  Preternatural 
Labours,  Hemorrhages,  Convulsions, 
Ruptures  of  the  Uterus,  Twins,  Lacta¬ 
tion,  Convalescence,  Inflammations, 
Puerperal  Fever,  and  Puerperal  Mania. 
We  have  no  doubt  they  will  be  fully 
valued  by  all  who  are  engaged  in  the 
practice  of  midwifery. 


We  invite  the  attention  of  our 
readers  to  the  prospectus  of  the  Caven¬ 


dish  Society,*  which  is  now  fully  or¬ 
ganised,  and  has  already  commenced 
its  labours  under  the  most  favourable 
auspices.  We  need  only  state  here, 
that  the  object  of  this  Society  is  to  print, 
publish,  and  circulate  valuable  original 
works  on  Chemistry.  To  accomplish 
this,  a  small  annual  subscription  is 
raised,  and  in  return,  each  member  will 
receive  one  or  more  volumes,  according 
to  the  number  of  subscribers.  There 
are  already  six  hundred  members,  and 
the  works  to  be  distributed  for  the  pre¬ 
sent  year,  of  which  we  have  one  now 
before  us,  may  be  considered  as  a  very 
fair  return  for  the  amount  of  the  sub¬ 
scription.  Our  readers  will  judge  from 
the  list  of  works  proposed  to  be  pub¬ 
lished,  how  far  the  objects  of  the 
Society  are  worthy  of  their  patronage. 
We  shall  only  observe,  that  if  the  plan 
beearriedout  as  it  has  been  commenced, 
it  will  deserve  the  support  of  all  men 
who  are  interested  in  the  progress 
and  diffusion  of  science.  Numerous 
valuable  memoirs  on  Chemical  science 
by  foreign  writers,  may,  by  the  general 
support  of  this  Society,  fall  into  the 
hands  of  students  and  practitioners, 
when  their  costliness,  or  the  fact  of 
their  being  published  in  French  or 
German,  might  otherwise  have  ex¬ 
cluded  them  from  general  circulation. 
Literary  Associations  of  this  kind, 
when  well  conducted,  are  productive  of 
much  good.  The  names  of  those  gen¬ 
tlemen,  who  constitute  the  Vice-Presi¬ 
dents  and  Council,  are,  we  think,  a 
sufficient  guarantee  that  the  expecta¬ 
tions  of  the  members  of  this  new 
Society  will  not  be  disappointed. 


Notwithstanding  the  rumours  which 
are  continually  reaching  us  of  the  pro¬ 
gress  of  the  Asiatic  Cholera,  it  is  satis¬ 
factory  to  perceive  that  the  state  of 
health  of  the  metropolis,  at  a  period  of 

*  Page  558. 


539 


STATE  OF  HEALTH  OF  THE  METROPOLIS. 


the  year  which  is  usually  regarded  as 
most  unhealthy,  is  on  the  whole  favour¬ 
able.  At  any  rate,  there  is  nothing 
to  indicate  alarm,  or  to  show  that 
bow’el-complaints  or  other  disorders, 
supposed  to  be  indicative  of  the  advent 
of  cholera,  are  on  the  increase.  Taking 
the  Registrar-General’s  return  of  the 
last  week,  (September  16),  they  are 
actually  on  the  decrease.  Thus  there 
were  only  six  deaths  from  Cholera 
(English)  to  a  weekly  summer  average 
of  seven  ;  and  as  to  Diarrhoea ,  wrhich  is 
looked  upon  as  the  special  forerunner 
of  Asiatic  cholera,  the  deaths  w  ere  only 
forty-two  to  a  quinquennial  weekly 
summer  average  of  sixty-six.  Among 
the  fatal  cholera  cases,  one  half,  and 
among  the  fatal  diarrhoea  cases,  two- 
thirds  occurred  among  infants.  There 
was  not  one  fatal  case  of  influenza. 
These  results  must  be  very  discouraging 
to  those  alarmists,  who,  some  months 
since,  held  out  to  the  public  the  very 
unsatisfactory  announcement,  that  “  un- 
mistakeable”  cases  of  Asiatic  cholera 
had  already  occurred  in  the  metropolis  ! 
It  is  now,  we  think,  abundantly  proved 
that  these  cases  wrere  really  mistaken 
in  their  nature,  and  that  there  was  no 
ground  for  the  absurd  rumour  of  the 
appearance  of  cholera  among  us.  Our 
readers  will  hardly  believe  that  the 
French  journals,  on  the  strength  of 
this  unfounded  rumour,  have  recently 
circulated  a  report  that  the  inhabitants 
of  London  had  been  actually  decimated 
by  the  Oriental  scourge,  and  that  the 
ravages  of  the  disease  at  the  time  of 
writing  were  too  frightful  to  contem¬ 
plate  !  A  French  correspondent  in 
London  has,  however,  undeceived  the 
Parisian  public,  and  has  thus  relieved 
them  of  a  large  amount  of  unnecessary 
sympathy. 

Although  the  picture  is  so  far  fa¬ 
vourable  in  this  point  of  viewq  and  the 
total  weekly  mortality  was  last  week 
much  below  the  average,  it  cannot  be 


denied  that  the  table  of  mortality  is  in 
another  respect  very  unfavourable.  We 
had  occasion  to  state,  in  our  short  sum¬ 
mary  of  the  preceding  w7eek,  that  there 
had  been  a  great  increase  in  the  deaths 
from  scarlet  fever.  The  deaths  from 
this  disease  wTere  145 ;  no  less  than 
quadruple  of  the  weekly  average ,  at  the 
present  season.  The  infantile  popula- 
lation  suffered  to  the  extent  of  141 
deaths  out  of  this  number.  What  are 
the  causes  which  have  suddenly  ren¬ 
dered  this  formidable  disease  so  pre¬ 
valent  and  so  fatal  ?  and  what  are  the 
best  means  of  subduing  its  ravages? 
Such  questions  are  of  far  greater  im¬ 
portance  at  the  present  time  than  the 
concoction  of  imaginary  specifics  for 
Asiatic  cholera.  It  offers  a  fit  subject 
for  the  investigation  of  a  Board  of 
Health,  constituted  not  of  ministerial 
nominees,  but  of  w7ell-informed  medical 
men.  Such  a  Board  is  yet,  however,  a 
desideratum  in  this  country.* 

While  discussing  the  Registrar’s 
return,  we  must  observe  that  the  fre¬ 
quent  changes  made  in  the  classifica¬ 
tion  and  specification  of  diseases  are 
most  objectionable.  We  find  nowin 
the  list  a  new  “  zymotic,”  under  the 
name  of  Noma  or  Canker.  Whose  in¬ 
vention  is  this  ?  We  are  at  a  loss  to 
conceive  the  necessity  for  its  introduc¬ 
tion  into  this  already  numerous  class  of 
diseases.  It  appears  from  the  table 
that  the  weekly  average  deaths  from 
noma  amount  to  only  three-tenths  of 
a  person  weekly  !  Hence  there  does 
not  appear  to  have  been  any  great 
public  necessity  for  its  addition  to  the 
list.  The  effect  of  such  a  system  is, 
that  we  are  constantly  incurring  the 
risk  of  confounding  mere  symptoms 
with  the  diseases  themselves. 

*  The  return  for  the  present  week.  Sept.  23d, 
show’s  a  slight  increase  in  the  total  deaths,  but 
those  from  diarrhoea  and  cholera  are  about  the 
same  as  in  the  preceding  week.  The  deaths 
from  scarlet  fever  were,  however,  no  less  than 
161,  of  which  154  were  among  infants. 


540 


QUARANTINE  ORDER  RESPECTING  CHOLERA. 


In  another  part  of  the  journal*  will  be 
found  a  Government  order  respecting 
the  conditional  imposition  of  quaran¬ 
tine  on  vessels  arriving  in  English 
ports  with  cases  of  cholera  on  board. 
This  indicates  a  wise  precaution,  and, 
at  the  same  time,  something  more 
than  a  suspicion  of  the  accuracy  of 
the  conclusion  at  which  the  Sani¬ 
tary  Commissioners  and  Lord  Lans- 
downe  have  recently  arrived — namely, 
that  the  cholera  was  not  communi¬ 
cable  from  one  person  to  another  in 
any  manner  whatsoever  !  We  are 
quite  at  a  loss  to  comprehend  this 
inconsistency.  If,  as  it  is  alleged, 
cholera  is  not  to  be  kept  out  by  qua¬ 
rantine  regulations, — not  because  they 
are  easily  open  to  evasion,  but  that  the 
disease  always  traverses  oceans  and 
continents  in  spite  of  them, — why  have 
we  all  these  petty  restrictions  on  com¬ 
mercial  enterprise  ?  Why  are  the 
clothing  and  bedding  of  cholera  pa¬ 
tients  to  be  “  thoroughly  immersed  in 
water,  under  the  direction  of  an  Officer 
of  Customs  ?”  or  why  are  vessels  with 
cholera  actually  on  board  to  be  detained 
until  orders  from  the  Lords  of  the 
Council  have  been  received  ?  There  is 
only  one  answer  to  these  questions, 
which  the  Lords  themselves  furnish  in 
another  part  of  the  order :  it  is,  that 
they  are  desirous  of  preventing  the 
introduction  of  cholera  into  this  country 
—an  admission  which  proves  that  they 
do  not  believe  in  the  conclusion  at 
which  the  Government  Commissioners 
have  arrived,  i.  e.  that  cholera  cannot 
be  transmitted  from  one  individual  to 
another.  Under  these  circumstances, 
how  is  it  to  be  expected  that  sanitary 
reports  will  create  a  feeling  of  security 
in  the  public  mind,  when  the  acts  of  the 
Government  indicate  a  positive  distrust 
of  them,  and  a  disbelief  in  the  official 
declarations  of  their  own  selected  Com¬ 
missioners  ? 


&cbteft>S. 


A  Course  of  Lectures  on  Dental  Phy¬ 
siology  and  Surgery ,  delivered  at  the 
Middlesex  Hospital  School  of  Medi¬ 
cine.  By  John  Tomes,  Surgeon- 
Dentist  "to  the  Middlesex  Hospital. 
8vo.  pp.  397.  London :  Parker. 
1848. 

The  recent  publication  of  Mr.  Tomes’s 
lectures  in  the  Medical  Gazette  has 
to  a  certain  extent  rendered  the  pro¬ 
fession  acquainted  with  his  researches 
in  denial  physiology  and  surgery.  In 
the  volume  before  us  he  has  collected 
them  from  the  scattered  numbers  in 
which  they  appeared,  and,  by  revision 
and  numerous  additions,  has  placed 
them  in  a  very  acceptable  form  before 
the  profession.  In  treating  the  subject, 
Mr.  Tomes  has  retained  the  oral  style, 
but  not  in  a  degree  to  damage  the 
effect  of  his  observations  :  on  the  con¬ 
trary,  each  lecture  may  be  considered 
as  the  chapter  of  a  treatise. 

The  reader  will  find  that  this  is  not 
a  work  written  on  the  principle  of  many 
dental  treatises,  i.  e.  of  merely  attract¬ 
ing  patients.  It  is  addressed  to  the 
profession,  and  more  especially  to 
those  members  of  it  who  intend  to 
take  up  the  practice  of  dental  surgery. 
A  considerable  space  is  judiciously  de¬ 
voted  to  Dental  Physiology  :  no  less 
than  six  out  of  sixteen  lectures  are 
given  to  this  important  subject;  and 
the  author  has  shewn,  by  the  mode  in 
which  he  has  treated  it,  that  he  is  not 
a  mere  compiler  of  the  labours  of 
others.  In  reference  to  the  structure 
of  the  enamel ,  Mr.  Tomes  observes — 

“  Structure  of  the  enamel. — The  enamel, 
the  hardest  of  the  dental  structures,  is  com¬ 
posed  of  dense  semi-transparent  fibres,  placed 
side  by  side,  and  closely  united.  Their  form 
is  an  approximation  to  a  six-sided  prism, 
and  their  size  tolerably  uniform,  being  from 
the  xof  ooth  to  the  Trnhroth  of  an  inch  in  dia¬ 
meter. 

“  The  direction  taken  by  the  enamel  fibre 
is,  for  the  most  part,  vertical  to  the  surface 
of  the  dentine  upon  which  it  rests ;  those 
therefore,  which  proceed  from  the  flat  sur¬ 
face  of  the  crown,  will  rise  vertically,  while 
those  from  the  lateral  surface  of  the  tooth 
will  be  horizontal.  Where  the  coronal  sur¬ 
face  of  the  dentine  is  concave,  the  enamel 
fibres  of  the  opposite  sides  of  the  concavity 
form  with  each  other  angles,  and  meet  at 
their  external  ends,  or  are  bent  out  of  their 


*  Page  556. 


MR.  TOMES’S  LECTURES  ON  DENTAL  PHYSIOLOGY  AND  SURGERY.  541 


course.  This  juncture  is  frequently  imper¬ 
fect,  and  leaves  a  fissure,  under  which  the 
dentine,  being  less  protected  from  external 
influence  than  on  the  other  parts  of  the 
crown  of  the  tooth,  is  more  frequently  at¬ 
tacked  by  disease.  The  fissures  on  the  crown 
of  the  molars  are  often  subject  to  this  defect 
of  development.  The  ends  of  the  enamel 
fibres  are  received  into  the  shallow  hexagonal 
depressions  of  the  coronal  surface  of  the  den¬ 
tine,  from  whence,  in  their  course,  they  de¬ 
scribe  frequent  curves.  Neither  are  the 
curves  in  one  plane  only  ;  on  the  contrary, 
where  the  enamel  is  thick,  the  fibres  are 
bent  about  in  each  direction.  Near  the  neck 
of  the  tooth,  where  the  enamel  is  thin,  a  sin¬ 
gle  fibre  may  be  traced  through  its  whole 
course.  There  it  makes  but  one  or  two 
curves,  and  these  mostly  in  one  plane. 

“  The  direction  taken  by  neighbouring 
fibres  is  not,  however,  at  all  times  perfectly 
parallel ;  indeed,  they  often  diverge,  or  cross 
each  other  at  considerable  angles.  Pre¬ 
suming  that  the  fibres  that  start  from  the 
surface  of  the  dentine  continue  their  course 
to  the  surface,  large  spaces  would  necessarily 
be  left  by  their  divergence.  No  such  space, 
however,  exists.  Fibres  of  shorter  length 
exist  and  occupy  these  positions.  The  curves, 
also,  seem  less  regular  than  those  formed  by 
the  dental  tubes.  Near  the  dentinal  surface 
of  the  enamel,  small  linear  interspaces  not 
unfrequently  exist  between  the  fibres.  With 
these  the  terminal  branches  of  the  dentinal 
tubuli  often  communicate. 

“  In  the  same  situation  we  commonly  find 
elongated  cavities,  of  irregular  outline,  larger 
than  the  enamel  fibres  themselves,  and  lying 
at  angles  with  them.  Such  cells  are  common 
in  old  worn  teeth.  Hence  their  presence 
cannot  be  detrimental. 

“  The  enamel  fibre  is  not  in  all  cases  solid, 
but  has  running  through  the  whole,  or  part 
of  its  length,  an  extremely  minute  cavity. 
This  is  best  seen  in  newly-developed  enamel, 
but  a  trace  of  the  canal  may  sometimes  be 
seen  in  that  of  adult  teeth.  Interposed  be¬ 
tween  the  fibres  of  the  tissue  under  consi¬ 
deration,  are  the  remains  of  the  membrane 
in  which  the  development  has  taken  place, 
and  which,  when  hardened  by  the  reception 
of  earthy  matter,  serves  to  connect  the  fibres. 
This  tissue,  however,  is  not  traceable  except 
in  imperfectly-developed  enamel,  unless  by 
the  aid  of  acids. 

“  The  individual  fibres  of  the  enamel  ap¬ 
pear  to  be  developed  in  sheaths  of  mem¬ 
brane,  and  united  to  each  other  by  the  ad¬ 
hesion  of  the  sheaths  and  subsequent  calcifi¬ 
cation  of  the  membrane,  in  common  with  the 
enamel  fibre  itself.  When  the  development 
is  perfect,  the  lateral  union  between  the  fibres 
is  marked  by  fine  delicate  lines ;  but,  when 
imperfect,  the  lines  are  large  and  coarse,  and 
the  enamel  has  an  opaque,  opaline  appear¬ 


ance,  or  else  is  discoloured.  The  imperfect 
union  occurs  in  patches,  sometimes  small, 
sometimes  large — in  one  case,  following  the 
course  of  a  bundle  of  fibres,  from  the  dentine 
to  the  surface  of  the  tooth  ;  in  another,  stop¬ 
ping  short  of  the  surface.”  (p.  52-4.) 

It  is  not,  perhaps,  sufficiently  consi¬ 
dered  how  much  the  perfection  of 
voice  depends  on  the  regularity  of  the 
teeth  and  the  form  of  the  mouth ;  and 
where,  in  singers  for  instance,  there  is 
imperfect  articulation,  this  is  often 
wrongly  attributed  to  a  want  of  educa¬ 
tion  ;  whereas  it  may  depend  on  phy¬ 
sical  causes,  and  arise  from  irremediable 
defect.  Phrenologists  pretend,  by  an 
examination  of  the  youthful  cranium, 
to  guide  parents  to  the  proper  selection 
of  a  profession  for  their  children  ;  but 
well-informed  dentists  may  with  much 
greater  reason  be  consulted  as  to  how 
far,  from  the  state  of  the  mouth,  a 
person  may  be  qualified  for  any  office 
requiring  public  speaking,  or  for  the 
profession  of  a  singer. 

“  The  teeth  are  important  as  organs  of 
articulation ;  so  much  so,  that,  when  lost, 
we  can  scarcely  make  ourselves  intelligible. 

“  Wherever  you  have  a  fine,  clear,  sono¬ 
rous  voice,  you  will  find  well-formed  and 
well-arranged  teeth  ; — each  tooth  will  occupy 
its  proper  place.  But,  what  is  perhaps  still 
more  important,  the  hard  palate  will  be  well 
formed  ;  that  is,  it  will  present  a  section  of  a 
large  arch,  perfectly  free  from  contraction, 
either  from  side  to  side,  or  from  before 
backwards.  There  will  not  be  a  deep  vaulted 
form,  neither  will  there  be  a  sudden  elevation 
immediately  behind  the  front  teeth,  so  com¬ 
mon  in  those  who  speak  with  indistinctness 
— on  the  contrary,  the  palate  will  rise  gra¬ 
dually. 

“The  mouth,  and  its  dental  appendages, 
are  not  of  the  first  importance  in  relation  to 
the  voice,  yet  they  are  highly  important  as 
auxiliaries,  and,  as  such,  their  condition 
should  not  be  lost  sight  of.  The  vocal  organ 
may  be  good,  even  first-rate,  but  the  mouth 
and  teeth  must  be  well  formed,  or  the  voice 
will  be  injured  in  its  passage  through  the 
mouth.  Those  who  are  by  nature  endowed 
with  the  first  qualities  of  voice,  and  have 
passed  through  an  efficient  course  of  vocal 
cultivation,  sing  with  a  fine,  pure,  clear,  full 
tone,  and  articulate  in  their  song  with  dis¬ 
tinctness.  They  pass  from  6ne  note  to  ano¬ 
ther  rapidly,  with  full  and  even  tone,  and 
articulate  words  as  distinctly  as  in  ordinary 
speaking,  and  yet,  in  doing  this,  lose  nothing 
in  quality  of  tone.  On  the  contrary,  those 
who  by  nature  are  less  favoured  (whatever 
may  be  their  degree  of  cultivation)  have 
supplementary  sounds  in  or  between  their 


542  me.  tomes’s  lectures  on  dental  physiology  and  surgery. 


tones.  The  tones  do  not  flow  freely.  A 
slight  hissing,  or  a  cavernous  or  a  nasal 
sound,  may  be  distinguished  either  in  the 
tones  themselves,  or  as  the  singer  passes  from 
one  tone  to  another.  Great  effort  is  made, 
and  yet  but  little  effect  produced.  The 
hearer  feels  as  though  there  was  some  impe¬ 
diment  to  the  free  delivery  of  the  voice.  When 
the  words  are  distinctly  articulated,  the  voice 
loses  its  tone.  This  induces  the  vocalist, 
who  feels  that  both  good  tone  and  the  clear 
enunciation  of  words  cannot  be  gained,  to 
sacrifice  the  words  to  the  tone,  so  that  the 
bystander  hears  the  air  only — the  words  are 
lost. 

“  It  has  been  usual  to  impute  these  de¬ 
fects  altogether  to  want  of  cultivation,  or  to 
inferiority  of  voice,  the  one  or  the  other,  as 
the  defects  are  more  or  less  apparent.  I 
think,  however,  it  may  be  shewn  that  they 
are  frequently  the  necessary  consequence  of 
the  form  of  the  mouth  and  palate.  And 
further,  that,  by  inspecting  the  mouth,  the 
degree  of  excellence  to  which  the  singer  can 
arrive  may  be  foretold.  In  other  words, 
that  a  good  orifice  of  exit  is  necessary  as  an 
adjunct  to  a  good  vocal  organ,  before  ex¬ 
cellence  in  the  vocal  art  can  be  attained. 
These  observations  have  been  made  when 
inspecting  the  mouths  of  professional  and 
other  vocalists.  At  present  I  offer  them 
without  going  into  details,  but,  after  further 
confirmation,  I  hope  to  place  them  on  a 
more  extended  scale,  and  in  a  more  useful 
form.  It  is  to  be  lamented  that  so  much 
time  and  labour  are  spent,  in  early  life, 
when  time  is  most  valuable,  in  learning 
singing ;  and  yet  so  little  progress  made, 
that  the  pupil  is,  after  all  the  expenditure, 
unable  to  sing  moderately  well.  Surely  it 
is  desirable  that  the  time  should  be  other¬ 
wise  employed,  if  the  failure  could  be  fore¬ 
told  by  the  formation  of  the  mouth.  And, 
on  the  contrary,  that  even  more  should  be 
spent,  when  the  capability  for  success  is 
indicated.  ”  (PP.  122-24). 

The  details  into  which  Mr.  Tomes 
enters  in  speaking  of  the  treatment  of 
diseases  of  the  teeth,  indicate  a  good 
practical  acquaintance  with  the  subject. 
Physiology  and  pathology  are  here 
judiciously  brought  to  bear  on  prac¬ 
tice.  The  uncertainty  of  remedial  ap¬ 
plications  in  relieving  toothache,  is 
occasionally  to  be  traced  to  the  depen¬ 
dence  of  the  dental  disease  on  disorder 
of  the  digestive  organs.  Hence,  when 
carious  teeth  become  painful  in  con¬ 
nection  with  dyspepsia,  the  stomach 
should  be  restored  to  health,  or  local 
applications  will  be  without  effect. 
The  author  fully  examines  the  various 
remedies  which  have  been  employed 


for  alleviating  the  severe  pain  arising 
from  the  inflammation  of  the  dental 
pulp.  Some  of  these  act  mechanically, 
L  e.  by  plugging  up  the  aperture  in  the 
tooth,  and  thus  prevent  the  contact  of 
irritating  substances  from  the  mouth, 
or  the  access  of  air  to  the  cavity.  A 
solution  of  mastic  in  alcohol,  or  of  gum 
copal  in  ether,  or  a  plug  of  cotton,  are 
very  commonly  employed ;  but  Mr. 
Tomes  thinks  that  a  solution  of  gutta 
percha  in  chloroform  is  preferable,  as 
it  is  less  liable  to  become  offensive  than 
mastic  or  copal.  Chloroform  alone 
has  been  lately  used  with  some  success 
for  the  purpose  of  alleviating  the  seve¬ 
rity  of  the  pain.  It  appears  to  act  as 
a  powerful  sedative.  In  addition  to 
the  mechanical  remedies  described 
above,  we  wTould  suggest  the  use  of  a 
plug  of  cotton  soaked  in  collodion,  or 
the  ethereal  solution  of  fulminating 
cotton,  the  preparation  of  which  is 
elsewhere  described.*  It  should  be 
stated  that  for  these  mechanical  reme¬ 
dies  to  be  effectual,  the  cavity  of  the 
tooth  should  be  thoroughly  dried  by 
cotton  immediately  before  their  intro¬ 
duction.  If  any  moisture  remain,  the  ad¬ 
hesion  will  not  be  perfect.  If  sedatives 
fail  to  give  relief,  escharotics  are  some¬ 
times  employed  for  the  purpose  of  de¬ 
stroying  the  dental  pulp.  Our  author 
is  inclined  to  think  well  of  the  chloride 
of  zinc  as  an  escharotic  application ;  it 
certainly  has  the  advantage  of  being 
attended  with  no  possible  injury,  even 
should  it  fail  to  give  relief.  It  is, 
therefore,  preferable  to  the  favourite 
American  escharotic,  arsenic,  which  we 
agree  with  the  author  in  thinking 
should  never  be  employed  in  dentistry. 
While  there  is  no  certainty  in  its  action 
on  the  dental  pulp,  there  is  the  very 
great  risk  that  a  portion  may  find  its 
way  into  the  stomach,  and  produce 
serious  symptoms. 

Some  years  ago  the  excision  of  the 
crowm  of  the  tooth  was  proposed,  in 
preference  to  extraction,  and  for  a  cer¬ 
tain  time,  like  all  novelties,  this  opera¬ 
tion  acquired  a  fashionable  repute.  We 
believe  that  the  inventor  of  this  new 
method  actually  received  a  prize  from 
the  Society  of  Arts  for  the  ingenuity 
displayed  in  the  construction  of  his  in¬ 
struments.  On  this  unscientific  method 
of  dealing  with  teeth,  Mr.  Tomes  justly 
observes — 


*  See  our  last  number,  page  516, 


MR.  TOMES’S  LECTURES  ON  DENTAL  PHYSIOLOGY  AND  SURGERY.  543 


“  The  excision  of  the  crown  is  attended 
with  almost  as  much  pain  as  the  extraction 
of  the  tooth  would  entail,  and  the  fangs  left 
are  very  liable  to  become  the  seat  of  the 
disease,  which  ultimately  obliges  their  re¬ 
moval,  and  thus  necessitates  a  second  ope¬ 
ration  when  one  would  have  done.  For 
these  reasons  I  cannot  advocate  the  inten¬ 
tional  adoption  of  Mr.  Wardroper’s  prac¬ 
tice.  Should,  however,  the  crown  of  a 
carious  tooth  be  accidentally  broken  off 
where  extraction  was  intended,  and  the  pain 
then  ceases,  the  roots  may  be  allowed  to 
remain  till  their  removal  is  more  imperiously 
called  for.”  (p.  273). 

Experience  has  long  since  confirmed 
the  opinion  expressed  by  Mr.  Tomes 
on  the  demerits  of  this  operation. 

The  importance  of  attending  to  the 
colour  of  the  gums,  as  a  means  of  diag¬ 
nosis,  in  chronic  poisoning  by  lead, 
has  received  a  good  deal  of  notice  from 
medical  writers  since  the  symptom  was 
first  pointed  out  by  Dr.  Burton,  in  1840. 
It  will,  however,  be  well  to  consider  the 
results  of  the  observations  of  a  dental 
surgeon  on  this  subject. 

“  It  has  been  observed  that  the  presence  of 
teeth  is  necessary  to  the  (blue)  colouring  of  the 
gum.  This  is  not  all,  however  :  the  necks 
of  the  teeth  must  be  encrusted  with  tartar, 
otherwise  the  edge  of  the  gums  will  not 
receive  the  blue  tinge  :  in  fact,  the  teeth 
are  necessary  only  as  affording  lodgment 
for  the  tartar.  I  conceive,  that,  if  tartar 
were  held  in  constant  contact  with  the  edge 
of  the  gums  by  any  other  means  than  its 
lodgment  on  teeth,  the  gums  would  be 
equally  tinged.  I  have  frequently  seen  the 
gums  about  teeth  encrusted  with  tartar  very 
blue,  and  in  the  same  mouth,  the  gums 
about  teeth  free  from  tartar,  perfectly  na¬ 
tural  in  colour. 

“  The  colouring  of  the  gum  maybe  the 
sole  indication  of  lead  in  the  system.  I  not 
unfrequently  find  among  my  patients  those 
whose  gums  are  blue,  but  who  declare  that 
they  have  never  suffered  from  colic  or  any 
other  effect  of  lead;  and,  indeed,  a  few  of 
these  say  they  have  not,  to  the  best  of  their 
knowledge,  been  exposed  to  lead.  A  short 
time  since,  a  gentleman  applied  to  me  to 
remove  a  troublesome  tooth.  I  found  the 
necks  of  the  teeth  encrusted  with  tartar,  and 
the  edges  of  the  gums  intensely  blue.  He 
stated,  on  inquiry,  that  he  had  just  returned 
from  China,  and  that  during  the  voyage  he 
had  been  salivuted  for  syphilis,  but  that  he 
had  not,  so  far  as  he  knew,  been  exposed  to 
the  action  of  lead,  either  by  inhalation  or 
any  other  mode. 

“  The  continuance  of  tartar  on  the  teeth 
is  necessary  to  the  continuance  of  blue  gum. 
If  the  whole  of  the  tartar  be  removed  from 


the  neck  of  the  tooth,  the  blue  tinge  on  the 
gum  will  gradually  fade,  while  its  intensity 
will  be  preserved  about  the  teeth  on  which 
the  tartar  is  allowed  to  remain.  I  cannot 
tell  you  how  long  it  will  be  before  the  colour 
will  be  wholly  gone,  when  the  tooth  is 
allowed  to  remain,  because  the  tartar  may 
re -accumulate,  and  thus  defeat  an  experi¬ 
ment  instituted  to  ascertain  that  point. 
When  the  tooth  is  removed,  however,  the 
blue  stain  disappears  in  two  or  three  weeks, 
as  the  following  case  would  indicate  : — I 
was  called  to  remove  an  aching  tooth  for  a 
lady  who  bad  taken  two  or  three  doses 
of  acetate  of  lead  for  the  suppression 
of  uterine  haemorrhage.  The  gums  exhi¬ 
bited  the  characteristic  blue  line.  Nine 
days  after  the  extraction  of  the  tooth,  the 
gums  had  come  together,  and  the  union  was 
marked  by  a  transverse  blue  line.  At  the 
expiration  of  three  weeks,  the  blue  line  had 
wholly  disappeared.  In  another  well- 
marked  case  of  blue  gum  the  patient  had 
nothing  to  do  with  lead  in  any  way,  and  had 
not  been  in  the  neighbourhood  of  recently- 
applied  paint ;  but  he  was  employed  silver¬ 
ing  mirrors,  in  which  mercury  and  tin  are 
the  metals  used.  These  are  not  solitary 
instances  in  which  I  have  found  strongly- 
marked  blue  gum,  and  yet  no  other  indica¬ 
tion  of  the  presence  of  lead  in  the  system, 
or  of  the  exposure  of  the  patient  to  the 
action  of  lead.  Hence  I  am  forced  to  sus¬ 
pect  that  other  metals  may  produce  a  similar 
discolouration  of  the  gum.  Should  future 
investigation  prove  this  suspicion  to  be  well- 
founded,  the  diagnostic  value  of  this  state  of 
gum  in  relation  to  lead  will  be  diminished. 
In  endeavouring  to  trace  by  what  process 
the  gums  are  stained  blue,  it  must  be  borne 
in  mind  that  the  tartar  itsplf  is  often  simi¬ 
larly  discoloured,  especially  where  it  is  in 
contact  with  the  gum.  The  colouring  ma¬ 
terial  is  probably  sulphuret  of  lead,  or  a 
similar  salt  of  some  other  metal.  Tartar, 
being  very  porous,  admits  into  its  substance 
fluids  charged  with  animal  matter,  which 
may  there  be  decomposed,  and  furnish  sul¬ 
phuretted  hydrogen,  as  a  product  of  decom¬ 
position.  Supposing  a  salt  of  lead  to  be 
present  in  the  tissues  of  an  adjoining  part,  a 
sulphuret  of  lead  would  be  formed,  which 
would  give  the  colour  in  question  to  the 
tissue  in  which  the  formation  took  place. 
This  action  would  be  continuous  so  long  as 
the  metal  remained  in  the  system,  and  the 
tartar  remained  to  afford  a  site  for  decom¬ 
position,  and  to  hold  the  products  against 
the  gum.  The  saliva  itself  contains  sulpho- 
cyanic  acid,  and  from  this  source  sulphur 
might  also  be  furnished.  Traces  of  lead 
may  be  found  in  the  tartar  of  those  affected 
by  that  metal.”  (pp.  308-10). 

Some  of  the  author’s  difficulties  ar« 


544  MR.  tomes’s  lectures  on  dental  physiology  and  surgery. 


removed  by  the  fact,  that  the  prepara¬ 
tions  of  mercury  have  been  found  to 
produce  occasionally  a  precisely  similar 
discolouration :  hence  the  c‘  blue  gum” 
cannot  be  regarded  as  essentially  cha¬ 
racteristic  of  the  presence  of  lead  in  the 
system,  or  of  the  individual  having  been 
exposed  to  the  emanations  of  that  metal. 
All  metals  susceptible  of  absorption, 
and  of  forming  black  sulphurets,  might 
give  rise  to  a  similar  appearance  of  the 
gums  ;  but  it  so  happens,  that  lead  and 
mercury  are  the  only  two  answering 
this  description,  which  are  much  used 
in  manufactures.  Bismuth  is  but  little 
employed,  or  probably  the  blue  gum 
would  be  found  to  result  equally  from 
the  absorption  and  deposit  of  this  metal. 
The  connection  of  blue  gum  with  the 
presence  of  tartaron  the  teeth,  is  worthy 
of  notice.  The  formation  of  sulphuret 
might  be  ascribed  to  the  action  of  the 
sulphur  contained  in  the  animal  matter 
of  tartar  and  of  the  gum.  A  salt  of 
lead  placed  in  contact  with  horn  or  any 
albuminous  matter,  slowly  discolours 
it,  turning  it  brown,  and  even  black, 
by  the  mere  effect  of  the  sulphur  which 
it  contains.  The  action  of  the  sul- 
phocyanic  acid  in  the  saliva,  therefore, 
is  not  required  to  explain  this  chemical 
effect.* 

The  daily  journals  teem  with  ad¬ 
vertisements  of  all  sorts  of  dentifrices, 
described  in  the  most  glowing  lan¬ 
guage;  and  some  of  these  tooth-powders 
are  especially  described  as  being  “re¬ 
commended  by  the  Faculty”  (who  this 
is, we  have  never  been  able  to  discover) 
on  account  of  the  valuable  property 
which  they  possess  of  “  dissolving  the 
tartar.”  There  is  one  short  answer  to 
this  recommendation,  namely,  that  any 
tooth-powder  which  will  dissolve  the 
tartar  will  also  dissolve  the  teeth. 

In  reference  to  plugging  teeth ,  Mr. 
Tomes  observes — 

“  In  making  the  plug,  our  aim  must  be, 
first,  to  so  perfectly  fill  the  cavity  that  all 
moisture  shall  be  excluded ;  and,  secondly, 
to  so  form  it  that  it  shall  be  sufficiently 
hard  to  resist,  equally  with  the  tooth,  the 
wear  of  mastication.  Unless  these  two  con¬ 
ditions  are  fulfilled,  our  work  will  be  im¬ 
perfect,  and  ultimately  fail. 

“  Gold  or  tin  foil  are  the  best  materials 
for  making  plugs.  Whichever  of  these  be 
chosen,  the  method  of  use  is  the  same. 

*  Sulphuret  of  lead,  as  a  result  of  the  reaction 
of  an  alkaline  sulphocyanide  on  a  salt  of  lead,  is 
not  readily  formed  until  the  mixture  has  been 
heated  to  212?. 


“  There  are  four  methods  of  introducing 
foil  for  making  a  plug.  In  one  the  metal  is 
folded  into  narrow  strips,  proportioned  in 
width  and  thickness  to  the  size  of  the  cavity. 
One  end  of  the  strip  is,  by  means  of  a  con¬ 
veniently  -  shaped  stopping  instrument, 
pressed  to  the  bottom  of  the  cavity.  The 
strip  is  then  bent,  and  a  fold  passed  to  the 
bottom  of  the  hole,  leaving  the  first  fold 
projecting  above  the  surface.  Fold  after 
fold  is  introduced,  till  the  cavity  is  tolerably 
full.  A  wedge-shaped  instrument  is  then 
introduced,  and  the  gold  pressed  towards 
the  walls  of  the  cavity ;  more  gold  is,  by  a 
similar  process,  pressed  into  the  cavity  so 
obtained.  This  process  is  repeated  till  the 
wedge  cannot  be  forced  into  the  plug.  A 
flattened  instrument  is  then  used  to  com¬ 
press  the  gold  in  the  cavity.  When  we  can 
make  no  further  effect  on  the  surface  of  the 
plug  by  compression,  the  surface  is  filed 
smooth  and  burnished.  By  a  careful  ad¬ 
herence  to  this  plan,  wre  make  a  plug  com¬ 
posed  of  layers  of  metal,  arranged  parallel 
to  the  walls  of  the  cavity,  and  therefore  not 
liable  to  fall  to  pieces  or  come  out.  But, 
on  the  other  hand,  had  we  made  the  folds  at 
a  right  angle  to  the  walls,  and  parallel  to 
the  bottom  of  the  cavity,  layer  after  layer 
would  have  peeled  off,  till  little  or  none  of 
the  plug  remained,  and  the  decay  would  have 
proceeded  to  the  destruction  of  the  tooth.” 
(p.  317). 

It  is  the  custom  with  many  dentists 
to  condemn  the  amalgam-plug;  but 
while  it  is  undoubtedly  inferior  as  a 
method  of  stopping  to  the  use  of  gold 
or  tin,  there  are  some  cases  in  which 
these  metals,  owing  to  the  carious  state 
of  the  tooth,  cannot  be  employed,  and 
we  either  extract  the  tooth  or  resort  to 
the  amalgam-plug. 

“  Where  the  cavity  of  a  tooth  is  so  large 
that  the  walls  are  too  thin  to  bear  the 
pressure  necessary  to  the  insertion  of  a  gold 
or  tin-foil  plug,  the  amalgam  of  silver  or  of 
palladium  may  be  advantageously  used. 
Having  prepared  the  cavity  as  for  the  use  of 
foil,  a  little  mercury  is  triturated  in  a  glass 
mortar  with  a  small  quantity  of  precipitated 
silver  or  palladium,  till  they  unite  and  form 
a  paste,  which  is  well  squeezed  in  a  piece  of 
wash  leather,  to  force  out  as  much  as  possi¬ 
ble  of  the  mercury.  The  paste  is  then  again 
rubbed  in  the  mortar,  or  in  the  palm  of  the 
hand,  and  then  introduced  into  the  cavity. 
The  cavity,  however,  must  be  first  well  dried 
with  lint,  and  care  must  be  taken  to  get  the 
amalgam  in  close  contact  with  the  whole 
circumference  of  the  cavity.  The  plug  so 
formed  hardens  in  a  few  hours,  after  which 
the  surface  should  be  well  burnished.” 
(p.  318). 


MR.  TOMES’S  LECTURES  ON  DENTAL  PHYSIOLOGY  AND  SURGERY.  545 


The  author  recommends  the  amalgam 
of  palladium  in  preference  to  that  of 
silver,  as  it  does  not  so  readily  produce 
a  discolouration  of  the  teeth. 

The  other  operations  on  the  teeth 
call  for  no  particular  notice.  Mr. 
Tomes  is  no  advocate  for  the  use  of 
chloroform  or  ether;  and  he  justly 
enough  remarks  that  the  remedy  is 
strangely  out  of  proportion  to  the  evil 
to  be  avoided.  When  his  work  was 
written  he  was  evidently  not  aware  of 
the  fatal  case  of  Mr.  Badger,  or  his 
condemnation  ot  anaesthetics  for  the 
trivial  purpose  of  allaying  temporary 
pain,  would  probably  have  been  ex¬ 
pressed  in  still  stronger  language  than 
he  has  used.  We  shall  here  extract 
some  interesting  cases  indicative  of  the 
injurious  action  of  chloroform  vapour, 
which  have  occurred  within  the  expe¬ 
rience  of  the  author,  as  they  throw  a 
new  light  upon  the  after-effects  pro¬ 
duced  by  this  singular  agent. 

“  I  have  become  acquainted  with  two 
cases  in  which  the  imagination  was  strangely 
affected  for  several  weeks  after  the  inhala¬ 
tion  of  chloroform.  A  lady  between  the 
age  of  thirty  and  forty  suffered  pain  from 
several  unsound  teeth.  Accompanied  by  a 
lady  who  had  recently  lost  a  little  girl,  and 
by  her  husband,  she  applied  to  a  dentist. 
Chloroform  was  administered,  and  the  tooth 
removed.  She  felt  great  difficulty  and 
anxiety  when  inhaling,  and  wished  to  dis¬ 
continue,  but  the  dentist  reassured  her,  and 
she  went  on.  Her  first  sensation,  on  re¬ 
covering,  was  the  sound  of  her  own  voice, 
calling  bitterly  for  the  little  girl  who  had 
recently  died.  This  affected  her  very  much, 
and  she  fell  into  a  violent  hysterical  fit.  On 
recovering  she  was  conveyed  home,  but  still 
bewildered,  and  at  times  hysterical.  For 
three  weeks  she  at  frequent  intervals  heard 
her  own  voice  calling  for  the  little  girl,  and 
this  was  immediately  succeeded  by  a  fit  of 
violent  hysterical  crying.  Her  friends  be¬ 
came  very  anxious  for  her  safety,  both  men¬ 
tally  and  bodily,  for  she  suffered  in  health, 
as  well  as  from  these  occasional  hallucina¬ 
tions.  Any  attempt  to  read  or  to  write 
brought  on  a  violent  headache,  and  in  addi¬ 
tion  to  these  evils  her  nights  were,  com¬ 
paratively,  sleepless.  She  eventually  re¬ 
covered  by  the  use  of  tonics,  stimulants,  and 
generous  living.  This  is  her  own  account. 
Her  friends  state  that  under  the  operation 
she  evinced  no  signs  of  pain ;  but  that  pre¬ 
vious  to  the  time  she  recollects  hearing  her 
own  voice,  she  had  been  calling  for  the 
child,  had  asked  its  mother  to  restore  it  to 
her,  and  expressed  the  most  bitter  feelings 
of  regret  at  its  loss.  The  lady  has  had  a 


tooth  out  since,  but  not  with  the  chloroform. 
She  seems  very  much  averse  to  its  use,  and 
says  nothing  would  induce  her  to  take  it 
again . 

“  In  the  second  case  the  hallucination 
took  a  different  form.  The  patient,  a  young 
lady,  under  thirty,  required  three  teeth  to 
be  removed.  Her  ordinary  dentist  declined 
giving  her  chloroform,  on  the  ground  that 
it  was  dangerous  in  all  cases,  and  that  it 
was  not  necessary  or  right  to  give  it  in 
tooth-drawing,  or  any  other  trivial  opera¬ 
tion.  Hence  she  sought  a  stranger  who  was 
less  punctilious.  She  was  soon  rendered 
insensible,  and  three  teeth  were  extracted 
during  the  time.  On  recovery  she  remem¬ 
bered  the  extraction  of  the  three  teeth,  and 
described  the  operation  correctly,  and  de¬ 
clared  it  was  attended  with  great  suffering  ; 
but  she  believed  the  pain  to  be  imposed  for 
sins  she  had  committed ;  that  in  truth  she 
had  been  in  purgatory,  and  had  suffered 
there,  and  had  again  to  go,  she  said.  At 
first  her  friends  thought  she  was  joking,  but 
after  a  little  time  they  discovered  that,  when 
unoccupied  with  external  objects,  the  mind 
constantly  fell  back  upon  this  idea.  In 
addition  to  this,  she  was  very  nervous  and 
excited,  and  in  the  evening  asked  to  have 
some  one  to  sleep  in  her  room.  This  proved 
fortunate,  for  during  the  night  she  was 
attacked  with  a  fit  of  collapse.  Brandy  was 
freely  administered,  and  a  medical  man  sent 
for,  who  with  stimulants  restored  her.  For 
a  fortnight  after  the  inhalation  she  con¬ 
tinued  very  miserable,  and  subject  to  the 
frequent  recurrence  of  these  hallucinations. 
Her  condition  caused  great  alarm  to  her 
friends,  who  could  not  tell  how  long  it 
might  continue,  and  did  not  feel  justified  in 
leaving  her  for  a  moment  alone  while  in  that 
uncertain  state  of  mind.  In  each  of  these 
cases  the  patients  were  reported  to  be  of 
highly  nervous  temperament,  and  subject, 
under  great  excitement,  to  hysterical  crying. 

“  Mr.  O.  Clayton  related  to  me  a  case  in 
which  catalepsy,  with  a  tendency  to  coma, 
was  induced  by  the  inhalation  of  ether,  and 
lasted  for  four  days.  The  pupils  were 
dilated,  and  the  patient  was  insensible  to 
all  that  was  passing  around  her,  but  could 
be  partially  roused  for  a  moment  by  loudly 
shouting  in  her  ear.  She  took  no  food, 
and  drank  only  when  forced  to  do  so.  If 
the  arm  was  raised  it  retained  the  position 
for  a  while,  and  then  slowly  fell  back  on  the 
bed.  There  seemed  great  reason  to  fear  a 
fatal  termination. 

“  The  patient  was  a  servant-maid,  and 
predisposed  to  slight  attacks  of  hysteria. 
She  required  a  tooth  to  be  removed,  and 
asked  to  take  ether.  She  recovered  from 
the  more  urgent  symptoms  under  the  use  of 
stimulants,  but  did  not  regain  her  usual 
state  of  health.  Neither  has  she  done  so  at 


546 


WORKS  OF  THE  CAVENDISH  SOCIETY. 


the  present  time,  though  many  months  have 
elapsed  since  she  inhaled  the  ether. 

“  I  am  indebted  for  the  following  interest¬ 
ing  case  to  the  kindness  of  my  friend  Mr. 
Chalk,  who  obtained  the  details  from  Mr. 
Bird,  of  Haverstock  Hill,  in  whose  practice 
the  case  occurred.  It  appears  that  two 
ladies  impaired  to  a  dentist’s,  one  to  have 
teeth  removed  when  under  the  influence  of 
chloroform ;  the  other  as  companion  to 
the  patient.  In  giving  the  history,  Mr. 
Bird  uses  the  words  of  his  patient  and  her 
friend,  and  his  own  in  relating  the  treat¬ 
ment  and  its  result.  The  patient  says : 
— “  Wishing  to  have  two  teeth  extracted,  I 
applied  to  a  highly  respectable  dentist,  for 
permission,  in  the  first  instance,  to  see  one 
of  his  patients  inhale  the  chloroform,  which 
he  kindly  allowed,  and  afterwards  appointed 
the  next  day  for  the  time  of  my  own  opera¬ 
tion.  I  accordingly  went,  accompanied  by 
a  female  friend,  and  took  my  seat  in  the 
operating  chair.  The  process  of  inhalation 
was  commenced.  I  distinctly  recollect 
hearing  the  gentleman  say,  ‘  she  is  now 
under  its  full  influence  ;7  and  he  commenced 
the  extraction,  when  I  gave  as  loud  a  scream 
as  I  did  on  any  previous  occasion  of  tooth¬ 
drawing,  although  I  felt  a  very  pleasant 
soothing  sensation.”  The  inhalation  was 
repeated  ;  and  here  I  must  let  her  friend 
speak  : — “  The  second  tooth,  a  stump,  was 
then  taken  out  without  the  least  signs  of 
pain  :  her  countenance  became  ghastly,  and 
my  friend  was  in  as  complete  a  state  of  in¬ 
toxication  as  could  well  be  borne — almost 
pulseless — scarcely  breathing  ;  and  I  made 
up  my  mind  she  would  die,  and  suggested 
the  propriety  of  calling  in  medical  assistance. 
The  windows  were  all  thrown  open,  brandy 
administered,  and  two  bottles  of  eau-de- 
Cologne  consumed  in  bathing  the  face.” 
This  state  lasted  three  hours,  when  she  was 
lifted  into  her  carriage,  and  taken  home, 
with  directions  to  let  her  go  to  bed  and 
remain  quiet.  This  was  about  7  in  the 
evening  ;  she  lay  nearly  all  night  in  a  rest¬ 
less,  half  unconscious  state,  until  5  o’clock 
the  next  morning,  when,  reaction  taking 
place,  I  was  sent  for,  and  found  my  patient  in 
a  high  state  of  delirium — obliged  to  be  held 
down  in  bed  ;  leeches,  blisters,  &c.  were  em¬ 
ployed — the  usual  mode  of  treatment  was 
adopted,  and  in  four  days  she  regained  her 
senses.  I  am  sorry  to  add  that  I  sometimes 
find  a  vacancy  in  her  manner,  which  leads  me 
to  forbode  insanity  sooner  or  later — a  con¬ 
dition  which  I  never  observed  previous  to 
the  inhalation,  although  I  have  been  ac¬ 
quainted  with  my  patient  for  ten  years.” 
(pp.  350-354). 

These  cases  convey  a  lesson  on  the 
use  of  aneesthetics,  by  which  the  most 
enthusiastic  chloroformists  may  profit. 


With  this  extract  we  shall  take  leave 
of  our  author,  by  complimenting  him 
upon  having  produced  one  of  the  best 
and  most  scientific  works  on  Dental 
Physiology  and  Surgery  which  we  have 
perused.  It  will  be  found  most  useful 
as  a  guide  to  the  dentist,  and  as  a  work 
of  reference  to  the  medical  practitioner. 
The  volume  is  illustrated  by  no  less 
than  one  hundred  and  thirty-five  well- 
executed  engravings.  One  of  them  (at 
page  22)  showing,  on  a  black  ground, 
the  distribution  of  nerves  to  the  teeth 
is  of  great  interest  in  a  pathological 
view,  as  it  furnishes  a  full  explanation 
of  the  sympathetic  neuralgic  pains 
suffered  by  those  whose  teeth  are  af¬ 
fected  with  caries.  The  statistical  dia¬ 
grams,  at  page  145, showing  the  relative 
liability  to  the  loss  of  teeth  at  different 
ages,  are  deserving  of  especial  com¬ 
mendation  for  the  great  ingenuity 
which  they  display. 


Works  of  the  Cavendish  Society ; 
founded  1846.  Chemical  Reports 
and  Memoirs,  edited  by  Thomas 
Graham,  Esq.,  Y.P.R.S.  &c.  Lon¬ 
don  :  Printed  for  the  Cavendish  So¬ 
ciety,  by  T.  R.  Harrison,  St.  Martin’s 
Lane.  1848. 

We  are  glad  to  welcome  the  appear¬ 
ance  of  the  first  volume  issued  by  this 
useful  Society.  It  contains  transla¬ 
tions  of  various  interesting  reports 
which  have  appeared  in  the  foreign 
scientific  journals,  and  which  are  here 
arranged  and  collected  in  an  easily- 
accessible  form.  The  articles  amount 
to  eight,  and  comprise — 1.  The  Rela¬ 
tions  of  the  Volumes  of  Bodies  to  their 
Atomic  Weights;  2.  On  the  Connec¬ 
tion  existing  between  the  Atomic 
Weights,  Crystalline  Form,  andDensity 
of  Bodies  ;  3.  On  Endosmosis ;  4.  On 
Isomorphism;  5.  On  the  Influence  of 
the  Association  of  Colours  in  Dyeing ; 
6.  On  the  Latent  Heat  of  Steam;  7.  On 
the  Artificial  Formation  of  Alkaloids ; 
8.  On  the  Connection  existing  between 
the  Pseudo-volcanic  Phenomena  of 
Iceland. 

From  this  list  of  the  contents,  it  will 
be  seen  that  this  volume  is  addressed 
more  particularly  to  the  advanced  che¬ 
mist  and  the  chemical  philosopher. 
The  articles  appear  to  have  been  judi¬ 
ciously  selected,  and  carefully  trans¬ 
lated.  The  task  of  translation  has  been 
assigned  to  Dr.  G.  E.  Day,  whose  name 


DR.  R.  D.  THOMSON  S  SCHOOL  CHEMISTRY. 


547 


must  be  well  known  to  our  readers, 
from  his  lectures  on  chemistry  and  the 
microscope,  in  relation  to  medicine, 
which  have  appeared  in  this  journal. 
The  memoir  on  Physical  Investigations 
on  Dyeing ,  by  M.  Chevreul,  and  the  re- 
portonthe  Artificial  formation  of.  Alka¬ 
loids,  by  M.  E.  Kop,  will  be  found  well 
worthy  of  perusal.  The  last  memoir 
in  the  series  is  of  great  interest  to  the 
student  of  geology  and  physical  geo¬ 
graphy.  This  volume  may  be  consi¬ 
dered  as  a  good  beginning  for  the 
Cavendish  Society;  and  we  think  its 
publication  cannot  fail  to  add  to  the 
list  of  members. 

School  Chemistry  ;  or  Practical  Rudi¬ 
ments  of  the  Science.  By  R.  D. 
Thomson,  M.D.  Lecturer  on  Che¬ 
mistry  in  the  University  of  Glasgow, 
&c.  Small  8vo.  pp.  232.  London  ; 
Longmans.  1848. 

The  title  of  this  little  volume  is  most 
happily  chosen.  Many  of  our  readers 
will  doubtless  recal  the  wish  of  their 
school-boy  days — when  chemistry  ap¬ 
peared  to  them  little  less  than  magic — 
for  some  safe  and  intelligible  hand¬ 
book,  neither  too  learned  nor  too  super¬ 
ficial,  to  direct  them  in  the  study  of 
this  interesting  science,  and  the  method 
of  performing  experiments.  Pinnock’s 
Catechisms,  or  dry  articles  on  theUseful 
Knowledge  principle,  copied  from  ency¬ 
clopedias,  were  then  regarded  as  works 
of  authority.  Even  the  interesting  Con¬ 
versations  of  Mrs.  Marcet  scarcely  sup¬ 
plied  the  want.  They  were  of  too  scien¬ 
tific  a  cast,  and  were  soon  laid  aside  for 
other  works  less  sound  but  of  greater 
pretension.  There  is  in  truth  no  defi¬ 
ciency  of  Manuals, Guides,  and  Elements 
of  Chemistry  in  the  present  day ;  but 
most  of  them  are  far  beyond  the  reach 
of  a  school-boy.  Ur.  R.  D.  Thomson 
has  contrived  to  adapt  his  matter  to  the 
use  of  schools,  and  to  make  such  selec¬ 
tions  from  the  science  as  can  be  readily 
comprehended  by  the  young.  In  a 
small  space,  and  in  concise  language, 
aided  by  numerous  illustrations,  he  has 
succeeded  in  giving  such  an  amount  of 
information  as  will  serve  to  initiate  a 
beginner  in  the  rudiments  of  Experi¬ 
mental  Chemistry.  We  must  object  to 
his  departing  from  ordinary  English 
nomenclature  in  a  work  of  this  kind, 
as  in  the  use  of  the  French  terms,  chlo- 
rohydric  and  cyanoliydric  for  hydro¬ 


chloric  and  hydrocyanic  acids,  and  also 
to  the  introduction  of  processes  for  the 
detection  of  poisons  in  stomachs,  &c., 
since  this  is  a  branch  of  chemistry 
which  is  hardly  required  to  form  a 
school  education.  No  youth  can  pe¬ 
ruse  this  book  without  deriving  from  it 
a  large  amount  of  useful  information  : 
at  the  same  time  it  should  be  studied 
with  a  master,  or  under  the  eye  of  one 
whose  experience  may  prevent  the  oc¬ 
currence  of  those  accidents  which  must 
inevitably  arise  when  boys  are  allowed 
to  have  free  access  to  chemical  com¬ 
pounds  and  apparatus. 


^rocntimgs  of  jcorictug. 
MEDICAL  SOCIETY  OF  LONDON. 

Monday,  September  25,  1848. 

Mr.  Hancock,  President. 

This  was  the  first  meeting  of  the  session: 
the  library  was  crowded  with  fellows  and 
visitors. 

The  President  made  some  remarks  on 
the  age  and  prosperity  of  the  Society.  He 
then  related  the  following  case  of 

Disease  of  the  appendix  cceci  cured  hy  ope¬ 
ration  ; 

as  it  appeared  to  be  of  value,  from  its  pre¬ 
senting  a  mode  of  treatment  which  might  be 
advantageously  pursued  in  certain  stages  and 
forms  of  mischief  resulting  from  the  pre¬ 
sence  of  impacted  faeces  or  foreign  sub¬ 
stances,  either  in  the  caecum  or  its  appendix, 
which  have  hitherto  for  the  most  part,  if  not 
invariably,  proved  fatal.  He  said  that  ab¬ 
scesses  of  the  abdomen  connected  with  the 
caecum  or  large  intestines,  and  attended  with 
fluctuation,  had,  from  time  to  time,  been 
opened  ;  but  he  was  not  acquainted  with  any 
instance  in  which  an  operation  had  been  at¬ 
tempted  under  the  circumstances  detailed  in 
the  following  case,  and  where  the  result  had 
been  so  entirely  satisfactory.  In  the  cases 
recorded,  the  presence  of  fluctuation  has 
proved  the  existence  of  matter  ;  but  the  fol¬ 
lowing  detail  will  show  that  we  should  not 
always  wait  for  this  unequivocal  sign.  Pa¬ 
tients  do  not  always  live  until  the  disease 
has  progressed  tkus  far  ;  they  frequently  sink 
and  die  without  any  further  symptoms  than 
those  of  inflammation  of  the  part ;  and  it  is 
to  this  class  of  cases  that  the  treatment  here 
related  appears  to  me  most  applicable.  I 
was  requested,  on  Saturday,  15th  April, 
1848,  to  see  a  lady,  aged  thirty,  in  consulta¬ 
tion  with  Dr.  Chowne  and  Mr.  Diamond 


548  disease;  of  the  appendix  oeci  cured  by  operation. 


Shewasof  delicate  constitution,  having  been  a 
s  even  months’  twin.  She,  about  twelve 
y  ears  since,  received  an  injury  to  the  spine 
whilst  playing  at  cricket  with  her  brothers, 
which  confined  her  to  her  bed  for  about 
\  i.ne  months.  Eventually  the  only  bad 
s  ymptoms  remaining  were  partial  paralysis 
of  the  lower  intestines,  so  that  the  bowels 
were  never  effectually  relieved  without  the 
a  id  of  an  enema,  and  severe  occasional  at- 
t  acks  of  pain,  for  which  she  took  large  doses 
of  laudanum.  She  married  about  five  years 
a  fter  the  receipt  of  the  injury,  and  her  preg¬ 
nancies  have  always  been  attended  through¬ 
out  with  violent  sickness  and  ill  health.  In 
April  1848,  she  was  pregnant  with  her  fifth 
c  h  ild ;  the  sickness  had  been  most  violent 
a  nd  distressing  during  the  whole  time,  opium, 
hydrocyanic  acid,  and  the  usual  remedies 
f  ailing  to  give  her  any  relief.  On  the  3rd, 
after  riding  out  for  an  hour,  she  felt  an  un¬ 
usual  dragging,  and  pain  in  the  right  side, 
obliging  her  to  keep  her  bed,  and  to  take 
opiates.  On  the  7th  she  was  suddenly 
seized  with  labour,  and  delivered  of  a  small 
male  child  six  or  seven  weeks  before  the  full 
time,  which  only  lived  about  twenty  hours. 
The  next  day,  the  8th,  whilst  turning  in 
bed,  she  felt  a  severe  pain  in  the  groin,  as 
she  described,  as  of  something  having 
snapped  asunder,  and  from  that  time 
she  continued  to  suffer  greatly  in  the 
whole  inguinal  region ;  but  as  the  pulse 
continued  about  90,  and  there  was  no 
particular  tenderness  on  pressure,  nothing 
was  done  but  the  administration  of  sedatives. 
On  the  10th,  the  pain  was  more  acute,  and 
a  slight  hard  swelling  could  distinctly  be 
traced  high  up  in  the  inguinal  region  ;  bowels 
had  been  slightly  relieved  by  the  enema. 
Six  leeches  were  applied  over  the  spot,  and 
subsequently  warm  fomentations,  which  were 
also  applied  over  the  labia,  the  lochia  having 
ceased,  and  the  urine  being  very  scanty.  She 
continued  much  the  same  until  the  13th  (a 
blister  having  been  applied  on  the  11th); 
the  cord-like  swelling  could  now  be  felt  more 
distinctly,  and  the  tenderness  extended  over 
the  whole  abdomen.  On  the  14th,  Dr. 
Chowne  first  saw  her  in  consultation.  Her 
tongue  was  brown  ;  pulse  about  90  ;  tender¬ 
ness  and  pain  the  same ;  bowels  not  relieved 
by  the  usual  enema.  A  dose  of  six  grains 
of  calomel  was  prescribed  for  her,  to  be 
followed  by  three  grains  every  two  hours, 
until  she  had  taken  twelve  grains.  At  the 
end  of  twelve  hours  the  bowels  were  only 
slightly  acted  upon  by  enema.  Fomenta¬ 
tions  continued,  with  saline  and  opiate  mix¬ 
ture.  I  first  saw  her  on  the  15th  :  she  was 
then  complaining  of  intense  pain  in  the  right 
inguinal  region  ;  could  not  bear  any  pressure 
on  that  part ;  the  whole  abdomen,  which 
was  tympanitic,  was  tender  on  pressure,  but 
not  sufficiently  so  to  be  very  urgent.  She 


had  observed  a  swelling  in  this  situation  be¬ 
fore  her  pregnancy  ;  but  previous  to  her  con¬ 
finement  it  had  not  caused  her  any  uneasi¬ 
ness.  From  the  slight  examination  which, 
on  account  of  the  soreness  of  the  blister,  I 
was  enabled  to  make,  I  was  disposed  to  sus¬ 
pect  mischief  about  the  caecum  or  its  appen¬ 
dix,  but  as  the  symptoms  were  not  very  ur¬ 
gent,  it  was  agreed  to  continue  the  opiates, 
and  apply  poultices  over  the  part  until  we 
met  again  on  the  17th. 

April  16. — Not  so  well ;  pain  more  acute 
more  decided  signs  of  peritonitis. 

17th. — Much  worse  than  when  we  last 
saw  her.  Her  countenance  anxious  ;  nose 
pinched ;  pulse  intermittent  and  running 
sickness  very  troublesome  ;  tongue  brown  in 
centre;  had  obtained  no  sleep,  although 
thirty  doses  of  the  solution  of  bi-meconate 
of  morphia  had  been  given  every  three  hours. 
Skin  cold  and  clammy  ;  complained  of  great 
pain,  and  fits  of  shivering,  which  were  most 
violent,  and  from  their  frequency  had  pre¬ 
vented  her  sleeping  ;  bowels  scarcely  relieved 
by  enema. 

The  blistered  surface  having  healed  up,  a 
more  decided  examination  could  be  made. 
The  cord-like  swelling  already  alluded  to  was 
more  apparent,  but  too  close  to  the  spine  of 
the  ilium  to  be  an  inguinal  hernia  ;  there 
was  also  thickening  and  hardness  extending 
outwards  towards  the  ilium,  where  she  com¬ 
plained  most  of  pain.  As  she  was  evidently 
sinking,  and  the  previous  treatment  had  been, 
of  no  avail,  I  proposed  to  make  an  incision 
from  the  spine  of  the  ilium  to  the  inner 
side  of  the  internal  abdominal  ring  over  the 
hardened  spot,  so  that  if  it  were  intestine  or 
omentum  it  could  be  freed  ;  or  if,  as  we 
thought  more  probable,  matter  had  collected 
in  the  right  iliac  fossa,  it  could  be  let  out, 
and  thus  give  our  patient  a  chance  of  reco¬ 
very.  This  having  been  agreed  to  by  Dr. 
Chowne  and  Mr.  Diamond,  who  attended 
the  case  with  me  throughout,  the  patient 
was  put  under  the  influence  of  chloroform,, 
and  an  incision  about  four  inches  long  made 
inwards  from  the  spine  of  the  ilium  above. 
Poupart’s  ligament,  but  as  close  to  it  as  pos¬ 
sible.  Upon  opening  into  the  abdomen,  a 
quantity  of  excessively  offensive  turbid  se¬ 
rum,  with  fibrinous  flocculi,  poured  out, 
mixed  with  air  globules,  and  also  patches  of 
false  membrane.  She  was  directed  to  be 
turned  on  her  side,  that  the  discharge  might 
freely  escape ;  a  poultice  to  be  applied,  and 
to  take  an  opiate. 

We  again  saw  her  at  ten  o’clock  that 
evening ;  her  abdomen  was  then  very  tym¬ 
panitic  and  painful ;  pulse  120  ;  skin,  how¬ 
ever,  warmer  than  before  the  operation  ;  the 
wound  has  discharged  very  freely,  the  fluid 
being  most  offensive. 

To  take  morphia  with  carbonate  of  am¬ 
monia  every  four  hours,  and  to  have  a 


DISEASE  OF  THE  APPENDIX  CjECI  CURED  BY  OPERATION.  549 


starch  enema,  with  five  drachms  of  sedative 
liquor  of  opium. 

18th. — Better;  has  passed  a  more  quiet 
night ;  wound  discharges  freely  a  turbid 
serous  fluid ;  bowels  have  been  relieved  by 
enema.  Tongue  white  ;  pulse  120  ;  suffers 
from  spasmodic  twitchings  of  body.  Abdo¬ 
men  very  tender  over  the  whole  surface,  and 
slightly  swollen. 

To  continue  the  sedative  draughts,  each 
containing  sixty  minims  of  the  solution  of 
morphia  every  three  hours,  with  starch  ene¬ 
ma,  with  six  drachms  of  solution  of  opium 
at  night. 

May  1st. — Has  gone  on  favourably  up  to 
this  date ;  the  opiate  enemata  have  been 
omitted,  but  the  opiate  draughts  continued, 
with  occasional  small  doses  of  calomel,  which 
have  greatly  controlled  the  sickness.  She 
has  been  allowed  as  much  nourishment  as 
she  will  take,  but  her  appetite  continues  bad. 
She  has  also  had  wine,  brandy,  and  bottled 
stout  from  time  to  time,  the  discharge  being 
large  in  quantity,  thin,  watery,  and  very 
offensive  ;  the  abdomen  has  become  soft  and 
painless  on  pressure.  To-day  she  is  not  so 
well,  suffering  great  pain  about  the  wound, 
which  is  inflamed,  and  the  edges  sloughy. 
Ordered  warm  fomentations  to  be  applied 
continually  over  the  whole  surface  of  the 
abdomen. 

2d. — Her  sleep  has  been  much  disturbed 
by  acute  pain  around  the  wound  ;  discharge 
thinner,  greenish,  and  very  offensive.  Upon 
carefully  examining  the  wound,  a  small 
round  ball  of  faecal  matter,  surrounded  by 
calcareous  deposit,  was  discovered,  and  upon 
further  examination,  a  second  piece  excavated 
on  one  side,  evidently  forming  a  cup  for  the 
former  piece,  and  which,  from  their  size,  I 
should  imagine  had  been  impacted  in  and 
escaped  by  ulceration  from  the  appendix  ver- 
miformis.  A  large  quantity  of  hard  faecu- 
lent  matter  passed  per  anum,  after  the 
enema. 

To  continue  the  nourishing  diet ;  and,  as 
profuse  perspirations  have  come  on,  to  take 
disulphate  of  quinine,  with  sulphuric  acid, 
and  infusion  of  roses  with  opiate  at  bed¬ 
time.  She  got  well  from  this  date  ;  the  dis¬ 
charge  gradually  improving  in  quality. 

In  some  remarks  upon  this  case,  Mr. 
Hancock  referred  to  the  frequency  of  opera¬ 
tions  on  the  abdomen  of  late,  particularly  in 
cases  of  ovarian  disease,  many  of  which  had 
been  successful.  As  far  as  he  knew,  the  in¬ 
stance  related  was  the  only  one  on  record  of 
an  operation  of  the  kind,  under  the  circum¬ 
stances  detailed.  He  should  not  argue,  or 
draw  general  conclusions  from  a  solitary  case, 
but  he  thought  that  it,  at  all  events,  would 
justify  us  in  having  recourse  to  such  a  pro¬ 
cedure  in  cases  of  peritonitis,  when  all  other 
means  had  failed,  and  without  which  death 
was  inevitable.  He  contended  that  the  ty¬ 


phoid  condition  into  which  patients  affected 
with  peritonseal  inflammation  fell,  did  not 
depend  upon  the  violence  of  the  disease,  but 
upon  the  acrid  nature  of  the  effused  fluid, 
the  removal  of  which  he  thought  the  only 
chance  of  saving  the  patient. 

Dr.  Bennett  made  some  remarks  on  the 
great  variety  observable  in  cases  similar  to 
that  related.  The  question  was,  when  to 
interfere,  and  when  to  leave  off  trusting 
to  nature.  He  related  a  case,  in  which  a 
tumor  formed  in  the  right  inguinal  region, 
but  which  eventually  spread  over  to  the 
opposite  side  ;  matter  formed  was  entirely 
circumscribed,  and  if  early  mechanical 
means  had  been  resorted  to,  the  man  might 
have  been  saved.  The  first  symptoms  were 
simply  those  of  obstruction  ;  inflammation 
came  on,  followed  by  suppuration  and 
sloughing,  which  terminated  fatally,  in  con¬ 
sequence  of  there  being  no  exit  to  the  matter. 
The  disease  had  commenced  in  the  head  of 
the  colon,  and  involved  the  caecum. 

Dr.  Waller  said,  there  was  at  present 
in  St.  Thomas’s  Hospital  a  woman  with  a 
large  tumor  in  the  abdomen.  She  had  been 
subject  to  occasional  attacks  of  peritonitis. 
There  was  no  fluctuation.  No  examination 
could  be  made  per  vaginam,  as,  after  de¬ 
livery,  sloughing  had  come  on,  and  this 
passage  was  closed.  Eventually  a  commu¬ 
nication  took  place  into  the  bladder,  and 
foetid  pus  in  large  quantities  was  voided. 
She  is  getting  well. 

Dr.  Chowne  made  some  general  remarks 
on  the  difficulty  of  diagnosis  in  cases  of 
tumor  in  the  abdomen,  many  kinds  of  which 
he  enumerated.  He  made  some  comments 
on  Mr.  Hancock’s  case,  which  he  thought 
a  warrant  for  interference  in  future  cases  of 
the  kind. 

Dr.  Golding  Bird  said,  that  the  great 
novel  point  in  Mr.  Hancock’s  case,  and  his 
subsequent  remarks,  was  the  opinion  he  had 
broached,  that  the  danger  and  fatal  results, 
in  cases  of  peritonitis,  depended  more  on 
the  acrid  nature  of  the  effused  fluid,  than  on 
the  severity  of  the  disease  itself.  From  his 
own  observation  and  experience  he  was  led 
to  believe  that  his  opinion  was  correct. 
After  the  details  of  this  case  he  should  not 
hesitate  to  recommend  a  similar  proceeding. 
He  related  a  case  in  point,  which  occurred 
in  Guy’s  Hospital. 

Mr.  Canton  detailed  with  great  minute¬ 
ness  the  post-mortem  appearances  in  two 
cases  of  trephlo-peritonitis  ;  in  one,  the 
matter  was  circumscribed ;  in  the  other, 
diffused  over  the  abdomen. 

Dr.  Copland  had  written  on  the  subject 
of  the  paper  sixteen  years  ago.  He  compli¬ 
mented  the  author  on  the  treatment  he  had 
adopted.  It  was  the  only  successful  case  he 
had  ever  heard  of.  The  difficulty  in  cases 
of  this  kind  was  in  the  diagnosis.  In  most 


550 


DR.  KRUGER  HANSEN  rS  SPECIFIC  FOR  CHOLERA 


of  the  cases  he  had  seen,  the  effusion  had 
spread  generally  into  the  abdominal  cavity. 
In  none  of  these  cases  had  he  seen  redness 
of  the  surface.  The  appearances  after  death 
were  various ;  there  was  generally  found  an 
acrid  purulent  secretion,  sometimes  circum¬ 
scribed,  but  generally  involving  the  cavity 
of  the  peritonseum ;  the  appendix  vermi- 
formis  was  .generally  diseased. 

Mr.  Djendy  suggested,  that  in  doubtful 
cases  the  exploring  needle  should  be  em¬ 
ployed. 

Mr.  Hancock  objected  to  this  proceed¬ 
ing,  as  the  needle  might  pass  into  the  intes¬ 
tine,  and  mislead  the  surgeon. 


('TomsponDence. 


DR.  KRUGER  HANSEN’S  SPECIFIC  FOR 
CHOLERA,  THE  COMPOSITION  OF  THE 
MIXTURA  PYROTARTARICA. 

[We  are  indebted  to  Dr.  Golding  Bird  for 
he  following  explanation  respecting  the 
composition  of  Dr.  K.  Hansen’s  mixtura 
pyrotartarica,  on  which  we  commented  in 
our  last  number  at  page  510.] 

The  mistura  pyrotartarica  is  in  both  the 
Danish  and  Wirtemberg Pharmacopoeias,  and 
in  the  latter  is  called  weisse  einfache  Mixtur, 
an  odd  name  for  such  a  compound.  It  is 
as  follows  in  the  Wirtemberg  formula,  from 
which  the  Danish  slightly  only  differs. 

JL  Liquoris  Pyrotartarici  libram  unam  ; 
Glei  Yitrioli  uncias  tres.  Distillent  ad  sic- 
cum.  Liquoriobtento,  adde  spiritus  theria- 
calis  camphoratse  uncias  viginti. 

The  Liquor  Pyrotartaricus  is  evidently  a 
mixture  of  pyrotartaric  and  pyroracemic 
acids,  with  pyrogenous  tarry  products.  It  is 
in  all  the  German,  Dutch,  and  Danish  Phar¬ 
macopoeias,  and  isjcalled  Brenzliche  Wein- 
stein-fleissigkeit.  The  following  is  the  for¬ 
mula  for  its  preparation  : — 

Jit.  Tartari  crudi  q.  s.  Fiat  destillatio  ex 
retorta  ferrea,  ad  dimidiam  capacitatis  re- 
pleta,  igne  prius  remissiore,  dein  sensim  ad 
rubedinem  augendo.  Producta  aerformia, 
quae  impetuose  prorumpant,  in  refrigeratorio, 
aqua  frigida  large  circumdata  frigefacto,  con- 
densantur.  Liquorem  elicitum  filtratione  ab 
oleo  empyreumatico  per  chartam  bibulam 
madefactam,  separa. 

The  other  ingredient  in  the  mistura  py¬ 
rotartarica,  the  sp.  theriac.  camph.,  is  thus 
prepared  according  to  the  Pharm.  Boruss., 
Slesv-Holst.,  Hamb.,  Hanno.,  and  others: — 
Jb.  Rad.  Angelicse,  libram  unam ;  Herbse 
Scordii  (the  Scordium  creticum),  Rad. 
Valerianae,  Bacc.  Juniperis,  aa.  uncias  tres; 
Sp.  Vin.  rect.  libras  sex  ;  Aquae  com.  q.  s. 
Destillatione  eliciantur  librae  sex,  in  quibus 
solve  camphorae,  §iss. 

15*  These  formulae  give  us  a  good  illustration 
of  the  curious  polypharmacy,  still  fashion¬ 


able  among  the  Teutons  and  Scandinavians. 
It  is,  however,  obvious  enough,  that  Dr. 
Kruger  Hansen’s  prescription  contains,  in 
addition  to  the  opium,  a  very  energetic  ner¬ 
vous  stimulant  and  diaphoretic  in  the  sp. 
ther.  camph.  of  the  mixt.  pyrotart.  in  ad¬ 
dition  to  the  product  obtained  by  distilling 
the  pyrogeneous  products  from  the  ignition 
of  crude  bitartrate  and  biracemate  of  potass 
with  sulphuric  acid.  If  creosote  is  yielded 
by  the  destructive  distillation  of  tartar,  this 
second  distillation  would  give  that  body  in  a 
purer  form,  at  least,  judging  by  the  plan 
used  at  present  to  obtain  it. 

September,  1848. 

ON  THE  USE  OF  CHLOROFORM  IN  MID¬ 
WIFERY.  REPLY  TO  MR.  CRAIG. 

Sir, — I  beg  the  favour  of  the  insertion  of  a 
few  words,  in  reply  to  the  unmeritedly  severe 
censures  of  Mr.  Craig,  bestowed  so  liberally 
on  all  “  the  undeliberative  administrators” 
of  chloroform  in  midwifery  practice  {vide 
Gazette,  Sept.  22d.) 

I  should  not  have  presumed  upon  your 
notice,  but  that  Mr.  Craig  has  selected  my 
remarks  on  this  subject  (Gaz.  August  11, 
1848)  for  special  castigation.  But  so  far 
as  I  am  individually  concerned,  I  think  that 
that  gentleman  will,  if  he  look  again  to  my 
words,  find  that  I  reprehended  the  indiscri¬ 
minate  employment  of  anaesthetic  agents, 
while  I  advocate  only  their  cautious  use,  and 
desire  only  to  know  whether  they  may  be 
safely  employed.  Not  that  I  assume  to 
myself  singularity  herein  ;  I  believe  that  if 
Mr.  Craig  had  taken  sufficient  pains  to 
ascertain  the  fact,  he  would  have  found  that 
they  form  a  very  small  number  to  whom  he 
could  have  affixed  the  charges  of  uncon¬ 
scientiousness,  suppression  as  to  failures, 
with  other  moral  delinquencies  which  he 
too  freely  employs  in  speaking  of  those  who 
have  ventured  to  use  a  remedy  which 
he  proscribes.  For  myself,  I  can  honestly 
affirm,  that  I  am  far  from  being  the  reck¬ 
less  thick  and  thin  advocate  of  “  doubt¬ 
ful,’’  “  dangerous,”  “  poisonous”  agencies, 
which  might  be  inferred  from  Mr.  Craig’s 
remarks.  I  hope,  that  having  a  full  sense 
of  human  destiny,  I  hold  in  due  value  human 
life  :  while  I  would  by  all  means  have  the 
domain  of  the  science  of  healing  extended, 

I  would  by  no  means  trifle  with  life,  much 
less,  in  the  words  of  Mr.  Craig,  select  as  my 
victim  “  the  wife  of  my  bosom.” 

I  would,  in  conclusion,  suggest  to  Mr. 
Craig,  that  such  injurious  insinuations  and 
unqualified  condemnations  of  those  from 
whom  he  differs,  is  not  the  most  advisable  nor 
the  speediest  method  by  which  he  or  any  one 
else  will  arrive  at  truth. 

I  remain,  &c. 

W.  B.  Kesteven. 

Holloway,  Sept.  23, 1848. 


QUARANTINE  PRECAUTIONS  AGAINST  CHOLERA. 


551 


i^Tctrica!  Intelligence. 


QUARANTINE  PRECAUTIONS  AGAINST 
CHOLERA — ORDER  IN  COUNCIL. 

A  communication  has  been  received  by 
the  Commissioners  of  the  Customs’  depart¬ 
ment,  through  their  secretary,  from  Mr. 
Greville,  one  of  the  clerks  of  the  Council, 
stating  that  with  reference  to  his  communi¬ 
cation,  dated  the  15th  of  June  last,  directing 
all  vessels  arriving  in  the  United  kingdom, 
having  foul  bills  of  health  (with  reference  to 
cholera),  to  be  released  from  quarantine 
without  any  medical  visit,  provided  that  no 
case  of  cholera  had  existed  on  board  any  such 
vessel  for  a  period  of  10  days  previously  to 
her  arrival,  he  (Mr.  Bathurst)  has  been  di¬ 
rected  by  the  Lords  of  the  Council  to  state 
for  the  information  of  the  Commissioners  of 
the  Customs,  that  it  is  the  expressed  desire 
of  their  Lordships  that  the  before-mentioned 
regulation  should  still  continue  in  force.  Mr. 
Bathurst  had  also  to  state  that  he  was  now 
further  directed  by  the  Lords  of  the  Council 
to  inform  the  commissioners  that  their  Lord- 
ships  are  of  opinion  that  instructions  should 
be  forthwith  transmitted  to  the  different  ports 
in  the  United  kingdom,  directing  that  in  the 
event  of  the  arrival  of  any  vessel  on  board  of 
which  a  case  of  cholera  shall  have  occurred, 
such  vessel  shall  be  detained  under  the 
restraint  of  quarantine  until  the  clothing  and 
bedding  of  the  following  persons  shall  have 
been  thoroughly  immersed  in  water,  under 
the  direction  of  an  officer  of  the  Customs- — 
viz.,  1.  Of  all  persons  who  shall  have  died 
of  cholera  on  board  of  such  vessel  at  any 
foreign  port  or  on  shore  at  such  port.  2. 
Of  all  persons  who  shall  have  died,  or  who 
shall  have  had  an  attack  of  cholera  on  board 
of  such  vessel  during  her  homeward  voyage. 
And  that  should  any  vessel  arrive  with  cho¬ 
lera  actually  on  board ,  such  vessel  should  be 
detained  under  quarantine  at  her  port  of 
arrival  until  further  orders  from  the  Lords  of 
the  Council  are  received.  In  pursuance  of 
this  communication  from  the  Lords  of  the 
Council,  with  a  view  to  prevent  the  intro¬ 
duction  of  cholera  into  this  country  by 
vessels  arriving  from  abroad,  express  di¬ 
rections  have  been  forwarded  by  the  com¬ 
missioners  to  the  officers  of  the  Customs’ 
department  at  the  several  ports  and  places 
throughout  the  United  kingdom,  as  well  as 
to  the  port  of  London,  to  take  care  that  their 
Lordships’  orders  be  duly  obeyed. 

THE  CHOLERA  IN  RUSSIA. - RIOTS  IN 

CONSEQUENCE  OF  ALLEGED  POISONING. 

A  letter,  dated  St.  Petersburgh,  10th 
inst.,  gives  an  account  of  a  disturbance 
which  occurred  in  that  city  in  consequence 


of  the  cholera  having  recommenced  its 
ravages  with  increased  severity,  and  parti¬ 
cularly  amongst  the  poorer  classes.  A 
report  was  circulated  amongst  the  people, 
that  the  aristocracy  had  employed  poison  to 
cut  them  off.  They  immediately  constructed 
barricades.  The  troops  were  about  to 
attack  them,  when  the  Emperor  arrived  on 
horseback,  attended  by  a  single  aide-de- 
camp.  The  Emperor  ordered  the  troops  to 
fall  back,  and,  ascending  the  barricade,  he 
addressed  the  insurgents  as  follows  : — 

“The  cholera,  my  children,  is  a  chastise¬ 
ment  which  God  inflicts  on  men,  and  to 
which  they  must  submit  with  resignation. 
All  the  reports  of  poisonings  are  pure  false¬ 
hoods,  invented  by  evil-minded  persons,  who 
are  the  enemies  of  the  people.” 

The  insurgents,  who  had  cast  themselves 
on  their  knees,  as  in  the  attitude  of  prayer, 
when  they  perceived  their  Czar,  remained 
silent,  with  the  exception  of  two,  who  com¬ 
menced  a  reply.  The  Czar  ordered  the  in¬ 
surgents  to  arrest  those  two  men,  and  then 
commanded  the  troops  to  return  to  their 
barracks.  The  insurgents  immediately 
seized  their  comrades  and  delivered  them  up 
to  the  police.  They  demolished  the  barri¬ 
cades  and  separated  peaceably. 

SANITARY  LEGISLATION.  PENALTIES  FOR 

IMPORTING  DISEASED  CATTLE  AND  EX¬ 
POSING  FOR  SALE  DISEASED  MEAT. 

An  Act  was  passed  in  the  late  session  to 
prevent  the  importation  of  diseased  sheep 
and  other  cattle,  and  also  to  prevent  until 
the  1st  of  September,  1850,  the  spreading 
of  contagious  or  infectious  disorders  among 
sheep,  cattle,  and  other  animals.  By  this 
statute,  infected  sheep  exposed  for  sale  may 
be  seized  and  destroyed,  together  with  pens, 
hurdles,  &c.,  with  power  to  impose  a  fine  of 
not  exceeding  ,£20,  on  parties  exposing  cattle 
knowing  them  to  be  diseased  ;  a  like  penalty 
on  persons  exposingmeatunfitfor  human  food, 
with  power  to  seize  and  destroy  the  same.  The 
Privy  Council  may  make  regulations  as  to 
the  removal  of  sheep,  &c.,  and  as  to  the 
purifying  of  yards,  stables,  &c.  The  act 
contains  22  sections,  pointing  out  the  penal¬ 
ties  for  disobedience,  and  the  manner  in 
which  the  fines  are  to  be  levied  and  re¬ 
covered. 

The  following  useful  hygienic  provision  is 
introduced  into  the  11th  and  12th  Victoria, 
chap.  107,  section  3.  “And  whereas  it  is 
expedient  to  make  more  effectual  provisions 
for  preventing  the  exposure  for  sale  of  any 
meat  unfit  for  human  food  ;  be  it  enacted, 
that  if  any  meat  unfit  for  human  food  be 
exposed  or  offered  for  sale  in  any  market, 
fair,  or  other  open  or  public  place,  it  shall 
be  lawful  for  such  clerks,  inspectors,  con¬ 
stables,  policemen,  or  other  persons,  autho¬ 
rized  as  aforesaid,  to  seize  the  same,  and  to 


552  ON  THE  NECESSITY  OF  RESTRICTING  THE  SALE  OF  POISONS 


report  such  seizure  to  such  mayor  or  justice 
as  aforesaid,  and  such  mayor  or  justice  may 
either  order  the  same  to  be  restored  or  to  be 
destroyed,  or  otherwise  disposed  of,  as  afore¬ 
said  ;  aud  any  person  publicly  exposing  or 
offering  such  meat  for  sale  shall,  upon  con¬ 
viction,  forfeit  and  pay  for  each  and  every 
such  offence  a  sum  not  exceeding  ^20.” 

ON  THE  NECESSITY  OF  RESTRICTING  THE 
SALE  OF  POISONS. 

It  is  certainly  competent  to  the  authorities 
to  check  the  present  facilities  for  obtaining 
poison,  and  this  is  a  point  of  more  conse¬ 
quence  than  might  at  first  be  thought,  for 
our  modern  Locustas  have  fortunately  no 
extensive  acquaintance  with  the  properties  of 
deadly  drugs.  In  every  single  case  which 
has  been  investigated,  we  believe  that  arsenic, 
in  its  commonest  form,  has  become  the  agent 
of  death,  insomuch  that  in  the  recent  ex¬ 
amples  it  was  proved  in  evidence  that  the 
term  “white  powdering”  was  used  in  the 
village  as  equivalent  to  poisoning.  By  stop¬ 
ping,  therefore,  the  indiscriminate  sale  of 
arsenic,  according  to  one  or  other  of  the  nu¬ 
merous  regulations  which  have  been  recom¬ 
mended  for  this  purpose,  the  chief,  if  not  the 
sole  instrument  of  mischief,  would  be  re¬ 
moved  from  the  reach  of  the  criminal.  In 
the  next  place,  though  it  may  seem  unna¬ 
turally  cruel  to  add  a  single  ounce  to  the 
burden  of  the  parish  surgeon,  yet  we  do 
conceive  that  the  peculiar  opportunities  of 
that  officer  enable  him,  when  his  vigilance 
has  been  once  quickened  by  suspicion,  to 
co-operate  most  effectually  with  the  local  au¬ 
thorities  in  the  detection  of  this  hideous 
crime.  But,  beyond  all  other  measures,  it 
is  imperatively  necessary  that  the  security 
supplied  by  the  common  law  of  the  land 
against  foul  play  with  human  life,  should  be 
no  longer  negatived  by  the  criminal  parsi¬ 
mony  of  county  officers.  We  mean  that  the 
duties  of  the  coroner  should  not  be  circum¬ 
scribed  by  the  economy  of  his  paymasters. 
It  is  matter  of  notoriety,  that  many  a  sus¬ 
picious  case  of  death  is  slurred  over  without 
notice  in  order  to  save  the  fees  incurred  by 
the  inquest ;  and  we  are  fully  persuaded  that 
the  impunity  thus  systematically  secured  to 
a  deed  of  death  has  often  been  mainly  instru¬ 
mental  in  urging  the  criminal  upon  a  career 
of  murder.  What  apprehensions,  indeed, 
could  be  entertained  of  law  or  justice  by  a 
woman  who  had  been  already  left  to  the  un¬ 
disturbed  perpetration  of  six  successive 
homicides  ?  Even  if  the  first  inquest  had 
been  unsuccessful,  yet  the  certainty  that  each 
attempt  would  be  followed  by  an  inquiry 
which  might  be  more  effectual  than  the  last, 
would  of  itself  have  induced  some  little 
scruple  and  hesitation,  and  disturbed,  at  all 
events,  that  triumphant  course  of  guilt  which 
combined  the  stimulus  of  success  with  the 


experience  of  impunity,  and  led  the  ignorant 
and  vicious  to  believe  that  to  take  the  life  of 
another  was  a  deed  as  safe  as  they  had  found 
it  to  be  easy. — Times. 

RESULTS  OF  FREE  TRADE  IN  POISON. 

[We  extract  the  following  from  a  provincial 
paper.]  An  inquest  was  recently  held  at 
Filkins,  Oxfordshire,  before  James  Westell, 
Esq.,  Coroner  for  the  western  division  of 
the  county,  touching  the  decease  of  Harriet 
Kitchener,  an  interesting  young  woman, 
wife  of  the  toll-keeper  at  the  adjoining  parish 
of  Broughton  Pogis,  and  who,  it  was  alleged, 
had  come  to  her  death  through  poisoning1. 
From  the  nature  of  the  evidence,  it  is  not 
unreasonable  to  believe  that  she  has  fallen  a 
victim  to  the  injudicious  practice  of  allowing 
the  keepers  of  “  general  shops”  in  the  coun¬ 
try,  though  totally  unacquainted  with  che¬ 
mistry,  to  retail  drugs  of  a  deadly  descrip¬ 
tion,  the  testimony  of  the  medical  man 
clearly  showing  that,  on  making  a  post-mor¬ 
tem  examination,  and  subjecting  the  con¬ 
tents  of  the  stomach  to  a  variety  of  tests, 
the  result  proved  the  presence  of  a  large 
quantity  of  arsenic,  which  arsenic,  it  was 
proved,  had  been  most  reprehensibly  supplied 
in  the  manner  above  noticed  to  Mary  Ann 
Batten,  an  intelligent  child,  ten  years  of  age, 
who  purchased  it  for  the  deceased  at  the 
shop  of  a  Mrs.  Smith,  at  Filkins,  though 
this  was  attempted  to  be  denied  by  the  shop- 
woman,  Ellen  Wroe,  who  served  it.  It 
was  stated  by  one  of  the  jurors  that  another 
child  had  bought  precipitate  of  mercury  at 
the  shop  on  the  same  evening,  and  this  was 
subsequently  proved  to  have  been  correct — • 
a  little  girl,  named  Harriet  Cook,  having 
purchased  some,  with  other  articles,  for  her 
mother.  The  coroner,  in  summing  up,  com¬ 
mented  in  strong  terms  on  the  unsatisfactory 
nature  of  the  evidence  adduced  by  Miss 
Ellen  Wroe,  who  either  could  not  or  would 
not  remember  what  had  taken  place,  and  had 
accordingly  given  them  vague  statements, 
totally  different  from  those  adduced  by  other 
witnesses.  The  question  the  Jury  had  to 
decide  was,  whether  the  deceased  had  taken 
such  poison  by  mistake  or  intentionally.  If 
they  arrived  at  the  first  conclusion,  their 
verdict  would  be  one  of  accidental  death ; 
but  if  they  considered  that  she  had  com¬ 
mitted  suicide,  they  must  pursue  a  further 
inquiry  with  the  view  of  ascertaining  the 
state  of  mind  in  which  she  was  at  the  time. 
After  consulting  for  a  short  time,  the  Jury 
gave  as^their  verdict,  That  the  deceased  died 
from  swallowing  arsenic,  but  whether  de¬ 
signedly  or  by  mistake ,  there  is  not  suffi¬ 
cient  evidence  to  shoiv.  [To  the  particulars 
which  we  have  thus  given  it  is  unnecessary  to 
add  but  a  few  words.  Although,  perhaps, 
from  the  intricate  circumstances  by  which 
the  case  was  aurrounded,  and  the  complicated 


RESULTS  OF  FREE  TRADE  IN  POISONS.  CAVENDISH  SOCIETY.  553 


nature  of  the  evidence  adduced,  it  was  diffi¬ 
cult  for  the  jury  to  arrive  at  another  con¬ 
clusion  than  that  which  they  unanimously 
came  to,  yet  one  thing  disclosed  at  the  in¬ 
quest  is  certain.  Two  little  children  of  ten¬ 
der  years  go  to  the  “general  shop”  of  a 
country  village,  where  it  would  appear  that 
drapery  and  drugs,  provisions  and  poison, 
are  indiscriminately  dealt  out  to  purchasers, 
and,  without  any  question  being  asked  of 
them,  they  receive  upon  paying  their  penny, 
enough  poison  to  produce  death  !  Surely 
this  is  an  evil  that  requires  a  remedy. 
Either  ignorant  persons  should  not  be  per¬ 
mitted  to  retail  poisons,  or  such  things 
should  only  be  sold  to  grown-up  people,  and 
then  never  without  the  purpose  for  which 
they  were  required  being  distinctly  ascer¬ 
tained. — Ed.  B.  M.~] 

CAVENDISH  SOCIETY. 

The  following  gentlemen  have  been  elected 
office-bearers  of  this  Society  : — 

President.  —  Professor  Graham,  V.P.R.S. 
Vice-Presidents. — Arthur  Aikin,  Esq.; 
Professor  Brande,  F.R.S.  ;  Earl  of  Burling¬ 
ton,  E.R.S.  ;  Professor  Daubeny,  F.R.S. ; 
Professor  Faraday,  F.R.S. ;  Rev.  Wm.  Ver¬ 
non  Harcourt,  F.R.S. ;  Sir  R.  Kane, 
M.R.I.A.  ;  The  Marquis  of  Northampton, 
P.R.S.  ;  Richard  Phillips,  Esq.,  F.R.S.  ; 
William  Prout,  M.D.  F.R.S.  ;  Thomas 
Thomson,  M.D.  F.R.S.  L.  &  E.  ;  James 
Thomson,  Esq.,  F.R.S.  Treasurer. — Henry 
Beaumont  Leeson,  M.D.,  St.  Thomas’s 
Hospital,  Southwark.  Council.  —  Jacob 
Bell,  Esq. ;  Benjamin  Brodie,  Esq.  ;  George 
E.  Day,  M.D.;  Warren  Dellarue,  Esq.; 
J.  P.  Gassiot,  Esq.,  F.R.S.  ;  J.  J.  Griffin, 
Esq. ;  A.  W.  Hofmann,  Esq.,  Ph.D. ;  Pro¬ 
fessor  W.  A.  Miller,  F.R.S.  ;  Jonathan 
Pereira,  M.D.  F.R.S.  ;  Lyon  Playfair, 
Ph.D.  F.R.S. ;  R.  Porrett,  Esq.,  F.R.S. ; 
Professor  T.  Redwood;  Edmund  Ronalds, 
Ph.D.;  Professor  Wheatstone,  F.R.S.; 
Alfred  White,  Esq.,  F.L.S;  Lieutenant- 
Colonel  Yorke.  Secretary. — Robert  Wa- 
rington,  Esq.,  Apothecaries’  Hall,  Bridge 
Street,  Blackfriars.  Collector.— Mr.  Charles 
Woodfall,  7,  Canterbury  Place,  Walworth.* 
The  Cavendish  Society  is  instituted  for  the 
promotion  of  Chemistry  and  its  allied 
sciences,  by  the  diffusion  of  the  literature  of 
these  subjects.  The  Society  effects  its  ob¬ 
ject  by  the  translation  of  recent  works  and 
papers  of  merit ;  by  the  publication  of 
valuable  original  works,  which  would  not 
otherwise  be  printed,  from  the  slender 
chance  of  their  meeting  with  a  remunerative 
sale  ;  and  by  the  occasional  republication 

*  Office  of  the  Society,  at  Mr.  John  Joseph 
Griffin’s,  53,  Baker  Street,  Portman  Square,  where 
members,  not  otherwise  supplied,  may  receive 
the  works  of  the  Society  on  application.  The 
Society  has  also  local  secretaries  in  most  of  the 
principal  towns  of  Great  Britain, 


or  translation  of  such  ancient  or  earlier 
modern  works  as  may  be  considered  interest¬ 
ing  or  useful  to  the  members  of  the  Society. 
Members  who  pay  an  annual  subscription  of 
one  guinea  are  entitled  to  a  copy  of  every 
work  published  by  the  Society  for  the  period 
during  which  their  membership  continues. 
The  number  of  works  thus  published  will 
necessarily  depend  on  the  number  of  annual 
subscribers  ;  but  it  is  anticipated  that,  when 
the  advantages  afforded  by  the  Society  become 
generally  known,  the  number  of  subscribers 
will  be  adequate  to  the  expense  of  publishing 
three  octavo  volumes  each  year.  The  works 
of  the  Society  will  be  handsomely  printed,  on 
a  uniform  plan,  for  members  only,  their 
publication  being  conducted  by  the  Council, 
who  are  annually  elected,  by  ballot,  from 
among  the  members,  each  member  having  a 
vote.  The  first  volume  of  the  Society’s 
publications,  edited  by  Professor  Graham, 
and  entitled  “  Chemical  Reports  and  Me¬ 
moirs,”  is  now  in  the  hands  of  members. 
In  choosing  these  Reports  a  selection  has 
been  made  of  those  which  treat  of  the  pre¬ 
sent  condition  of  our  knowledge  in  certain 
branches  having  a  special  interest  in  the  pre¬ 
sent  state  of  chemical  science  ;  and  the  Me¬ 
moirs  are  on  subjects  of  general  and  practical 
interest. 

The  translation  of  Gmelin’s  Chemistry  is 
in  a  forward  state.  The  first  volume  of  the 
work,  which  wiil  form  the  second  of  the  So¬ 
ciety’s  publications,  will  be  ready  for  circu¬ 
lation  in  a  few  months.  This,  together  with 
the  volume  of  “  Chemical  Reports  and  Me¬ 
moirs,”  the  members  will  receive  in  return 
for  their  first  year’s  subscription ;  and  should 
the  number  of  members  increase  to  the  ex¬ 
tent  expected  (from  about  600,  the  present 
number,  to  900  or  1,000),  the  Council  will 
be  enabled  to  publish  another  volume  of 
Gmelin’s  Chemistry  as  part  of  the  return  for 
this  year. 

With  reference  to  future  publications, 
several  works  have  been  brought  under  the 
consideration  of  the  Council,  among  which 
are — 

1.  The  Life  and  Works  of  Cavendish. 
2.  Rammelsberg’s  Dictionary  of  the  Chemi¬ 
cal  part  of  Mineralogy.  3.  Kopp’s  History 
of  Chemistry.  4.  Buff’s  Outlines  of  Expe¬ 
rimental  Physics  for  Chemists.  5.  Otto’s 
Economic  Chemistry.  6.  Berthier  on  As¬ 
saying.  7.  G.  Rose’s  Crystallography. 

It  has  been  considered  by  the  Council 
that  the  completion  of  the  translation  of 
Gmelin’s  Chemistry  ought  to  be  effected  writh 
the  least  possible  delay,  and  they  therefore 
propose  making  arrangements  for  the  publi¬ 
cation  of  two  more  volumes  of  the  work  next 
year,  one  volume  to  be  a  continuation  of  in¬ 
organic ,  and  the  other  the  commencement 
of  organic  chemistry.  “  The  Life  and  Works 
of  Cavendish  ”  have  been  suggested  as  the 


564  GENERAL  HOSPITAL,  NEAR  NOTTINGHAM.  CHOLERA  IN  PARIS. 


third  volume  for  the  second  year,  should  the 
funds  of  the  Society  admit  of  the  publication 
of  three  volumes.  *>. 

Robt.  Warington, 

August  1848.  Honorary  Secretary. 

THE  GENERAL  HOSPITAL,  NEAR 
NOTTINGHAM. 

It  is  gratifying  to  report  that,  during  the 
last  year,  1131  of  theafflicted  poor  have  par¬ 
taken,  within  this  hospital,  of  the  important 
advantages  of  skilful  medical  treatment  and 
attentive  nujrsing  ;  and  that  advice  has  been 
given,  and  medicines  dispensed,  to  3843 
out-patients.  Still  it  must  be  matter  of 
regret  that,  in  a  time  of  unusual  adversity  to 
the  poorer  classes,  it  should  have  become 
necessary  for  the  Governors  to  resolve,  at 
their  Annual  Meeting,  on  the  29th  of 
March,  that  the  four  additional  beds  which 
were  put  up  in  April  1844,  should  not  be 
occupied  during  the  present  depressed  state 
of  the  finances.  This  painful  course  was 
taken  in  consequence  of  the  large  sum  of 
£826.  10s.  4Jd.  appearing  upon  the  year's 
account  as  the  balance  against  the  Charity, 
which  had  accrued  from  the  following  causes, 
viz.  the  increased  prices  of  provisions,  the 
unusually  large  arrear  of  unpaid  subscrip¬ 
tions,  and  unusually  small  receipts  of  lega¬ 
cies  and  donations.  In  reference  to  these 
points  it  may  be  observed,  that,  could  pro¬ 
visions  have  been  purchased  at  the  same 
prices  as  in  the  year  ending  on  the  1st 
March,  1846,  the  expense  in  the  Matron’s 
department  would  have  been  about  £1800, 
instead  of  ,£2006.  2s.  7§d.,  and  that  the 
sum  derived  from  subscriptions,  legacies, 
and  donations,  fell  short  of  the  annual  re¬ 
ceipt,  upon  an  average  of  the  last  ten  years, 
by  £702. 

The  Governors  are  apprised  that  there 
will  be  an  election  on  the  2d  of  November, 
the  day  of  the  ensuing  Anniversary,  of  a 
successor  to  Mr.  Francis  Sibson,  who  has 
resigned  the  office  of  Resident  Surgeon 
Apothecary — an  office  he  has  filled  with 
great  medical  ability,  with  uniform  and  un¬ 
wearied  kindness  to  the  patients,  and  to  the 
complete  satisfaction  of  the  Weekly  Com¬ 
mittee,  for  the  last  thirteen  years. 

***  It  appears  that  the  average  daily 
number  of  in-patients  in  1847-8  wasl29,  and 
each  remained,  on  an  average,  41  days.  The 
number  of  out-patients  was  647,  and  each 
remained  on  the  books  about  62  days. 

The  physicians  to  this  useful  Provincial 
Institution  are — Dr.  R.  S.  Hutchinson,  Dr. 
J.  C.  Williams,  Dr.  C.  Storer ;  the  sur¬ 
geons — Mr.  W.  Wright,  Mr.  G.  M.  White, 
and  Mr.  H.  C.  Attenburrow. 

THE  CHOLERA  IN  PARIS. 

L’  Union  Medicale  reports  that  a  case  of 
Asiatic  cholera,  fatal  in  twelve  hours,  has 


just  occurred  at  the  Hotel  Dieu,  in  Paris, 
but  there  is  no  account  of  the  disease  having 
spread. 

THE  NEW  GENERAL  BOARD  OF  HEALTH. 

The  Queen  has  been  pleased  to  constitute 
and  appoint  Anthony  Ashley  Cooper,  Esq. 
(commonly  called  Lord  Ashley),  and  Edwin 
Chadwick,  Esq.,  C.B.,  to  be  members  of 
the  General  Board  of  Health. 

The  General  Board  of  Health  held  its 
first  sittings  at  Gwydyr  House  on  Tuesday 
last;  the  President,  the  Right  Hon.  the 
Viscount  Morpeth,  in  the  chair.  The  Board 
was  attended  by  Professor  Owen,  Dr.  South- 
wood  Smith,  Dr.  Sutherland,  of  Liverpool, 
and  Mr.  R.  D.  Grainger. 

NAVAL  MEDICAL  APPOINTMENTS. 

Medical  Officers  in  the  navy  have  com¬ 
monly  to  complain  of  the  slowness  of  their 
promotion — seldom  have  we  to  record,  that 
it  comes  too  heavily  on  them.  Yet  the 
following  is  a  case  in  point : — 

A  vacancy  having  occurred  in  the  Marine 
Hospital  at  Plymouth,  Dr.  Andrew  Millar, 
of  the  Hibernia,  was  appointed  to  the 
vacancy,  and  Dr.  Vaughan,  of  the  Sidon, 
was  appointed  to  the  Hibernia,  vice  Millar, 
by  the  Lords  Commissioners  of  the  Admi¬ 
ralty.  Before  the  news  of  the  promotion 
reached  this  place,  Dr.  Watts,  of  the  Naval 
Hospital,  Malta,  died,  and  again  Dr.  Millar 
had  the  good  fortune  to  receive  the  vacant  ap¬ 
pointment  by  Sir  William  Parker.  The  latter 
is  certainly  the  best,  but  it  remains  to  be  seen 
to  which  of  the  two  Dr.  Millar  will  ulti¬ 
mately  be  appointed.  Sir  William  Parker 
has  attached  a  note  to  his  order  to  the  effect 
that,  “  notwithstanding  the  appointment  of 
Dr.  Millar  to  Plymouth,  he  is  to  continue  at 
Bighi,  till  the  wishes  of  the  Lords  of  the 
Admiralty  can  be  ascertained  on  the  sub¬ 
ject.*’ 

FORMULA  FOR  THE  PREPARATION  OF  THE 
ETHEREAL  SOLUTION  OF  GUN-COTTON. 

We  have  found  considerable  difficulty  in 
preparing  the  gun-cotton  in  a  state  to  ensure 
its  solubility  in  sulphuric  ether.  Our  ex¬ 
periments  would  lead  to  the  conviction,  that 
the  finest  quality  of  gun-cotton,  which  we 
have  had  no  difficulty  in  preparing,  is  inso¬ 
luble,  or  nearly  so,  in  that  liquid.  A  gun¬ 
cotton,  of  ready  solubility,  and  easy 
manufacture,  may  be  prepared  as  follows  : — 
Take  of  nitric  acid,  sp.  gr.  1*350  (the  ordi¬ 
nary  sp.  gr.  of  commercial  nitric  acid),  *ij.  ; 
sulphuric  acid  (commercial)  ^iv.  Having 
mixed  the  acids  in  a  glass  vessel,  stirring  them 
with  a  glass  rod,  add  immediately,  of  freshly 
carded  cotton,  5ij.  3ij.,  and  digest  for  the 
period  of  fifteen  minutes.  The  acid  is  now 
to  be  poured  off  the  cotton,  and  the  latter 
washed  with  water  until  litmus  paper  is  not 


DR.  COTTON  S  CASE  OF  RESECTION  OF  THE  ELBOW. 


555 


affected.  The  cotton  is  to  be  finally  squeezed 
between  the  folds  of  a  clean  towel,  to  re¬ 
move  as  much  water  as  possible  ;  teazed  out, 
and  finally  pressed  between  sheets  of  blotting 
paper,  until  quite  dry,  and  instantly  thrown 
into  rectified  sulphuric  ether.  The  quantity 
of  gun-cotton  thus  formed  is  sufficient  for 
about  a  pound  of  ether.  It  should  form  a 
transparent,  colourless  liquid,  somewhat  of 
the  appearance  of  thin  mucilage. — British 
Amer.  Journal. 

STATISTICS  OF  THE  MEDICAL  PROFESSION 
IN  THE  RUSSIAN  EMPIRE. 

In  1839,  there  were  in  Russia  4787  physi¬ 
cians,  of  whom  2529  held  official  occupa¬ 
tions — 5  in  the  Privy  Council,  51  Acting 
Councillors  of  State,  244  holding  this  hono¬ 
rary  title,  391  veterinary  surgeons,  9  oculists, 
2  professed  lithotomists,  and  89  dentists. 
About  one-sixteenth  of  the  whole  number 
resided  in  large  towns.  Surgery  stands 
higher  than  medicine.  Those  who  dispense 
medicines  are  paid  on  a  better  scale  than 
those  who  prescribe  them. — V Union  Me¬ 
dicate. 

DR.  C.  E.  LAVENDER  ON  THE  INJURIOUS 
EFFECTS  OF  SULPHATE  OF  QUININE. 

I  am  by  no  means  persuaded  that  quinine  is 
a  harmless  agent,  or  that  it  may  be  given  in  al¬ 
most  any  quantity  without  producing  hurt¬ 
ful  consequences.  When  pushed  too  far, 
painful  fulness  of  the  brain,  alarming  sounds, 
and  ringing  in  the  ears,  deafness,  slight  deli¬ 
rium,  twitching  of  tendons  and  hiccough, 
will  be  some  of  the  consequences.  Caution 
must,  therefore,  be  exercised  not  to  push 
this  valuable  remedy  too  far.  Overwork 
the  brain,  and  the  vital  powers  may  become 
exhausted  by  too  long  continued  and  excesr 
sive  action.  In  this  way,  I  have  no  doubt, 
frequently-repeated  heroic  doses  of  quinine 
exhaust  the  vital  powers,  cause  indirect  de¬ 
bility,  and  thus  hasten  that  very  collapse  (in 
fever)  which  quinine,  judiciously  adminis¬ 
tered,  is  so  well  calculated  to  avert. — Ame¬ 
rican  Journal  of  Med.  Sciences,  July  1848. 

apothecaries’  hall. 

Names  of  gentlemen  who  passed  their  exa¬ 
mination  in  the  science  and  practice  of  medi¬ 
cine,  and  received  certificates  to  practise,  on 
Thursday,  September  14th,  1848: — John 
Wilmhurst,  Reading  —  Walter  Garslang, 
Clitheroe,  Lancashire— -James  Parker,  Augh- 
ton,  Lancashire — James  Thomas  Jackson, 
yiverstone,  Lancashire  —  William  Prowse, 
Bristol — John  Jones  Merriman,  Kensington 
— William  England,  Dudley,  Worcester¬ 
shire. 

OBITUARY. 

On  the  22d  inst.,  at  Staines,  John  Win- 
stone,  M.D.  M.R.C.S.L.,  late  of  35,  Char¬ 


terhouse  Square,  in  the  70th  year  of  his 
age. 

At  Sleaford,  Lincolnshire,  on  Sunday, 
the  17th  inst.,  Mr.  Thomas  Jacobson,  sur¬ 
geon,  deeply  regretted  and  deservedly  la¬ 
mented. 


^elections  from  ^Journals. 


RESECTION  OF  THE  ELBOW  :  SUBSEQUENT 

AMPUTATION  OF  THE  UPPER  ARM.  BY 

CHARLES  COTTON,  ESQ.  M.D.  F.R.S. 

LYNN.* 

Isabella  Boulton,  aged  twenty-four 
years,  admitted  into  the  Lynn  Hospital,  Feb. 
7th,  1847,  with  disease  of  the  left  elbow,  of 
twelve  months  standing.  Had  two  years 
before  been  a  patient  in  the  hospital  for 
disease  of  the  same  joint,  which  yielded  to 
constitutional  treatment,  and  Scott’s  plan. 
She  complains  of  frequently-occurring  tor¬ 
turing  pains  in  the  shoulder  and  hand,  an 
the  least  movement  of  the  limb  causes  in 
sufferable  distress.  The  fore-arm  is  semi* 
flexed  and  fixed,  and  the  joint  ends  of  the 
elbow  bones  are  considerably  enlarged. 

February  25th.  Excision  of  the  diseased 
parts  having  been  sanctioned  in  consultation, 
the  patient  was  brought  into  the  operating 
room,  and  seated  in  a  chair,  in  the  presence 
of  most  of  the  medical  gentlemen  in  the  town 
and  neighbourhood,  who  attended  to  witness 
the  operation,  and  the  use  of  ether  inhala¬ 
tion  ;  the  influence  of  ether  being  speedily 
and  completely  induced,  and  kept  up  by 
causing  the  patient  to  inhale  the  vapour  afc 
intervals.  Mr.  Cotton,  sitting  behind,  and 
grasping  firmly  the  fore -arm  with  the  left 
hand,  proceeded  to  make,  with  a  strong 
scalpel,  an  incision  about  three  inches  in 
length,  on  the  ulnar  side  of  the  back  of  the 
elbow,  in  direction  of  the  limb,  and  by 
a  bold  cut  from  outer  to  inner  condyle,  fall¬ 
ing  into  the  middle  of  it  at  right  angles* 
penetrated  the  articulation.  The  flaps  were 
then  dissected  back,  and  the  ligamentous  and. 
muscular  connections  (much  disorganized) 
further  detached,  by  cutting  close  upon  the 
bones.  The  ulnar  nerve,  imbedded  in  greatly 
degenerated  soft  parts,  was  turned  over  the 
inner  condyle.  The  ends  of  the  bones  were 
now  protruded,  and  being  deeply  damaged 
by  caries,  the  entire  removal  of  their  articular 
extremities  was  determined  upon,  and  quickly 
effected,  by  applying  the  saw,  (the  soft  parts 
being  guarded  by  a  copper  spatula,)  to  the 
end  of  the  humerus,  and  afterwards  to  the 
olecranon,  and  continuing  the  sawing  through, 
the  head  of  the  ulna,  that  of  the  radius  being 


*  Forwarded  for  insertion  in  the  London 
Medical  Gazette. 


556  SORE  NIPPLES  AND  THEIR  TREATMENT. ** 


removed  by  the  cuttingforceps.  Three  freely- 
bleeding  vessels  were  secured  by  ligatures, 
and  the  flaps  brought  in  apposition  by 
sutures.  The  patient,  who  throughout  did 
not  betray  the  least  evidence  of  pain  or 
knowledge  of  the  operation ,  sobbed  hys¬ 
terically  on  the  withdrawal  of  the  ether, 
and  when  removed  to  bed  vomited,  and 
complained  much  of  its  depressing  and 
nauseating  effects.  The  patient  slowly  re¬ 
covered  and  left  the  hospital,  but  returned 
on  the  7th  July.  There  has  been  gradual 
wasting  of  the  limb,  and  constant  pain,  which 
now  extends  from  the  elbow  to  the  shoulder, 
chest,  and  back  ;  entire  loss  of  mobility ;  the 
hand  has  a  peculiar  purple-like  and  shining 
appearance ;  the  thumb  is  contracted  towards 
the  palm,  and  the  fingers  fixed  over  it ;  elbow 
admits  of  passive  flexion,  giving  great  pain; 
desires  to  have  the  arm  removed. 

On  the  26th.  Upper  arm  amputated  at 
the  centre,  by  antero- posterior  flaps  ;  great 
vascularity,  five  ligatures  required.  Ether 
inhaled ;  had  no  recollection  of  the  opera¬ 
tion,  although  she  moaned  much  during  its 
performance,  and  afterwards  felt  great  sink¬ 
ing  and  distress  at  the  stomach,  and  became 
pallid  and  very  sick.  Ordered  a  teaspoonful 
of  brandy  to  be  repeated  a  few  times  at  in¬ 
tervals.  The  stump  was  quite  healed  by  the 
25th  August. 

Morbid  appearances  of  the  amputated 
limb. — On  dissecting  the  amputated  limb  it 
was  found  that  all  the  structures  around  the 
elbow  were  consolidated  ;  a  fistulous  passage 
from  a  small  posterior  subcutaneous  abscess 
led  to  the  head  of  the  ulna  ;  tendinous  at¬ 
tachment  of  the  biceps  to  tubercle  of  the 
radius  undisturbed ;  brachialis  anticus  con¬ 
verted  into  a  tawny  yellowish  tough  fascial 
structure,  adherent  to  the  ulna,  lined  by  the 
synovial  membrane,  and  forming  in  front 
the  capsule  of  the  joint  ;  triceps  tendon 
firmly  attached  posteriorly  ;  the  median  and 
radial  nerves  in  the  region  of  the  elbow  ap¬ 
peared  larger  than  natural,  as  did  the  ulnar 
nerve,  upon  which,  about  an  inch  apart, 
were  found  two  bulbous  expansions,  the  size 
of  horse  beans  ;  the  ends  of  the  bones, 
tolerably  compact  in  structure,  and  but  little 
enlarged,  were  strongly  connected  together 
by  direct  and  oblique  fibres  of  ligamentous 
tissue,  presenting  several  points  undergoing 
cartilaginous  and  bony  transformation  ;  soft 
parts  of  the  forearm  and  hand  pale  and  atro¬ 
phied. 

Remarks. — The  limited  circumstances  of 
the  patient,  and  considerations  whether  a  shor¬ 
tened  and  stiffened  limb  might  not  prove  less 
of  service  than  the  adaptation  of  an  artificial 
one  after  amputation,  alone  contraindicated 
excision.  The  general  health  appeared  good, 
age  favourable,  and  the  pain  and  distress  to 
have  only  a  local  origin  ;  the  reported  results 
of  similar  operations,  too,  were  highly  en¬ 


couraging,  and  the  use  of  ether- inhalation 
disarmed  of  importance  any  objections  which 
might  be  urged  on  the  ground  of  pain  and 
tediousness  of  the  operation.  Nothing  at 
first  could  exceed  the  well-doing  and  progress 
of  the  case,  and  the  inspection  of  the  parts 
afterwards  removed,  showed  how  admirably 
nature  meets  such  emergencies ;  granula¬ 
tions  proceeded  quickly  but  soundly  to  fill 
up  the  wound,  the  discharge  seemed  to 
expend  itself  freely,  daily  becoming  more 
healthy,  and  partial  motion  of  the  hand  was 
allowed,  without  much  inconvenience.  This 
desirable  state  of  matters  did  not,  however, 
prove  of  lasting  duration  ;  in  less  than  five 
months  a  return  of  pain,  (sympathetic 
neuralgia,  and  hyperaesthesia,  showing  per¬ 
manent,  local,  or  centric  morbid  impression,) 
together  with  the  wasted  and  useless  state  of 
the  limb,  now  an  incumbrance,  obliged  the 
patient  again  to  present  herself  at  the  hos¬ 
pital,  and  to  beg  that  the  arm  might  be 
amputated. 

The  failure  of  the  operation  of  excision 
seems  justly  attributable  to  the  advanced 
stage  of  disease  of  the  joint-ends  of  the  bones, 
destroying,  secondly  the  muscles,  &c.,  and 
seriously  involving  the  nerves.  An  error 
was,  most  probably,  committed  in  the  en¬ 
deavour  to  preserve  the  mobility  of  the  elbow, 
instead  of  securing  absolute  rest  and  utmost 
proximity  of  bone-surfaces,  to  favour  the 
deposition  of  callus,  and  bring  about  close 
union  by  anchylosis,  hard  or  soft,  particularly 
as  the  degenerated  state  of  the  muscular 
structure,  observed  at  the  time  of  the  opera¬ 
tion,  gave  but  little  hope  of  its  peculiar  irrita¬ 
bility  and  contractile  power  being  likely  to 
be  retained  or  regained. — Prov.  Journ.  1848. 


SORE  NIPPLES  AND  THEIR  TREATMENT. 

Sore  nipples  may  not  only  incapacitate  a 
woman  from  nursing, — a  deprivation  in  it¬ 
self  often  sufficiently  grievous, — but  they 
may,  as  we  have  before  observed,  give  rise 
to  mammary  abscess,  from  an  extension  of 
the  inflammation  backwards,  along  the  ducts, 
to  the  substance  of  the  gland.  This,  in 
point  of  fact,  is  the  great  danger  to  be  ap¬ 
prehended,  and  every  other  consideration 
should  give  way  to  it. 

When  there  is  reason  to  dread  such  a 
result,  the  child  is  entirely  withheld  from  the 
affected  breast,  which  is  kept  soft  by  rubbing, 
and  if  the  nipple  itself  appear  to  be  the  seat 
of  any  inflammation,  a  bread  and  water 
poultice  is  applied  to  it. 

Of  the  various  topical  applications  for  sore 
nipples  employed  in  this  Hospital,  it  may  be 
well  to  mention  two  or  three  whose  value 
has  been  established  by  long  experience. 

Amongst  these  the  tincture  of  catechu 
holds  a  high  place,  and  has  been  found  a 
very  excellent  astringent;  like  the  other 


MODE  OF  ARRESTING  HAEMORRHAGE  FROM  UMBILICAL  CORD.  557 


remedies  of  this  class,  it  is  best  adapted  for 
the  simply  excoriated  or  abraded  nipple. 
Nearly  similar  to  it  is  the  solution  of  pure 
tannin,  so  highly  recommended  by  Mr.  Druitt. 
It  is  made  by  dissolving  five  grains  in  an 
ounce  of  distilled  water.  We  have  not 
observed  it  to  possess  any  superiority  over 
the  catechu,  except  in  being  more  cleanly. 
The  following  is  a  favourite  lotion  with  Dr. 
Johnson,  who  has  been  in  the  habit  of  using 
it  for  many  years  :  —  R  Sub-borat.  Sodee, 
5ii.  ;  Cretse  precipitat.,  $i. ;  Spiritus  Vini, 
Aquae  Rosae,  aa  ^iii.  M.  fiat  lotio. 

This  may  be  applied  alternately  with  the 
following  ointment,  or  the  latter  may  be 
used  alone :  —  R  Cerae  Albae,  3ivss. ;  01. 
Amygdal.  dulc.  5L  ;  Mellis  despumat.  ^ss. ; 
Dissolve  ope  caloris,  dein  adde  gradatim, 
Bals.  Peruviani,  5iiss.  M.  fiat  unguentum. 

In  some  cases  we  have  seen  benefit  result 
from  the  use  of  tincture  of  galls  and  com¬ 
pound  tincture  of  benzoin  (Friar’s  balsam), 
in  equal  proportions. 

It  is  always  well  to  have  in  mind  a 
number  of  these  diffei'ent  preparations,  for 
it  not  unfrequently  happens  that  one  will 
answer  our  purpose  when  others  have  failed. 
For  fissured  nipples  some  authors  strongly 
advise  the  application  of  solid  nitrate  of 
silver ;  but  our  experience  does  not  permit 
us  to  speak  of  it.  Dr.  Johnson  thinks  it  is 
sometimes  a  good  remedy  in  such  cases,  at 
a  remote  period  of  delivery  ;  but  that  during 
the  puerperal  state  its  use  is  not  advan¬ 
tageous,  as  it  is  apt  to  be  followed  by  mam¬ 
mary  abscess. — M'Clintock  and  Hardy’s 
Practical  Observations ,  pp.  13-14-15. 


HEMORRHAGE  FROM  THE  UMBILICAL  CORD 
ARRESTED  BY  PLASTER  OF  PARIS. 

[Mr.  Hill  has  addressed  the  following  com¬ 
munication  to  the  Dublin  Medical  Press : — ] 
I  was  called  upon  to  see  an  infant,  eight 
days  old,  from  whose  navel  there  had  been 
bleeding  for  five  hours.  Several  applications 
had  been  applied  without  effect.  The  child 
appeared  considerably  sunk  by  the  discharge, 
rather  full  size,  cord  thick,  and  vessels  ap¬ 
parently  large.  I  put  a  small  compress  on 
the  part,  which  was  retained  by  the  pressure 
of  the  finger.  I  saw  at  once  the  nature  of 
the  case,  and  sent  home  for  some  plaster  of 
Paris  that  I  am  in  the  habit  of  keeping.  I 
mixed  up  two  table- spoonfuls  of  it  in  a  cup 
with  water  into  a  thick  paste,  and  hastily 
removing  the  compress,  I  let  the  contents 
of  the  cup  flow  out  on  the  part,  where  it 
immediately  settled  and  hardened.  I  re¬ 
mained  with  the  child  some  hours,  and  kept 
the  abdomen  partially  exposed  to  the  air.  A 
few  cracks  having  taken  place  in  the  plaster, 
I  filled  them  up  with  fresh.  I  then  put  a 


bandage  on  the  infant,  removing  it  occa¬ 
sionally,  and  filling  up  the  cracks  that  took 
place  for  the  purpose  of  keeping  the  plaster 
solid,  which  I  did  for  four  days.  It  was 
then  removed,  and  the  bleeding  did  not  re¬ 
turn.  On  examining  the  cast,  there  appeared 
three  small  papillae ,  which  I  suppose  cor¬ 
responded  to  the  two  arteries  and  vein  which 
they  occupied  until  the  vessels  became  im¬ 
pervious. 

I  claim  no  merit  of  originality  for  this 
practice.  I  took  the  hint  from  Dr.  Churchill, 
who,  in  a  very  excellent  paper  on  the  umbili¬ 
cal  cord,  published  in  the  50th  volume  of 
the  Edinb.  Medical  and  Surgical  Journal, 
p.  302,  for  the  year  1838,  has  suggested 
this  plan  of  treatment.  The  practitioner  in 
this  case,  who  was  a  pharmacien,  put  a  large 
piece  of  old  linen  about  the  cord,  after 
dividing  it,  and  being  saturated  with  blood 
it  became  hard,  and  threatened  erysipelatous 
inflammation  on  the  surface,  to  avoid  which, 
he  pulled  away  the  cloth  and  remains  of  the 
cord  before  the  process  of  separation  had 
begun,  or  the  vessels  became  impervious. 
The  plaster  is  worth  a  trial  in  such  cases, 
before  more  active  means  are  adopted ;  it 
has  to  recommend  it  simplicity,  and  freedom 
from  danger. 


SYMPATHY  OF  THE  IRIDES  IN  CASES  OF 
AMAUROSIS. 

A  curious  phenomenon  is  sometimes  ob¬ 
served  in  the  eyes  of  amaurotic  individuals, 
which  affords  a  beautiful  illustration  of  the 
sympathy  between  the  two  organs.  A  pa¬ 
tient  may  be  perfectly  blind  in  one  eye  ;  but 
if  the  two  irides  be  examined  together,  as  to 
the  power  of  contraction  of  the  pupils,  both 
contraqt^And  dilate  normally.  In  such  cases 
the  impressions  made  upon  the  retina  of  the 
amaurotic  eye  might  be  supposed  the  cause 
of  the  motions  of  the  corresponding  pupil. 
This  is  not  really  the  case  ;  for  if  the  healthy 
eye  be  closed,  the  pupil  of  the  other  at  once 
becomes  motionless  :  it  is  from  sympathy 
that  the  impression  upon  one  produces  an 
effect  on  the  other.  Hence,  in  examining 
an  amaurotic  eye  respecting  the  motions  of 
the  iris,  it  is  always  necessary  to  close  the 
healthy  organ,  when  the  real  influence  of 
the  retina  over  the  iris  of  the  diseased  eye 
will  be  seen.  In  some  cases,  however,  in 
which  both  eyes  are  amaurotic,  the  motions 
of  the  iris  are  performed  naturally  ;  but  in 
the  great  majority,  the  condition  of  the  pupil 
affords  indication  of  a  paralysed  retina, — » 
Morgan  on  Diseases  of  the  Eye. 


1 


558  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY,  ETC. 


BIRTHS  &  DEATHS  in  the  Metropolis 
During  the  week  ending  Saturday,  Sept.  23. 


Births. 
Males....  638 
Females. .  612 

1250 


Deaths. 
Males....  541 
Females..  497 

1038 


Av.  of  5  Sum. 
Males ....  495 
Females..  477 

972 


Deaths  in  different  Districts. 


The  following-  is  a  selection  of  the  numbers  o 
Deaths  from  the  most  important  special  causes1 


Small-pox  .  34 

Measles  .  13 

Scarlatina  . 161 

Hooping-cough..  30 

Diarrhoea  .  46 

Cholera  .  7 

Typhus  .  58 

Dropsy .  13 

Sudden  deaths  ..  9 


Paralysis .  16 

Convulsions  ....  27 

Bronchitis .  28 

Pneumonia .  39 

Phthisis . 102 

Dis.  of  Lungs,  &c.  5 

Teething .  6 


Dis.  Stomach,  &c.  8 
Dis.  of  Liver,  &c.  9 


(34  in  number  ; — Registrars'  Districts,  129. 
Population,  in  1841,  1,915,104.) 


Hydrocephalus..  29 
Apoplexy .  29 


Childbirth .  2 

Dis .  of  U  terus,  &c .  1 


West— Kensington;  Chelsea;  St.  George, 
Hanover  Square;  Westminster;  St.  Martin 
in  the  Fields ;  St.  James  . .  (Pop.  301,326)  130 
North  —  St.  Marylebone  ;  St.  Pancras  ; 

Islington ;  Hackney . (Pop.  366,303)  170 

Central — St. Giles  and  St.  George;  Strand; 
Holborn ;  Clerkenwell ;  St.  Luke ;  East 
London ;  West  London ;  the  City  of 

London  . (Pop.  374,759)  198 

East— Shoreditch ;  Bethnal  Green  ;  White¬ 
chapel  ;  St.  George  in  the  East ;  Stepney ; 

Poplar . (Pop.  393,247)  259 

South  —  St.  Saviour  ;  St.  Olave  ;  Ber¬ 
mondsey  ;  St.  George,  Southwark ; 
Newington;  Lambeth;  Wandsworth  and 
Clapham  ;  Camberwell ;  Rotherhithe  ; 
Greenwich  . .' . (Pop.  479,469)  281 

Total .  1038 


Remarks. — The  total  number  of  deaths  was 
66  above  the  weekly  summer  average.  The 
deaths  from  Scarlatina  are  still  on  the  increase. 


METEOROLOGICAL  SUMMARY. 


Mean  Height  of  Barometer .  29’8 

“  “  Thermometer1  .  56- 7 

Self-registermg  do.b _ max.  99'1  min.  24-5 

“  in  the  Thames  water  —  58'5  —  56*2 


a  From  12  observations  daily.  b  Sun. 

Rain,  in  inches,  ‘IS:  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological. — The  mean  temperature  of  the 
week  was  about  1°  below  the  mean  of  the  month. 


Causes  of  Death. 

All  Causes . 

Specified  Causes . 

1.  Zym0fic(orEpidemic,Endemic, 

Contagious)  Diseases . . 
Sporadic  Diseases,  viz. — 

2.  Dropsy,  Cancer,  &c.  of  uncer¬ 

tain  seat  . 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  . 

4.  Lungs  and  other  Organs  of 

Respiration . 

5.  Heart  and  Bloodvessels . 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion . 

7.  Diseases  of  the  Kidneys,  &c 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c . 

9.  Rhematism,  Diseases  of 
Bones,  Joints,  &c . 

10.  Skin,  Cellular  Tissue,  &c... 

11.  Old  Age . 

12.  Violence,  Privation,  Cold, 

Intemperance . 


the 


and 


1038 

Av.  of 
5  Sum. 

972 

1036 

968 

393 

257 

45 

45 

102 

120 

78 

80 

36 

28 

64 

79 

12 

8 

5 

10 

5 

7 

3 

1 

43 

50 

25 

8 

BOOKS  &  PERIODICALS  RECEIVED 

DURING  THE  WEEK. 

The  Student’s  Clinical  Memorandum  Book. 

Rapport  address^  a  M.  le  D(:l^gu£  du  Gouverne- 
ment  Provisoire  sur  les  Traitements  Ortho- 
pMiques  de  M.  le  Doctcur  J.  Guerin,  &c. 

Casper’s  Wochenschrift  der  Ges.  Heilkunde. 
Nos.  35  and  36.  26th  August  and  3d  Sept. 

British  American  Journal.  Sept.  1848. 

Henke’s  Zeitschrift  fur  die  Staatsarzneikunde, 
Nos.  1,  2,  3,  1848. 

Plain  Directions  for  the  Prevention  and  Treat¬ 
ment  of  Cholera.  By  Thomas  Allen,  M.R.C.S. 


NOTICES  to  CORRESPONDENTS. 

The  communications  of  Dr.  E.  A.  Parkes  and  of 
Dr.  C.  H.  Jones  have  been  received,  and  will 
be  inserted.  Proofs  shall  be  forwarded. 


THE  GENERAL  INDEX. 

We  have  to  announce  to  onr  Subscribers  that  a  General 
Index  to  the  first  40  Volumes  of  the  London  Medical  Gazette 
will,  it  is  calculated,  form  a  large  Volume  of  about  700  pages. 
The  cost  of  the  Index  Volume,,  respecting  which  many  inquiries 
have  been  made,  Mill  be  Twenty-four  Shillings ;  and  it  is  proposed 
to  commence  it  so  soon  as  the  Names  of  Five  Hundred  Subscribers 
have  been  obtained. — The  printers,  Messrs.  Wilson  and  Ogilvy, 
57,  Skinner  Street,  will  receive  the  Names  of  Subscribers. 


&ontroit  JUrthral  <§a?dte. 


Sccturcs. 


LECTURES 

ON 

PRETERNATURAL  AND  COMPLEX 
PARTURITION. 

'  By  Edward  W.  Murphy,  A.M.  M.D. 

Professor  j  of  Midwifery,  University  College, 
London. 


Introductory  Lecture. 

Review  of  the  rise,  progressj^ind  present 
state  of  obstetric  medicine-^Hippocrates 
— Celsus  — Albucasis  —  Avicenna.  The 

1 6th  Century  —  Rhodion  —  Raynalde — 
Ambrose  Pare —  Guillemeau —  Operation 
of  turning  introduced.  The  17th  Cen¬ 
tury  —  Mauriceau — Harvey — Chamber- 
len — introduction  of  the  forceps — pro¬ 
gressive  improvement  of  midwifery .  The 
18  th  Century — Sir  Fielding  Ould — 
Chapman —  Giffard — Burton — Smeilie — 
William  Hunter — Rigby  of  Norwich — 
Denman. 

Present  state  of  obstetric  medicine — Em¬ 
bryology  —  Intra-uterine  — pathology — 
mechanism  of  parturition — Anaesthesia — 
Conclusion. 

Gentlemen, — You  are  now  about  to  enter 
upon  another  branch  of  medical  science  the 
Theory  andPractice  of  Midwifery, — a  subject 
which  admits,  I  might  almost  say  courts,  the 
most  scientific  inquiry;  one  that  is  capable  of 
the  highest  improvement,  a  correct  knowledge 
of  which  is  of  the  greatest  value  to  the  prac¬ 
titioner,  and  yet  a  subject  which,  I  am  sorry 
to  add,  has  hitherto  received,  and  is  still  re¬ 
ceiving,  but  an  indifferent  attention.  That 
such  should  be  the  case  is  a  matter  of  deep 
regret,  when  we  find  its  consequences  re¬ 
corded  yearly,  monthly,  nay,  almost  weekly, 
in  the  medical  periodicals.  A  case  is 
reported  that  bears  on  the  face  of  it  the  im¬ 
press  of  ignorance  ;  a  death  is  recorded,  and 
an  inquest  held,  which  establishes  the  grossest 
mismanagement  of  some  unfortunate  patient : 
thus  the  evidences  of.  extreme  ignorance  in 
the  practice  of  midwifery  are  beginning,  I 
regret  to  say,  to  accumulate.  On  the  other 
hand,  we  may  observe  a  few  scientific  men 
exerting  themselves  with  great  energy  to 
develope  the  theory,  and  to  improve  the 
principles,  of  its  practice,  a  few  certainly 
“  rari  nantes  in  gurgite  vasto ;”  but  sufficient 
to  prove  that  midwifery  admits  the  most 
scientific  investigation. 

xlii.— 1088.  Oct.  6,  1848. 


It  appeared  to  me,  therefore,  advisable,  to 
devote  this  first  lecture  to  a  general  outline 
of  the  subject,  and,  taking  a  brief  review  of 
the  rise,  progress,  and  present  condition  of 
obstetric  medicine,  to  make  you  acquainted 
with  its  chief  and  most  attractive  features.  I 
would  wish  to  excite  some  desire  to  cultivate 
a  more  intimate  acquaintance  with  midwifery, 
so  as  to  secure  you  from  the  possibility  of 
those  mischances  that  we  sometimes  read  of, 
and  perhaps  to  stimulate  a  dormant  zeal  for 
its  improvement. 

In  the  history  of  midwifery  I  shall  not 
occupy  your  time  with  minute  details  of  its 
early  origin ;  I  need  not  commence  with. 
Esau  and  Jacob,  the  first  record  of  twins, 
and  report,  as  has  sometimes  been  done,  the 
several  remarkable  births  in  the  sacred 
writings;  neither  is  it  necessary  to  relate 
the  obstetric  knowledge  of  the  Greek, 
Roman,  and  Saracenic  periods,  which  is  only 
interesting  so  far  as  it  proves  the  untiring 
zeal  of  the  fathers  of  medicine.  When  mid¬ 
wifery  was  left  only  to  midwives,  we  find 
Hippocrates  and  Celsus,  Avicenna  and  Al¬ 
bucasis,  devoting  themselves  to  its  improve¬ 
ment.  Hippocrates  first  alluded  to  the  use 
of  instruments  in  the  practice  of  midwifery. 
Celsus  pointed  out  the  manner  of  extracting 
the  placenta.  Avicenna  of  Bucharest  describes 
a  forceps,  the  parent  of  the  present  cranio¬ 
tomy  forceps  ;  and  Albucasis  published  the 
first  record  of  obstetric  medicine.  In  his 
work  are  drawings  of  the  various  instruments 
then  made  use  of,  the  number  and  complexity 
of  which  only  betray  their  ignorance  of  the 
subject. 

The  period  between  the  12th  and  16th 
centuries  may  be  considered  as  a  blank;  the 
faint  illumination  that  midwifery  had  pre¬ 
viously  received,  was  soon  lost  in  the  obscu¬ 
rity  of  the  dark  ages  which  succeeded  ;  nor 
was  it  until  the  newly-discovered  art  of 
printing  gave  a  facility  for  communicating  a 
knowledge  of  medkine,  that  we  find  any 
materials  to  form  a  'connected  history. 

In  the  16th  century,  Rhodion  published 
(1502)  the  first  collection  of  obstetric  pre¬ 
cepts  ;  this  work  was  translated  into  English 
by  Raynalde,  and  published  in  1540.  The 
title  of  Raynalde’s  book  (black  letter)  is 
“The  birth  of  mankind;  or  the  woman’s 
book,”*  by  no  means  an  inappropriate  title, 
as  it  equally  shews  the  pomposity  of  the 
author  and  the  intention  of  the  work,  which 
not  only  contains  numerous  precepts  for 
midwives,  but  also  several  domestic  hints  for 
the  patient  herself,  even  to  the  use  of  cos¬ 
metics. 

Midwifery  was  then  a  term  which  per¬ 
fectly  expressed  the  nature  of  the  practice  ;  a 


*  The  Byrtli  of  Mankinde ;  or  the  Woman’s 
Boke,  By  J.  Raynalde,  1540. 


560 


DR.  MURPHY  ON  THE  PROGRESS  OF  MIDWIFERY. 


branch  that  was  exclusively  confined  to  mid¬ 
wives  ;  one  that  was  followed  only  by  them, 
and  which  received  but  little  attention  from 
medical  men.  Raynalde’s  book,  although 
intended  for  their  instruction,  was  considered 
by  the  midwives  as  an  inroad  upon  their  pro¬ 
vince, — it  was  consequently  opposed  by  many 
of  them ;  nevertheless,  the  attack  of  the 
doctor  on  midwifery  was  soon  more  actively 
followed  up.  The  physician  and  surgeon  be¬ 
gan  to  give  obstetrics  a  larger  share  of  their 
attention,  and  hence,  in  1573,  we  find  Am¬ 
brose  Pare*  boldly  stepping  forward  to  rescue 
midwifery  from  the  degraded  situation  in 
which  he  then  found  it.  He  had  the  temerity 
to  open  obstetric  wards  in  Hotel  Dieu,  for 
the  purpose  of  instructing  midwives  !  His 
rash  experiment  would  have  failed,  had  he 
not  had  some  means  of  proving  his  superior 
knowledge  of  midwifery :  this  he  soon  ac¬ 
complished  by  pointing  out  and  proving  the 
advantage  of  turning  by  the  feet  in  shoulder 
presentations,  in  preference  to  the  former, 
and  apparently  the  simpler  practice  of  at¬ 
tempting  to  replace  the  head.  The  precepts 
and  practice  of  Ambrose  Pare  were  followed 
and  taught  by  his  intelligent  pupil  Guille- 
meau,  who  published,  in  1598,  “  The  happy 
delivery  of  women.  ”f  When  artificial  de¬ 
livery  was  necessary,  G.’s  chief  resource  was 
to  turn  the  child ;  this  operation  was  per¬ 
formed  for  all  forms  of  hemorrhage,  for  con¬ 
vulsions,  and  arm  presentations;  it  was  only 
withheld  in  very  protracted  labours  where 
the  child  was  dead.  “  For,”  he  observes, 
“whensoever  the  child’s  head  is  much 
entered  within  the  os  pubis,  it  is  impossible 
to  thrust  him  upward  and  turn  him,  without 
much  endangering  the  mother,  and  causing 
great  contusion  of  the  womb,  from  whence 
proceeds  divers  accidents,  and  sometimes 
death,  as  I  have  seen  it  often  happen.”  Guil- 
limeau  therefore  proposed  a  crotchet  some¬ 
what  resembling  theinstrument  recommended 
by  my  late  predecessor  Dr.  Davis,  and  by  Dr. 
Ramsbotham,  for  decapitation  of  the  child, 
only  that  it  had  a  more  pointed  extremity. J 
This  instrument  G.  says  “  must  be  fastened 
to  the  side  of  the  child’s  head,  as  about  his 
ear  or  bone  of  the  temples,  or  in  some  other 
place  if  it  may  be  done  conveniently,  as 
within  the  hollow  of  the  eye  or  hinder  bone 
of  the  head.Ӥ  This  crotchet  was  afterwards 
improved  upon,  sometimes  made  double  and 
locking  ;  but  thus  far  the  accoucheur  had 
only  two  means  of  effecting  the  delivery  of 
his  patient — either  by  turning  or  the  crotchet. 


*  De  la  Generation  de  1’  Homme,  &c.,  par 
Ambrose  Pare. 

t  The  happy  delivery  of  women.  By  Guille- 
meau.  Translation— printed  by  Hatfield,  1612. 

¥  Op.  cit.  p.  139. 

§  Page  138. 


Fig.  1. 


Fig.  1. — Guillemeau’s  Crotchet. 

The  17th  century  is  remarkable  for  a  more 
rapid  advance  in  the  improvement  of  mid¬ 
wifery.  In  France,  Mauriceau  obtained  the 
highest  eminence  in  his  profession,  and  pub¬ 
lished  a  most  comprehensive  work  on  the 
subject.* 

In  England  our  attention  is  at  once  ar¬ 
rested  by  the  illustrious  Harvey,  who  did 
not  give  way  to  the  prejudices  of  his  day,  and 
think  obstetric  medicine  unworthy  of  his 
notice.  He  applied  his  great  mind  to  the 
development  of  its  principles,  and  in  1651 
published  his  “  Exercitationes  de  genera- 
tione  animalium,  de  partu,  de  membranis 
et  humoribus  uteri.”  In  these  he  not  only 
brought  forward  his  new  doctrine  of  genera¬ 
tion,  “  omnia  ex  ovo,”  which  had  displaced 
the  absurd  speculations  of  previous  physiolo¬ 
gists,  but  he  also  explained  the  mechanism 
of  parturition,  advocated  Pare’s  and  Guille¬ 
meau’s  practice  of  turning  in  transverse 
presentations,  mentioned  cases  of  superfoeta- 
tion  in  women  that  lie  had  attended,  gave 
numerous  illustrations  of  the  duration  of 
pregnancy,  both  in  man  and  in  the  inferior 
animals,  and  also  described  several  derange¬ 
ments  of  the  uterine  functions. 

These  essays,  although  no  doubt  composed 
long  before,  had  not  been  published  until 


*  Mauriceau,  Traits  des  maladies  des  femmes 
grosses  et  de  celles  qui  sont  accoucMes.  EdL 
6me,  1721,  Paris. 


DR.  MURPHY  ON  THE  PROGRESS  OF  MIDWIFERY. 


561 


Harvey  reached  the  advanced  age  of  73.  To 
publish  at  such  an  age,  when  he  could  hardly 
hope  to  reap  the  profits  of  his  industry, 
needs  some  explanation  ;  and  as  the  manner 
of  the  publication  strongly  proves  the  cha¬ 
racter  of  the  man,  it  is  worthy  of  being  no¬ 
ticed.  Harvey  lived  in  the  troubled  period 
of  the  Stuarts.  He  was  physician  to  Charles 
I.  He  was  exposed  to  the  persecutions  of 
the  Puritans  ;  but  the  greatest  that  he  en¬ 
dured,  and  that  which  drove  him  from  public 
life,  was  from  his  own  profession,  in  conse¬ 
quence  of  his  heretical  doctrine  of  the  cir¬ 
culation  of  the  blood  !  In  his  retirement  he 
was  not  idle, but  employed  the  greater  portion 
of  his  time  in  his  researches  in  ovology, — a 
subject  that  he  followed  so  entirely  for  his 
own  amusement,  that  the  results  would  have 
been  lost  perhaps  to  the  profession  had  it 
mot  been  for  a  visit  paid  to  him  by  his  friend 
Hr.  Ent.  Among  many  other  subjects  of 
philosophical  interest  which  formed  the  topics 
of  their  conversation,  that  of  generation  was 
alluded  to,  when  Harvey  casually  referred  to 
his  own  observations.  Dr.  Ent  requested  to 
see  them,  hinted  about  their  publication,  and 
after  some  modest  altercation,  Harvey 
brought  them  to  him,  with  permission  to  use 
his  own  discretion,  either  to  publish  or  sup¬ 
press  them.  “  I  went  from  him,”  says  Dr. 
Ent  “  like  another  Jason,  in  possession  of 
the  golden  fleece,  and  when  I  came  home 
and  perused  the  pieces  separately,  I  was 
amazed  that  so  vast  a  treasure  should  have 
been  so  long  hidden.”  Thus  was  published 
a  work  which  stands  second  only  to  his  trea¬ 
tise  on  the  Circulation  of  the  Blood,  in  the 
important  change  which  it  produced  in  the 
opinions  of  the  profession. 

About  this  time  appeared  a  physician  as 
remarkable  for  the  success  of  his  practice, 
the  reputation  to  which  he  rose,  and  the 
fortune  he  acquired,  as  his  contemporary 
was  for  the  loss  of  his  practice,  the  neglect, 
almost  the  contempt  to  which  he  was 
occasionally  submitted,  while  labouring  to 
establish  the  important  theory  with  which 
his  name  has  now  become  synonymous. 
Such  is  public  opinion,  and  so  capricious  are 
the  influences  which  govern  it,  that  while 
u  the  circulator,”  as  Harvey  was  called,  and 
his  new  doctrine,  were  objects  of  the  most 
galling  derision,  Dr.  Chamberlen,  and  his 
secret  mode  of  delivering  women,  rose  rapidly 
into  repute.  Chamberlen’s  secret  was  the 
forceps,  a  most  valuable  improvement  upon 
thedestructiveinstrumentspreviously  in  use. 
As  its  inventor,  Dr.  Chamberlen  deserves 
all  the  credit  that  belongs  to  his  inventive 
genius,  but  we  cannot  look  upon  him  as 
contributing  in  any  way  to  elevate  the  cha¬ 
racter  of  his  profession.  His  invention  was 
kept  a  close  secret,  except  from  his  three 
sons,  who  also  practised  midwifery  :  it  was, 
in  fact,  a  family  inheritance.  Not  only  the 


profession,  and  consequently  the  great  ma¬ 
jority  of  the  public,  were  deprived  of  the 
advantage  of  the  improvement,  but,  from 
the  great  facility  which  the  forceps  gave  to 
terminate  the  delivery  of  the  parturient  wo¬ 
man,  a  temptation  was  offered  to  Cham¬ 
berlen,  to  which  he  readily  yielded,  to  use 
the  forceps  far  more  frequently  than  was 
either  necessary  or  justifiable.  The  Cham- 
berlens  naturally  looked  upon  the  forceps  as 
omnipotent,  and,  in  their  zeal,  often  used  it 
very  unscrupulously.  At  that  time  Paris 
was  the  great  school  of  midwifery.  Ambrose 
Pare,  Guillimeau,  Mauriceau,  raised  it  to 
the  highest  reputation.  The  celebrity  of 
this  new  secret  operation  rapidly  spread  to 
France,  and  Dr.  Hugh  Chamberlen  soon 
visited  Paris,  for  the  purpose  of  selling  his 
secret.  He  boldly  asserted  that  it  was  in 
his  power  to  deliver  any  woman  without  the 
necessity  for  destroying  the  child.  It  so 
happened  that  Mauriceau,  then  in  the  zenith 
of  his  reputation,  had  a  case  of  labour  so 
difficult,  from  extreme  pelvic  contraction, 
that  he  could  not  hope  to  extract  the  child 
even  by  perforation  :  labour  was  protracted 
to  the  eighth  day.  It  seemed  a  favourable 
opportunity  for  Chamberlen,  who  expressed 
great  surprise  that  so  eminent  a  man  as 
Mauriceau  could  not  deliver  her.  He  pro¬ 
mised  to  do  so  in  half  an  hour  ;  several  half 
hours,  however,  had  passed  when  Cham¬ 
berlen  gave  it  up  in  despair.  The  woman 
died  the  following  day  ;  and,  on  inspection, 
the  uterus  was  found  to  be  torn  in  several 
places  by  the  forceps.  Louis  XIV.  was 
then  on  the  throne  of  France,  and,  in  those 
days  of  arbitrary  power,  Chamberlen  very 
quickly  returned  with  his  secret  to  England, 
where  he  published  a  translation  of  Mauri- 
ceau’s  elaborate  work.* 

This  era  is  remarkable  for  the  advance 
that  midwifery  had  made  :  Harvey  placed  it 
in  connection  with  one  of  the  most  interest¬ 
ing  of  physiological  inquiries.  Chamberlen 
had  contrived  an  instrument  which  has  pro¬ 
duced  a  most  important  change  in  the  prac¬ 
tice  of  midwifery,  and  gave  the  accoucheur 
an  influence  which  he  could  not  previously 
obtain  ;  but  it  was  also  characterized  by  the 
introduction  of  a  principle  that  has  had  a 
most  mischievous  effect  upon  it.  With  the 
Chamberlens,  midwifery  was,  in  the  strictest 
sense  of  the  term,  an  art — the  mode  of  de¬ 
livery  a  secret  to  be  learned  ;  and  a  meddle¬ 
some  interference  to  abbreviate  the  salutary 
efforts  of  nature  was  viewed  as  an  evidence 
of  superior  skill.  Without  wishing  to  de¬ 
prive  Chamberlen  of  the  merit  that  is  justly 
due  to  his  inventive  genius,  I  confess  that  I 
can  only  look  upon  him  in  the  light  of  a 

*  The  Diseases  of  Women  with  Child,  and  in 
Child-bed,  &c.  &c.  Written  in  French  by 
Francis  Mauriceau,  and  translated  by  Hugh 
Chamberlen,  Lond.  1736* 


562 


Dll.  MURPHY  ON  THE  PROGRESS  OF  MIDWIFERY. 


fortunate  empiric,  who,  like  all  of  that  class, 
called  in  the  powerful  aid  of  mystery  and 
secresy  for  his  own  aggrandisement,  but,  so 
far  as  he  wras  concerned,  left  the  profession 
as  ignorant  as  ever  about  the  proper  mode 
of  delivery. 

The  lives  of  Harvey  and  of  Chamberlen 
form  striking  contrasts  :  the  scientific  emi¬ 
nence  of  the  one  —  the  quackery  of  the 
other  ;  the  persecution  and  professional 
losses  of  Harvey — the  great  reputation  and 
affluence  of  Chamberlen.'  I  regret  to  find 
that  the  unjust  distinction  seems  not  to  have 
ceased  even  with  their  lives.  I  speak  as  a 
stranger ;  but,  like  all  strangers  on  their 
first  arrival  in  this  great  metropolis,  I  visited 
that  venerable  pile  which  contains  the  ashes 
of  your  poets — your  philosophers — your  men 
of  science — your  most  illustrious  statesmen 
— your  monarchs.  While  thus  tracing 
through  Westminster  Abbey  the  monu¬ 
mental  history  of  your  country,  I  found  a 
most  imposing  cenotaph  to  Chamberlen.  I 
looked  around,  and  asked,  where  is  Harvey  ? 
I  thought  I  heard  its  vaulted  aisles  echoing 
and  re-echoing  my  question. 

During  the  17th  century,  the  practice  of 
midwifery  was  gradually  undergoing  a 
change  in  its  character.  Hitherto  it  had 
been  very  much  neglected,  and  left  altoge¬ 
ther  to  the  midwife,  unless  when  the  efforts 
of  nature  failed  in  completing  the  delivery  ; 
then  that  anomalous  hybrid,  the  man- 
midwife,  was  sent  for;  and  to  send  for  his 
assistance,  under  such  circumstances,  im¬ 
plied  the  necessity  for  an  operation  fatal  to 
the  child,  and  often  extremely  dangerous  to 
the  mother  :  the  instruments  employed  were 
often  unmanageable,  and  the  cases  very 
unfavourable.  The  man-midwife’s  frequent 
ill  success  was  anything  but  advantageous 
to  him,  and  in  no  way  contributed  to  raise 
him  in  public  estimation.  The  first  step  in 
the  way  of  improvement  was  made  by  Am¬ 
brose  Pare  :  the  operation  of  turning  the 
child  in  the  uterus  placed  preternatural 
labours  in  a  new  light :  the  death  of  the 
child  was  no  longer  the  necessary  conse¬ 
quence  of  a  cross  birth.  The  next  most 
important  change  was  the  introduction  of 
the  forceps.  An  additional  security  for 
the  preservation  of  the  child  was  now  af¬ 
forded  :  it  was  not  necessary  to  destroy  it 
because  a  natural  labour  became  difficult. 
A  higher  value  was  therefore  placed  upon 
the  accoucheur’s  assistance ;  the  gloomy 
forebodings  that  clouded  his  character  began 
to  disappear,  and  more  attention  was  there¬ 
fore  paid  to  the  improvement  of  midwifery. 

The  18th  century  consequently  included  a 
much  more  numerous  list  of  eminent  obste¬ 
tric  authors.  No  attention  whatever  had 
been  paid  previously  to  the  mechanism  of 
parturition.  It  was  supposed  that  the  head 
of  the  child  always  passed  in  the  conjugate 


measurement  of  the  pelvis,  until  Sir  Fielding 
Quid,  of  Dublin,*  made  it  the  object  of  his 
attention.  Having  been  at  Paris,  and  pre¬ 
sent  at  a  labour  which  was  delayed  in  con¬ 
sequence  of  the  funis  being  round  the  neck 
of  the  child,  he  had  the  opportunity  of  ob¬ 
serving,  that,  while  the  head  was  descending 
and  receding  with  the  pains,  the  face  always 
turned  upwards.  Those  who  were  present 
thought  it  an  irregularity,  and  would  no 
doubt  have  interfered,  only  fortunately  a 
few  pains  completed  the  delivery.  This  fact 
was  not  lost  upon  Sir  Fielding  Ould  :  he 
made  the  manner  in  which  the  head  passed 
through  the  pelvis  the  subject  of  his  constant 
attention,  and  first  proved  its  spiral  direc¬ 
tion.  This  also  was  the  first  step  towards 
founding  a  true  basis  for  obstetricy — the 
first  attempt  to  determine  from  observation, 
not  from  preconceived  notions,  the  true 
process  of  parturition.  At  this  period  also 
the  invention  of  Chamberlen  attracted  much 
attention.  The  high  value  attached  to  a 
means  of  delivery  by  which  both  mother  and 
child  might  be  saved,  made  “  the  secret 
mode  of  delivering  women”  a  most  desirable 
problem  to  solve.  Of  those  who  could  not 
find  it  out,  some  of  course  abused  it ;  and 
we  find  Dr.  Maubrey,  in  his  “  Female  Phy¬ 
sician,”  blaming  very  much  “  the  dangerous 
instruments  then  in  use.”f  Others,  how¬ 
ever,  took  a  different  course :  inventive 
genius  w7as  put  on  the  rack  to  discover  the 
secret,  and  some  succeeded  in  finding  out  at 
least  the  principle  of  construction.  A  series 
of  cases  were  detailed  by  Giffard,  and  pub¬ 
lished  by  Dr.  Iiody,  in  which  a  forceps 
is  figured  as  Chamberlen’s,  but  made  alto¬ 
gether  differently.  Afterwards  Chapman,  the 
first  who  publicly  taught  midwifery  in  London, 
published  a  work  especially  for  the  purpose 
of  making  known  its  use,  and  thus  divulging 
the  secret.  The  forceps  Chapman  employed 
was  similar  to  Giffard’s,  but  Chamberlen’s 
was  still  a  secret.  From  this  time  the  for¬ 
ceps  and  other  obstetric  instruments  were 
constant  objects  of  attention.  The  man- 
midwife,  as  he  was  called,  became  an  ope- 


*  A  Treatise  on  Midwifery.  By  Fielding  Ould. 
Dublin,  1742. 

f  The  Female  Physician.  By  John  Maubrey, 
M.D.  London,  1724.  Maubrey’s  5th  qualifica¬ 
tion  of  the  “  Extraordinary  (or  man)  Midwife”  is 
as  follows:— 

“  He  ought  in  fine  to  handle  her  (the  patient) 
decently,  and  treat  her  gently,  considering  her 
as  the  weaker  vessel,  whose  elegant  and  tender 
body  will  admit  no  rough  usage.  Wherefore, 
upon  this  account,  I  would  have  all  practitioners 
in  the  art  debarred  from  the  use  of  instruments, 
which  would  secure  many  a  mother  from  being 
wounded  or  mangled,  and  many  an  infant  from 
being  cut  or  torn  to  pieces.”  Again,  he  says — 
“  What  can  be  more  inconsistent  with  the  tender 
nature  of  women,  or  more  terrible  to  them,  than 
to  see  men  come  armed  against  themselves  and 
their  tenderer  infants  with  knives,  hooks,  and 
iron  forceps  ?” — p.  180. 


DR.  MURPHY  ON  THE  PROGRESS  OF  MIDWIFERY. 


563 


rator  of  no  mean  importance  ;  and,  therefore, 
all  agreed  in  offering  improved  instruments  ; 
but  the  different  writers  of  the  period  pre¬ 
sent  a  remarkable  contrast  in  the  alterations 
they  proposed,  and  in  their  manner  of  sug¬ 
gesting  them. 

Dr.  Burton,  of  York,  offers  to  his  readers’ 
attention  a  most  complicated  machinery  in 
most  bombastic  language,  in  which  he  pro¬ 
fesses,  in  the  most  patriotic  spirit,  his  strong 
desire  “  to  prefer  the  public  good  to  his 
own  private  interest,”  and  his  wish  “that 
every  person  may  be  as  capable  of  assisting 
the  fair  sex  as  himself.”*  Dr.  Burton’s 
patriotism  is  expended  in  the  construction 
of  instruments  that  few  but  himself  could 
use.  Compare  the  language  and  the  instru¬ 
ments — the  inflation  of  the  one,  and  the 
complexity  of  the  other — and  you  can  ima¬ 
gine  the  original  of  Sterne’s  “  Dr.  Slop.” 
No  wonder  Mr.  Shandy  complained  of  “his 
vile  instruments.” 

Fig.  2. 


Fig.  2. — Dr.  Burton’s  Forceps. 

*  “These  dangerous  and  tedious  ways  of  deli¬ 
vering  women  induced  me  to  spend  a  few  serious 
thoughts  in  order  to  contrive  some  more  safe 
and  expeditious  method  of  relieving  the  fair  sex ; 
and  I  hope  my  labour  has  not  been  in  vain.  And 
as  I  always  professed  myself  an  advocate  to  serve 
my  country  to  the  utmost  of  my  power,  I  do  in 
this  (as  I  have  hitherto  done  upon  all  occasions) 
prefer  the  public  good  to  my  own  private  interest, 
and  therefore  now  take  this  method  of  laying 
open  to  the  world  the  improvements  that  I  have 
made,  that  every  person  may  be  as  capable  of  as¬ 
sisting  the  fair  sex  as  myself.” — An  Essay  to. 
wards  a  Complete  New  Epstein  of  Midwifery 
p.  231.  By  John  Burton,  M.D.  London,  1751. ' 


Smellie*  forms  a  remarkable  contrast  to 
Burton  :  to  him  we  are  indebted  for  those 
improvements,  both  in  the  forceps  and 
other  instruments,  which  are  the  basis  of 
their  present  construction  ;  by  him  also  we 
are  taught  a  more  careful  discrimination  of 
suitable  cases,  as  well  as  clearer  rules,  for 
the  application  of  the  forceps.  Smellie 
published  a  comprehensive  work  on  Mid¬ 
wifery,  as  well  as  the  first  series  of  plates  in 
folio,  which  made  any  approach  to  an  accu¬ 
rate  representation  of  the  position  of  the 
child  in  the  uterus,  though  it  still  contained 
the  errors  of  the  day,  in  which  a  vivid  ima¬ 
gination  supplied  all  the  defects  of  anato¬ 
mical  knowledge. 

The  public  prejudice  against  obstetric 
operations,  and  their  dread  of  them,  still 
prevailed  to  a  great  extent;  and,  notwith¬ 
standing  Smellie’s  admitted  skill  in  the  use 
of  instruments,  he  found  it  necessary  to  use 
secresy  in  his  operations.  This  prejudice 
also  favoured  the  most  virulent  attacks 
against  him,  and  we  find  him  treacherously 
assailed  by  an  envious  rival  under  the  as¬ 
sumed  name  of  Mrs.  Nihellf ;  his  lectures 
were  ridiculed,  and  the  phantom  or  model 
he  had  contrived  to  illustrate  his  mode  of 
operating,  was  made  the  especial  object  of 
merriment. 

Smellie  brought  the  art  of  midwifery  to  a 
great  degree  of  perfection ;  but  to  William 
Hunter  we  are  indebted  for  a  scientific 
knowledge  of  parturition.  The  latter  fol¬ 
lowed  in  the  footsteps  of  Harvey.  He  care¬ 
fully  traced  the  development  of  the  ovum, 
and  examined  its  successive  changes  from 
the  earliest  germ  to  the  matured  infant.  He 
described  faithfully  the  alterations  of  struc¬ 
ture  in  the  gravid  uterus,  and  seized  with 
avidity  every  opportunity  that  was  afforded 
him  to  illustrate  his  subject.  The  result 
was,  that  splendid  record  of  his  industry, 
his  “  Illustrations  of  the  Anatomy  of  the 
Gravid  Uterus  and,  whether  we  consider 
the  success  with  which,  under  no  ordinary 
difficulty,  he  has  demonstrated  the  develop¬ 
ment  of  the  foetus,  the  general  accuracy  of 
his  conclusions,  the  fidelity  of  his  facts,  and 
the  truth  of  his  illustrations,  the  work  com¬ 
mands  our  admiration  for  the  research  and 
surprising  industry  of  its  author.  Hunter’s 
plates  differed  from  all  that  preceded  them  : 
they  were  faithful  representations  of  nature, 
and  perfectly  conveyed  his  beautiful  dissec¬ 
tions  of  the  gravid  uterus.  These  plates, 
and  the  injected  preparations  to  demonstrate 
the  circulation  in  the  placenta,  still  maintain 


*  A  Treatise  on  the  Theory  and  Practice  of 
Midwifery;  with  Cases.  By  W.  Smellie,  M.D. 
Lond.  1752.  A  Set  of  Anatomical  Plates,  1754. 

t  A  Treatise  on  the  Art  of  Midwifery.  By 
Eliza  Nihell.  1760. 

i  Anatomia  uteri  humani  gravidi,  &c.  Will. 
Hunter,  M.D.  1774. 


564 


DR.  MURPHY  ON  THE  PROGRESS  OF  MIDWIFERY. 


their  pre-eminent  character,  and  contribute 
still  further  to  invest  midwifery  with  some¬ 
thing  having  the  characters  of  science. 

Towards  the  close  of  the  18tb  century, 
midwifery  was  placed  in  a  very  different  po¬ 
sition  from  what  it  had  been  at  the  com¬ 
mencement.  The  instruments  employed  in 
operations  were  greatly  improved — the  rules 
for  operating  more  clearly  laid  down  :  but 
what  was  of  equal  importance,  a  better  descri- 
mination  was  exercised  in  those  cases  that 
required  instrumental  aid  :  the  process  of 
Nature  in  parturition  was  better  understood, 
and  the  accoucheur  was  called  upon  not  merely 
to  operate,  but  to  determine  whether  an  ope¬ 
ration  was  necessary,  and  if  it  might  be 
avoided.  His  advice  became  valuable  as  an 
obstetric  physician  ;  the  public  began  to  re¬ 
pose  in  him  more  of  their  confidence,  and  his 
assistance  was  sought  for  more  frequently  in 
ordinary  labours.  Obstetric  authors  conse¬ 
quently  increased,  and  we  find  Osborne, 
Perfect,  Bland,  Denman,  John  Clark,  Rigby 
of  Norwich,  Joseph  Clarke  and  Dease  of 
Dublin,  Hamilton  of  Edinburgh,  all  contri¬ 
buting  their  quota  to  the  general  stock  of 
obstetric  knowledge. 

Looking  back  upon  the  course  of  this  his¬ 
tory,  we  perceive  that  midwifery  at  first  was 
entirely  the  business  of  midwives,  and  con¬ 
sidered  to  be  unworthy  the  attention  of  me¬ 
dical  men.  The  exertions  of  a  few  removed 
this  prejudice  ;  but  it  was  still  viewed  purely 
as  an  art  in  which  the  ready  application  of 
instruments  seemed  to  be  the  essential  re¬ 
quisite.  We  then  find  the  immortal  Harvey 
and  William  Hunter  raising  it  to  the  position 
of  a  medical  science ;  the  latter,  especially, 
proving  that  it  was  something  more  than  an 
art.  He  found  the  artists  in  the  profession 
were  too  often  intruders  on  the  duties  of  Na¬ 
ture,  and  that  sometimes  her  operations  were 
not  only  interfered  with,  but  frequently  al¬ 
together  deranged  by  their  ignorant  med¬ 
dling.  Hunter  enforced  in  his  lectures  the 
necessity  of  viewing  parturition  as  a  natural 
process.  He  urged  that  our  attention  should 
be  directed  to  favour,  not  to  hasten  her 
efforts.  He  objected  strongly  to  the  princi¬ 
ple  acted  upon  by  the  advocates  of  the  quick 
and  secret  mode  of  delivery.  His  views, 
supported  by  the  clearest  demonstrative  evi¬ 
dence,  soon  began  to  effect  an  important 
change  in  the  practice  of  midwifery  ;  and  al¬ 
though  it  is  true  that  he  sometimes  carried 
his  caution  too  far,  as,  for  instance,  leaving 
the  placenta  for  days  in  the  uterus  that  it 
might  be  expelled  naturally — objecting  to 
artificial  delivery  when  the  uterus  was  rup¬ 
tured,  still  he  effected  a  most  essential  im¬ 
provement  in  checking  uncalled-for  interfer¬ 
ence,  and  in  placing  the  study  of  obstetric 
medicine  on  its  true  basis  in  proving  it  to  be 
the  study  of  Nature. 

Thus  we  find  midwifery  in  its  early  origin 


wending  its  way  through  a  barren  and  unin¬ 
teresting  tract,  clouded  in  mists  of  the  darkest 
ignorance  :  then  we  observe  it  slowly  emerg¬ 
ing  from  obscurity  in  proportion  as  it  re¬ 
ceived  light  from  those  eminent  men,  the 
luminaries,  as  it  were,  in  the  cycle  of  obste¬ 
tric  history.  In  its  further  progress  we  per¬ 
ceive  it  gradually  rising  over  the  difficulties 
that  opposed  its  advance ;  and  now  we  can 
follow  it  as  it  expands  into  a  clear  and  steady 
stream,  and  becomes  an  important  tributary 
to  medical  science. 

Time  will  not  permit  me  to  allude  to  more 
than  two  of  the  authors  we  have  enumerated — 
to  Rigby  of  Norwich,  and  to  Denman. 

Rigby,*  the  native  of  a  town  distinguished 
for  its  medical  men — educated  by  Priestly, 
a  pupil  of  Martineau,  the  companion  of 
Cross — had  given  to  midwifery  the  same 
spirit  of  inquiry  that  he  had  to  other  medical 
subjects,  and  with  a  similar  successful  result. 
In  1776,  he  published  an  Essay  on  Uterine 
Haemorrhages,  that  at  once  commanded  the 
attention  of  the  profession.  Rigby  pointed 
out  to  them  a  marked  distinction  in  the  cha¬ 
racter  of  floodings  at  the  time  of  delivery ; 
and  proved  that  the  operation  of  Ambrose 
Pare  (turning)  was  not  necessary  in  all  cases 
of  severe  haemorrhages.  He  showed  that  in 
certain  cases  it  might  be  dispensed  with  al¬ 
together,  while  in  others  it  was  unavoidable. 
He  pointed  out  that  the  practice  in  this  re¬ 
spect  must  be  governed  by  the  position  of 
the  placenta  :  that  when  it  was  attached  to 
the  mouth  of  the  womb  the  child  must  be 
delivered  by  turning  ;  if  to  any  other  part 
that  operation  was  very  seldom  required. 
This  fact  had  also  been  brought  forward  by 
Levret,  in  France,  about  the  same  time,  and 
therefore  Rigby’s  claim  to  the  discovery  of 
a  new  fact  has  been  questioned  and  denied. 
I  shall  not  here  trespass  on  your  time  with 
this  “  vexata  questio.”  I  faithfully  believe 
Rigby  knew  nothing  whatever  of  Levret’s 
experience,  and  I  am  satisfied  that  this  view 
of  the  treatment  of  floodings  was  perfectly 
new  to  the  British  obstetrician  :  the  best 
proof  I  can  give  you  is  that  his  Essay  ran 
rapidly  through  five  editions  ;  and  I  can  find 
in  no  other  British  author,  previous  to 
Rigby,  any  such  classification  of  ante-partum 
hsemorrhages. 

Denman  was  the  author  of  a  work  which 
is  now  a  standard  in  the  obstetric  catalogue.'!' 
He  avoided  the  extremes  of  Smellie  and  of 
Hunter.  Denman  wns  less  bold  than  the 
former  in  the  application  of  instruments ; 
less  hesitating  than  the  latter  w'hen  interfer¬ 
ence  was  called  for:  holding,  as  it  were,  the 
balance  between  these  eminent  authorities, 
he  laid  down  principles  which,  taken  as  a 

*  An  Essay  on  Uterine  Haemorrhage,  &c. ; 
with  Cases.  By  Edward  Rigby,  M.D.  1776. 

J  f  Introduction  to  the  Practice  of  Midwifery. 
By  T.  Denman,  M.D. 


DR.  MURPHY  ON  THE  PROGRESS  OF  MIDWIFERY. 


565 


whole,  may  be  considered  as  the  safest  guides 
to  practice.  I  can  very  conscientiously  re¬ 
commend  his  work  to  your  attention.  It  is 
the  result  of  extensive  experience,  improved 
by  a  sound  and  unbiassed  judgment ;  and  if 
the  study  of  an  author  can  communicate  any 
sympathetic  influence — if  his  tone  can  be  so 
conveyed — I  have  an  additional  reason  for 
recommending  to  you  Denman,  because  if 
you  can  acquire  from  the  study  of  his  work 
the  same  caution  in  avoiding  precipitate  in¬ 
termeddling — if  you  are  taught  to  exercise 
the  same  calm  discrimination  in  the  difficul¬ 
ties  of  practice — the  same  clearness  in  arriv¬ 
ing  at  a  correct  conclusion — and  you  find 
your  judgment  improved  by  his  observations, 
you  will  receive  a  rich  reward. 

Denman’s  success  in  practice,  and  the 
eminence  to  which  he  had  attained,  was  the 
natural  consequence  of  his  great  ability  ;  and 
if  I  have  mentioned  his  work  to  you  as  an 
object  of  study,  so  I  might  point  to  his 
career  as  an  example  to  follow.  I  would  ask 
you  not  alone  to  read  his  work,  but  to  read 
his  life — a  short  memoir,  given  with  the  most 
unaffected  simplicity.  I  would  ask  you  to 
observe  him  as  he  passed  through  the  trials, 
the  difficulties,  the  early  struggles  of  his  pro¬ 
fessional  life.  You  will  find  a  remarkable 
example  of  perseverance  and  self-control 
conquering  a  natural  impetuosity  of  temper, 
in  order  to  acquire  that  steadiness  which  he 
knew  to  be  essential  to  success.  You  may 
mark  his  professional  advancement — moving 
slowly,  step  by  step,  while  the  ultimate  re¬ 
ward  of  his  exertions  seemed  to  be  immea¬ 
surably  removed.  An  untiring  exertion 
among  the  poor  formed  the  broad  basis  of 
Denman’s  professional  character  :  a  daunt¬ 
less  perseverance  under  difficulties,  and  a 
steady  attention  to  the  improvement  of  mid¬ 
wifery,  enabled  him  to  build  up  securely  his 
future  reputation ;  moderation  in  success 
aided  in  raising  him  to  his  highest  expecta¬ 
tions,  until  ultimately  he  reached  that  pin¬ 
nacle  on  which  the  favour  of  the  aristocracy 
crowned  his  diligent  exertions.  It  is  true, 
that  if  the  student  were  to  look  at  Denman 
standing  on  such  an  eminence,  he  might  be 
discouraged  ;  because,  however  he  might  be 
the  object  of  his  admiration,  still  he  would 
scarcely  hope  to  rise  to  the  elevation  upon 
which  Denman’s  reputation  so  securely  rests. 
But  I  would  again  say,  read  his  life,  and  ask 
yourselves,  Are  not  the  means  of  success 
equally  within  your  reach  as  they  were  with¬ 
in  his  ?  May  not  you,  equally  as  Denman, 
hope  to  receive  the  reward  of  your  indus¬ 
trious  attention,  and  become  eminent  in 
your  profession  ? 

With  Denman  I  shall  close  this  brief  sum¬ 
mary  of  British  midwifery  :  there  are  other 
distinguished  names,  of  more  recent  date,  to 
which  I  might  solicit  your  attention  if  it  were 
mv  design  to  continue  this  review  into  the 


19th  century.  I  could  point  out  to  you 
living  examples  of  the  truth  of  these  obser- 
tions,  in  which  the  same  untiring  exertions, 
and  the  same  zeal  in  the  cultivation  and  im¬ 
provement  of  midwifery,  are  forming  the 
“  monumentum  sere  perennius but  this  is 
unnecessary,  perhaps  even  in  bad  taste.  The 
praises  that  we  lavish  on  the  dead  must  be 
checked  when  speaking  of  the  living,  lest  it 
may  be  governed  by  prejudice,  or  degenerate 
into  mere  fulsome  adulation.  Your  own 
penetration  will  in  time  select  among  the 
living  the  best  examples  to  follow  ;  and  if  I 
seek  to  review  the  biography  of  past  cen¬ 
turies,  it  is  because  that  such  annals  are 
generally  forgotten  in  the  business  of  the 
present  time.  They  are  not  unlike  those 
epitaphs  which  had  been  intended  to  remain 
as  imperishable  records  of  individual  worth. 
It  is  often  very  difficult  to  collect  the  me¬ 
moirs,  and  sometimes  even  to  trace  the 
names,  of  individuals  once  well  known,  if 
not  eminent,  when  they  are  obscured  by  the 
mould  that  time  generates,  and  neglect  per¬ 
mits  to  accumulate  about  them. 

Having  placed  before  you  this  sketch  of 
the  rise  and  progress  of  midwifery,  we 
should  next  proceed  to  consider  its  present 
condition  ;  but  to  do  this  part  of  our  subject 
justice,  would,  I  fear,  require  another  lec¬ 
ture  ;  time  will  permit  me  to  point  only  to 
a  few  prominent  features  that  are  worthy  of 
attention. 

You  have  observed  the  improvements 
that  have  gradually  been  introduced  into  the 
practice  of  midwifery,  by  which  many  lives 
have  been  saved  that  otherwise  would  have 
been  sacrificed.  You  have  perceived  the 
effect  on  the  public  mind  produced  by  these 
proofs  of  superior  knowledge  :  midwifery  has 
been  taken  from  the  midwife,  and  become 
the  profession  of  the  educated  physician. 
The  public  do  not  now  believe  that  because 
parturition  is  a  natural  process,  it  should  be 
left  entirely  to  nature,  and  that  no  further 
education  is  required  than  what  is  necessary 
to  tie  and  divide  the  navel-string.  They 
are  aware  that  the  safety  of  those,  who  are 
most  dear  to  them,  often  depends  entirely  on 
the  skill  and  judgment  of  the  educated  medi¬ 
cal  attendant  ;  consequently  they  look  for 
such.  Neither  are  they  blinded  by  the 
prudest  arguments  of  ignorance,  who,  like 
Mrs.  Nihell,  and  many  since,  would  fain 
persuade  them  of  the  indelicacy  of  com¬ 
mitting  an  ordinary  delivery  to  the 
charge  of  the  accoucheur.  The  days 
when  these  arguments  possessed  any 
value,  have  long  since  passed  away  ;  never¬ 
theless,  the  same  delicacy  of  feeling  and  re¬ 
fined  sense  of  propriety  still  remains.  There 
is  no  alteration  here  ;  but  the  reason  that 
such  pleadings  are  not  now  listened  to  is  the 
conviction  of  the  public  that,  education  is 
just  as  much  required  in  midwifery  as  in  any 


DR.  MURPHY  ON  THE  PROGRESS  OF  MIDWIFERY. 


566 


other  branch  of  medicine,  and  they  know  it 
is  not  to  be  found  among  midwives.  These 
facts  must  greatly  enhance  the  value  of  an 
obstetric  education,  and  should  be  a  strong 
inducement  to  lead  you  to  give  midwifery  at 
least  an  equal  share  of  attention  as  other 
medical  sciences ;  but  there  is  one  fact  be¬ 
yond  all  others  that  should  be  impressed 
upon  you  minds  as  a  stimulus  to  exertion. 
Midwifery  is  the  most  treacherous  pursuit 
an  ignorant  person  ever  adopted.  He  or 
she  may  go  on  successfully  in  practice,  (so 
long  as  nature  does  everything),  for  a  longer 
or  a  shorter  time,  when  suddenly  a  difficulty 
arises,  for  which  they  are  quite  unprepared — 
danger  is  imminent,  and  death  may  take 
place  before  the  assistance  of  the  educated 
practitioner  can  possibly  be  had,  or,  worse 
than  all,  presumptuous  ignorance  may  as¬ 
sume  the  garb  of  education,  and  the  pre¬ 
tender  may  attempt  to  perform  an  opera¬ 
tion  to  which  he  is  quite  unequal,  death  is 
the  result,  and  the  coroner's  inquest  exposes 
such  proofs  of  gross  incompetency  as  are 
only  equalled  by  the  unparalleled  audacity 
with  which  he  first  ventured  upon  the  ope¬ 
ration — an  office  which  he  must  have  been 
perfectly  conscious  that  he  could  not  fulfil. 
Be  not  deceived,  therefore,  by  the  apparent 
facility  of  midwifery  practice ;  do  not  look 
upon  it  with  ennui,  and  say  that  “  there  is 
nothing  in  it."  On  the  contrary,  there  is  a 
great  deal  in  it  :  much  has  been  done  in  the 
art  of  midwifery,  but  much  still  remains  to 
do  in  the  science  of  obstetric  medicine.  You 
are  now  entering  upon  the  study  of  mid¬ 
wifery  with  many  advantages.  Our  aids  to 
knowledge,  both  in  the  theory  and  practice, 
have  greatly  increased.  Embryology  has 
attained  a  great  degree  of  perfection, — you 
should  make  it  your  study :  and  when  the 
physiology  of  the  ovum  is  understood,  its 
pathology  is  easily  learned.  Intra-uterine 
pathology  is  a  wide  field,  as  yet  but  imper¬ 
fectly  cultivated.  The  whole  function  of 
parturition  and  the  mechanism  of  delivery 
is  better  understood  now  than  formerly : 
this  subject  you  can  still  follow  up — add 
your  mite  to  the  knowledge  already  collected 
— and  perhaps  assist  in  improving  the  prin¬ 
ciples  of  practice. 

We  have  now  also  introduced  to  our 
notice,  a  new  agent  in  the  practice  of  mid¬ 
wifery,  which,  if  its  value  be  hereafter  esta¬ 
blished,  is  calculated  to  produce  as  remark¬ 
able  an  effect  upon  it  as  Ambrose  Pare’s 
operation  of  turning,  or  Chamberlen's  for¬ 
ceps.  I  allude  to  the  introduction  of  agents 
calculated  to  diminish,  if  not  to  remove  the 
pains  of  labour.  Of  these,  the  chief  is  chlo¬ 
roform,  the  most  powerful  anodyne  yet 
discovered,  of  great  value  in  lessening  the 
sufferings  of  the  parturient  women,  but  an 
agent  of  such  power  that,  like  hydrocyanic 
acid,  it  has  caused  sudden  death.  In  the 


hands,  therefore,  of  an  ignorant  person,  you 
can  imagine  the  danger  of  chloroform,  but 
with  those  who  have  studied  its  properties, 
(and  there  is  much  yet  to  learn)  who  un¬ 
derstand  the  mode  of  its  administration,  and 
can  safely  employ  it,  you  can  perceive  the 
advantage  thus  given  them.  This  inquiry  is 
still  before  you,  and  requires  you  to  apply 
to  it  all  the  education  you  have  already  ac¬ 
quired  both  in  physiology  and  chemistry. 
When  you  have  ascertained  the  nature  of 
the  vapour,  the  tests  of  its  purity,  its  effects 
on  the  nervous  system,  and  on  the  blood, 
and  the  safest  mode  of  administering  it, 
there  still  remains  to  decide,  whether  it  is 
proper  to  use  anaesthesia  in  midwifery  at  all 
or  not.  In  the  examination  of  this  question, 
do  not  be  led  away  either  by  extravagant 
praises  of  chloroform  on  the  one  side,  or  by 
a  senseless  condemnation  of  it  on  the  other  ; 
neither  expect  to  perform  miracles,  nor  fear 
to  commit  a  homicide  by  its  use  :  “  in  medio 
tutissimus  ibis."  Do  not  from  preconceived 
prejudices  decide  at  once  in  the  negative, 
but  arrive  at  the  affirmative  with  caution. 
Look  upon  chloroform,  if  you  please,  as  a 
poison,  but  examine  it  as  you  would  hydro¬ 
cyanic  acid,  or  opium,  or  arsenic,  or  aconite, 
all  of  which  are  rank  poisons,  nevertheless, 
are  used  as  medicines,  and  in  educated  hands, 
are  most  valuable  remedies.  All  these, 
when  first  used,  and  even  now  when  in¬ 
cautiously  given,  have  caused  death ;  such 
has  happened  with  chloroform  :  but  as,  in 
the  former  instances,  these  fatalities  did  not 
explode  them  from  practice,  but  only  led  to 
increased  care  in  their  administration,  so 
now  the  few  deaths  that  have  occurred  from, 
chloroform  among  the  thousands  who  have 
taken  it,  should  only  teach  us  prudence,  lest 
the  use  of  it  may  become  an  abuse,  and  thus 
lead  to  its  prohibition.  This  new  agent  is 
now  running  the  same  course  that  the  for¬ 
ceps  did  when  first  invented.  That  novel 
aid  to  delivery  was  far  more  frequently 
called  upon  than  was  at  ail  necessary  :  hence 
a  great  deal  of  mischief  was  done  with  the 
forceps,  until  at  length  it  was  almost  given 
up.  So  also  those  who  never  used  the  for¬ 
ceps,  who,  perhaps,  never  saw  the  instru¬ 
ment,  made  it  the  object  of  their  bitterest 
attacks  :  vituperation,  sarcasm,  ridicule, 
were  severally  aimed  against  “  the  dange¬ 
rous  instrument :"  nevertheless,  the  forceps 
escaped  all  this,  and  is  now  acknowledged 
to  be  a  valuable  aid  in  practice.  Thus  I 
think  it  is  with  chloroform.  It  was  scarcely 
announced,  when  the  journals  were  teeming 
with  cases,  in  which  it  had  been  successfully 
used ;  presently  a  fatal  accident  occurs — 
then  a  second — and  a  third.  The  profession 
take  alarm — become  sceptical — and  then 
condemn  without  much  reflection.  We 
have  also  our  Dr.  Maubreys  and  Mrs. 
Nihells,  attacking  in  no  measured  terms  the 


DR.  MURPHY  ON  THE  PROGRESS  OF  MIDWIFERY. 


567 


employment  of  chloroform ;  their  very 
arguments  proving  that  they  have  never  used 
it,  and  consequently  can  know  nothing  but 
by  hearsay  about  it.  A  question  of  fact  can 
only  be  determined  by  an  appeal  to  facts  ; 
and  if  this  appeal  be  made  with  due  caution, 
and  by  one  who  knows  the  properties  of  the 
agent  he  is  using,  the  result,  I  feel  con¬ 
scious,  will  prove  the  value  of  chloroform. 
In  determining,  therefore,  on  the  propriety 
of  using  anaesthesia  in  the  practice  of  mid¬ 
wifery,  decide  it  by  facts,  and  not  by  a  priori 
prejudices.  There  is  only  one  argument  of 
this  kind  that  commands  our  attention,  be¬ 
cause  it  is  specious,  and,  if  it  were  true, 
would  be  the  most  powerful  against  it  that 
could  be  employed.  In  this  country,  where 
the  Bible  is  read  and  valued,  a  religious  ob¬ 
jection  is  a  strong  one  ;  and  in  this  instance, 
if  valid,  would  be  damnatory. 

The  sin  of  our  first  parent  brought  upon 
woman  this  condemnation.  “  In  sorrow  shalt 
thou  bring  forth  children.”  It  is  said  that 
by  using  means  to  lessen  the  pains  of 
labour,  we  are  removing  the  sorrows  of  child¬ 
birth — we  are  preventing  the  punishment  to 
which  woman  is  condemned — we  are  abro¬ 
gating  the  Divine  decree.  Such  an  objec¬ 
tion  as  this  seems  to  me  scarcely  to  require 
all  the  learned  criticism  on  the  interpreta¬ 
tion  of  Scripture,  that  has  been  so  ably  ad¬ 
vanced,  to  refute  it.  In  the  present  genera¬ 
tion,  when  the  effects  of  sin  are  so  manifest, 
it  may  truly  be  said  that  the  pains  of  labour 
form  a  very  small  part  of  the  sorrows  of 
child-birth ;  but  the  foundation  of  such  an 
objection  is  perfectly  unstable.  How  could 
we — the  very  lowest  class  in  the  intellectual 
kingdom — the  link  between  mind  and  mat¬ 
ter — a  mere  zoophyte  in  the  scale  of  intelli¬ 
gences  ? — how  could  we  blot  out  a  single 
particle  of  the  ordinances,  or  interrupt  the 
designs  of  the  Master  Mind,  “  whose  ways 
are  not  as  our  ways,  and  whose  thoughts  are 
not  as  our  thoughts  ?”  The  supposition  that 
we  could  prevent  the  fulfilment  of  the 
Divine  sentence,  is  to  assume  imperfection 
in  the  Divine  attributes.  The  objection  asserts 
an  impossibility,  and  may  be  taken  as  a 
specimen,  and  perhaps  the  best  specimen,  of 
the  class  of  a  priori  arguments.  In  place  of 
losing  time  in  these  discussions,  rather  seek 
to  know,  whether  chloroform,  while  it  re¬ 
lieves  the  pain,  may  interrupt  the  process  of 
parturition. — Has  it  any  influence  on  the 
child’s  life  ?  or  on  the  mother’s  health  sub¬ 
sequently  ?  above  all,  whether  it  may  be 
used  without  risk  ?  because  we  have  no 
right  to  expose  the  parturient  woman  to  any 
risk  for  the  mere  object  of  saving  her  from 
the  pains  of  labour.  If  you  determine  these 
questions  in  the  experimental  manner  that 
1  have  pointed  out ;  (and  when  I  say  “  ex¬ 
perimental,”  you  will  not  understand  me  as 
wishing  to  encourage  untaught  and  reck¬ 


less  experiments),  I  think  you  will  find 
that  chloroform,  so  far  from  interrupting 
parturition,  renders  it  more  easy — that  the 
patient’s  recovery,  especially  from  severe 
labour,  is  much  more  favourable — that  when 
administered  carefully,  it  may  be  given  with¬ 
out  the  slightest  risk — and  that  it  does  not 
poison  the  child.  It  is  necessary,  how¬ 
ever,  to  bear  in  mind,  that  there  are  many 
patients  who  go  through  their  labours  cheer¬ 
fully  and  well  without  the  slightest  un¬ 
favourable  interruption  :  you  would  not  give 
chloroform  to  these.  There  are  also  certain 
constitutions  as  intolerant  of  chloroform,  as 
there  are  patients  who  cannot  bear  opium. 
This  should  teach  you  the  importance  of 
caution  in  your  trials  of  it ;  and  if  you  find 
any  tendency  to  convulsions,  or  to  coldness 
of  the  surface,  or  unusual  pallor,  to  withhold 
its  use  altogether.  These  points,  however, 
we  shall  consider  in  the  course  of  these  lec¬ 
tures. 

In  conclusion,  let  me  urge  upon  you  the 
importance  of  a  sound  obstetric  education, 
and  not  to  be  deceived  into  the  belief  that  it 
needs  little  attention  :  be  assured  that  you 
might  hereafter  repent  so  fatal  an  error. 

You  have  read,  no  doubt,  with  painful 
interest,  the  melancholy  fate  of  the  Ocean 
Monarch,  a  splendid  ship,  leaving  the  port 
of  Liverpool  in  full  sail,  having  all  her  can¬ 
vas  spread,  the  admiration  of  all  observers. 
An  accident  occurs  on  board,  the  conse¬ 
quence  of  neglect — a  spark  becomes  a  flame 
— the  flame  a  conflagration — and  this  noble 
vessel  sinks  a  burning  ruin  at  the  very 
moment  that  she  felt  the  most  secure. 

This  awful  catastrophe  will  supply  an  apt 
illustration  of  my  meaning;  and  I  would  beg 
of  you  to  recollect,  that  more  than  one  mem¬ 
ber  of  our  profession,  sailing  in  the  full 
tide  of  a  successful  practice,  has,  through 
the  merest  accident,  foundered  :  that  acci¬ 
dent,  too,  rendered  fatal  from  neglect — the 
neglect  of  his  obstetric  education — and  I 
might  truly  add,  attended  in  like  manner 
with  a  frightful  sacrifice  of  human  life. 


GENTLEMEN  ADMITTED  LICENTIATES  OF 
THE  ROYAL  COLLEGE  OF  PHYSICIANS. 

At  a  meeting  of  the  Comitia  Majora,  on 
Saturday,  September  30th,  the  following 
gentlemen  were  admitted  Licentiates  of  the 
Royal  College  of  Physicians : — William  John 
Fitton,  Upper  Harley  Street — Charles  Bland 
Radcliffe,  Queen  Square,  Bloomsbury — Wil¬ 
liam  Addison,  GreatMalvern — Alfred  Swaine 
Taylor,  F.R.S.  Lecturer  on  Medical  Juris¬ 
prudence,  See.  in  Guy’s  Hospital. 

On  the  same  day,  William  Siyman,  of 
Newtown,  Montgomeryshire,  was  admitted 
an  Extra  Licentiate  of  the  said  College. 


568  DR.  TODD  ON  THE  TREATMENT  OF  RHEUMATIC  FEVER. 


CLINICAL  LECTURE 

ON  THE 

TREATMENT  of  RHEUMATIC 
FEVER, 

Delivered  at  King’s  College  Hospital, 

Bv  R.  B.  Todd,  M.D.  F.R.S. 

Physician  to  the  Hospital. 

(Reported  by  Mr.  H.  H.  Salter,  Med.  Schol. 

K.C.L.) 

Lecture  V. 

I  wish  to-day,  gentlemen,  to  direct  your 
attention  to  the  treatment  of  Rheumatic 
Fever,  and  the  case  by  reference  to  which 
I  shall  particularly  illustrate  my  observa¬ 
tions,  is  that  of  Elizabeth  Stocking,  set.  23, 
admitted  on  the  1 9th  of  April,  and  still  in 
the  hospital — a  case  in  which  the  prominent 
characteristics  of  the  disease  are  very  well 
marked,  and  which,  therefore,  may  be  pro¬ 
perly  selected  as  a  good  example  of  the 
malady.  Let  me  take  this  opportunity  of 
recommending  you  to  study  with  care,  by 
taking  full  and  daily  notes  of  them,  a  few 
cases  of  this  disease:  it  is  a  disease  which, 
by  and  by,  you  will  be  frequently  called 
upon  to  treat ;  we  are  seldom  without 
several  examples  of  the  disease  in  the  hos¬ 
pital  ;  and,  by  taking  careful  notes  of  some 
eight  or  ten  of  these  cases  now,  you  will  so 
impress  upon  your  minds  the  history  and 
symptoms  of  the  disease,  that  you  will  be 
well  prepared  to  treat  them  for  yourselves, 
and  each  new  case  will  be  the  more  profit¬ 
able  to  your  practical  knowledge.  This  is 
the  more  to  be  recommended,  because  rheu¬ 
matic  fever  is  a  disease  which  exhibits  re¬ 
markably  little  variety  of  symptoms  or 
difference  of  phase  :  in  one  case  the  symp¬ 
toms  may  be  more  severe  than  in  another, 
but  the  same  essentials  which  characterize 
the  disease  are  present  in  all.  Therefore,  I 
say,  study  a  few  cases  carefully,  and  you 
will  get  a  good  knowledge  of  this  disease 
before  you  are  called  upon  to  treat  it  on 
your  own  responsibility. 

The  case  of  Elizabeth  Stocking  affords  us, 
as  I  have  said,  a  good  opportunity  of  study¬ 
ing  the  characteristic  symptoms  of  rheu¬ 
matic  fever.  What,  then,  are  these  charac¬ 
teristic  symptoms?  They  are — 1st,  A 
peculiar  affection  of  the  joints,  involving 
more  or  less  swelling  and  pain  of  them  ; 
this  almost  always  commences  in  the  lower 
joints,  and  then  travels  up  to  the  higher : 
thus,  first  we  find  it  in  the  ankles,  and  then 
in  the  knees,  and  then  it  attacks  the  upper 
extremities;  the  implication  of  the  joints  is 
almost  always  shewn  by  what  may  be  con¬ 


sidered  its  peculiar  characteristic — sivelling. 
Almost  invariably  there  is  an  increase  of 
the  synovial  secretion,  sometimes  to  a  very 
great  extent,  so  as  to  prove  a  source  of 
great  annoyance  to  the  patient.  The  syno¬ 
vial  membranes  in  this  condition  are  highly 
vascular ;  so  much  so,  that  I  have  some¬ 
times  seen  them,  in  cases  where  I  have  had 
an  opportunity  of  examining  them,  as  red  as 
the  conjunctiva  when  in  a  state  of  violent 
inflammation.  Another  characteristic  of 
the  disease  is,  its  tendency  to  shift  its  posi¬ 
tion.  To-day  it  will  be  in  the  right  knee, 
which  will  be  swollen,  hot,  and  tender; 
to-morrow  all  this  will  have  disappeared, 
and  you  will  have  the  same  symptoms  in  the 
left.  This  erratic  tendency — this  disposi¬ 
tion  to  wander  from  joint  to  joint — is  a 
symptom  which  you  should  carefully  keep 
in  mind ;  where  it  exists  in  a  very  marked 
degree,  it  must  be  considered  a  bad  feature, 
indicative  of  a  low  form  of  the  disease  and 
a  low  state  of  the  vital  powers ;  and  it  is  to 
cases  in  which  this  symptom  is  prominent 
that  depressing  treatment  is  found  to  be  par¬ 
ticularly  prejudicial, — often  aggravating  the 
disease  generally,  and  this  feature  of  it  in 
particular.  The  erratic  tendency  is  present 
not  only  in  rheumatic  fever,  but  likewise  in 
the  analogous  disease  of  gout ;  and  it  was 
this  that  led  the  old  writers  to  regard  the 
internal  inflammations  which  are  apt  to 
come  on  in  the  course  of  these  diseases  as 
“metastatic” — an  idea  which,  however  it  may 
have  some  support  in  gout,  is  inadmissible  in 
rheumatic  fever.  It  by  no  means  follows 
that  an  inflammation  of  an  internal  part 
should  be  a  metastasis  of  an  external  inflam¬ 
mation,  even  should  the  latter  diminish  or 
cease  on  the  appearance  of  the  former  ;  but 
a  strong  objection  to  the  doctrine  of  metas¬ 
tasis  is  founded  on  the  fact  that  we  often 
find  that  they  manifest  themselves  simulta¬ 
neously,  and  sometimes  that  the  internal 
inflammation  comes  first ;  and  it  rarely 
happens  that  the  external  inflammation  be¬ 
comes  diminished  or  exacerbated  by  the 
increase  or  diminution  of  the  internal,  and 
vice  versa. 

Another  feature  of  this  disease  is  the  pro¬ 
fuse  sweating  by  which  it  is  accompanied. 
This  is  not  distinctly  of  a  critical  or  sanitary 
nature,  as  we  sometimes  see  it  in  other  fevers; 
for  the  sweats  do  not  produce  any  marked 
immediate  good  effect,  either  on  the  joints 
which  are  implicated  in  the  disease,  or  in 
the  general  state  of  the  patient.  In  this 
case  the  sweating  was  profuse  :  you  doubt¬ 
less  recollect  how  it  poured  forth  from  the 
patient’s  head  and  chest,  and,  indeed,  from 
the  surface  of  her  body  universally  ;  and 
from  that  you  may  judge  how  much  must 
have  escaped.  I  must  say,  however,  that 
I  do  not  regard  these  sweats  as  otherwise 
than  salutary  within  certain  limits  ;  1  think 


DR.  TODD  ON  THE  TREATMENT  OF  RHEUMATIC  FEVER. 


569 


that,  in  the  early  days  of  the  fever,  they 
should  be  encouraged,  as  an  important 
medium  for  the  elimination  of  noxious 
matter  from  the  system,  and  that  you  ought 
to  be  cautious  how  you  stop  such  sweats, 
except  where  they  are  distinctly  debilitating  to 
the  patient.  Large  quantities  of  free  acid  are 
carried  off  by  these  sweats.  You  remember 
that  we  applied  litmus  to  the  skin  of  this 
patient  several  times,  and  that  it  always  was 
deeply  reddened.  In  contrast  with  this 
extraordinary  action  of  the  skin,  we  remark 
generally,  as  it  is  with  our  patient,  a  de¬ 
ficiency  in  the  quantity  of  the  urine,  and  an 
abnormal  condition  of  it ;  that  fluid  being 
loaded  with  lithates  and  purpurates,  and 
even  oxalates,  and  sometimes,  as  in  a  patient 
now  in  the  hospital,  containing  blood.  The 
kidney  is  in  some  degree  irritated ;  less 
water  passess  off  by  it,  but  apparently  a 
large  amount  of  solid  ingredients. 

Another  characteristic  symptom,  which 
always  accompanies  this  disease  more  or 
less,  is  the  furred  condition  of  the  tongue. 
The  state  of  the  tongue  is  the  best  index  to 
the  true  condition  of  the  patient ;  so  long  as 
it  continues  furred,  you  cannot  say  that  you 
have  succeeded  in  thoroughly  eradicating 
the  rheumatic  state  ;  and  I  would  warn  you 
not  to  be  confident  in  the  result  of  your 
treatment  unless  you  see  the  tongue  become 
quite  clean  ;  even  although  the  pain  in  the 
joints  and  other  external  signs  may  have 
been  subdued,  yet,  if  the  tongue  remain 
furred,  I  should  greatly  fear  that  the  patient 
may  suffer  a  relapse,  or  that  he  may  linger 
on  in  the  rheumatic  state  for  a  considerable 
time. 

Further,  we  had  in  this  case  signs  of 
internal  rheumatic  inflammation,  affecting 
the  heart,  indicated  by  a  rubbing  sound 
heard  on  the  base  of  the  heart, — leading  to 
the  conclusion  that  there  had  been  an  effu¬ 
sion  of  lymph  on  the  opposed  surfaces  of 
the  pericardium.  This  was  evidently  not 
metastatic,  because  it  co-existed  with  an 
undimir.ished,  or  but  slightly  diminished, 
inflammation  of  the  external  parts.  All 
these  symptoms  —  namely,  the  articular 
swellings — the  profuse  sweats — the  high- 
coloured  and  loaded  urine  —  the  furred 
tongue — the  tendency  to  heart  affection — 
are  present  in  all  cases  of  rheuumatic  fever ; 
nor  can  we  regard  a  case  as  of  this  nature 
in  which  these  symptoms  are  not  present. 
In  too  many  the  heart  affection  actually 
takes  place  ;  in  all  it  is  to  be  apprehended, 
and,  if  possible,  guarded  against. 

There  are,  however,  tw'o  points  in  this  j 
case  which  are  peculiar,  or,  at  least,  which 
do  not  occur  constantly  in  cases  of  rheu¬ 
matic  fever.  First,  you  will  remember  that 
I  have  pointed  out  to  you  several  times  at 
our  visits,  on  the  skin  of  this  patient,  a 
copious  eruption  of  what  have  been  called 


sudamina  or  miliary  vesicles :  they  were 
scattered  all  over  the  surface  of  the  thorax, 
and  if  you  passed  your  finger  over  the  skin, 
you  found  it  rough ;  these  sudamina  are 
seen,  on  close  examination,  to  be  minute 
vesicles  filled  with  pellucid  fluid.  They  are 
not  specially  characteristic  of  rheumatic 
fever,  but  they  are  characteristic  of  a 
sweating  state.  If  a  patient  suffering  under 
typhus  fever,  pneumonia,  phthisis,  &c., 
sweats  profusely,  these  sudamina  are  apt  to 
appear  upon  the  skin  in  great  numbers. 
The  presence  of  these  sudamina  must  not  be 
regarded  as  indicative  of  any  special  form  of 
disease,  but  merely  as  an  accompaniment  of 
a  state  of  profuse  perspiration.  The  second 
peculiarity  in  the  case  of  this  woman  is, 
that  the  rheumatic  fever  followed  quickly 
upon  the  puerperal  state.  The  connection 
between  rheumatic  fever  and  deranged  ute¬ 
rine  secretions  is  very  remarkable.  Some 
of  the  most  severe  cases  I  have  ever  seen 
have  followed  dysmenorrhoea.  It  would 
seem  as  if  in  these  cases  the  uterus  were 
but  imperfectly  evacuated,  and,  its  contents 
getting  into  the  circulation,  produced  a 
morbid  state  of  the  blood,  which  gives  rise 
to  the  symptoms  which  we  see,  and  requires 
for  its  cure  the  elimination  of  the  unhealthy 
material  by  the  various  emunctories. 

Not  unfrequently  after  the  puerperal  state 
the  patient  exhibits  all  the  symptoms  of  or¬ 
dinary  rheumatic  fever :  the  same  profuse 
sweats,  the  swollen  joints,  the  fever,  and 
the  lithic  urine ;  but  in  some  cases  the 
disease  runs  a  more  formidable  course,  the 
joints,  instead  of  getter  better  after  a  time, 
continue  to  get  worse,  till  at  last  the  carti¬ 
lages  ulcerate,  pus  is  secreted  in  large  quan¬ 
tities,  and  fills  the  synovial  membranes  to 
distension :  the  articular  extremities  of  the 
bones  are  laid  bare,  and  the  rough  osseous 
surfaces  grate  against  each  other  when  the 
limb  is  moved.  I  have  seen  all  the  large 
joints  in  this  condition.  At  the  same  time 
deposits  of  pus  form  in  the  muscles,  and  in 
other  parts.  Some  of  the  French  writers 
describe  this  disease  under  the  name  of 
“puerperal  acute  rheumatism It  is,  in 
fact,  a  form  of  puerperal  fever,  due  to  in¬ 
flammation  of  some  of  the  uterine  veins  in 
which  pus  is  formed,  which,  infecting  the 
blood,  excites  articular  and  other  inflamma¬ 
tions  in  its  passage  through  the  circulation. 
Such  cases  throw  light  on  the  pathology 
of  rheumatic  fever,  and  show  how  a  morbid 
matter,  generated  at  one  part  of  the  circula¬ 
tion  and  carried  through  its  round,  may  oc¬ 
casion  serious  disturbance  in  the  local  nutri¬ 
tion  of  the  various  parts  through  which  it 
may  be  undergoing  elimination,  and  give 
rise  to  a  train  of  symptoms  closely  resem¬ 
bling  and  not  to  be  distinguished  (save  by 
the  history)  from  those  of  rheumatic  fever. 

In  our  patient,  Stocking,  there  seems  to 


570 


DR.  TODD  ON  THE  TREATMENT  OF  RHEUMATIC  FEVER. 


have  been  some  morbid  state  of  the  uterus 
prior  to  the  developement  of  the  rheumatic 
condition.  Immediately  after  her  confine¬ 
ment  she  seems  to  have  had  symptoms  of 
peritonitis,  which  appeared  to  yield  to  treat¬ 
ment  ;  but  she  had  not  long  recovered  from 
these  symptoms  when  the  rheumatic  condi¬ 
tion  showed  itself. 

Having  now  described  to  you  the  promi¬ 
nent  points  of  this  case,  I  must  proceed  to 
that  upon  which  I  wish  to  dwell  particularly, 
and  which,  indeed,  is  the  main  object  of 
this  lecture,  namely,  the  treatment  of  rheu¬ 
matic  fever.  Upon  this  subject  there  still 
exists  a  good  deal  of  difference  among  prac¬ 
titioners  ;  and  as  I  have  myself,  after  much 
inquiry,  come  to  some  decided  conclusions 
as  to  the  line  of  practice  which  should  be 
pursued  in  these  cases,  and  as  they  are  con¬ 
firmed  to  me  by  my  daily  experience,  I  am 
anxious  to  bring  the  whole  subject  before 
you,  and  explain  fully  to  you  the  principles 
which  regulate  my  practice  in  the  treatment 
of  this  formidable  malady. 

Now,  it  is  important  that  we  should  de¬ 
termine  what  are  the  particular  objects  we 
should  keep  in  view  in  the  treatment  of  a 
disease  of  an  acute  kind.  They  are  these  : — 

1st.  To  relieve  pain. 

2dly.  To  strike  at  the  root  of  the  malady. 

3dly.  To  cure  our  patient  with  as  little 
trial  to  his  constitution  as  possible,  so  that 
afterwards  he  may  not  be  in  a  worse  condi¬ 
tion  than  he  was  before.  We  often  hear  in 
society  such  expressions  as  these — “  I  was 
always  very  well  till  Dr.  So-and-so  treated 
me  for  rheumatic  fever,  and  he  purged  and 
bled  me  to  such  a  degree,  and  treated  me  so 
violently,  that  my  constitution  could  not 
stand  it,  and  I  have  never  been  the  man  I 
was  before.”  Now,  let  us  endeavour  to 
conquer  this  frightful  malady,  and  let  it  be 
our  boast  that  when  we  have  done  so  we 
leave  our  patient  a  constitution  unimpaired, 
at  least  by  our  remedies.  In  some  cases  it 
Is  not  possible  to  effect  this :  the  lungs  may 
become  affected,  the  pleura,  or  the  pericar¬ 
dium,  and  so  much  organic  mischief  may  be 
done  in  a  short  time  as  to  leave  important 
organs  permanently  damaged  ;  still,  notwith¬ 
standing  these  lesions,  the  general  nutritive 
powers  need  not  be  materially  injured. 

4thly.  A  good  plan  of  treatment  should 
aim  at  securing  for  the  patient  a  short  con¬ 
valescence  ;  I  do  not  speak  of  a  speedy  cure, 
because  that  is,  to  a  certain  extent,  implied 
in  a  short  convalescence.  At  the  same  time, 

3  must  caution  you  against  the  so-called 
rapid  cures  said  to  be  effected  by  the  heroic 
methods  of  treating  rheumatic  fever.  If 
these  cures  are  rapid,  they  leave  a  tedious 
and  painful  convalescence  ;  and,  indeed,  it 
may  be  more  properly  said  in  such  cases 
that  the  treatment  converts  an  acute  into  a 
chronic  disease,  rather  than  that  it  cures  the 


former.  Such  a  cure,  if  cure  it  can  be 
called,  is  not  what  you  should  aim  at  secur¬ 
ing  for  your  patients  ;  nor  is  that  a  bond 
fide  cure  of  rheumatic  fever  unless  the 
febrile  and  constitutional  symptoms  are 
subdued,  the  secretions  re-established  in  their 
normal  quality  and  quantity,  and  the  joints 
relieved  of  their  swelling  and  pain  :  if  such 
a  cure  as  this  can  be  effected  in  a  short 
time,  not  entailing  a  tedious  convalescence, 
your  patients  will  have  good  reason  to 
be  satisfied.  Now  I  must  tell  you  that 
I  do  not  believe  that  a  bond  fide  cure 
and  a  short  convalescence  are,  in  the  gene¬ 
rality  of  cases,  really  obtainable  by  the  heroic 
modes  of  treatment ;  and  I  would  add  my 
conviction  that  it  is  not  desirable  to  shorten 
very  much  the  period  of  cure  in  this  disease, 
as  it  is  not  likely  that  a  sufficient  elimination 
of  morbid  matters  can  be  effected  in  a  very 
short  time.  These  so-called  rapid  cures  are 
also  apt  to  leave  the  patient  very  subject  to 
relapse,  which  you  should  endeavour  to 
guard  against  as  much  as  against  a  tedious 
convalescence. 

Before  I  enter  on  the  description  of  the 
treatment  of  the  disease,  let  me  come  to 
some  understanding  with  you  as  to  its  na¬ 
ture  ;  we  cannot  adopt  a  particular  plan 
of  treatment  without  having  some  theory  of 
the  nature  of  the  disease.  Now,  what  is  the 
most  reasonable  view  of  the  pathology  of 
this  disease  ?  I  have  not  time  to  enter  fully 
into  the  discussion  of  this  question  with  you, 
and  I  must  therefore  be  content  with  simply 
recounting  to  you  the  articles  of  my  own 
creed  upon  this  subject. 

Rheumatic  fever,  then,  I  would  say,  is  a 
.  state  of  high  febrile  excitement,  induced  by 
the  accumulation  of  a  peculiar  morbid  pro¬ 
duct,  or  materies  morbi,  in  the  circulation  ; 
and  the  symptoms  which  accompany  it  are 
merely  caused  by  certain  local  derange¬ 
ments  and  disturbances  produced  at  those 
points  whence  its  elimination  from  the  sys¬ 
tem  is  taking  place.  This  materies  morbi  is 
the  result  of  a  vitiated  state  either  of  primary 
or  secondary  assimilation,  or  of  both,  and 
the  parts  where  it  accumulates  are  just  those 
parts  which,  while  they  are  very  vascular, 
and  therefore  contain  a  large  quantity  of  the 
diseased  material,  present  the  least  obstruc¬ 
tion  to  its  escape  from  the  circulation. 
These  are  the  delicate  synovial  membranes 
of  the  joints,  and  the  almost  identical  struc¬ 
tures  of  the  serous  membranes — the  pericar¬ 
dium,  endocardium,  pleura,  the  air-cells  of 
the  lung  itself,  and  even  the  peritoneum  : 
parts  where  the  bloodvessels  are  covered  by 
but  a  film  of  membrane.  These  membranes, 
being  largely  supplied  with  rheumatic  blood, 
pour  forth  into  their  cavities  an  enormous 
amount  of  their  ordinary  secretion,  contami¬ 
nated  with  the  diseased  material.  Thus,  the 

svnovial  membranes  become  distended  with 
* 


DR.  TODD  ON  THE  TREATMENT  OF  RHEUMATIC  FEVER. 


571 


a  morbid  synovia,  which,  instead  of  being 
alkaline,  as  it  is  in  health,  has  a  reaction 
decidedly  acid  :  and  thus,  likewise,  the  pro¬ 
fuse  sweats  are  due  to  the  irritation  esta¬ 
blished  in  the  skin  by  the  morbid  product, 
and  the  abundant  fluid  thus  got  rid  of  has, 
like  the  synovia,  a  marked  acid  reaction  : 
the  functions  of  the  kidneys  are,  doubtless, 
similarly  affected,  and  you  get  an  abundance 
of  lithic  acid  in  the  urine.  But  this  morbid 
matter  may  escape  likewise  through  the  se¬ 
rous  membranes,  as  it  does  at  the  synovial, 
or  at  the  lungs,  or  at  the  heart ;  and  hence, 
at  any  of  these  places  it  may  excite  inflam¬ 
mation,  and  at  all  of  them  is  it  disposed  to 
do  so  :  and  it  is  evident  that  the  more  its 
elimination  is  encouraged  and  favoured  at 
the  skin,  at  the  kidneys,  at  the  joints,  and 
at  the  mucous  membrane  of  the  alimentary 
canal,  the  less  likely  are  the  other  important 
parts  to  suffer — the  less  chance  have  you  of 
pleurisy,  pneumonia,  pericarditis,  &c. 

Treatment. — I  think  the  most  instructive 
way  in  which  we  can  discuss  the  treatment 
of  this  disease,  will  be  for  me  to  enumerate 
the  various  methods  which  have  been  pro¬ 
posed  for  this  purpose,  and  to  point  out  the 
reasons  for  rejecting  some  and  for  adopting 
others.  As  many  as  seven  different  plans 
may  be  specified,  of  which  I  shall  place  last 
that  which  I  am  in  the  habit  of  following 
here,  and  which  I  call  the  treatment  hij 
elimination. 

The  first  plan  is  that  by  venesection.  It 
was  thought  by  many,  and  still,  unfor¬ 
tunately,  is  thought  by  some,  that  when 
called  to  a  case  of  rheumatic  fever,  they  have 
only  to  open  a  vein,  and,  if  they  succeed  in 
taking  away  a  sufficient  quantity  of  blood, 
which,  in  many  instances,  they  think  should 
be  little  short  of  two  or  three  pints,  that 
they  may  by  this  large  and  rapid  abstraction 
of  blood  cut  short  the  disease,  and  convert  a 
malady  which  ordinarily  lasts  some  weeks, 
into  one  of  a  few  days’  duration.  Fre¬ 
quently  not  content  with  one  large  bleeding, 
they  will  pursue  the  practice,  and  bleed  a 
second,  a  third,  or  a  fourth  time,  at  short 
intervals,  and  in  large  quantities. 

The  great  advocate  of  this  practice  at  the 
present  day  is  Bouillaud,  of  Paris ;  now,  if 
you  look  through  the  record  of  his  cases  as 
given  in  his  book,  you  will  see  that  his 
patients,  although  some  of  the  more  urgent 
symptoms  are  apparently  very  quickly  over¬ 
come,  yet  linger  on  in  the  hospital  for  a  con¬ 
siderable  period,  suffering  much  from  chronic 
rheumatism,  and  exhibiting  an  extreme 
anaemia,  from  which  they  but  slowly,  if  ever, 
recover.  This  plan  of  treatment  has  been 
advocated  by  some  English  physicians,  and 
among  others,  by  the  celebrated  Sydenham, 
who,  however,  in  the  latter  part  of  his  career, 
abandoned,  or  greatly  moderated  it,  and,  I 
am  happy  to  say,  the  number  of  its  sup¬ 


porters  at  present  is  very  small.  It  is  a 
practice  from  the  adoption  of  which  I  would 
most  earnestly  dissuade  you,  as  having  the 
support  neither  of  reason  nor  of  experience, 
and  as  being  fraught  with  the  most  dangerous 
consequences  to  your  patients. 

I  could  tell  you  of  several  cases  in  which 
a  fatal  result  had  been  clearly  produced  by 
by  the  adoption  of  this  method  of  treatment, 
which  most  probably  would  have  recovered 
completely  had  they  been  let  alone,  or  treated 
by  a  milder  method.  One  case  in  particular 
made  a  deep  impression  upon  me.  The  sub¬ 
ject  of  the  case  was  a  young  and  strong  man, 
of  great  promise  in  his  profession  ;  he  was 
seized  with  rheumatic  fever,  and  one  of  the 
knee-joints  was  severely  affected.  On  a 
previous  occasion,  a  similar  attack  seemed  to 
yield  readily  to  a  very  large  bleeding,  and  the 
patient  recovered.  His  medical  attendant, 
naturally  enough,  determined  on  the  second 
attack  to  adopt  the  same  treatment,  which 
had  seemed  so  successful  before,  and  accord¬ 
ingly  bled  him  very  largely,  and  applied 
leeches  to  the  inflamed  joint.  The  result 
was  violent  delirium  ;  and  death  by  ex¬ 
haustion  in  the  course  of  eight-and-forty 
hours. 

I  would  go  so  far  as  to  say,  that  even  were 
wre  certain  that  venesection  would  produce 
the  desired  effect  on  the  leading  symptoms 
of  the  disease,  we  should  yet  hesitate  ere  we 
make  use  of  a  remedy  which,  in  the  general 
effect  it  may  have,  is  most  uncertain  and 
most  perilous  ;  in  one  case  you  may  relieve 
your  patient ;  in  another  you  may  send  him 
to  a  premature  grave  ;  or  in  the  same  indi¬ 
vidual,  in  a  first  attack,  you  may  obtain 
complete  relief  by  this  method,  and  in  a 
second  attack  you  may  kill  him. 

2.  The  second  plan  of  treatment  is  that 
by  moderate  venesection  and  diaphoretics. 
This  may  be  called  an  “  expectant  ” 
treatment,  but  it  is  more  than  that  as  regards 
the  venesection ;  while  in  other  respects  it 
sufficiently  merits  the  name.  The  advocate 
of  such  a  plan  will  say — “  when  I  am  called 
in  to  a  case  of  rheumatic  fever,  I  think  it 
advisable  to  commence  the  treatment  by 
abstracting  about  10  or  12  oz.  of  blood,  and. 
then  to  give  sudorifics  and  purgatives.” 
Now,  the  objection  which  I  entertain  to  this 
treatment  is  this,  that  the  routine  abstraction 
of  blood  is  in  all  cases  unnecessary,  and  in 
many  injurious,  and  that  the  other  part  of 
the  treatment  can  exercise  little  or  no  influ¬ 
ence  on  the  disease.  The  tendency  of  rheu¬ 
matic  fever  is  to  impoverish  the  blood, 
especially  as  regards  that  highly  important 
portion  of  it,  its  colouring  matter.  All  that 
bleeding  really  effects  is  to  relieve  fever  for 
a  few  hours  (which,  however,  may  quickly 
return),  while  it  undoubtedly  aids  the 
bleaching  power  of  the  rheumatic  matter, 
and,  as  1  have  observed  in  several  cases,  it 


572 


DR.  TODD  ON  THE  TREATMENT  OF  RHEUMATIC  FEVER 


increases  much  the  tendency  to  a  chronic 
rheumatic  state,  and  consequently  prolongs 
the  convalescence.  That  bleeding  in  rheu¬ 
matic  fever  is  unnecessary,  and  that  its 
omission  diminishes  rather  than  increases 
the  tendency  to  certain  internal  inflamma¬ 
tions,  I  am  so  convinced,  that  for  several 
years  I  have  not  abstracted  blood,  in  any 
way,  in  a  single  case  of  the  disease.  The 
treatment  of  rheumatic  fever  by  the  ab¬ 
straction  of  blood,  even  in  moderate  quan¬ 
tity,  but  more  especially  in  large  quantity, 
appears  to  me  to  increase  the  danger  of 
internal  effusions  into  the  pericardium  and 
the  pleura,  and  also  into  the  synovial  sacs 
of  the  joints.  Under  this  treatment  we 
meet  with  the  most  violent  and  trouble¬ 
some  cases  of  delirium,  which,  under  other 
methods,  either  does  not  occur,  or  is  deve¬ 
loped  in  a  form  sufficiently  easily  controlled. 
I  am  very  much  disposed  to  believe  that 
this  treatment  predisposes  to  pericarditis  or 
endocarditis ;  and  that,  if  these  affections 
occur  in  a  case  in  which  venesection  had 
been  freely  practised,  they  are  much  less 
tractable  than  when  you  have  to  deal  with 
them  in  a  patient  who  has  not  suffered  from 
loss  of  blood. 

3.  A  third  plan  is  that  by  mercury.  Some 
recommend  that  calomel  and  opium  should 
be  freely  administered  until  salivation  is  pro¬ 
duced.  The  great  objection  to  this  treat¬ 
ment  is,  that  it  is  an  attempt  to  cure  one 
fever  by  setting  up  another,  and,  in  some 
respects,  a  worse :  even  supposing  the  ori¬ 
ginal  disease  succumbs,  your  patient  comes 
out  of  his  rheumatic  fever  with  loose  teeth, 
ulcerated  gums,  and  all  the  painful  and 
offensive  concomitants  of  ptyalism.  Now,  I 
say  that  under  such  circumstances  the 
remedy  is  nearly  as  bad  as  the  disease ; 
and,  moreover,  it  does  not  in  the  least 
guard  the  patient  against  what  may  be 
termed  the  accidents  of  his  malady — those 
severe  internal  inflammations — pericarditis, 
endocarditis,  pneumonia,  pleuritis,  peritoni¬ 
tis.  I  have  more  than  once  seen  peri¬ 
cardial  inflammation  supervene  while  the 
patient  was  in  a  state  of  salivation ;  and 
when  we  consider  how  differently  various 
persons  are  affected  by  a  mercurial  course, 
and  how  much  some  suffer  from  it,  even  if 
given  in  small  quantity,  I  hold  that  it  is 
highly  inexpedient  to  adopt  this  plan  of 
treatment  except  in  cases  where  some  serious 
internal  inflammations  have  already  set  in, 
which  it  is  desirable  to  combat  by  the 
antiphlogistic  powers  of  mercury. 

4.  Another  plan  of  cure  which  has  been 
proposed  is  by  colchicum  and  by  guaiacum. 
These  drugs,  but  especially  colchicum,  have 
long  been  considered  to  possess  a  specific  in¬ 
fluence  over  rheumatic  and  gouty  affections; 
and  it  has  been  laid  down  that  the  rheumatic 
condition  will  be  subdued  in  just  such  pro¬ 


portion  as  you  get  your  patient  under  the 
influence  of  the  colchicum,  somewhat  in  the 
same  way  as  quinine  exercises  a  specific  in¬ 
fluence  on  ague.  Now  I  think  it  requires 
only  two  or  three  cases  to  a  candid  mind  to 
prove  the  fallacy  of  this  doctrine  :  I  myself 
have  frequently  given  this  remedy  the  fairest 
trials,  but  I  could  never  discover  any  effect 
from  it  sufficient  to  entitle  it  to  the  character 
of  a  specific.  That  it  is  capable  of  exerting 
a  remarkable  influence  on  gout  I  do  not 
deny  ;  but  even  this  must  be  admitted  with 
considerable  limitation,  and  it  is  certainly 
far  from  exercising  any  similar  or  analogous 
influence  in  rheumatism,  whether  acute  or 
chronic.  The  effect  of  guaiacum  has  also  been 
supposed  to  be  specific,  and  similar  to  that 
of  colchicum ;  but  I  am  equally  indisposed 
to  give  it  that  character.  Both  these  medi¬ 
cines,  when  given  in  large  doses,  purge,  and 
if  given  in  such  doses  I  have  no  doubt  they 
may  do  some  good,  on  the  principle  of  elimi¬ 
nating  the  morbid  material,  by  the  alimen¬ 
tary  canal ;  but  unless  you  give  them  in  such 
doses  as  to  produce  colliquative  purging,  you 
do  but  little  towards  cutting  short  the  disease; 
and  if  you  do  give  them  in  these  large  doses, 
you  produce  a  degree  of  prostration  and 
debility  which  is  sometimes  more  dangerous 
than  the  disease,  and  you  leave  your  patient 
to  linger  through  a  tedious  convalescence. 
Colchicum  given  in  small  doses  produces  no 
good  effect  in  rheumatic  fever  according  to 
my  experience  ;  on  the  contrary,  I  fear  that 
in  some  cases  it  has  a  prejudicial  influence  on 
the  nervous  system,  making  it  more  irritable 
and  susceptible  of  impressions,  and  rendering 
the  patient  more  obnoxious  to  the  various 
accidents  that  are  liable  to  occur  in  the  course 
of  the  disease. 

5.  Treatment  by  opium. — This  plan  of 
treatment  has  been  lately  revived  by  a  very 
able  physician,  Dr.  Corrigan,  of  Dublin. 
It  has  much  to  recommend  it,  and,  on  the 
whole,  you  will  find  it  extremely  serviceable 
in  practice ;  but  I  do  not  recommend  it 
alone :  its  great  value  consists  in  relieving 
suffering,  and  soothing  the  nervous  system, 
while  it  promotes  diaphoresis.  The  opium 
is  given  in  large  and  frequently-repeated 
doses,  care  being  taken  not  to  produce  too 
much  narcotism  ;  but  upon  this  point  in 
general,  there  is  not  much  need  for  fear, 
as  there  seems  to  be  in  the  generality  of 
patients  a  remarkable  tolerance  of  opium. 
Our  patient,  Elizabeth  Stocking,  to  whose 
case  I  have  already  referred,  was  ordered  on 
the  23rd  a  grain  of  opium  to  be  given  every 
three  hours,  in  addition  to  half  a  grain  of 
the  muriate  of  morphia,  w7hich  she  had  pre¬ 
viously  been  taking  at  night  :  in  48  hours 
she  thus  took  16  grains  of  opium,  exclusive 
of  the  morphia,  yet  her  pupils  were  not  at 
all  contracted,  nor  was  she  in  any  degree 
narcotized.  The  effect  upon  her  has  been 


DR.  TODD  ON  THE  TREATMENT  OF  RHEUMATIC  FEVER. 


573 


most  beneficial :  her  nervous  excitement  has  I 
been  calmed  down,  and  her  pain  materially 
relieved.  It  will  not,  however,  do  to  employ 
this  plan  alone, — it  should  be  conjoined  with 
other  treatment.  I  do  not  recommend  it  by 
itself. 

G.  A  sixth  plan  of  treatment  proposed 
long  ago  by  Dr.  Haygarth,  consists  in  giving 
bark  in  large  doses,  for  which  more  recently 
the  less  bulky  sulphate  of  quinine  has  been 
substituted.  Now  just  imagine  the  state  in 
which  the  pathology  of  a  disease  must  be, 
when  measures  so  completely  at  the  opposite 
extremes  of  our  therapeutical  resources  are 
advocated  for  it — as  venesection  to  the 
amount  of  two  or  three  pints  on  the  one 
hand,  and  large  doses  of  quinine  on  the 
other :  some  would  even  give  as  much  as 
five  or  ten  grains  two  or  three  times  a  day. 
Now  I  have  tried  both  methods  of  treat¬ 
ment,  and  I  approve  of  neither  ;  but  if  I  were 
tied  down  to  one  or  other  of  them,  I  should 
not  hesitate  to  choose  that  by  bark.  In 
cases  where  the  sweating  is  colliquative,  and 
the  urine  copious  and  pale,  with  abundant 
precipitates  of  pale  lithates,  I  have  seen 
great  good  done  rapidly  by  the  use  of  qui¬ 
nine  ;  but  I  am  not  prepared  to  advise  you 
to  adopt  this  treatment  from  the  beginning, 
because  it  tends  to  check  the  secretions,  and 
it  may  favour  the  development  of  internal 
inflammations. 

7.  The  seventh  and  last  mode  of  treat¬ 
ment  that  I  shall  mention  to  you,  is  that 
which  you  have  seen  me  adopt  frequently 
in  this  hospital,  namely,  the  treatment  by 
elimination.  I  give  it  this  name,  in  order 
that  you  may  keep  well  in  view  its  main 
object — to  promote  the  elimination  of  morbid 
matter  by  the  various  emunctories,  and  also 
that  you  may  bear  in  mind  the  view  of  the 
pathology  of  the  disease  upon  which  it  is 
founded. 

It  is  probable  that  the  materies  morbi  in 
rheumatic  fever  is  lactic  acid.  We  know 
that  the  natural  emunctory  of  this  is  the 
skin  :  many  chemists  maintain  that  it  will 
also  escape  by  the  kidneys,  and  if  it  ever 
does  so,  perhaps  this  is  more  likely  during 
rheumatic  fever  than  at  any  other  time  ;  and 
again,  since  vitiated  digestion  is  apt  to  pro¬ 
duce  it  in  undue  quantity,  and  it,  therefore, 
exists  abundantly  in  the  stomach,  there  is 
every  reason  to  think  a  certain  proportion  of 
it  may  be  carried  off  through  the  alimentary 
canal.  The  indications  are,  therefore,  to 
promote  the  action  of  the  skin,  the  kidneys, 
and  the  bowels  ;  to  use  antacid  remedies  ;  and 
to  give  large  quantities  of  fluid  for  the  free 
dilution  of  the  materies  morbi,  and  in  aid  of 
the  drainage  by  diaphoresis  and  diuresis. 

The  best  way  to  promote  the  action  of  the 
skin  is  by  opium,  especially  if  you  combine 
with  it  nitre  and  ipecacuanha.  For  this 


purpose  I  use  a  compound,  which  resembles 
the  original  Dover’s  powder,  which  con¬ 
tains  nitrate  of  potass  instead  of  sulphate 
of  potass,  as  prescribed  in  the  Pharmacopoeia 
compound  ipecacuan  powder.  Our  usual 
prescription  is  one  grain  of  opium,  one  grain 
of  ipecacuanha,  and  five  grains  of  nitre  :  this 
must  be  given  every  two,  three,  or  four 
hours,  according  to  the  urgency  of  the 
symptoms  and  the  need  the  patient  has  for 
opium.  This  drug  quiets  the  nervous  sys¬ 
tem,  and  procures  sleep,  and  with  the  ipeca¬ 
cuan  promotes  sweating ;  while  the  nitre 
acts  upon  the  kidneys,  and  the  ipecacuan 
may  exercise  some  influence  on  the  liver. 
Next  you  must  give  purgatives  to  such  an 
extent  as  to  keep  the  bowels  in  a  loose  state, 
but  not  carrying  the  purgatives  so  far  as  to 
weaken  your  patient,  or  worry  him  by  oblig¬ 
ing  him  to  be  frequently  moved  in  or  from, 
bed.  You  will  find  it  advantageous  to 
use  an  alkaline  purgative  ;  and  there  cannot 
be  a  better  medicine  for  this  purpose  than 
our  hospital  nostrum — the  white  mixture 
containing  magnesia  and  sulphate  of  mag¬ 
nesia.  Sometimes  you  may  give  the 
potassio-tartrate  of  antimony  with  advantage, 
but  as  it  is  a  depressing  remedy,  it  is  not 
always  advisable  to  use  it. 

But,  while  we  are  thus  alkalizing  our 
patient,  and  giving  internally  sudorifics 
and  diaphoretics,  is  it  advisable  to  attend 
to  the  state  of  the  joints  ?  The  diligent 
physician  will  tell  you  by  all  means  to 
attack  them  at  once  : — but  there  is  such 
a  thing  as  “  nimium  diligentite”  in  physic 
as  well  as  in  any  other  matters.  Many  will 
say,  the  best  thing  you  can  do  is  to  leech 
a  painful  and  swollen  joint.  1  formerly 
tried  it  extensively,  but  for  some  time  past 
I  have  not  done  so,  as  I  generally  found  it 
either  a  useless  or  an  injurious  practice. 
You  may  apply  leeches,  and  in  a  short  time 
after  you  will  find  the  pain  and  swelling  re¬ 
moved,  and  you  may  be  disposed  to  say  to 
yourself,  “  here  is  a  proof  of  their  efficacy 
but  wait  twenty-four  hours,  and  then  you 
will  generally  find  the  pain  and  swelling  as  bad 
as  ever,  and  the  joint  in  just  the  same  con¬ 
dition  as  before.  Now  apply  leeches,  and 
you  will  probably  fail  to  give  any  relief. 
You  have  by  the  first  application  relieved  the 
pain  for  a  time,  but  you  have  produced  no 
permanent  good, — you  have  rendered  the  dis¬ 
ease  more  erratic,  and  less  amenable  to  subse¬ 
quent  treatment.  Frequently  when  you 
leech  a  joint,  the  pain  and  swelling  subside, 
but  its  fellow  becomes  swollen  :  leech  it, 
and  the  swelling  and  pain  return  to  the  origi¬ 
nal  joint.  Nothing  is  more  important  to 
avoid,  nor  more  troublesome  if  not  prevented, 
than  the  erratic  tendency  of  the  rheumatic 
state.  It  will  fly  from  joint  to  joint,  and  in 
pursuing  it  with  leeches  you  only  drive  it 


574 


DR.  GEOGHEGAN’s  PROCESS  FOR  THE  MORE  SECURE 


out  of  one  joint  into  another.  I  am  satis¬ 
fied  that  leeching  the  joints  favours  this 
erratic  tendency. 

I  am  not  prepared,  however,  to  advise  you 
to  neglect  the  local  treatment  of  the  joints. 
When  they  are  much  swollen  and  painful, 
you  may  give  great  ease  to  your  patient  by 
enveloping  them  in  a  large  quantity  of  the 
soft  carded  cotton — what  is  commonly  called 
cotton-wool.  Over  this  you  must  wrap  a 
sheet  of  oiled  silk,  so  as  to  cover  in  the  wool 
completely,  taking  care  to  have  no  part  of 
it  exposed.  By  this  air-tight  covering,  you 
keep  the  joints  in  a  complete  vapour- bath  ; 
and  when  you  come  to  remove  the  oiled  silk 
and  wool  after  twelve  or  twenty-four  hours, 
you  find  the  wool  completely  saturated  with 
moisture,  which  generally  is  strongly  acid. 
You  have  seen  this  in  Elizabeth  Stocking’s 
case  :  we  find  the  plan  so  generally  useful, 
that  it  is  adopted  in  the  hospital  in  nearly 
every  case.  It  affords  great  relief,  supports 
and  keeps  the  limb  steady,  and  at  the  same 
time  promotes  sweating.  I  may  just  men¬ 
tion,  that  this  plan  of  enveloping  the  joint 
in  wool  and  oiled  silk  is  often  very  beneficial 
in  gout. 

In  a  few,  and  only  a  very  few,  cases,  I  have 
found  the  pain  aggravated  by  the  heat  which 
this  mode  of  wrapping  generates  ;  and  in  cases 
where  it  is  desirable  to  keep  down  the  sweat¬ 
ing,  it  is  not  advantageous  to  carry  this  plan 
beyond  a  day  or  two. 

You  perceive  that  all  the  means  em¬ 
ployed  in  this  mode  of  treatment  tend 
to  elimination,  and  to  the  relief  of  pain 
—  the  opiate  sudorific  —  the  nitre  act¬ 
ing  on  the  kidneys — the  purgatives  on  the 
mucous  membrane  of  the  bowels — the  wool 
on  the  joints. 

During  this  treatment,  while  you  allow 
your  patient  the  liberal  use  of  simple 
diluents,  you  must  give  a  fair  amount  of 
nourishment  from  the  first ;  and  I  think 
this  may  be  best  supplied  by  a  small  quan¬ 
tity  of  good  beef-tea,  given  frequently 
throughout  the  day. 

I  have  many  more  remarks  to  make  on 
other  points  in  the  treatment  of  rheumatic 
fever  ;  but  must  content  myself  now  with 
having  given  you  an  outline  of  the  eliminatory 
mode  of  treatment,  and  reserve  my  further 
observations  for  another  lecture. 


IODIDE  OF  POTASSIUM  A  CURE  FOR  NURSES’ 
SORE  MOUTH. 

Dr.  H.  D.  Holt  states  {New  York  Journ. 
of  Med .,  May  1848R  that  every  case  he  has 
treated  of  this  disease  “  has  yielded  within 
forty-eight  hours  to  the  use  of  iodide  of 
potassium  ingr.  v.  doses  three  times  a  day.” 

American  Journal  of  Med.  Sciences,  J  uly 
1848. 


0uginal  Communication*. 


A  PROCEDURE 

FOR  THE 

MORE  SECURE  DETECTION  of  AR¬ 
SENIC  in  MINUTE  QUANTITY. 

By  T.  F.  Geoghegan,  M.D. 

Prof.  Forens.  Med.  Royal  College  of  Surgeons 

in  Ireland. 

The  practitioner  when  called  upon  in 
his  capacity  of  medical  witness  to  pro¬ 
nounce  on  the  presence  of  poison,  when 
the  quantity  capable  of  elimination  is 
extremely  minute,  often  experiences 
considerable  difficulty  in  giving  an 
opinion  sufficiently  definite  for  judicial 
purposes. 

The  embarrassment  alluded  to  does 
not  arise  from  the  organic  contamina¬ 
tions  of  the  matter  examined,  nor  from 
the  effects  of  putrefaction  upon  it.  The 
former  may  no  doubt  completely  mask 
the  presence  of  vegetable  poisons,  wffiile 
the  latter  may  render  nugatory  a  search 
for  the  mineral  acids,  or,  in  conjunc¬ 
tion  with  the  first-named  influence, 
may  so  far  modify  some  of  the  metallic 
poisons  as  practically  to  place  them, 
in  our  reports,  in  an  equivocal  position, 
considered  as  deadly  agents.  The  in¬ 
convenience  which  the  present  com¬ 
munication  proposes  to  remove  in  a 
particular  case,  results  from  the  impos¬ 
sibility  of  subdividing  a  very  minute 
quantity  of  a  poisonous  substance,  so 
as  to  apportion  it  amongst  such  a  num¬ 
ber  of  reagents  as  shall  suffice  for  its 
unequivocal  detection,  without  obscur¬ 
ing  the  indications  of  some,  or  multiply¬ 
ing  those  of  others.  It  is  presumed 
that  most  practitioners  have  encoun¬ 
tered  this  difficulty  in  the  case  of  ar¬ 
senic — a  substance  which  so  frequently 
gives  rise  to  grave  and  intricate  medico¬ 
legal  inquiries.  The  number  of  re¬ 
agents  which  may  be  requisite  to  fur¬ 
nish  this  conjoint  evidence  for  the 
valid  discrimination  of  poison,  can  only 
be  indicated  by  reference  to  individual 
substances,  and  by  a  careful  considera¬ 
tion  of  the  chemical  habitudes  of  each. 
Even  in  special  cases  much  difference 
of  opinion  and  practice  prevails.  Thus, 
in  relation  to  arsenic,  it  has  been  the 
custom  to  attach,  as  I  conceive,  too 
exclusive  importance  to  reduction  and 


DETECTION  OF  ARSENIC  IN  MINUTE  QUANTITY. 


575 


oxidation,  in  comparative  neglect  of 
other  indications,  which,  when  pro¬ 
perly  associated,  are  equally,  if  not 
more,  distinctive,  and  which  I  propose 
to  show  may,  in  almost  all  cases,  be 
conjoined  with  the  former.  The  me¬ 
thod  of  reduction  devised  by  Reinsch, 
has,  in  the  case  of  complex  mixtures, 
from*  its  facility  and  delicacy,  super¬ 
seded  all  others,  with  the  exception  of 
that  of  Marsh.  The  deposition,  there¬ 
fore,  of  metallic  arsenic  upon  copper, 
may  be  taken  as  the  starting-point  in 
our  inquiry. 

I  deem  it  not  unimportant  to  notice 
that  I  have  sometimes  encountered 
deposits  on  copper  closely  simulating 
in  appearance  that  produced  by  ar¬ 
senic,  although  not  a  particle  of  arse- 
nious  acid  could  be  obtained  by  subli¬ 
mation,  nor  any  evidence  of  the  pre¬ 
sence  of  other  metallic  poison.  On  the 
other  hand,  the  usual  tin-grey  metallic 
appearance  of  arsenic,  (when  decisively 
precipitated  upon  copper)  is  often  re¬ 
placed  by  a  black-coating  quite  desti¬ 
tute  of  metallic  lustre. 

With  reference  to  the  sublimate,  after¬ 
wards  obtained  by  heating  the  copper 
foil,  I  have  to  observe,  that  when  its 
amount  is  very  minute,  although  its 
apparently  crystalline  character  can 
generally  be  recognised  by  a  lens,  or 
even  by  the  naked  eye,  the  precise 
figure  of  the  crystal  cannot  be  discerned 
with  sufficient  precision  without  the 
aid  of  a  microscope  of  ordinary  power. 
The  octohedra  are  then  observed  with 
admirable  definition,  either  perfect,  or 
more  frequently  variously  truncated  on 
their  terminal  and  base  angles,  and  in¬ 
termixed  with  a  few  tetrahedra. 

Crusts,  seemingly  crystalline  to  the 
lens,  are  occasionally  obtained  from 
well-dried  foil,  apparently  covered  with 
arsenic,  which  on  being  submitted  to 
the  microscope  prove  to  be  either  glo¬ 
bules  of  fluid,  or  crystals  not  having 
the  figure  of  arsenious  acid,  and  devoid 
also  of  its  chemical  properties.  The 
composition  of  the  latter  I  have  not  as 
yet  succeeded  in  determining.  The 
globules  of  fluid  are  probably  either 
water  derived  from  a  thin  film  of  orga- 
•  nic  matter,  which  adheres,  despite  of 
washing  and  drying,  to  the  copper  (es¬ 
pecially  in  operating  on  fluids  pre¬ 
viously  submitted  to  the  process  of 
carbonization  by  sulphuric  acid),  or 
hydrochloric  acid,  resulting  from  the 
partial  decomposition  of  the  sub¬ 


chloride  of  copper,  which  also  at¬ 
taches  to  the  foil,  and  of  which  a 
portion  sublimes  as  an  amorphous 
crust,  deposited  in  the  tube  beneath 
the  true  arsenical  one. 

I  am  satisfied  from  the  foregoing  con¬ 
siderations,  that  any  who  shall  feel  dis¬ 
posed  to  accept  as  evidence  of  arsenic 
a  well-marked  coating  of  the  copper, 
together  with  the  production  of  a  bril¬ 
liant,  crystallinedooking  sublimate, fall 
into  a  dangerous  error.  If,  however, 
the  crystalline  figures  above  stated  be 
observed  with  the  microscope,  they  are 
so  peculiar,  constant,  and  well-defined, 
as  of  themselves  to  furnish,  under  the 
circumstances  of  their  production,  a 
strong  presumption  of  the  presence  of 
arsenious  acid.  It  is  true  that  the  latter 
compound  is  dimorphous;  I  believe, 
notwithstanding,  that  it  is  never  ob¬ 
tained  as  a  sublimate  in  medico-legal 
researches,  in  any  but  the  octohedral 
form.  Thus  I  have  found  that  a  solu¬ 
tion  of  arsenite  of  ammonia  yields,  by 
spontaneous  evaporation,  silvery  crys¬ 
talline  scales  of  arsenious  acid,  ap¬ 
parently  similar  to  those  described  by 
Wohler  as  referable  to  the  rhombic 
system.  On  heating  these  they  sublime 
in  the  ordinary  form.* 

Few,  however,  who  are  conversant 
with  the  grave  responsibilities  of  public 
medicine,  will  be  content  with  obtain¬ 
ing  the  amount  of  evidence  already 
considered  :  and  hence  the  chemical 
properties  of  a  solution  of  the  subli¬ 
mate  are  generally  sought  to  be  scru¬ 
tinized;  but  in  many  cases,  from  its  very 
trivial  amount,  with  but  indifferent 
success.  Minute  quantities,  doubtless, 
when  dissolved,  will  furnish  an  indica¬ 
tion  by  the  use  of  a  single  test,  as  the 
ammonio-nitrate  of  silver,  or  sul¬ 
phuretted  hydrogen.  It  would  be, 
however,  much  more  satisfactory  to 
obtain,  if  possible,  the  conjoint  evidence 
of  all  the  fluid  tests.  The  necessity 
for  a  method  fulfilling  the  above  indi¬ 
cation  having  frequently  forced  itself 
upon  me  in  practice,  I  have  been  led  to 
propose  the  following  procedure,  by 
which  a  given  quantity  of  arsenious 
acid  may  be  transferred  undiminished 


*  It  is  known  tliat  arsenite  of  ammonia  cannot 
be  obtained  by  evaporating  its  solution  in  the 
ordinary  way  :  and  I  have  ascertained,  by  experi- 
|  ment,  that  the  above  crystals,  from  spontaneous 
I  evaporation,  are  destitute  of  ammonia,  and  have 
|  a  faint  acid  reaction  like  that  of  opaque  arsenic. 
The  transparent  acid  will  be  found  (as  stated  by 
Bussy)  at  once  to  redden  litmus. 


r.  ■  v/.  ....  r  ,  » 

576  MR.  KESTEVEN  ON  THE  SPECIFIC  GRAVITY  OF  THE  URINE. 


to  each  of  the  fluid  tests  in  succession. 
As  minute  precautions  in  manipulation 
vitally  affect  the  result,  it  may  be  pre¬ 
mised,  that  want  of  success  in  the 
application  of  the  fluid-tests  to  small 
sublimates,  sometimes  arises  from  not 
reducing  the  latter  to  powder  before 
attempting  their  solution.  The  subli¬ 
mate  being  carefully  detached  by  a 
glass  rod,  aided  by  a  fine  stream  of  dis¬ 
tilled  w’ater,  should  be  received  in  a 
small  porcelain  mortar,  and  carefully 
triturated.  The  solution  having  been 
effected  by  boiling,  should  (1)  be  pre¬ 
cipitated  wThen  cool,  by  ammonio- 
nitrate  of  silver.  The  yellow  arsenite 
obtained  is  to  be  next  decomposed  by 
a  slight  excess  of  pure  hydrochloric 
acid,  and  the  filtered  solution  treated 
(2)  by  a  current  of  sulphuretted  hydro¬ 
gen.  Having  ascertained  the  solubility 
of  the  resulting  sulphuret  in  ammonia, 
it  should  now  be  dissolved  in  nitro- 
muratic  acid,  and  evaporated  to  dryness 
(avoiding  excess  of  heat  at  the  close), 
redissolved  and  precipitated  (3)  by  ni¬ 
trate  (or  ammonio-nitrate)  of  silver, 
which  yields  the  brick-red  arseniate 
(4).  Finally,  the  latter  being  decom¬ 
posed  by  hydrochloric  acid,  in  mini¬ 
mum  quantity,  the  filtrate  should  be 
heated  with  a  few  drops  of  an  aqueous 
solution  of  sulphurous  acid,  the  excess 
of  the  latter  expelled,  and  hydrated 
oxide  of  copper,  with  ammonia,  in  mi¬ 
nute  quantity,  added.  We  can  thus 
elicit  the  reactions  of  the  four  fluid  tests 
from  a  quantity  of  arsenious  acid  which 
would  prove  refractory  by  the  common 
method  of  subdivision,  and  are  hence 
enabled  to  ensure  a  satisfactory  issue 
in  difficult  cases.  The  final  step  of  the 
operation  is  not  always  successful,  the 
ammonio  sulphate  of  copper  being,  even 
in  experiments  in  larger  quantities,  a 
much  less  delicate  test  than  those  pre¬ 
viously  named.  Having  obtained, 
however,  the  antecedent  results,  the 
evidence  of  the  presence  of  arsenic 
may  be  deemed  complete.  Modifica¬ 
tions  of  the  foregoing  method  will  at 
once  suggest  themselves,  and  may  be 
adopted  at  pleasure.  It  may  occur  to 
the  instructed  reader,  that  the  success 
of  the  copper  test  might  be  secured  by 
reprecipitation  and  sublimation  of  the 
arsenic  subsequent  to  the  formation  of 
arseniate  of  silver:  as,  howTever,  there  is 
reason  to  believe  that  no  inconsiderable 
portion  of  the  metal  is  often  retained 
by  the  copper  foil  as  an  arseniuret,  this 


procedure  cannot  be  recommended. 
Such  retention  indeed  constitutes  a 
reason  for  assigning  to  the  method  of 
Marsh  a  superior  delicacy,  although, 
in  a  practical  point  of  view,  that  of 
Reinsch  is  equal  to  all  the  emergencies 
of  medico-legal  experience. 


ON  THE 

SPECIFIC  GRAVITY  OF  THE 
URINE. 

By  W.  B.  Kesteven,  M.R.C.S. 


That  the  specific  gravity  of  the  urine 
serves  to  indicate  the  quantity  of  solid 
matters  eliminated  by  the*  kidnesy, 
and  that  deviations  from  the  average 
standard  of  the  specific  gravity  of  urine 
in  health  indicate  corresponding  de¬ 
viations  from  the  normal  amount  of 
waste  of  the  tissues  voided  by  the 
renal  excretion,  are  propositions  to 
which  even  those  who  have  given  but 
a  slight  degree  of  attention  to  the  phy¬ 
siology  and  pathology  of  the  urine  will 
yield  their  assent.  It  follows,  then,  that 
the  attainment  of  an  exact  average 
figure,  whereby  to  express  the  specific 
gravity  of  healthy  urine,  is  most  de¬ 
sirable  ;  else  we  cannot,  from  this 
property  of  the  urine,  derive  that  as¬ 
sistance  in  the  elucidation  or  detection 
of  disease  which  otherwise  it  is  capable 
of  affording. 

It  appears  to  the  writer  that  authors 
generally,  though  somewhat  indefinite 
in  their  statements  of  this  average,  in¬ 
cline  towards  too  high  a  figure ;  that 
the  specific  gravity  of  urine  in  disease 
has  been  assumed  as  the  standard  of 
that  excretion  in  health.*  Obviously, 
the  determination  of  this  point  is  of 
primary  importance;  since  there  is  no 
other  method  so  readily  available,  or  so 
sure,  w'hereby  to  estimate  the  quantity 
of  solid  urine  daily  evacuated,  the  only 
other  mode,  that  of  evaporation,  being 
inconvenient,  and  in  the  end  found  to 
be  less  correct. 

It  may  seem  presumption  in  an  ob¬ 
scure  individual  to  suppose  that  he  has 
arrived  at  certainty,  where  such  autho¬ 
rities  as  Prout,  Bright,  Muller,  Bird, 
Rees,  Day,  &c.  &c.  are  not  found  to 

*  The  Lectures  lately  delivered  before  the  Col¬ 
lege  of  Physicians,  by  Ur.  Golding  Bird,  establish 
the  necessity  of  an  accurate  average  sp.  gr.  for 
urine  ( vide  London  Medical  Gazette,  new 
series,  Nos.  160  to  172). 


* 

MR.  KESTEVEN  ON  THE  SPECIFIC  GRAVITY  OF  THE  URINE.  577 


be  agreed  ;  but  such  men  as  these  will 
be  the  last  to  judge  presumptuous  any 
effort  having  for  its  single  aim  the 
extension  of  our  knowledge  of  disease, 
or  its  means  of  alleviation. 

The  need  of  a  closer  approximation 
to  a  correct  average  will  be  at  once 
apparent  when  we  find  that  some 
authors  give  from  1* * * § *005  to  1-030,* 
while  others  give  from  1*016  to  1*020. 
Different  averages  are  given  by  Prout-j*, 
Simon|,  Muller,  Bird§,  Becquerel,  and 
doubtless  by  others. 

The  writer  has  for  some  time  past 
been  making  a  series  of  observations 
directed  to  the  attainment,  if  possible, 
of  a  more  definite  average.  The  re¬ 
sult  hq  has  arrived  at  is,  that  about 
1*016,  or  from  1*015  to  1*018,  will  be 
found  a  correct  representative  of  the 
specific  gravity  of  healthy  urine.  He 
may  observe,  that  these  figures  do  not 
differ  much  from  those  given  by  Bird 
and  Becquerel. 

That  the  average  which  is  most  fre¬ 
quently  assumed  is  too  high,  and  ap¬ 
proximates  nearer  to  disease  than 
health,  is  evidenced  by  the  recorded 
observations  of  the  specific  gravity  of 
urine  in  inflammatory  and  febrile  acute 
diseases,  where  the  solid  matters  ex¬ 
creted  in  the  urine  are  usually  greatly 
increased :  thus  we  shall  find  it  vary 
in  these  cases  from  1*020  to  1*035.|| 
Also,  in  certain  derangements  of  the 
digestive  organs  attended  with  copious 
depositions  of  uric  acid,  urates,  ammo- 
niacal  salts,  oxalates,  and  phosphates, 
it  ranges  from  1-020  to  1*030.  That 
the  specific  gravity  of  urine  in  disease 
seldom  exceeds  these  figures,  expe¬ 
rience  fully  confirms. 

It  is  only  necessary  to  allude  to  the 
various  circumstances  of  diet,  tempera¬ 
ture,  &c.  &c.,  which  influence  the 
specific  gravity  of  urine,  in  order  to 
state  that  it  is  indispensable  that  they 
be  carefully  estimated  in  our  calcula¬ 
tions  ;  and,  further  to  enforce  those 
cautious  modes  of  procedure,  in  ascer¬ 
taining  the  specific  gravity  of  urine  in 
disease,  which  are  so  fully  and  ably 
expounded  in  the  lectures  before  al¬ 
luded  to. 


*  Muller;  Baly’s  translation, 

t  Prout ;  Urinary  Diseases. 

$  Simon’s  Animal  Chemistry;  translated  by 
Day. 

§  Dr.  Golding-  Bird,  Urinary  Deposits. 

||  Simon,  Day’s  translation ;  Dr.  Bird,  Urinary 
Deposits. 


The  writer  may  be  perhaps  permitted 
to  point  out  one  or  two  conditions  of 
the  urine  in  disease  having  a  special 
and  direct  relation  to  the  matter  in 
hand,  and  which  will  illustrate  that 
need  of  a  correct  standard  which  he  is 
anxious  to  enforce.  A  constantly  low- 
specific  gravity,  with  a  constant  small¬ 
ness  of  quantity,  inevitably  indicates 
serious  deviation  from  health.  Unless, 
then*  we  have  arrived  at  a  correct, 
average,  how  can  we  ascertain  or 
affirm  the  existence  of  such  a  combina¬ 
tion  of  conditions,  yet  so  all  important 
to  be  known  if  it  exists,  and  as  soon  as 
it  exists  ?  If  our  average  for  health 
be  taken  at  too  high  a  number,  shall 
we  not  incur  the  risk  of  assuming  a 
danger  not  present  ?  On  the  other 
hand,  by  admitting  too  low  an  average, 
may  we  not  overlook  disease  until  it 
has  outstripped  us  in  its  course  ? 

The  morning  urine  of  health  has  a 
higher  specific  gravity  than  that  of  the 
evening ;  in  disease  the  reverse  holds. 
The  importance  then  of  not  forming 
an  opinion  from  the  specific  gravity  of 
a  single  specimen,  is  obvious ;  and,  at 
the  same  time,  it  is  equally  apparent 
that  herein  is  a  valuable  aid  to  the 
detection  of  obscure  disease. 

The  real  quantity  of  refuse  tissue 
daily  and  hourly  passing  off  by  the 
renal  excretion  is,  if  our  observations 
be  correct,  sure  to  be  quite  erroneously 
estimated  by  the  higher  average  of 
e.  g.  1*025;  for  assuming,  as  we  do, 
1*016  as  correct,  the  loss  by  oversight 
will  be  from  nine  to  ten  grains  solid 
matter  for  every  ounce  of  fluid  urine. 
The  consequences  resulting  from  such 
miscalculations  will  more  especially 
make  themselves  apparent  when  we 
reflect  on  the  operation  of  those  diure¬ 
tics  which  act  chemically  on  the  refuse 
tissues,  and  act  as  “renal  alteratives,”* 
contrasting  them  with  the  other  class, 
which  merely  dilute  the  secretion. 

The  writer  has,  in  the  preceding 
remarks,  made  it  his  endeavour  to 
shew  the  true  average  specific  gravity 
of  urine,  and  the  value  of  this  as  ail 
indication  of  disease  and  its  treatment. 
If  he  should  seem  merely  to  have  gone 
over  a  part  of  the  extensive  field  of 
urinary  pathology  in  the  footsteps  of 
one  who  has  so  plentifully  scattered 
around  him  the  fruits  of  its  scientific 
cultivation,  he  would  remark  that  the 


*  Lectures  by  Dr.  Bird. 


578 


MR  SIBSON  ON  THE  LOCAL  ACTION  OF  OPIUM. 


observations  which  he  now  submits  are 
addressed  to  one  point  only  of  that  rich 
district ;  and  that,  written  before  the 
perusal  of  Dr.  Bird’s  lectures,  they  have 
been  corrected  and  modified  thereby. 
In  conclusion,  he  will  rest  fully 
satisfied  if  they  shall  be  the  means  of 
directing  attention  in  any  degree  to 
those  lectures,  so  replete  with  scientific 
and  practical  knowledge. 

1,  Manor  Road,  Upper  Holloway, 

Sept.  18,  1848. 


ON  THE 

NARCOTIC  POISONS, 

PARTICULARLY  OPIUM,  AND  THEIR 
ANTIDOTES. 

Bv  Francis  Sibson. 


It  is  my  object  in  this,  and  the  follow¬ 
ing  papers  on  the  same  subject,  to  de- 
velope  the  results  of  an  inquiry  into  the 
therapeutics  of  poisoning  by  narcotics, 
and  more  particularly  by  opium.  That 
the  most  proper  means  of  treating  such 
cases  are  as  yet  either  not  agreed  upon, 
or  not  generally  known,  is  evidenced 
by  the  great  variety  of  practice,  and 
the  frequent  want  of  success  in  their 
treatment.  The  importance  of  the  in¬ 
quiry  is  shewn  by  the  very  great  num¬ 
ber  of  persons  that  annually  fall  vic¬ 
tims  to  poisoning  by  narcotics,  especially 
by  opium. 


In  the  years  1837-1S38  the  deaths  by 
poisoning  amounted  to  .  .  .  543 

Of  these,  the  total  number  poi¬ 
soned  by  opium,  laudanum, 
morphia,  and  opiate  cordials, 

were . 198 

A  number  greater  than  that  by 

arsenic . 185 

Poisoned  by  other  narcotics  .  .  44 

viz.,  by  Prussic  acid  ....  2 7 

Oil  of  bitter  almonds  ...  4 

Nux  vomica .  3 

Strychnia .  2 

Belladonna .  2 

Carburetted  hydrogen  ...  2 

Hemlock,  monkshood,  wolfs 
bane,  and  gin,  of  each 


1 


These  returns  (Medical  Gazette,  xxv. 
284,  and  Taylor  on  Poisons,  186)  show 
that  the  largest  proportion  of  cases  of 
poisoning  in  this  country  are  by  opium, 
exceeding  even  those  by  arsenic. 

There  can  be  no  doubt,  as  Mr.  Taylor 


remarks,  that  the  number  of  deaths 
from  poisons  which  annually  occur  ill 
England  and  Wales  are  much  greater 
than  this  table  represents. 

I  may  add,  that  this  remark,  appli¬ 
cable  to  all  of  kinds  poisoning,  is  espe¬ 
cially  applicable  to  poisoning  by  opium, 
that  drug  being  used  so  extensively  by 
the  ignorant,  and  acting  so  silently,  and 
with  so  many  of  the  appearances  of 
natural  death.  The  extent  to  which 
this  is  so,  may  be  surmised  from  the 
fact,  that  of  the  198  cases  poisoned  by 
opium,  106  were  either  from  overdose 
or  by  mistake ;  64  of  the  remainder 
being  suicidal,  and  in  3  only  was  it 
“  wilfully  administered.”  So  long  as 
thisis  the  only  country  in  Europe  where 
the  sale  of  poisons  is  indiscriminate,  we 
must  expect  that  the  number  of  persons 
poisoned  by  opium  will  be  immeasura¬ 
bly  greater  in  this  country  than  in  any 
other. 

Since  opium  is  the  preponderating 
cause  of  death  from  narcotic  poisoning 
in  this  country,  I  shall  devote  the  chief 
portion  of  these  papers  to  an  inquiry 
into  the  action  of  opium  as  a  poison, 
with  the  view'  of  ascertaining  the  best 
means  of  averting  its  poisonous  and 
fatal  effects. 

On  the  local  action  of  opium. 

Before  endeavouring  to  ascertain  the 
action  of  opium  on  the  complicated 
human  organism,  I  shall  inquire  into 
the  evidences  of  its  local  action  on  sepa¬ 
rate  portions  of  the  animal  organism. 

During  the  last  century,  especially 
towards  the  latter  part  of  it,  many  of 
the  great  physiologists  of  that  day 
busied  themselves  with  this  very  ques¬ 
tion,  of  the  local  action  of  opium  and 
other  agents.  Amongst  these  were 
Whytt,  Monro,  Fontana,  Alston,  Yalli, 
and  Humboldt. 

The  numerous  experiments  and  ob¬ 
servations  of  Humboldt  (Annals  of  Me¬ 
dicine,  iv.  223-271)  convinced  him  that 
opium,  like  other  stimuli,  exhausts  only 
in  consequence  of  excessive  excitation. 
He  exposed  muscle  shortly  after  its 
removal  from  the  living  frog  to  oxy- 
muriatic  acid :  the  effect  was  first  to 
stimulate,  and  then  to  exhaust  muscular 
contractility.  This  exhaustion  may 
be  removed,  he  found,  by  opium,  which 
re-excites  and  then  again  exhausts 
contractility. 

“  This  exhaustion  may  be  removed, 
(he  found)  by  oxymuriatic  acid  or  oxide 


% 


MR.  S1BS0N  ON  THE  LOCAL  ACTION  OF  OPIUM. 


579 


of  arsenic,  while  opium  also  is  capable 
of  removing  the  inexcitabilitv  produced 
by  them”  p.  272.  I  ought  to  state  that 
these  are  the  words  employed  in  the 
copious  abstract  of  Humboldt’s  work 
in  the  Annals — the  previous  details 
being  inferred,  rather  than  actually 
extracted,  from  the  statements  in  that 
abstract. 

From  the  observations,  then,  of 
Humboldt,  and  of  Michselis  quoted  by 
him,  we  may  infer  that  the  action  of 
opium  on  the  direct  application  of  it 
either  to  nervous  or  muscular  tissue,  is 
first  to  augment,  and  then  to  exhaust 
their  excitability. 

These  inferences  are  corroborated  by 
the  more  recent  experiments  of  Dr. 
Wilson  Philip  (on  the  Vital  Functions, 
133),  who  observed,  that  when  opium 
or  tobacco  are  applied  in  very  small 
quantity  to  a  muscle,  they  tend  to  ex¬ 
cite  muscular  action;  in  larger  quan¬ 
tity  they  immediately  destroy  the 
muscular  power.  They  produce  these 
effects  in  the  hollow  muscles,  as  the 
heart  and  the  intestines,  chiefly  when 
applied  to  their  internal  surfaces.  They 
produce  the  same  effect  when  applied 
locally  to  either  the  nervous  or  the 
sanguiferous  systems. 

In  all  these  cases  the  stimulant  effect 
of  the  opium  is  more  considerable  than 
that  of  the  tobacco,  and  the  sedative 
effect  of  the  latter  is  more  considerable 
than  that  of  the  former. 

These  observations  of  Dr.  Wilson 
Philip  differ  in  this  respect  from  those 
of  Humboldt,  that  while  the  latter 
noticed  that  opium  first  stimulates,  and 
then  exhausts  excitability,  the  former 
noticed  that  the  application  of  a  small 
quantity  of  the  poison  immediately  ex¬ 
cites,  whilst  that  of  a  large  quantity 
immediately  exhausts  excitability.  He 
does  not  state  that  the  opium  first 
excites  and  then  exhausts. 

Humboldt’s  and  Wilson  Philip’s  ex¬ 
periments  taken  together,  illustrate  the 
whole  question,  first  in  the  application 
of  a  small  quantity  or  dose— that  is,  in 
a  therapeutical  point  of  view — a  small 
dose  of  opium  being  a  true  stimulant, 
as  Sydenham  said,  almost  the  only  true 
stimulant ;  while  the  application  of  a 
large  quantity  or  dose  exhibits  the 
poisonous  action. 

Plumboldt’s  experiments  shew  that 
these  two  opposite  actions  are  not  really 
opposed  to,  but  are  dependent  upon, 
and  consecutive  to,  each  other ;  and 


that,  when  the  application  of  a  large 
quantity  of  opium  appeared  to  be  im¬ 
mediately  followed  by  exhaustion,  that 
exhaustion  was  in  reality  preceded  by 
the  excitation,  just  as  lightning  in  de¬ 
stroying  vital  contractility,  primarily 
and  violently  excites  it. 

Valli  (on  Animal  Electricity,  73)  was 
much  puzzled  on  finding  that  when  he 
applied  opium  to  the  isolated  tibial 
nerve  of  a  frog,  the  excitability  of  the 
muscles  of  the  leg  was  in  some  experi¬ 
ments  destroyed,  and  in  others  in¬ 
creased.  These  experiments  are  ex¬ 
plained  by  those  of  Humboldt  and 
Wilson  Philip.  The  cases  in  which 
excitability  was  increased  were  evi¬ 
dently  in  the  earlier  stages,  and  those 
in  which  it  was  destroyed  in  the  latter 
stages  of  the  action  of  opium. 

The  great  experimenters  before  alluded 
to,  afford  ample  and  interesting  illus¬ 
tration  of  the  local  effect  of  opium  in 
destroying  excitability. 

Whytt  immersed  the  heart,  still  pul¬ 
sating,  of  a  frog  in  water,  and  another 
pulsating  heart  in  a  watery  solution  of 
opium.  The  heart  in  the  watery  solu¬ 
tion  ceased  to  pulsate  before  the  heart 
in  water. 

In  ten  minutes  both  hearts  were 
taken  out :  they  were  then  motionless. 
That  which  had  been  in  the  watery 
solution  of  opium  could  not  be  stimu¬ 
lated  to  contract,  and  it  never  moved 
again  ;  that  which  had  been  in  water 
could  be  stimulated  to  contract — and  in 
a  few  minutes  it  of  itself  resumed  its 
pulsation.  (Physical  Essays,  vol.  ii). 

Monro  poured  ten  drops  of  a  watery 
solution  of  opium  underneath  the  skin 
among  the  muscles  of  the  left  thigh. 
After  ten  minutes  that  leg  seemed  to  be 
weaker,  and  in  ten  minutes  more  the 
muscleslost  their  power,  andthe  toes  had 
little  sensibility:  theanimalseemednow 
to  be  a  great  deal  stupified,  and  its 
heart  gave  now  onl  y  25  strokes  in  a 
minute.  An  hour  and  a  half  after  the 
beginning  of  the  experiment,  the  toes 
seemed  to  have  quite  lost  their  sensibi¬ 
lity,  and  the  muscles  their  motion; 
but  the  animal  jumped  by  the  help  of 
the  other  hind  extremity.  Two  days 
thereafter  this  leg  had  recovered  both 
its  sense  and  motion,  and  the  animal 
seemed  quite  well.  (Physical  Essays, 
xiv.  827.)  Fontana  says,  (on  Poisons, 
ii.  3G4)  “  I  plunged  half  the  body  of  a 
leech  into  a  watery  solution  of  opium, 
and  found  in  a  little  time  that  this  part 


580  MR.  SIBSON  ON  THE  EFFECT  OF  OPIUM  ON  THE  CIRCULATION. 


had  lost  all  motion,  whilst  the  other 
half  continued  in  action.  I  looked 
upon  it  as  something  very  extraordi¬ 
nary,  that  one  half  of  the  creature 
should  become  dead,  whilst  the  other 
half  continued  in  the  state  of  not  hav¬ 
ing  undergone  any  change  or  suffered 
any  injury.” 

The  interesting  experiments  detailed 
above,  prove  that  almost  every  and  any 
organ  of  the  body  may  be  affected  by 
the  local  action  of  opium ;  and  that 
the  organ  affected  by  it  has  its  excita¬ 
bility  first  increased,  and  then  ex¬ 
hausted. 

If  the  poison  be  applied  to  the 
voluntary  muscles,  or  to  the  heart  or 
intestines,  the  muscular  contractility 
is  first  excited,  and  then  exhausted. 
If  it  be  applied  to  the  individual  nerves, 
or  to  the  whole  limb,  sensation  and 
motion  are  first  excited,  and  then  para¬ 
lysed. 

There  is  now  no  occasion  to  bring 
forward  proof  that  the  narcotic  poisons 
as  well  as  all  other  soluble  substances, 
when  received  into  the  stomach  or  into 
the  rectum,  and  in  some  animals,  and 
with  some  agents  when  applied  to  the 
skin,  pass  into  the  circulation. 

As  the  opium  enters  the  blood  when 
it  acts  upon  the  system,  it  necessarily 
follows  that  the  opium  admitted  into 
the  circulation  is  carried  with  the 
blood  to  every  organ  and  portion  of  the 
frame.  Every  part  of  the  organism  is 
subjected  to  the  immediate  and  charac¬ 
teristic  influence  of  the  poison  ;  and  as 
Whytt  says,  opium  destroys  by  render¬ 
ing  the  several  organs  insensible  to  the 
stimuli  destined  by  nature  to  excite 
them. 

As  the  opium  when  admitted  into 
the  system  is  first  diffused  through 
and  applied  to  the  whole  circulating 
apparatus,  I  shall  first  inquire  into  the 
effect  of  opium  on  the  circulation  in 
the  capillaries,  arteries,  and  veins. 

The  effect  of  opium  on  the  circulation. 

Dr.  Allston,  that  he  might  observe 
the  effect  of  opium  on  the  circulation 
in  frogs,  performed  the  following  beau¬ 
tiful  experiments,  which  he  thus  de¬ 
tails  : — 

“  (a)  In  the  physic  garden  at  Holy- 
rood  House,  I  one  evening  put  a  strong 
big  paddock  into  a  pot  of  water, 
wherein  a  small  quantity  of  opium  was 
dissolved;  it  soon  appeared  to  be  un¬ 
easy,  by  making  strong  efforts  to  get 


out  of  it,  but  in  a  short  time  it  flagged 
or  grew  dull,  making  very  little  mo¬ 
tion,  and  next  morning  it  was  dead, 
and  much  swelled.”  This  experiment 
proves  that  opium  can  enter  the  circu¬ 
lation  through  the  integuments,  and  so 
destroy  life.  This  had  not  hitherto,  I 
believe,  been  demonstrated. 

“  O)  Assisted  by  Mr.  Robert  Fuller¬ 
ton,  a  curious  gentleman,  and  very 
dexterous  in  microscopical  observa¬ 
tion,  (in  August,  1733,)  I  conveyed 
through  a  small  glass  tube,  a  few  drops 
of  a  solution  of  opium  in  water  into  a 
frog’s  stomach,  and  putting  the  animal 
into  a  glass  cylinder,  adapted  it  so  to  a 
good  microscope  that  we  had  a  distinct 
view  of  a  part  of  the  membrane  be¬ 
twixt  the  toes  of  its  hinder  foot,  where 
the  circulation  of  the  blood  may  easily 
be  seen.  My  design  was,  since  I  found 
opium  killed  frogs,  to  observe  if  there 
was  any  visible  change  made  by  it  in 
the  blood  itself,  or  in  its  motion 
neither  of  us  could,  indeed,  see  any 
alteration  in  the  blood  as  to  its  consis¬ 
tence,  colour  of  the  serum,  magnitude, 
figure  or  colour  of  the  red  globules  ; 
but  we  very  distinctly  saw  a  surprising 
diminution  of  the  blood’s  velocity,  for  it 
did  not  move  half  so  swiftly  as  it  uses 
to  do  in  these  creatures.  We  alter¬ 
natively  looked  at  it  again  and  again,  and 
in  less  than  half  an  hour  saw  the  velo¬ 
city  of  the  blood  gradually  increase, 
the  uneasy  frog  recover  its  wonted 
vigour,  and  the  blood  its  common  cele¬ 
rity  ;  upon  which  we  took  out  the  pad- 
dock,  put  it  in  a  bason  of  clean  water, 
and  allowed  it  half  an  hour  to  refresh 
itself — then  gave  it  another  dose  of 
opium — fixed  it  to  the  microscope  with 
all  expedition — and  viewed  it  as  before. 
The  blood  then  moved  yet  slower  than 
it  did  the  first  time,  and,  its  velocity 
gradually  decreasing,  at  length  it  stag¬ 
nated,  first  in  the  smaller,  then  in  the 
larger  vessels,  and  in  about  a  quarter 
of  an  hour  the  animal  expired. 

“  One  thing  was  very  observable  all 
along — viz.  that  notwithstanding  the 
diminished  velocity  of  the  blood,  there 
was  no  sensible  diminution  of  the  fre¬ 
quency  of  the  pulse :  yea,  when  there 
was  no  circulation  or  progressive  mo¬ 
tion  of  the  blood  in  this  part,  the  pulse 
was  visible  by  an  undulatory  motion — 
that  is,  the  blood  returned  as  far  back 
at  every  diastole  of  the  heart  as  it  was 
protruded  by  the  preceding  systole : 
this  continued  till  the  frog  was  quite 


MR.  SIBSON  ON  THE  EFFECT  OF 


dead,  or  at  least  appeared  to  be  so. 
When  we  had  lost  all  hope  of  its  re¬ 
covery,  I  opened  it,  and  found  nothing 
in  its  stomach  but  a  clear  mucus  like  a 
jelly,  a  little  coloured  with  the  opium 
of  which  it  was  full :  everything  else 
seemed  perfectly  natural.  This  ex¬ 
periment  we  frequently  repeated,  and 
it  had  always  the  same  appearance  and 
event.  The  recovery,  however,  of  one 
of  the  frogs  which  for  a  considerable 
time  seemed  to  be  dead,  is  not  to  be 
omitted.  My  friend  and  I  one  evening 
killed  as  before,  a  couple  of  frogs  with 
opium:  one  of  them,  which  was  the 
strongest,  I  laid  half  in  water  on  a  tile 
in  the  bottom  of  the  water-pot,  that  if 
it  recovered  it  might  sit  either  wet  or 
dry  as  it  liked  best;  the  other  I  left  on 
the  earth,  dry,  under  a  hedge.  Next 
morning  when  1  returned  to  the 
garden,  1  found  the  one  under  the 
hedge  dead,  as  I  left  it ;  but  the  other  in 
the  water-pot  was  alive,  and  appeared 
to  be  in  perfect  health.”  (Medical 
Essays,  v.  130.) 

These  two  very  interesting  experi¬ 
ments,  which  for  their  real  illustrative 
value,  in  elucidating  the  action  of  opium 
on  the  system,  as  well  as  for  their  histo¬ 
rical  interest,  are  well  worth  repeating 
here,  I  combined  into  one  experi¬ 
ment,  which  1  devised  in  the  following 
manner.  The  experiment  is  easily 
performed  : — 

Experiment. — I  attached  a  frog  to 
Mr.Goadby’s  frog-holder, so  that  either 
web  could  be  placed  under  the  micro¬ 
scope.  I  plunged  the  left  leg  into  a 
test-tube  containing  a  watery  solution 
of  opium — the  right  leg  into  one  con¬ 
taining  water.  The  tubes  were  so  ar¬ 
ranged,  that  they  could  be  withdrawn, 
and  either  web  be  placed  under  the 
microscope  without  disturbing  the 
frog. 

Before  the  immersion  of  the  left  leg 
into  the  solution  of  opium,  the  circula¬ 
tion  was  very  rapid  :  the  corpuscles  in 
the  arteries  shot  past  so  rapidly  that 
they  could  scarcely  be  distinguished. 
Those  in  the  veins  and  the  large  capil¬ 
laries  moved  rapidly,  while  those  in 
the  small  capillaries  moved  slowly. 

After  the  left  leg  had  been  immersed 
in  the  solution  of  opium  for  ten 
minutes,  the  motion  of  the  blood  in  the 
smaller  capillaries  of  that  leg  was 
quickened,  and  the  blood  circulated 
through  many  capillaries  previously 
devoid  of  corpuscles.  The  movement  of 


OPIUM  ON  THE  CIRCULATION.  581 


the  blood  in  the  artery  and  vein  was 
less  rapid.  The  circulation  in  the 
right  leg  was  not  altered. 

After  a  further  immersion  of  ten  mi¬ 
nutes  the  circulation  in  the  left  leg  was 
further  modified,  that  in  the  right  leg 
being  not  perceptibly  changed. 

After  the  left  leg  had  been  replaced 
for  half  an  hour,  the  frog  was  again 
observed.  Whenever  the  skin  was 
touched,  either  on  the  left  or  right  leg, 
the  frog  cried  out  in  a  peculiar  manner, 
the  creature  being  universally  con¬ 
vulsed.  The  skin  was  touched  re¬ 
peatedly,  and  in  rapid  succession,  with 
the  effect  of  producing  convulsions, 
which  became  less  and  less  strong  each 
time  they  were  excited.  At  length  the 
convulsions  could  be  no  longer  excited 
by  touching  the  left  leg,  and  after  a 
time  they  ceased  also  to  be  excitable 
in  the  right  leg.  After  a  little  rest  the 
convulsions  could  again  be  excited. 

The  left  leg  was  swollen,  being  evi¬ 
dently  more  vascular  than  the  right. 

The  capillaries  in  the  left  leg  were 
now  much  enlarged,  several  corpuscles 
moving  slowly,  side  by  side,  through 
capillaries  that  were  previously  empty. 
The  blood  moved  much  more  slowly 
both  in  the  arteries  and  the  veins. 

The  circulation  in  the  right  leg  was 
now  very  perceptibly  modified,  and,  as 
nearly  as  it  could  be  observed,  to  the 
same  extent  as  that  in  the  left  leg  was 
affected  after  being  immersed  in  the 
solution  of  opium  for  ten  minutes. 

After  are-immersion  for  an  hour  and 
a  half,  quick  feeble  tetanic  spasms  of 
both  limbs  were  excited  by  the  slightest 
motion — by  walking  across  the  room, 
or  touching  the  microscope,  or  by 
touching  the  skin  of  either  leg.  These 
convulsions  ceased  when  the  legs  were 
touched  alternately  and  in  rapid  suc¬ 
cession  :  the  left  leg  first  lost  its  exci¬ 
tability,  and  then  the  right.  The 
convulsive  motions  were  the  least  in 
the  left  leg. 

It  was  found  during  the  last  obser¬ 
vation  that  the  animal  was  quite  un¬ 
conscious,  and  had  ceased  to  breathe. 

The  capillaries  were  now  very  much 
enlarged  in  the  left  leg,  being  greatly 
distended  and  almost  blocked  up  with 
the  accumulation  of  blood  corpuscles, 
the  motion  of  which  was  but  just  per¬ 
ceptible.  The  movement  of  the  blood 
in  the  arteries  and  veins  was  exceed¬ 
ingly  sluggish.  The  right  leg  was 
similarly  affected,  but  the  capillaries 


582  ANALOGIES  OF  THE  CHOLERA  OF  1830-31  AND  OF  1847-48 - 


were  not  so  much  distended,  and  the 
circulation  was  not  so  slow,  as  they 
were  in  the  left  leg. 

The  circulation  became  progressively 
slower,  and  convulsions  were  no  longer 
excitable.  About  four  hours  after  the 
first  immersion  in  opium  the  heart  was 
exposed,  pulsating  slowly,  emptying 
itself  on  each  contraction,  and  receiving 
and  sending  out  but  little  blood.  After 
the  heart  was  cut  out,  the  movement 
of  the  blood  in  both  webs  continued, 
though  it  was  very  sluggish,  and  in  the 
left  leg  was  only  observed  in  the  large 
artery  and  vein. 

In  the  next  paper  I  shall  remark  on 
these  experiments,  and  carry  on  a  far¬ 
ther  inquiry  into  this  subject. 


ADVANTAGES  AND  DISADVANTAGES  OF 
FEVER  HOSPITALS. 

It  is  pretty  clear  that  the  risk  of  contagion 
has  certain  limits,  varying  at  different  times  ; 
and  when  these  limits  are  passed,  as  con¬ 
stantly  happens  in  Fever  hospitals,  the  dis¬ 
ease  is  liable  to  spread.  Probably  if  the 
patients  of  a  Fever  hospital  could  be  kept  as 
widely  separated  as  are  the  fever  patients  in 
a  general  hospital,  the  disease  would  be  as 
little  liable  to  spread  amongst  them ;  and,  if 
the  attendants  had  absolutely  as  few  cases  of 
fever  to  look  after,  they  would  enjoy  an 
equal  immunity  from  its  contagion  with 
those  connected  with  a  general  hospital. 
Under  ordinary  circumstances,  there  would 
appear,  therefore,  to  be  no  particular  advan¬ 
tage  in  fever  hospitals  or  wards  arranged  on 
such  a  scale  as  to  prevent  all  chance  of  con¬ 
tagion,  since  it  would  be  better  to  fill  up  the 
intervals  which  must  be  preserved  between 
fever  patients,  if  it  is  safe  so  to  do,  with 
patients  suffering  from  other  diseases,  than 
to  let  them  remain  empty.  But  on  a  sud¬ 
den  outbreak  of  fever,  especially  in  a  sea¬ 
port  liable  to  a  large  influx  of  strangers, 
their  utility  with  all  their  danger  is  very 
great.  Fever  may  be  stopped  at  once  in  a 
locality  by  transferring  all  the  sick  to  the 
wards  of  a  hospital ;  for,  much  as  it  may 
spread  within  the  walls,  it  never  passes 
them,  as  it  does  among  the  habitations  of 
the  poor ;  and  the  existence  of  an  institu¬ 
tion  exclusively  devoted  to  the  reception  of 
this  class  of  cases,  prevents  the  wards  of  a 
general  hospital  from  being,  on  such  an 
outbreak,  converted  spontaneously,  by  con¬ 
tagion,  into  fever  wards. —  OrmerocVs  Clini¬ 
cal  Observations  on  Fever . 


MEDICAL  GAZETTE. 


FRIDAY,  OCTOBER  6,  1848. 

One  of  the  most  remarkable  facts  con¬ 
nected  with  the  Asiatic  Cholera  is, 
that,  in  its  present  progress  throughout 
Europe,  it  should  follow  so  nearly  the 
course  which  it  took  in  1830-1.  The 
researches  of  Dr.  Lasegue  have  shown 
that  this  analogy  not  only  exists  in 
respect  to  the  time  at  which  the  places 
are  visited,  but  in  respect  to  the  dura¬ 
tion  of  the  disease  at  each  place.*  The 
cholera  appeared  at  Tiflis  on  the  5th 
May,  1830;  at  Astrachan  on  the  21st 
June;  and,  ascending  the  Volga,  it 
reached  the  Russian  province  of  Kasan 
on  the  17th  of  September  in  the  same 
year.  In  1847  the  cholera  made 
its  appearance  at  Tiflis  on  the  1st  June ; 
at  Astrachan  on  the  31  st  July;  and 
reached  Kasan  on  the  4th  October. 
In  1830,  as  in  1847,  it  took  five  months 
to  traverse  the  same  district. 

In  1830,  taking  the  course  of  the 
Dnieper,  it  reached  Stavropol  on  the 
6th  September  ;  Novo  Tscherkosk  on 
the  1 0th ;  Taganrog  on  the  8th  October, 
and  Kiev  on  the  8th  January,  1831. 
In  1847,  the  cholera  broke  out  at 
Stavropol  on  the  16th  July;  at  Novo 
Tscherkosk  on  the  30th;  at  Taganrog 
on  the  15th  August;  and  at  Kiev  on 
the  5th  October.  Although,  as  a 
general  rule,  those  districts,  towns, 
and  cities  which  were  visited  in  1830, 
have  been  attacked  by  the  disease  on 
the  present  occasion,  Dr.  Lasegue 
has  pointed  out  one  very  remarkable 
exception.  In  1830-1,  the  disease 
spread  through  the  provinces  on  the 
western  frontiers  of  Russia ;  but  in 
1847,  from  some  singular  and  un¬ 
explained  cause,  these  provinces  have 


*  L'  TJnion  Medicate ,  Sept.  1848. 


PROGRESS  AND  MORTALITY. 


583 


escaped ;  and  to  this  may  be  perhaps 
ascribed  our  immunity  from  the  disease 
np  to  the  present  time. 

The  ravages  of  the  disease  were  sus¬ 
pended  in  the  winter  of  1830,  as  well 
as  in  that  of  1847.  In  both  instances 
Moscow  formed  the  extreme  western 
limit  of  the  pestilence;  and  in  the 
spring  of  1831,  as  well  as  in  that  of 
1848,  the  disease  resumed  its  course. 
It  appeared  in  St.  Petersburg!!  on  the 
25th  June,  1831,  and  it  broke  out  in 
this  city,  and  spread  through  it  with 
fearful  rapidity,  on  the  16th  June, 
1848.  It  attacked  Berlin  on  the  31st 
August,  1831,  and  on  the  15th  August, 
1848.  It  is  well  known  that  the  dis¬ 
ease  first  appeared  in  England,  at 
Sunderland,  on  the  26th  October,  1831 ; 
and  it  will  be  a  remarkable  confirma¬ 
tion  of  the  analogies  hitherto  observed 
in  its  progress  on  the  Continent,  if  the 
rumour  that  it  has  now  appeared  in 
one  of  our  seaports  on  the  north¬ 
eastern  coast  should  prove  to  be  well 
founded.*  If  we  are  to  be  guided  by 
this  analogy,  the  cholera  may  not  ap¬ 
pear  in  the  metropolis  until  the  ensuing 
winter.  The  first  cases  were  announced 
in  London  on  the  13th  February,  1832, 
and  they  occurred  in  the  immediate 
vicinity  of  the  docks.  The  disease  ap¬ 
peared  in  Paris  in  the  spring  of  1832, 
and  that  city,  therefore,  may  escape 
the  visitation  until  the  spring  of  1849. 
From  the  singular  analogies  already 
established,  it  can  hardly  be  expected 
that  either  England  or  France  should 
escape  the  disease  on  the  present  occa¬ 
sion  ;  and  it  is  therefore  satisfactory  to 
know  that  every  precaution  which 
reason  can  suggest  has  been  adopted 
by  our  Government,  in  order  to  miti¬ 
gate  what  appears  to  be  an  inevitable 
calamity. 

It  is  worthy  of  remark  that  in  1830-1 , 
as  in  1847-8,  the  cholera  has  manifested 


*  See  page  598. 


itself  chiefly  in  the  great  lines  of  inter¬ 
course  along  frequented  roads,  and  the 
banks  of  navigable  rivers,  attacking 
chiefly  towns  and  cities  where  the 
population  was  most  dense,  producing 
the  largest  amount  of  mortality  in  its 
first  onset,  then  slowly  diminishing  in 
severity,  and  finally  disappearing  to 
reappear  in  a  neighbouring  locality. 
According  to  Dr.  Lasegue,  the  greatest 
rapidity  with  which  the  cholera  has 
spread  over  any  locality  has  not  ex¬ 
ceeded  a  rate  of  from  250  to  300  miles 
a  month.  This  comparatively  slow 
progress,  together  with  its  advance  in 
the  face  of  prevailing  winds,  is  very 
unlike  the  usual  mode  of  diffusion  of  a 
purely  epidemic  disease’. 

It  was  confidently  announced  a  year 
since,  that  the  cholera,  as  it  then  pre¬ 
vailed  on  the  Continent,  had  lost  much 
of  its  severity,  and  was  far  less  mortal 
than  the  disease  of  1830-1.  This  state¬ 
ment,  however,  is  contrary  to  fact.  In 
comparing  its  fatality  in  the  countries 
to  which  its  ravages  have  been  hitherto 
confined,  the  deaths  are,  even  compara¬ 
tively  speaking,  more  numerous  than 
on  the  former  visitation.  In  the  Russian 
empire  alone,  between  the  months  of 
April  and  August  1848,  no  less  than 
505,328  persons  were  attacked  with 
cholera,  and  of  these  210,836  died — a 
mortality  of  more  than  forty  per  cento 
The  tables  published  by  the  Sanitary 
Board  of  St.  Petersburg!!,  shew  that  in 
estimating  the  mortality  produced  by 
the  disease,  in  fourteen  of  the  principal 
cities  of  the  empire,  it  appears,  that  in 
1847,  of  21,295  attacked,  11,361  died; 
and  in  1830-1,  of  15,559  attacked,  9,018 
died.  The  proportion  of  those  attacked 
to  the  total  population,  was  about  the 
same.  Thus,  in  the  Russian  empire, 
the  proportion  of  deaths  to  the  attacks 
was — 

In  1830-1  In  1847 

1  to  1*7  1  to  1*8 


584  ANALOGIES  OF  THE  CHOLERA  OF  1830-31  AND  OF  1847-48 


and  the  proportion  of  those  attacked  to 
the  total  population  was — 

In  1830-1  In  1847 

1  to  196  inhabitants  1  to  19'7  ditto. 
Even  in  Berlin,  where  it  was  alleged 
that  the  cholera  had  appeared  in  a 
much  milder  form,  in  the  present  in¬ 
vasion,  we  find  that  from  the  15th 
August  to  the  1st  of  September,  the 
attacks  were  3 77,  and  the  deaths  235 — 
or  no  less  than  64  per  cent!  This 
great  mortality  may  be  ascribed  to  the 
severely  epidemic  form  in  which  the 
disease  has  prevailed  in  that  city. 

Experience  has  added  one  fact  of 
importance  in  a  prophylactic  view  to 
our  knowledge  of  this  terrible  pesti¬ 
lence.  As  a  general  rule,  the  Russian 
practitioners  have  observed,  that  the 
suddeyitiess  of  an  attack  of  cholera  is 
apparent,  and  not  real — it  is  in  its 
severe  form,  the  secondary  and  intrac¬ 
table  stage  of  a  disease  which,  at  its 
commencement,  is  comparatively  mild 
and  tractable ;  and  which,  if  taken 
in  time,  may  be  without  difficulty 
arrested  by  simple  remedies.  Their 
experience  has  led  them  to  the  con¬ 
clusion,  that  diarrhoea  is  a  precur¬ 
sory  symptom  of  an  attack  of  Asiatic 
cholera;  and  that  this  diarrhoea  may 
or  may  not  be  attended  with  pain 
in  the  abdomen.  There  is  very  fre¬ 
quently  an  entire  absence  of  pain — a 
circumstance  which  leads  to  the  neglect 
of  means  for  remedying  what  appears  to 
be  a  temporary  disorder,  but  which  may 
turn  out  to  be  the  forerunner  of  the 
fatal  malady.  In  the  diarrhoea  pre¬ 
ceding  cholera,  when  pain  has  been 
noticed,  it  has  been  simple  uneasiness, 
with  a  sense  of  contraction  in  the 
bowels.  The  number  of  evacuations 
may  be  from  one  to  six  or  more  daily  : 
they  retain  in  this  stage  their  fsecal 
colour  and  odour,  and  are  in  this  re¬ 
spect  very  different  from  those  alvine 
discharges,  which  occur  in  the  more 
advanced  stage  of  the  disorder;  for 


these  have  no  feecal  odour  or  colour, 
and  resemble  rice-water.  This  simple 
diarrhoea  may,  therefore,  be  considered 
to  be  the  commencement  of  an  attack 
of  Asiatic  cholera,  this  name  being  ap¬ 
plied  only  to  the  last  stage  of  the  dis¬ 
ease. 

The  diarrhceal  stage  may  last  only  a 
few  hours, — two  or  three  days,  or  even 
longer.  If  properly  treated,  the  second 
stage  may  be  entirely  averted — if 
neglected,  this  will  commence  suddenly 
and  violently  with  those  severe  symp¬ 
toms  which  are  commonly  the  precur¬ 
sors  of  death.  The  suddenness  of  an 
attack  of  cholera  is,  therefore,  only  ap¬ 
parent, — when  inquiry  has  been  made, 
the  milder  stage,  although  in  some  in¬ 
stances  of  very  short  duration,  had 
really  existed,  but  was  overlooked. 
These  views  of  the  Russian  physicians 
are  strongly  confirmed  by  the  observa¬ 
tions  made  by  Dr.  Monneret,  the 
French  Medical  Commissioner  at  Con¬ 
stantinople  and  Trebizond.  We  can¬ 
not  now  enter  into  the  question, 
whether  cholera  does  or  does  not  in 
some  instances  destroy  life  without 
a  diarrhoeal  stage.  This  is  quite 
foreign  to  our  object,  which  is  that  of 
endeavouring  to  find  out  some  warning 
symptom  of  the  disease,  so  that  the 
person  attacked  may  be  placed  on  his 
guard,  and  induced  to  seek  medical  ad¬ 
vice  without  loss  of  time.  Let  us  admit, 
for  the  sake  of  argument,  that  from 
100  cases  diarrhoea  may  not  appear 
in  14  :  our  remarks  are  directed  to 
the  86  who  suffer  from  this  very  com¬ 
mon  premonitory  symptom. 

It  follows,  from  the  preceding  ob¬ 
servations,  that  when  cholera  is  preva¬ 
lent  in  a  locality,  the  slightest  distur¬ 
bance  of  the  bowels  requires  attention. 
Considering  the  possible  risk  incurred 
by  neglect,  the  fact  that  there  is  only 
one  evacuation  more  than  common,  or 
that  the  evacuation  is  more  liquid  than 
natural,  should  receive  immediate  no- 


STATE  OF  HEALTH  OF  THE  METROPOLIS. 


585 


tice.  If  the  diarrhoea  really  depend  on 
other  causes,  and  not  on  cholera,  no 
mischief  will  follow  from  its  arrest  by 
medicine  ; — if,  however,  it  depend  on 
the  cholera-poison  beginning  already 
to  operate  on  the  body — then,  by  re¬ 
sorting  to  treatment,  a  life  may  be 
saved.  It  must  be  remembered  that 
we  have  no  means  of  determining  a 
priori  on  what  the  diarrhoea  depends  ; 
and,  contrary  to  popular  belief,  it  ap¬ 
pears  that  the  diarrhoea  of  cholera  is 
really  of  a  more  mild  description  than 
that  which  arises  from  any  local  cause 
of  irritation  in  the  bowels. 

It  is  satisfactory  to  know  that  the 
instructions  issued  by  our  Government 
are  based  on  these  views  ;  and  there  is 
no  one,  however  destitute,  who  may 
not  procure  the  means  of  averting  from 
himself  the  attack  of  a  dire  pestilence. 
If  any  reasoning  be  required  to  compel 
persons  to  adopt  these  measures  of 
common  prudence,  it  will  surely  be 
enough  to  say,  that  when  the  cholera 
has  reached  its  second  stage  art  is 
powerless  before  it.  All  kinds  of  treat¬ 
ment  have  failed  to  diminish  the  num¬ 
ber  of  deaths;  and  the  recoveries  in  this 
stage  are  probably  more  to  be  ascribed 
to  the  innate  energies  of  the  constitution 
— to  the  vis  vita  in  combating  the  poison 
— than  to  any  of  the  supposed  remedial 
measures  adopted.  In  the  treatment 
of  the  premonitory  diarrhoea,  aroma¬ 
tics,  astringents,  and  opiates  combined, 
have  been  found  the  most  efficacious. 
The  compound  Chalk  powder  wTith 
opium®  will  probably  be  the  most  use¬ 
ful  and  popular  remedy.  We  think, 
however,  that  opiate  medicines  of  what¬ 
ever  kind  should  not  be  prescribed  ex¬ 
cept  by  medical  men.  Age  and  other 
circumstances  require  especial  consi¬ 
deration  in  regulating  the  dose  of  any 
medicine  containing  opium.  Besides 
this  treatment,  the  individual  should 
avoid  in  his  diet  all  vegetables  and  li¬ 
quids  which  have  a  tendency  to  produce 


irritation  of  the  bowels  :  he  should  be 
warmly  clad,  and  should  not  be  allowed 
to  expose  himself  to  wet  or  damp. 

On  the  whole,  there  can  be  no  doubt 
that  we  are  better  prepared  to  encounter 
this  malady  at  the  present  time  than 
in  1830-1  ;  and  as  we  were  then  spared 
more  than  other  nations,  we  may  hope 
that,  should  the  disease  appear  among 
us,  it  will  not  turn  out  to  be  so  for¬ 
midable  in  its  reality,  as  the  anticipa¬ 
tions  of  the  public  have  led  them  to 
expect.  It  is  highly  improbable  that 
it  will  destroy  more  lives  than  the  in¬ 
fluenza  of  last  winter,  although  this 
disease  spread  in  its  destructive  course 
without  exciting  the  notice  or  the  fears 
of  the  public. 


The  deaths  registered  during  the  last 
week  (Sept.  30)  are  greatly  above  the 
weekly  average ;  but  this  is  only  an 
apparent  excess.  The  Registrar-Gene¬ 
ral  informs  us  in  a  note,  that  an  un¬ 
usually  large  number  of  inquests,  the 
accumulation  of  former  weeks,  have 
been  included  in  this  number.  Scarlet 
fever  is  still  very  prevalent  and  fatal, 
the  deaths  having  been  154  to  a  weekly 
average  of  37.  On  the  other  hand,  it 
is  highly  satisfactory  to  find  that  the 
deaths  from  diarrhoea  and  cholera  are 
much  below  the  average  of  the  season* 
There  were  44  fatal  cases  of  Diarrhoea , 
including  28  among  infants,  to  a  weekly 
summer  average  of  66  ;  and  of  Cholera, 
there  were  only  4  cases,  including  2 
among  infants,  to  a  weekly  summer 
average  of  7. 


OBITUARY. 

On  Wednesday,  the  27th  ult.,  at  Chiches¬ 
ter,  Mr.  Edward  Miller,  surgeon,  late  of 
Shanklin,  Isle  of  Wight,  in  the  28th  year  of 
his  age. 

On  the  16th  ult.,  at  Beckenham,  Mr. 
William  Merrick,  surgeon,  aged  49. 


586  DR.  TODDS  CYCLOPAEDIA  OF  ANATOMY  AND  PHYSIOLOGY. 


licinefosk 


The  Cy  elopes  dia  of  Anatomy  and  Phy¬ 
siology.  Part  XXXII.  Edited  by 

Robert  B.  Todd,  M.D. 

The  circumstances  which  fortunately 
led  to  the  authorship,  by  Dr.  Johnson, 
of  the  article  “Ren,”  are  detailed  in 
the  following  note. 

“  In  explanation  of  the  use  of  the  Latin 
word  ren,  as  the  heading  of  this  article,  the 
editor  deems  it  necessary  to  state  that  the 
article  was  undertaken  some  years  ago  by  a 
gentleman  who  failed  to  complete  his  en¬ 
gagement  in  time  for  its  publication  under 
the  title  kidney  ;  it  was  found  necessary, 
consequently,  to  postpone  the  subject, 
and  to  adopt  the  present  title.  The  article 
was  subsequently  committed  to  other  hands, 
in  which  it  shared  a  similar  fate  to  that  which 
it  experienced  at  first,  and  it  ultimately  fell 
into  the  hands  of  its  present  able  author. — 
Ed.”  (p.  231.) 

This  article  is  not  only  interesting 
to  the  physiologist  as  a  description  of 
the  exquisite  structure  of  the  kidney, 
but  it  is  also  of  practical  value  to  the 
medical  man,  in  that  it  clearly  connects 
the  healthy  structure  of  that  organ 
with  the  chain  of  morbid  alterations 
from  that  structure,  conveying  at  the 
same  time  the  signs  by  which  the 
diseases  of  the  kidney  may  be  recog¬ 
nised  during  life. 

The  invaluable  researches  of  Mr. 
Bowman  into  the  structure  of  the  Mal¬ 
pighian  bodies,  necessarily  form  the 
most  important  feature  in  the  physiolo¬ 
gical  part  of  this  article,  which  is,  in¬ 
deed,  written  by  a  member  of  the  same 
brilliant  school  in  which  Mr.  Bowman 
is  so  distinguished. 

From  Mr.  Bowman’s  researches 
(Phil.  Trans.  1842),  it  appears  that  the 
urinary  tubes,  in  their  straight  course 
from  their  open  extremities  through 
the  medullary  tissue  towards  their  op¬ 
posite  termination,  divide,  but  do  not 
reunite ;  and  after  making  numerous 
convolutions  in  the  cortical  tissue,  each 
tube  terminates,  not  in  a  mere  blind 
extremity,  but  in  a  flask-like  dilatation. 
This  globular  expansion  of  the  end  of 
the  urinary  tube  is  the  capsule  of  the 
Malpighian  body.  The  Malpighian 
capsule,  and  the  wall  of  the  urinary 
tube  with  which  it  is  continuous,  are 
the  same  in  structure,  each  being  com¬ 


posed  of  the  same  basement  membrane  j 
but  while  the  tubes  are  lined  with  glo¬ 
bular,  nucleated,  secreting  epithelium, 
containing  small  globules  of  fat,  the 
Malpighian  capsule  is  only  lined  here 
and  there  by  a  remarkably  transparent 
epithelial  cell,  not  manifestly  nucleated. 
One  of  the  most  interesting  discoveries 
of  Mr.  Bowman  is  the  existence  of 
vibratile  cilia  in  the  neck  of  the  cap¬ 
sule.  These  cilia  do  not  extend  over 
the  inner  lining  of  the  capsule,  but 
they  line  the  inner  walls  of  the  tubes 
in  reptiles,  and  probably  in  mammalia. 
The  cilia  have  a  lashing  motion,  and 
they  propel  the  fluid  from  the  interior 
of  the  capsule  into  and  along  the  tubes. 

Each  Malpighian  capsule  is  perfo¬ 
rated  by  an  artery,  which,  dilating 
suddenly,  breaks  up  into  diverging 
tortuous  branches,  forming  a  vascular 
tuft.  The  walls  of  the  vessels  of  the 
tuft  are  peculiar  for  their  thinness : 
they  readily  yield,  being  easily  rup¬ 
tured,  after  death  by  injection,  or  dur¬ 
ing  life  by  any  unusual  acceleration  or 
impediment  in  the  local  circulation. 
The  capillary  branches  reunite  into  a 
single  small  vein,  which  emerges,  per¬ 
forating  the  capsule,  where  the  artery 
enters.  This  vein  Mr.  Bowman  calls 
a  portal  vein,  as  it,  after  leaving  the 
Malpighian  body,  again  branches  out, 
forming  a  fine  capillary  plexus  round 
the  convoluted  urinary  tubes. 

Dr.  Gerlach  has  demonstrated  that 
small  nucleated  cells  stud  the  Mal¬ 
pighian  vascular  tufts,  and  he  consi¬ 
ders  the  Malpighian  capsule  to  be,  not 
a  blind  termination,  but  a  lateral  diver¬ 
ticulum  of  the  uriniferous  tube.  Mr. 
Toynbee,  in  his  valuable  paper  on  the 
Intimate  Structure  of  the  Kidney, 
holds  that  the  urinary  tube  penetrates 
the  Malpighian  capsule,  forms  in  it  a 
convoluted  course  in  contact  with  the 
vascular  tufts,  and  then  emerges.  Dr. 
Johnson  rejects  these  view's  for  that  of 
Mr.  Bow’man,  who  demonstrates  that 
the  tube  arises  from  the  capsule  pretty 
much  as  the  urethra  does  from  the 
bladder. 

Professor  Muller  has  acknowledged 
and  confirmed  the  accuracy  of  Mr. 
Bow'man’s  observations.  Professor 
Muller’s  own  description  of  the  simple 
kidney  of  the  myxinoid  fishes — in 
which  a  large  capsule,  containing  a 
tuft  of  vessels,  terminates  in  a  small 
urinary  tube — confirms,  by  analogy, 
the  accuracy  of  Mr.  Bowman’s  view. 


DR.  TODD’S  CYCLOPAEDIA  OF  ANATOMY  AND  PHYSIOLOGY.  587 


Mr.  Bowman  considers,  with  reason, 
that  it  is  the  function  of  the  tubes  to 
secrete,  by  means  of  its  secreting  epi¬ 
thelium,  the  characteristic  principles 
of  the  urine,  while  it  is  that  of  the 
Malpighian  tufts  to  eliminate  from 
the  blood  the  purely  watery  portion. 

The  knowledge  of  the  epithelial  cells, 
interesting  physiologically,  is  impor¬ 
tant  pathologically.  The  secreting 
epithelial  cells  in  the  convoluted  por¬ 
tion  of  the  urinary  tube  are  spherical, 
have  a  distinct  nucleus,  and  usually 
contain  very  minute  globules  of  oil. 
The  epithelium  lining  the  straight 
tubes  of  the  pyramids  differs  essentially 
from  that  in  the  convoluted  tubes ; — 
while  the  latter  is  the  spheroidal  or 
glandular,  the  former  is  the  lamellar 
or  scaly  variety  of  epithelium. 

Diseases  of  the  Kidney. 

That  portion  of  this  article  devoted 
to  the  diseases  of  the  kidney  is  of  very 
great  value:  it  is  an  additional  evi¬ 
dence  of  the  distinguished  success  with 
which  Dr.  Johnson  has  investigated 
those  diseases. 

The  most  important  diagnostic  indi¬ 
cation  of  the  diseases  of  the  kidney  is 
supplied  by  observing  the  nature  of 
the  organic  urinary  sediments.  These 
sediments  consist  of  epithelial  cells 
and  blood-corpuscles,  and  of  cylindrical 
moulds  or  casts.  These  fibrinous 
moulds,  first  described  by  Franz  Simon, 
have  been  cast  off  from  the  urinary 
tubes.  The  tubes  have  been  blocked 
up  by  various  materials,  which,  being 
thrown  off,  are  found  in  the  urine, 
accurate  casts  of  the  blocked-up  tubes. 

The  component  parts  of  these  casts 
of  the  tubes  differ  in,  and  characterize 
different  diseases. 

In  haemorrhage  from  the  kidneys, 
fibrinous  moulds  of  the  tubes,  in  which 
are  entangled  blood-corpuscles,  but  no 
epithelial  cells,  are  found  in  the  urinary 
sediment,  along  with  free  blood-cor¬ 
puscles.  In  such  cases  the  Mal¬ 
pighian  capsules  and  the  tubes  are  dis¬ 
tended  with  blood.  Heemorrhage  from 
the  kidney  may  thus  be  distinguished 
from  heeraorrhage  from  the  bladder. 

In  acute  suppurative  nephritis,  the 
moulds  from  the  tubes  entangle  pus- 
globules,  which  are  also  found  float¬ 
ing  tree  in  the  urine.  In  cases  of  this 
class,  abscesses  are  scattered  through 
the  kidney. 

In  acute  desquamative  nephritis, 


which  occurs  very  frequently  in  scar¬ 
latina,  the  cylindrical  fibrinous  moulds 
of  the  tubes  entangle  both  blood-cor¬ 
puscles  and  epithelial  cells,  which  are 
also  found  floating  free  in  the  urinary- 
sediment.  In  such  cases  the  kidneys 
are  enlarged,  apparently  by  the  deposit 
of  a  granular  material  in  the  cortical 
structure,  and  the  tubes  are  filled  with 
nucleated  cells,  differing  in  no  essen¬ 
tial  character  from  those  lining  the 
tubes  in  health :  the  Malpighian  bodies 
are  usually  transparent  and  healthy. 
The  abnormal  products  in  the  blood 
are  in  these  cases  eliminated  by  an 
excessive  development  of  epithelial 
cells,  which  are  thrown  into  the  tubes 
and  washed  out  with  the  urine.  The 
desquamation  from  the  inner  surface 
of  the  tubes  is  analogous  to  that  which 
occurs  on  the  skin  subsequent  to  the 
eruption  of  scarlatina. 

In  chronic  desquamative  nephritis — 
essentially  of  the  same  nature  as  the 
acute  form,  its  frequent  cause  being 
the  gouty  diathesis — the  casts  of  the 
tubes  consist  of  fibrine  entangling  epi¬ 
thelial  cells,  like  those  in  the  acute 
variety,  but  not  usually  blood-cor¬ 
puscles.  In  these  cases  the  tubes  are 
filled  and  rendered  opaque  by  an  accu¬ 
mulation  of  epithelial  cells  :  their  walls 
are  no  longer  lined  by  normal  epithe¬ 
lial  cells ;  their  basement  membrane 
being  in  some  cases  entirely  denuded  ; 
in  others,  lined  by  small,  delicate,  trans¬ 
parent,  nucleated  cells. 

After  the  tubes  have  lost  their  nor¬ 
mal  epithelial  lining  (which  they  pro¬ 
bably  never  recover),  they  may  undergo 
one  of  three  changes  : — 

1st.  The  tubes  may  be  filled  with  a 
whitish  glistening  material ; 

2d.  They  may  become  atrophied ; 

3d.  They  may  be  dilated  in  the  in¬ 
tervals  of  the  fibrous  matrix  in  which 
they  are  imbedded.  These  dilated  tubes 
form  the  serous  cysts  so  often  seen  in 
the  cortical  tissue.  M.  Simon  has 
erroneously  conjectured  that  these 
cysts  are  greatly  -  dilated  epithelial 
cells. 

In  fatty  degeneration  of  the  kidney , 
the  fibrinous  moulds  of  the  urinary 
tubes  entangle  epithelial  cells  more  or 
less  distended  with  oil :  they  frequently 
also  entangle  blood-corpuscles.  The 
cells  and  blood-corpuscles  are  also 
found  free  in  the  urine,  which  s  more 
or  less  albuminous.  In  cases  of  this 
class  the  kidney  is  usually  enlarged, 


588  DR.  todd’s  cyclopaedia  of  anatomy  and  physiology. 


and  its  cortical  portion  is  soft  and 
pale,  and  interspersed  with  numerous 
small,  yellow,  opaque  specks.  The 
convoluted  tubes  are  usually  filled  in 
different  degrees  with  epithelial  cells 
distended  with  oil;  some  being  quite 
free,  while  others  are  ruptured  by  the 
great  accumulation.  The  yellow  specks 
are  composed  of  the  distended,  some¬ 
times  ruptured,  tubes. 

In  another  and  simpler  form  of  fatty 
degeneration  of  the  kidney,  which 
may  be  brought  on  in  animals  by  con¬ 
fining  them  in  a  dark  room,  all  the 
tubes  become  almost  uniformly  dis¬ 
tended  with  oil. 

Fatty  degeneration  of  the  kidney  is 
very  commonly  associated  with  fatty 
degeneration  of  the  liver : — 

“  The  three  forms  of  disease  just  alluded 
to — viz.  acute  and  chronic  desquamative 
nephritis,  and  fatty  degeneration  of  the 
kidney — include  the  greater  number  of  those 
cases  to  which  the  term  ‘  Bright’s  disease’ 
is  commonly  applied. 

u  In  a  paper  published  two  years  since, 
I  maintained  that  the  term  ‘  Bright’s  dis¬ 
ease’  should  be  confined  to  those  cases  in 
which  there  is  fatty  degeneration  of  the 
kidney  ;  but,  after  a  further  consideration 
of  the  subject,  I  am  of  opinion  that,  if  the 
expression  *  Bright’s  disease’  is  retained,  it 
should  be  used  only  as  a  generic  term  to 
include  several  diseases,  the  existence  and 
importance  of  which  were  first  made  known 
by  Dr.  Bright.  In  order  to  convey  a  pre¬ 
cise  idea  of  the  particular  form  of  Bright’s 
disease  alluded  to,  it  is  clearly  necessary  to 
use  some  terms  having  a  more  definite 
meaning,  and  I  have  suggested  some  which 
appear  sufficiently  expressive  for  the  pur¬ 
pose.”  (p.  263). 

For  the  figures  of  the  moulds  of  the 
urinary  tubes  in  the  urinary  sediment, 
which  characterize  during  life  the 
various  renal  diseases,  and  for  the  de¬ 
tailed  account  of  those  diseases,  we 
have  much  pleasure  in  referring  to  the 
very  valuable,  and,  in  part,  original 
article  of  Dr.  Johnson,  which  he  con¬ 
cludes  with  the  following  remarks  : — 

“  In  concluding  the  brief  sketch  of  the 
pathology  of  the  kidney,  I  will  venture  to 
predict  that,  within  a  very  short  space  of 
time,  the  diseases  of  the  kidney  will  be  more 
completely  and  generally  understood,  with 
reference  to  their  pathology,  diagnosis,  and 
treatment,  than  those  of  any  other  organ. 
There  are  two  circumstances  which  justify 
such  an  anticipation  : — 1st,  there  is  perhaps 
no  important  organ  in  the  body  whose  mi¬ 


nute  structure  has  been  so  completely  and 
so  clearly  demonstrated  as  that  of  the  kidney 
has  been  by  Mr.  Bowman;  and,  2d,  the 
morbid  deposits  or  accumulations  to  which 
the  kidney  is  liable,  occur,  almost  without 
exception,  in  such  a  situation,  within  the 
uriniferous  tubes,  that  portions  of  these 
materials  are  being  continually  washed  out 
by  the  stream  of  liquid  which  is  poured 
into  the  extremities  of  the  tubes,  and  so 
they  come  within  the  sphere  of  our  daily 
observation:  thus  affording  the  pathologist 
and  the  practitioner  an  opportunity  of  ascer¬ 
taining  the  nature  and  tracing  the  progress 
of  disease  which  is  not  presented  in  the  case 
of  any  other  internal  organ.”  (p.  264). 

Professor  Rymer  Jones  furnishes  a 
very  elaborate  descriptive  article  on 
Reptiles,  which  is  of  great  length,  occu¬ 
pying  60  pages,  and  is  very  richly 
illustrated,  containing  no  fewer  than 
70  engravings.  The  whole  article  is 
of  great  interest,  especially  to  the  com¬ 
parative  anatomist ;  but,  from  the  na¬ 
ture  of  its  subject,  it  does  not  admit  of 
analysis. 

The  article  by  Dr.  John  Reid,  on 
Respiration,  which  is  not  completed  in 
this  number,  will,  we  think,  prove  to  be 
one  of  the  most  important  communica¬ 
tions  to  this  very  valuable  Cyclopeedia. 
It  is  distinguished  by  profound  research. 
By  a  strict  induction,  all  the  truths 
worked  out  by  the  various  and  succes¬ 
sive  inquirers,  down  to  the  most  recent, 
are  so  brought  together,  that  we  have 
in  this  article  a  complete  view  of  the 
accumulation  of  facts  in  each  depart¬ 
ment  of  the  subject.  We  shall  re¬ 
serve  our  notice  of  this  article  for  the 
present. 


Handbuch  der  allgemeinen  und  speciel- 
len  Gewebelehre  des  menschlichen 
K'orpers,  fiir  Aertze  und  Studirende . 
By  Dr.  J.  Gerlach.  Maintz,  1843. 

This  is  the  first  of  three  parts  of  a 
handbook'  on  the  general  and  special 
anatomy  of  the  human  body.  As  spe¬ 
cified  in  the  preface,  it  is  designed  to 
afford  to  the  student  a  clear  and  com¬ 
prehensive  account  of  the  minute 
structure  of  the  several  animal  tissues, 
and  to  the  practitioner  who  may  be  de¬ 
sirous  of  informing  himself  on  this  sub¬ 
ject,  a  work  embodying  the  most  recent 
facts  and  descriptions  relating  to  it.  Dr. 
Gerlach  seems  to  be  well  qualified  to 
undertake,  and  bring  to  a  satisfactory 
completion,  a  task  of  this  kind.  His 


CASE  OF  ALLEGED  POISONING  BY  EXTRACT  OF  BELLADONNA.  589 


name  is  familiarto  us,  particularly  from 
an  excellent  description  of  the  minute 
anatomy  of  the  kidney,  which  appeared 
in  Muller’s  Archiv  about  three  years 
ago.  From  that  description  w7e  ex¬ 
tracted*  at  some  length  the  account  of 
his  method  of  injecting  the  urinary  tu¬ 
bules,  by  mixing  the  fluids  of  double 
injections,  and  not  injecting  them  se¬ 
parately.  That  plan  seems  to  have 
been  very  successfully  used  by  him  in 
the  examination  of  other  tissues  besides 
those  of  the  kidney ;  and  he  states 
that  in  the  succeeding  parts  of  the  pre¬ 
sent  work  will  be  given  many  impor¬ 
tant  results  obtained  by  means  of  it. 

The  handbook  is  divided  into  two 
principal  portions— the  first  relating  to 
the  general,  the  second  to  the  special, 
anatomy  of  the  tissues.  The  first  divi¬ 
sion  is  principally  occupied  with  an 
account  of  cells  and  of  their  various 
modifications,  as  corpuscles  of  blood, 
lymph  and  chyle,  and  cells  of  pigment, 
epithelium,  and  fat.  The  full  descrip¬ 
tion  of  these,  which  are  rightly  in¬ 
cluded  among  tissues,  is  followed  by 
an  account  of  fibro-cellular  and  elas¬ 
tic  tissues,  as  the  best  examples  of 
elementary  structures.  The  develop¬ 
ment  of  fibro-cellular  tissue  from  cells 
is,  by  Dr.  Gerlach,  limited  to  that 
which,  with  Henle,  he  calls  the  form¬ 
less  variety  of  the  tissue  ;  namely,  the 
ordinary  cellular  tissue.  The  develop¬ 
ment  of  that  variety  of  which  fibrous 
membranes  and  tendons  are  construct¬ 
ed  he  believes,  with  others  before  him, 
to  be  effected  by  the  agency  of  nuclei 
scattered  in  the  midst  of  a  textureless 
blastema.  The  nuclei  irrange  them¬ 
selves  in  rows,  corresponding  with 
which  the  blastema  breaks  up  into  rib¬ 
bon-like  strips,  and  each  of  them  again 
splits  up  into  a  multitude  of  fibrils, 
whence  results  a  fasciculus  of  fibro- 
cellular  tissue. 

The  second  division  of  the  work  is 
occupied  with  an  account  of  the  com¬ 
pound  tissues,  and  includes,  as  far  as 
the  present  published  part  extends,  the 
two  kinds  of  muscles,  cartilage,  bone, 
and  tooth  ;  the  microscopic  structure  of 
each  of  which  is  well  described.  As 
one  among  other  good  points  in  the 
work,  we  may  mention  that  after  the 
consideration  of  each  tissue  a  few  hints 
are  given  as  to  the  best  modes  of  pre¬ 
paring  it  for  microscopic  examination. 


We  cannot  praise  the  few  illustrations 
scattered  through  the  work,  for  they  are 
neither  artistically  good,  nor  sufficiently 
accurate  to  render  them  useful.  They 
might,  indeed,  with  some  few  excep¬ 
tions,  be  omitted  with  advantage,  for 
the  accompanying  text  is  usually  co¬ 
pious  and  clear.  We  do  not  doubt  the 
wTork  will  be  well  received  by  the 
members  of  the  profession  in  Ger¬ 
many,  though,  like  their  English 
brethren,  they  would  doubtless  be 
better  pleased  to  receive  a  whole  than 
half  a  work,  especially  when  that  half 
stops  in  the  middle  of  a  sentence,  as 
Dr.  Gerlach’s  does.  As  far  as  our  ex¬ 
perience  extends,  we  do  not  think  that 
the  several  portions  of  a  piece-meal 
work  follow  each  other  with  greater 
rapidity  and  punctuality  on  the  conti¬ 
nent  than  in  this  country :  and  as  hu¬ 
man  nature  is  the  same  all  over  the 
world,  Dr.  Gerlach  would  probably 
have  secured  more  customers  and  read¬ 
ers  of  his  work  by  delaying  its  publi¬ 
cation  until  the  whole  was  finished, 
instead  of  issuing  but  a  third  of  it  at 
once. 


#Vbtcal  trials  ant)  Tnqucstg. 


CASE  OF  ALLEGED  POISONING  BY  EXTRACT 
OF  BELLADONNA.  WAS  DEATH  PRO¬ 
DUCED  BY  POISON,  OR  WAS  IT  THE  RE¬ 
SULT  OF  DISEASE  ?  CONFLICTING  MEDI¬ 
CAL  EVIDENCE. 

[The  following  case  is  of  great  profes¬ 
sional  interest.  There  can  be  no  doubt 
that  the  porter  who  gave  out  extract  of 
belladonna  with  merely  verbal  instruc¬ 
tions ,  was  guilty  of  gross,  not  to  say  crimi¬ 
nal,  neglect,  especially  as  he  admitted  that 
he  knew  it  to  be  poisonous.  The  prin¬ 
cipal  question  at  the  inquest  was — Did  the 
deceased  die  from  the  effects  of  belladonna, 
or  from  natural  causes  ?  In  reference  to 
this  question  a  great  difference  of  opinion 
arose  among  the  medical  witnesses.  Taking 
the  whole  of  the  facts  as  stated  at  the  in¬ 
quest,  we  are  inclined  to  think  that  death 
from  the  action  of  belladonna  was  not 
proved ,  and  that  the  verdict  of  the  jury  was 
correct.  The  reasons  assigned  by  Mr.  Law 
against  death  from  belladonna  are  forcible. 
It  is  not  enough  in  these  cases,  that  death 


*  Medical  Gazette,  vol.  xxxvii.  p.  8. 


590  CASE  OF  ALLEGED  POISONING  BY  EXTRACT  OF  BELLADONNA. 


from  poison  should  be  rendered  probable.  It 
must  be  made  absolutely,  undeniably,  and 
unequivocally  certain ,  or  no  verdict  to  in¬ 
culpate  another  can  be  returned.] 

An  inquest  was  held  at  the  Town  Hall, 
Sheffield,  on  Thursday,  July  6th,  on  the 
body  of  Thomas  Greaves,  alleged  to  have 
died  from  the  effects  of  an  overdose  of  ex¬ 
tract  of  belladonna,  taken  by  mistake. 

Hannah  Greaves,  widow  of  the  deceased, 
examined. — I  live  in  Love-lane,  Sheffield. 
My  husband  was  76  years  of  age,  and  for¬ 
merly  a  silversmith.  He  was  lately  in  the 
habit  of  assisting  Mr.  Butterworth,  a  pub¬ 
lican,  in  Fargate.  He  was  an  out-patient  of 
the  Sheffield  Infirmary,  and  had  been  there 
twice.  He  went  there  on  Tuesday  last,  the 
4th  of  July,  about  nine  o’clock,  and  returned 
home  about  eleven  in  the  forenoon.  He 
brought  from  the  Infirmary  a  box  of  pills, 
some  ointment  in  a  box,  and  a  plaster.  The 
ointment  was  of  a  black  colour.  He  would 
not  take  any  of  the  stuff  till  Mrs.  Taylor 
came.  She  came  about  from  five  to  six  in 
the  evening.  I  saw  him  take  a  pill  out  of 
the  box,  and  a  small  portion  of  black  stuff  out 
of  a  box.  He  took  it  with  his  own  fingers, 
and  said  he  was  to  take  it,  but  there  were  no 
directions.  There  wras  no  reading  or  direc¬ 
tion  on  the  pill-box  or  the  ointment-box. 
He  went  to  bed  about  seven  o’clock.  Before 
he  went  to  bed  he  seemed  dilatory  about  un¬ 
dressing  himself,  and  his  speech  was  gone. 
He  took  his  breath  very  hardly,  and  rattled, 
and  got  worse  and  worse  all  the  night  until 
the  morning.  We  never  had  our  clothes  off 
during  the  night.  He  complained  all  night 
of  inflammation  of  his  breast,  and  that  he 
could  not  get  his  breath  well.  He  died  next 
day  at  eleven  o’clock  in  the  forenoon.  He 
never  spoke  to  me  all  the  night.  Just  before 
he  died  he  began  to  vomit,  and  asked  my 
daughter  for  me.  I  asked  him  if  he  wanted 
anything,  and  he  said  no.  He  was  convulsed 
all  night.  Mrs.  Taylor  put  the  plaster  on. 

I  think  the  stuff  my  husband  took  vras 
not  so  big  as  a  pill.  I  cannot  say  whether 
he  used  a  spoon  or  a  knife  on  that  occasion. 
He  could  read  a  little.  Neither  of  my 
daughters  saw  him  take  the  physic. 

Martha  Taylor,  midwife,  wife  of  James 
Taylor,  of  Love-lane,  shoemaker,  examined. 
— The  deceased  went  to  the  Infirmary  on 
Tuesday  morning  last.  He  brought  from 
thence  a  plaster  for  his  stomach,  some  pills, 
and  an  electuary.  He  had  had  a  strengthen¬ 
ing  plaster  on  before,  and  he  was  to  bathe  it 
with  warm  water,  then  take  it  off,  and  put 
the  other  in  its  place.  This  was  the  one  he 
brought  that  morning  from  the  Infirmary. 

I  saw  both  the  boxes.  There  was  no  label 
nor  direction  on  them  how  to  take  them. 
He  had  his  printed  Infirmary  paper  with 


him,  and  another  with  a  prescription  on. 
He  asked  me  how  many  of  the  pills  he  should 
take,  and  I  told  him  to  take  only  one  of 
them.  He  did  so,  and  afterwards  took  a 
little  bit  of  the  black  stuff  out  of  the  other 
box.  He  got  it  out  of  the  box  with  the  end 
of  a  teaspoon  ;  it  was  only  a  little  bit.  This 
was  between  five  and  six  in  the  evening. 
About  nine  o’clock,  I  went  into  the  house, 
and  saw  him  sat  on  the  bedside  trembling.  He 
could  not  speak.  I  saw  him  three  or  four 
times  between  six  and  nine  o’clock.  He 
was  then  in  bed,  and  appeared  to  be  asleep, 
and  to  take  his  breath  very  thick.  I  did  not 
see  him  again  after  nine  o’clock.  I  did  not 
observe  before  I  left  him  that  he  was  con¬ 
vulsed.  Fie  lay  very  still  when  I  saw  him, 
but  he  moaned  very  much  when  sat  on  the 
bedside  about  nine  o’clock.  I  don’t  think 
he  was  then  sensible.  Fie  told  me  that  he 
was  to  take  the  pills  in  the  black  stuff  or 
“  electuary,”  as  he  called  it.  I  am  sure  he 
called  it  “  electuary.” 

Eliza  Greaves,  widow  of  William  Greaves, 
and  daughter  of  the  deceased,  examined. — 

I  live  in  Eyre  Lane.  I  went  on  Tuesday 
night  last,  about  seven,  to  my  father’s 
house,  and  found  him  sitting  on  the  bedside. 

I  asked  him  how  he  was,  but  he  could  not 
speak.  I  asked  my  mother  why  my  father 
did  not  get  into  bed,  as  he  was  a  long  time 
undressed,  and  she  said,  “  Tommy,  get  into 
bed  ;  thou’ll  get  cold.’’  I  again  asked  him 
how  he  was,  when  he  tried  to  speak,  but  he 
shook  his  hands  about  and  could  not  utter  a 
word.  He  kept  knocking  his  hands  and 
feet  about.  I  left  at  half-past  nine,  and  re¬ 
turned  about  ten,  when  he  was  very  hot,  and 
his  face  seemed  red  and  swollen.  He  con¬ 
tinued  knocking  his  hands  about,  but  kept 
his  feet  stiller.  I  left  him  at  half-past 
twelve,  when  he  was  insensible.  I  returned 
to  the  house  at  nine  next  morning,  when, 
thinking  he  was  much  worse,  I  fetched  Mr. 
Pearson,  surgeon,  of  Bank  Street,  and  then 
went  home.  I  did  not  see  him  take  any  of 
the  stuff.  I  asked  my  mother  what  had 
made  him  so  ill,  and  she  said  he  had  taken 
a  pill  and  some  ointment,  which  Mrs.  Taylor 
had  given  him.  His  sight  was  very  bad.  I 
saw  Mrs.  Taylor  give  my  father,  about  half¬ 
past  seven,  about  an  ounce  of  castor  oil, 
which  Mrs.  Taylor  said  would  perhaps  send 
the  stuff  he  had  taken  through  him.  Mrs. 
Taylor  gave  him  the  pill  and  the  ointment  (?), 
and  he  took  it. 

William  Hudson,  porter  to  the  Sheffield 
General  Infirmary,  was  then  called.  Being 
duly  cautioned  by  the  Coroner  that  he  need 
not  say  anything  to  criminate  himself,  the 
witness  made  the  following  statement : — I 
have  been  porter  to  the  Sheffield  General 
Infirmary  ten  years  and  a  half.  I  gave 
Thomas  Greaves  his  medicine  on  Tuesday 
morning  last.  I  gave  him  a  plaster,  and  a 


CASE  OF  ALLEGED  POISONING  BY  EXTRACT  OF  BELLADONNA.  591 


box  of  belladonna.  I  gave  him  direc¬ 
tions  how  to  use  the  plaster — to  spread 
what  was  in  the  box  on  the  plaster, 
and  apply  it  to  the  part  affected.  I  was 
very  particular  in  giving  him  directions,  as 
he  was  an  old  man.  I  told  him  the  direc¬ 
tions  twice  over,  and  said,  “Do  you  pro¬ 
perly  understand  what  you  have  to  do  with 
what  is  in  the  box  ?”  He  replied  that  he 
perfectly  understood  it.  I  also  gave  him  a  box 
of  pills,  with  the  direction  on  the  box,  to 
take  two  pills  three  times  a  day.  There  was 
a  label  on  the  box  of  pills  when  I  gave  it  to 
him,  although  there  is  none  on  now.  I 
do  not  know  the  quantity  of  belladonna 
that  I  put  into  the  box.  The  reason  why 
I  did  not  spread  the  belladonna  on 
the  plaster  was,  that,  as  he  was  an  old 
man,  I  thought  he  had  better  spread  it  him¬ 
self  when  he  got  home.  The  plaster  would 
not  have  been  of  any  use  to  him  if  it  had 
been  spread  at  the  Infirmary,  as  he  would 
have  squeezed  it  together.  I  gave  no  written 
or  'printed  directions  on  the  box  of  the 
belladonna,  as  to  its  use,  because  I  had  told 
him  it  was  to  be  put  on  the  plaster,  and  he 
knew  perfectly  well  what  it  was  for.  He 
had  not  used  it  before.  I  know  that  bella¬ 
donna  is,  to  a  certain  extent ,  of  a  poisonous 
nature.  Mr.  Oakes,  an  assistant,  was  in 
the  Infirmary  surgery  when  I  gave  Greaves 
the  stuff.  Mr.  Oakes  and  I  had  to  deliver 
medicines  to  about  900  patients  that  morn¬ 
ing.  We  have  never  had  a  direction  for  the 
use  of  belladonna  as  a  plaster ;  when  used 
in  any  other  way  there  is  a  direction.  Mr. 
Law  has  always  said  to  me,  “  Send  out  a 
proper  direction  with  everything. ”  We 
never  did  give  any  other  than  a  verbal  direc¬ 
tion  with  belladonna  as  a  plaster.  It  was 
not  from  inattention  to  my  duties,  or  idle¬ 
ness,  that  I  did  not  spread  the  belladonna, 
but  from  regard  to  the  welfare  of  the  old 
man.  We  have  never  had  a  mistake  with 
belladonna  before,  and  it  has  been  sent  out 
in  this  way  for  ten  years.  I  think  it  was 
not  my  duty  to  spread  the  belladonna  on 
the  plaster,  but  to  send  it  out  as  we  had 
done  before.  I  know  that  belladonna  is  an 
expensive  article,  and  I  think  there  was  not 
more  in  the  box  than  was  necessary  for  the 
plaster.  I  am  very  sorry  that  the  circum¬ 
stance  has  occurred,  but  I  will  take  care 
for  the  future  that  belladonna  is  not  sent 
out  in  that  way  again.  We  have  no  labels 
marked  “poison.” 

The  Coroner — You  ought  to  have. 

Witness — When  we  have  anything  of 
poison,  we  write  a  label. 

The  Coroner — That  is  not  proper.  Did 
you  write  one  on  this  box  ? 

Witness — No. 

The  Coroner — You  ought  to  have  printed 
labels. 

By  a  Juryman — There  was  no  mention  of 


an  electuary,  nor  did  I  call  the  box  of  bella¬ 
donna  an  electuary.  Had  it  been  an  elec¬ 
tuary,  I  should  have  put  it  in  a  pot,  and  not 
in  a  box. 

Nathaniel  Pearson,  surgeon,  examined. — 
I  was  called  in  on  Wednesday  morning  at 
half-past  nine  to  attend  the  deceased.  I 
found  him  in  a  dying  state,  gasping  for 
breath  ;  and,  as  I  considered  him  past 
the  aid  of  remedies,  I  did  not  admi¬ 
nister  anything  to  him.  I  left  him  about 
ten,  and  he  died  in  about  an  hour  after.  I 
have  since,  assisted  by  Mr.  Wm.  Jackson, 
made  a  post-mortem  examination  of  the  body 
of  the  deceased.  Externally,  the  body  pre¬ 
sented  a  somewhat  emaciated  appearance, 
and  there  were  no  marks  of  violence.  The 
vessels  and  membranes  of  the  brain  were 
highly  injected,  and  the  larger  vessels  dis¬ 
tended  with  dark-coloured  blood.  The 
cavities  of.  the  brain  were  also  distended 
with  serous  fluid,  and  the  substance  of  the 
brain  itself  was  softer  than  natural.  The 
spinal  canal  was  distended  with  a  similar 
fluid,  and  its  vessels  highly  injected.  The 
stomach  appeared  in  a  natural  state,  both 
externally  and  internally,  except  at  the 
upper  part  of  the  larger  curvature  internally, 
where  the  mucous  membrane  presented  a 
blackened  appearance,  of  the  size  of  the 
palm  of  the  hand,  indicating  a  state  of  in¬ 
cipient  mortification  of  the  part.  The  ab¬ 
dominal  viscera  otherwise  presented  no  un¬ 
healthy  appeai’ance.  The  heart  was  quite 
natural  in  appearance ;  the  lungs  in  an  un¬ 
collapsed  state,  and  much  darker  in  appear¬ 
ance  than  natural :  they  were  filled  with  air, 
arising  from  an  obstructed  condition  of  the 
respiratory  organs.  The  bladder  and  the 
intestines  were  perfectly  healthy.  •  I  ascribe 
the  death  of  the  deceased  to  the  effects  of  a 
narcotic  poison.  Belladonna  would  produce 
precisely  the  appearances  which  we  found  in 
the  organic  structures  after  death.  I  should 
say  the  quantity  alleged  to  be  taken,  as  on 
the  paper  produced,  contained  four  grains. 
Belladonna  is  so  seldom  given  internally, 
that  it  is  difficult  to  state  the  smallest 
amount  that  would  produce  death.  I  think 
that  five  grains,  under  the  circumstances  of 
the  advanced  age  of  the  deceased,  and  the 
disordered  state  of  the  chest,  would  produce 
death.  The  pupils  of  the  eye  of  the  deceased 
were  considerably  dilated.  I  do  think, 
without  doubt,  that,  in  this  instance,  bella¬ 
donna  has  been  the  cause  of  death.  Taking 
the  state  of  his  health,  before  he  took  the 
dose,  into  consideration,  and  comparing  that 
state  with  the  symptoms  after  taking  the 
dose,  and  further  observing  the  evidences  of 
disease  after  death,  I  am  quite  convinced 
death  was  produced  from  narcotic  poison, 
and  no  other  cause.  Mr.  Jackson  fully 
concurred  with  me  in  opinion  as  to  the  cause 
of  death.  The  box  contained  five  drachms 


592  CASE  OF  ALLEGED  POISONING  BY  EXTRACT  OF  BELLADONNA. 


of  the  extract  of  belladonna ,  which  was 
more  than  was  necessary  for  the  plaster  pro¬ 
duced.  Belladonna  is  a  medicine  very  un¬ 
certain  in  its  operation. 

At  the  request  of  the  Coroner,  the  inquest 
was  then  adjourned  to  Wednesday,  July 
12th.  The  following  additional  evidence 
was  then  given  : — 

Mr.  William  Jackson,  surgeon,  Sheffield. 
— I  did  not  know  Thomas  Greaves,  the  de¬ 
ceased.  On  Thursday,  the  6th  instant,  I 
assisted  Mr.  Pearson  in  making  a  post¬ 
mortem  examination  of  the  body  of  a  man 
in  Love  Lane,  who  appeared  to  be  upwards 
of  78  years  of  age.  [The  witness  corrobo¬ 
rated  the  evidence  given  on  the  first  inquiry 
by  Mr.  Pearson,  as  to  the  appearances  of 
the  body  when  so  examined.]  I  have  no 
doubt  but  that  the  congested  state  of  the 
brain,  and  the  effusion  of  fluid  in  the  cavi¬ 
ties  of  the  brain  at  its  base,  as  well  as  in  the 
spinal  canal,  produced  the  death  of  the  de¬ 
ceased.  The  appearances  might  arise  from 
the  excessive  use  of  spirituous  liquors  ;  the 
action  of  a  narcotic  poison ;  or  it  may  have 
arisen  from  the  peculiar  state  of  the  brain 
arising  from  natural  causes.  If  I  am  to 
take  for  granted  the  evidence  given  by  Mr. 
Pearson  as  to  the  symptoms  previous  to 
death,  and  the  statement  he  has  given  on 
oath,  I  should  say  death  arose  from  a  nar¬ 
cotic  poison.  Connecting  that  statement  with 
the  appearances  we  found  after  death,  we  are 
justified  in  stating  that  deceased  died  from 
a  narcotic  poison,  but  I  cannot  swear  it  was 
belladonna.  If  I  had  not  been  made  ac¬ 
quainted  with  the  symptoms  during  life,  I 
should  not  have  been  able  to  state  positively 
the  precise  cause  of  the  death  of  the  de¬ 
ceased.  The  effects  of  belladonna  are  pretty 
certain  if  it  be  pure,  but  they  may  be  modi¬ 
fied  by  peculiarity  of  the  constitution  of 
the  person  who  takes  it.  I  never  saw  a 
fatal  case  before  of  poisoning  by  bella¬ 
donna,  if  this  is  to  be  considered  one.  I 
cannot  undertake  to  say  what  would  be  the 
minimum  dose  that  would  produce  death. 
I  have  given  belladonna  extensively  in  prac¬ 
tice,  but  I  do  not  remember  a  case  in  which 
I  could  safely  give  more  than  two  grains. 
I  think  if  I  had  seen  the  patient  an  hour 
before  he  died,  I  should  have  made  an  at¬ 
tempt  to  relieve  his  stomach  of  the  poison. 
I  think  the  friends  of  the  deceased  were 
highly  culpable  in  not  sooner  applying  for 
medical  aid,  as  it  is  probable  his  life  might 
have  been  saved.  In  the  interval  of  from 
six  o’clock  in  the  evening  till  nine  next 
morning,  the  belladonna  would  be  absorbed 
into  the  system.  The  blackened  state  of 
the  stomach  of  the  deceased  is  a  strong 
corroboration  of  the  person  having  taken 
some  poison.  I  cannot  say  that  the  deceased 
died  from  the  use  of  spirituous  liquors.  From 
the  mere  examination  of  the  brain  it  would 


be  impossible  to  say  from  what  cause  he  died. 
A  large  dose  of  belladonna,  if  pure,  would 
certainly  produce  death.  It  is  of  great  im¬ 
portance  in  a  public  institution  that  the  me¬ 
dicine  should  be  genuine.  I  have  no  doubt 
the  drugs  are  obtained  from  a  respectable 
dealer.  The  action  of  belladonna  is  upon 
the  nervous  system,  and  produces  stupor, 
sleep,  delirium,  paralysis,  and  loss  of  articu¬ 
lation,  which  are  the  mode  of  death.  If  I 
had  been  called  in  at  ten  o’clock  at  night,  I 
might  have  saved  his  life. 

Mr.  Henry  Oakes,  dispenser  of  medicine 
at  the  Sheffield  Infirmary. — I  have  served 
an  apprenticeship  to  a  chemist  and  druggist. 
I  did  not  know  the  deceased.  He  was  an 
out-patient  of  the  Infirmary.  I  did  not 
hear  William  Hudson,  the  porter,  give  direc¬ 
tions  to  him  or  any  one  else  on  Tuesday 
morning  week  respecting  belladonna  ;  nor  did 
I  see  him  put  any  in  a  box.  The  reason 
why  the  porter  is  allowed  to  give  out  medi¬ 
cines  is  because  there  is  more  work  than  one 
person  can  do.  That  morning  we  had  to 
deliver  medicine  to  800  or  900  persons;  I 
think  additional  help  is  necessary.  Our  or¬ 
ders  are,  not  to  send  out  medicines  without 
written  or  printed  orders :  and  they  never 
do  if  I  know  it.  It  is  not  usual  to  send  out 
belladonna  in  a  box,  if  it  is  intended  to  be 
used  as  a  plaster.  If  Hudson  had  given 
Greaves  or  any  other  person  any  directions 
about  belladonna  being  spread  upon  a  plaster 
that  morning,  I  should  have  heard  him,  and 
prevented  him  doing  so.  I  should  not  have 
sent  belladonna  in  a  box.  I  have  never 
known  it  so  sent  out.  1  believe  the  bella¬ 
donna  was  genuine.  I  think  it  is  not  possi¬ 
ble  that  those  directions  should  have  been 
given  without  my  hearing  them.  We  have 
no  labels  with  poison  printed  upon  them. 
When  we  have  no  printed  labels  we  write 
one,  for  poison. 

Mr.  Joseph  Law,  surgeon  to  the  Infir¬ 
mary. — Having  heard  the  medical  evidence, 
in  which  are  detailed  both  the  symptoms 
which  preceded  death,  and  the  appearances 
which  were  observed  on  the  post-mortem 
examination,  I  am  decidedly  of  opinion  that 
the  deceased  did  not  die  either  from  bella¬ 
donna  or  from  any  narcotico-acrid  poison. 
I  have  not  one  word  to  say  in  justification 
of  the  manner  in  which  this  box,  whether 
containing  belladonna  or  not,  was  sent  out 
of  the  Infirmary.  I  should  have  disapproved 
of  its  being  sent  out,  even  accompanied  by 
the  fullest  possible  either  written  or  printed, 
directions.  It  was  done  contrary  to  a  well- 
understood  order  which  I  have  given  and  fre¬ 
quently  repeated.  The  dose  of  belladonna 
which  (if  this  beacaseof  poisoning)was given, 
was  only  four  grains ;  now  there  is  not  on 
record  one  case  in  which  either  four  grains, 
or  any  similar  dose,  produced  death.  On 
looking  at  all  the  authorities  I  could,  ending 


CASE  OF  ALLEGED  POISONING  BY  EXTRACT  OF  BELLADONNA.  593 


my  researches  with  this  work  by  Taylor, 
printed  in  the  present  year,  I  find  twenty 
reports  of  cases  of  poisoning  (but  not  fatal) 
by  belladonna.  In  these  cases  I  find  the 
largest  dose  taken  was  one  ounce,  and  that 
the  doses  varied  (and  the  symptoms  also) 
from  that  quantity  downward  ;  but  where 
the  doses  were  very  small,  the  symptoms 
were  also  trifling.  There  is  not  a  fatal  case 
of  poisoning  by  the  extract  of  belladonna 
taken  internally  on  record.  There  was  in  the 
case  of  Thomas  Greaves,  the  deceased,  dila¬ 
tation  of  the  pupil,  but  no  insensibility  of  it, 
and  dilatation  without  insensibility  is  not  a 
sign  of  poisoning  by  belladonna.  The  first 
and  most  prominent  symptoms  of  poisoning 
by  belladonna  were  all  absent.  There  was 
no  dryness  of  the  mouth  and  gullet ,  no  diffi¬ 
culty  in  swallowing ,  no  tumefaction,  and, 
in  the  evidence  of  the  medical  witnesses,  no 
mention  is  made  of  redness  of  the  face,  hands, 
or  any  other  part  of  the  surface  of  the  body. 
Nausea,  a  common  symptom  of  poisoning 
by  belladonna,  was  not  spoken  of  as  one  of 
the  symptoms  preceding  death,  There  was 
the  absence  of  that  lively  talkative  delirium 
which  has  characterized  almost  every  case 
of  belladonna  poisoning ,  either  by  the  ex¬ 
tract,  the  root,  the  leaves,  or  the  berries  ; 
and  instead  of  these  symptoms,  it  is  my  me¬ 
dical  opinion  that  we  had  the  symptoms 
which  usually  result  from  that  kind  of  effu¬ 
sion  into  the  ventricles  of  the  brain  and  the 
spinal  canal  which  was  sworn  to.  The  first 
medical  witness  stated  that  there  was  serous 
effusion  in  the  ventricles  of  the  brain,  and 
in  the  spinal  canal ;  but  Mr.  Jackson  stated 
that  this  effusion  was  found  in  these  situa¬ 
tions,  and  also  at  the  base  of  the  brain. 
Now,  serous  effusion  is  quite  sufficient  to 
produce  death  ;  but  whether  it  exists  in  any 
or  in  all  of  these  situations  it  is  no  sign  what¬ 
ever  of  poisoning  by  belladonna.  There  is 
one  case,  and  only  one,  recorded  in  which 
there  was  softening  of  the  brain.  The  ap¬ 
pearances,  therefore,  of  the  brain  were  not 
those  of  poisoning  by  belladonna.  The  tu- 
bercula  quadrigemina  are  pointed  out  by  a 
very  high  authority,  Flourens,  as  being  the 
part  of  the  brain  principally  affected,  and 
the  condition  of  this  part  of  the  brain  has 
not  been  alluded  to  either  by  Mr.  Jackson 
or  Mr.  Pearson.  We  find  a  black  patch,  as  . 
large  as  the  palm  of  the  hand,  on  the  upper 
part  of  the  larger  curvature  of  the  stomach, 
and  this  black  patch  is  sworn  to  as  a  patch 
of  incipient  mortification.  M.  Gaultier  de 
Claubry  had  180  cases  of  poisoning  by  bella¬ 
donna  berries,  and  he  examined  the  fatal 
cases  ;  but  neither  he,  nor  Beck,  nor  Taylor, 
nor  any  other  authority  whatever,  make  any 
mention  of  mortification  in  any  organ  or 
texture  of  the  body  as  one  of  the  symptoms 
of  poisoning  by  belladonna  in  any  form. 
Neither  of  the  medical  gentlemen  who  have 


given  evidence  here  have  seen  a  case  of  p  i- 
soning  by  belladonna,  and  all  medical  facts 
and  pathological  principles  oppose  the  belief 
that  four  grains  of  the  extract  of  belladonna 
could  produce,  either  in  sixteen  hours  or  any 
longer  period,  a  patch  of  mortification  in  the 
stomach.  I  am  quite  aware  that  these  au¬ 
thorities  speak  of  rapid  decomposition  of  the 
bodies  killed  with  belladonna  ;  but  rapid  de¬ 
composition  of  the  whole  body  is  neither 
mortification,  nor  in  the  remotest  manner 
allied  to  it.  A  mortified  patch  of  mucous 
membrane  would  not  be  black  unless  it  were 
dyed  black  by  some  extraneous  body.  In 
all  the  cases  I  have  witnessed  (and  they  are 
not  few),  the  colour  has  been  the  colour  of 
the  secretions — generally  yellow — sometimes 
grey,  but  never  black ;  and  I  know  that  if 
the  whole  of  the  four  grains  swallowed  had 
been  applied  to  that  part  of  the  stomach,  and 
if  not  one  atom  of  it  had  been  mixed  with 
the  secretions  generally,  it  could  not  possi¬ 
bly  have  blackened  so  large  a  surface.  It  is 
my  opinion  that  I  ought  to  have  had  the  op¬ 
portunity  of  witnessing  the  post-mortem 
examination  of  the  deceased  ;  and  it  is  my 
opinion  that  I  have  a  right  to  complain  that 
this  opportunity  was  not  afforded  me.  It  is 
my  opinion  that  a  very  small  amount  of 
mortification  of  the  stomach,  much  smaller 
than  thepatch  sworn  to  in  this  case, would  have 
produced  death  ;  and  it  is  quite  certain  that 
this  mortification  was  not  produced  by  bel¬ 
ladonna.  Belladonna  was  sworn  to  by  the 
first  medical  witness  as  a  narcotic  poison 
simply — not  as  a  narcotico-acrid  poison. 
Now,  it  is  only  by  its  acrid  property  that  it 
could  affect  the  stomach  at  all,  or  produce 
any  local  effect  whatever.  John  Bailey,  the 
author  of  a  very  important  monograph  on 
the  medical  use  of  belladonna,  says  that  he 
began  his  medical  career  with  one  grain,  and 
gradually  increased  it,  but  subsequent  ex¬ 
perience  taught  him  that  it  was  best  to  begin 
with  three  grains,  and  he  adhered  to  that 
plan.  I  estimate  the  number  of  out-patients 
receiving  medicine  on  Tuesday  at  about  400  ; 

I  think  that  there  is  ample  provision  made 
for  dispensing  the  medicines ;  and  I  think 
also  that  when  I  am  in  the  Dispensary,  di¬ 
rections  might  and  would  be  given  by  ano¬ 
ther  dispenser  that  I  might  not  hear.  I  am 
decidedly  of  opinion  that  four  grains  of 
belladonna,  given  to  the  deceased,  though 
labouring  under  a  disease  of  the  chest,  would 
not  produce  death  ;  and  I  am  further  of  opi¬ 
nion  that  in  an  old  man,  enfeebled,  exhausted, 
and  diseased,  it  would  require  a  more  power¬ 
ful  agency  to  produce  serious  organic  lesion, 
than  in  a  young,  vigorous,  and  healthy 
person  ;  the  lower  the  vital  actions,  the  more 
difficult  it  is  to  produce  active  morbid  action  : 
at  the  same  time  I  admit  that  the  old  and 
feeble  man  would  die  under  the  production 
of  more  trifling  organic  lesions  than  would 


594  CASE  OF  ALLEGED  POISONING  BY  EXTRACT  OF  BELLADONNA. 


be  required  to  kill  the  healthy  and  vigorous 
subject.  The  deceased  had  a  condensed  (?) 
lung  ;  and  the  other  appearances  spoken  to 
are  sufficient  to  cause  death.  I  think  he  died 
from  natural  causes,  and  not  from  the  effect 
of  any  narcotico-acrid  poison.  The  prescrip¬ 
tion  was  not  written  by  Mr.  Overend,  but 
by  Dr.  Thompson. 

Mr.  Pearson  said  he  was  sorry  if  he  had 
committed  any  breach  of  professional  eti¬ 
quette  in  not  inviting  Mr.  Law  to  be  present 
at  the  ■post-mortem  examination.  It  was 
not  intentional,  but  arose  from  his  being 
much  engaged  at  the  time. 

The  Coroner,  after  carefully  reading  over 
and  commenting  on  the  evidence,  said,  it 
appeared  from  the  statement  of  Mrs.  Taylor, 
that  the  deceased  had  taken  but  a  very  small 
bit  of  the  black  stuff  out  of  the  box  (meaning 
the  extract  of  belladonna),  and  on  being  de¬ 
sired  to  show  to  the  Jury  how  much  he  had 
taken,  it  appeared,  from  the  opinion  of  Mr. 
Pearson,  to  be  only  about  four  grains.  Now, 
the  dose  for  an  adult  varies  from  one  to  five 
grains.  The  extract,  when  taken  in  large 
doses,  produces  all  the  symptoms  of  a  pow¬ 
erful  narcotic  poison  ;  but  it  is  stated  in 
Taylor’s  and  Guy’s  works  on  “Medical 
Jurisprudence,”  that  there  have  been  very 
few  instances  known  of  this  poison  proving 
fatal,  and  that  patients  have  recovered  from 
very  large  doses.  A  case  is  published  by 
Mr.  Clayton,  where  a  man  took  forty  grains 
of  the  extract,  and  recovered  ;  and  another 
case  occurred  at  St.  George’s  Hospital,  under 
Sir  B.  Brodie,  in  which  an  ounce  of  the  ex¬ 
tract  had  been  taken,  and  the  person  re¬ 
covered.  It  is,  therefore,  pretty  clear  that 
it  is  a  medicine  uncertain  in  its  operation, 
and  not  so  active  a  poison  as  its  common 
name  would  imply,  and  is  much  less  virulent 
than  some  of  the  other  narcotico-irritant 
poisons.  Christison,  in  his  able  work,  states 
if  the  accident  is  taken  in  time,  poisoning 
with  belladonna  is  rarely  fatal ;  for  as  the 
state  first  induced  is  delirium ,  not  stupor, 
suspicion  is  soon  excited,  and  emetics  may 
be  made  to  act  before  a  sufficient  quantity  of 
the  poison  has  been  absorbed  to  prove  fatal. 
In  this  instance,  the  quantity  taken  by  the 
deceased  being  small,  it  did  not  produce  that 
extravagant  delirium  common  in  these  cases, 
but  there  were  dilated  pupils,  and  the  other 
symptoms  mentioned  by  the  witnesses.  Now, 
should  not  the  friends  of  the  deceased  in  this 
case,  when  they  found  the  state  in  which  he 
was,  soon  after  he  had  taken  the  pill  and 
the  extract  of  belladonna,  have  immediately 
sent  for  a  medical  man,  and  not  have  waited 
till  nine  o’clock  of  the  following  morning 
(when  the  patient  was  dying)  before  they 
called  in  medical  assistance  ?  and  should  not 
the  medical  man  even  then  have  adopted 
prompt  remedies,  as  his  patient  lived  more 
than  an  hour  after  he  saw  him  ?  The  facts 


of  the  whole  case  are  now  before  you  in  evi¬ 
dence,  and  if  you  are  of  opinion  that  the 
quantity  of  the  extract  of  belladonna  taken 
by  Thomas  Greaves  produced  his  death, — 
and  that  the  porter,  William  Hudson,  in 
sending  out  that  poisonous  medicine  without 
proper  printed  or  written  directions ,  shewed 
such  negligence  and  disregard  for  human 
life,  as  will  in  your  judgment  render  it  ne¬ 
cessary  that  this  case  should  be  sent  before  a 
higher  tribunal,  I  am  afraid  it  will  be  your 
duty  to  find  him  guilty  of  manslaughter, — it 
being  clearly  laid  down,  that  if  a  party  is 
guilty  of  negligence,  and  death  results,  the 
party  guilty  of  that  negligence  is  also  guilty 
of  manslaughter.  But  if  you  should  be  of  a 
contrary  opinion,  you  will  have  to  say  whe¬ 
ther  the  deceased  came  to  his  death  “  acci¬ 
dentally  from  taking  belladonna  by  mistake,” 
or  that  he  died  from  natural  causes.  I  do, 
however,  consider  it  my  duty  ..strongly  to 
condemn  the  loose  and  dangerous  manner  in 
which  poisonous  medicines  have  been  per¬ 
mitted  to  be  sent  out  from  the  Sheffield 
General  Infirmary,  by  William  Hudson,  the 
porter,  and  to  suggest  to  the  proper  autho¬ 
rities  there,  that  in  future  the  porter  should 
not  be  permitted  to  give  out  any  medicines, 
and  that  none  should  on  any  account  what¬ 
ever  be  sent  out  without  full  and  proper 
written  or  printed  directions.  It  also  ap¬ 
pears  to  me,  that  on  account  of  the  great 
number  of  patients  at  the  Infirmary,  com¬ 
petent  additional  assistance  should  be  imme¬ 
diately  obtained,  properly  to  dispense  the 
medicines  prescribed. 

The  Jury  fully  concurred  with  the  Coroner 
in  his  remarks  as  to  the  loose  manner  in 
which  medicines  were  sent  from  the  Infir¬ 
mary  ;  and  they  recommended  the  instant 
dismissal  of  the  porter  from  his  situation. 

The  Jury,  after  retiring  for  some  time,  re¬ 
turned  the  following  verdict: — “The  Jury 
ai*e  of  opinion  that  there  is  not  sufficient  evi¬ 
dence  to  satisfy  them  that  the  deceased  has 
died  from  the  fatal  effects  of  belladonna,  and 
they,  therefore,  return  a  verdict  that  he  died 
from  natural  causes.  The  Jury,  however, 
blame  the  friends  for  not  sooner  calling  in 
medical  assistance.” — Provincial  Journal , 
Sept.  20. 


©otre&ponDence. 


GENERAL  INDICES  TO  PERIODICALS. 

Sir, — I  have  a  set  of  the  British  and 
Foreign  Medical  Review,  and,  as  most  of 
your  readers  may  do  when  they  have  a  diffi¬ 
cult  case  or  an  obscure  point  to  get  clearer 
notions  of,  I  have  often  turned  to  the  In¬ 
dexes,  and  with  much  trouble  discovered 
what  I  wanted.  But  the  new  general  Index, 


INSTRUCTIONS  RESPECTING  THE  TREATMENT  OF  CHOLERA.  595 


C..-  -  ■  - -  - . — - - - 

in  one  volume,  renders  me  at  once  master 
of  all  the  contents  of  the  series;  and  the 
great  advantages  in  making  the  set  of  prac¬ 
tical  use  urges  me  to  recommend  all  who 
have  the  volumes  to  purchase  the  Index.  I 
have  not  your  series,  though  I  read  your 
numbers  regularly,  but  I  congratulate  those 
who  possess  the  whole  that  you  are  about  to 
publish  an  Index  also,  and  I  trust  the  sale 
of  these  general  Indexes  will  be  sufficiently 
remunerative  to  lead  to  their  general  adop¬ 
tion  by  all  editors  and  publishers  of  Reviews 
and  Serials.  If  they  do  not  sell,  they  will 
not  be  undertaken  ;  and  the  only  reason  they 
will  not  sell  must  be  from  ignorance  of  their 
usefulness,  for  by  such  an  Index  a  whole 
shelf  of  otherwise  useless  books  are  rendered 
of  practical  value.  Dr.  Johnson  said,  that 
next  to  having  a  thing  was  to  know  where  to 
find  it.  This  is  no  advertisement  in  the 
form  of  a  letter.  I  have  no  possible  interest 
in  the  matter,  except  that  general  interest 
for  the  good  of  my  profession  which  I  hope 
I  shall  always  feel. — I  am,  sir, 

Yours  obediently, 

M.  D. 

***  We  quite  agree  in  the  view  taken  by 
our  correspondent,  and  trust  that  his  advice 
will  be  followed. 


- - — -  -  — 

#ktuc£d  Intelligence. 


CENTRAL  BOARD  OF  HEALTH. - INSTRUC¬ 

TIONS  TO  THE  PUBLIC  RESPECTING  THE 
TREATMENT  OF  CHOLERA. 

As  there  seems  reason  to  apprehend  that 
Cholera  may  again,  perhaps  within  a  short 
period,  reach  this  country,  the  Commis¬ 
sioners  of  Health  deem  it  advisable  to  submit, 
for  general  information,  the  following  ob¬ 
servations  in  reference  to  the  epidemic,  and 
to  the  measures  proper  to  be  adopted  in  the 
event  of  its  re-appearance  in  this  country. 

The  Commissioners  of  Health  are  anxious 
to  impress  upon  all  persons  the  important 
difference  that  exists  between  Cholera  and 
Fever,  with  respect  to  the  mode  of  propaga¬ 
tion  of  these  epidemic  diseases.  Fever,  it  is 
well  known,  is  highly  contagious,  or  easily 
propagated  from  one  individual  to  another, 
while  all  experience  shows  that  Cholera  is 
rarely,  if  ever,  contagious ;  consequently, 
the  separation  of  the  sick  from  the  healthy 
— a  measure  so  essential  in  checking  the 
spread  of  Fever — is  not  required  in  Cholera, 
and  the  friends  and  relatives  of  persons  at¬ 
tacked  with  cholera  may  be  under  no  appre¬ 
hension  of  catching  the  disease,  and  need  not 
be  deterred  from  affording  to  the  sick,  in 
their  own  dwellings,  every  needful  assistance 
and  attention.  This  view  of  the  subject 


■  - .  .  .  ■'  1 

has  an  important  bearing  upon  the  measures 
to  be  adopted  in  meeting  a  visitation  of 
Cholera.  In  contending  against  epidemic 
Fevers,  it  has  been  found  necessary  to 
maintain  large  Hospital  Establishments  for 
the  purpose  of  preventing  the  spread  of  the 
disease  by  infection,  and  of  affording  to  the 
sick  those  attentions  which  are  so  often  re¬ 
quired  during  the  tedious  recovery  from 
Fever  ;  but  the  case  is  different  with  respect 
to  Cholera,  and  the  Commissioners  of 
Health,  after  mature  consideration,  do  not 
advise  that  Cholera  should  be  met  with  an 
extended  system  of  Hospital  accommoda¬ 
tion,  such  as  is  needful  in  epidemics  of 
Fever,  but  recommend,  in  preference,  a 
general  system  of  prompt  and  efficient 
Dispensary  relief,  for  the  following  rea¬ 
sons  : — 

Istly.  That  Cholera  being  rarely,  if  ever, 
contagious,  there  is  not  the  risk  of  infection, 
as  in  Fever,  in  leaving  the  sick  in  their  own 
dwellings,  or  in  receiving  them  into  General 
Hospitals. 

2dly.  That  an  attack  of  Cholera  being 
usually  so  sudden,  and  its  whole  duration  so 
short,  the  delay  necessarily  attendant  upon 
the  removal  of  the  patient  to  Hospital  may 
lead  to  loss  of  life,  or  of  the  time  most  valua¬ 
ble  for  treatment. 

3dly.  That  the  Medical  treatment  of 
Cholera,  being  much  more  simple  than  that 
of  Fever,  can  be  efficiently  conducted  at  the 
dwellings  of  the  patients,  and  the  required 
assistance  to  medical  treatment  can  be  as 
effectively  given  by  the  families  and  friends 
of  the  sick,  as  by  nurses  in  Hospitals. 

4thly.  That  recovery  from  Cholera  not 
being  ordinarily  followed  by  prolonged  de¬ 
bility,  such  as  attends  on  Fever,  patients  on 
their  recovery  from  an  attack  of  Cholera  do 
not  generally  stand  in  need  of  the  same 
lengthened  Hospital  attendance  as  Fever 
patients. 

The  Commissioners  of  Health  do  not, 
however,  advise,  that,  in  the  event  of  the 
appearance  of  Cholera,  Hospital  relief  should 
be  altogether  dispensed  with,  as  there  is 
always,  particularly  in  cities,  a  large  class  of 
persons  who  have  neither  friends  nor  the 
means  of  support,  and  to  such  persons  effi¬ 
cient  relief  cannot  be  afforded  except  in 
Hospitals.  The  non-contagious  character  of 
Cholera  fortunately  removes  all  objection  to 
the  receiving  of  persons  suffering  under  the 
disease  into  the  ordinary  Hospitals  of  the 
country,  whether  County  Infirmaries  or 
Fever  Hospitals,  all  of  which  the  Commis¬ 
sioner's  of  Health  advise  should  be  open  and 
in  readiness  to  receive  destitute  patients  in 
Cholera.  The  Commissioners  of  Health 
believe,  that  besides  the  advantages  of  afford¬ 
ing  prompt  and  efficient  relief  to  destitute 
persons  affected  with  Cholera,  the  admission 
of  such  patients  into  the  ordinary  Hospitals 


596  INSTRUCTIONS  RESPECTING  THE  TREATMENT  OF  CHOLERA. 


of  the  country  would  be  attended  with  salu¬ 
tary  moral  effects.  It  would  greatly  lessen, 
if  not  quite  remove,  the  generally-prevailing 
apprehensions  respecting  the  highly  conta¬ 
gious  nature  of  the  disease,  and  would  thus 
dispose  the  friends  and  relatives  of  the  sick 
to  be  more  active  and  constant  in  their  at¬ 
tentions  ;  the  sick  themselves,  no  longer 
treated  like  persons  stricken  by  a  pestilence, 
would  acquire  confidence,  and  with  confi¬ 
dence  a  strength  that  would  enable  them  the 
better  to  struggle  with  the  disease. 

Nature  of  the  Attach. — It  seems  to  be  a 
well-established  fact,  and  one  that  cannot  be 
too  strongly  impressed  upon  the  minds  of 
the  people  generally,  as  upon  this  fact  de¬ 
pends  the  best  hope  of  successfully  contend¬ 
ing  with  the  disease,  that  in  nearly  all  cases 
of  Cholera,  there  are  two  stages  of  the  dis¬ 
ease  ;  the  first  being  merely  Diarrhoea,  or 
simple  looseness  of  the  bowels  ;  the  second 
being  the  stage  of  Collapse  or  Blue  Cholera, 
marked  by  cramps,  failure  of  the  circulation, 
lividity  of  the  skin,  cold,  clammy  perspira¬ 
tion,  and  all  the  other  well-known  symptoms 
of  the  disease.  In  the  first  stage  of  the  dis¬ 
ease,  medical  treatment  is  frequently  suc¬ 
cessful  :  in  the  second  stage  too  often  of  no 
avail. 

The  first  stage,  Diarrhoea ,  or  mere  loose¬ 
ness  of  the  bowels,  may  be  of  a  few  hours' 
duration,  or  may  continue  from  one  to  seve¬ 
ral  days.  It  is  most  important  to  bear  in 
mind,  that  this  Diarrhoea  may  be  entirely 
•without,  pain ;  indeed,  it  most  frequently  is 
without  pain,  or  merely  accompanied  with 
trifling  griping  or  uneasiness.  This  absence 
of  pain,  or  the  little  accompanying  uneasi¬ 
ness,  has  too  often  thrown  the  patient  off  his 
guard,  who  has  thus  neglected  the  warning 
of  his  danger,  and  has  allowed  the  time  for 
cure  to  pass  by.  It  may  be  safely  asserted, 
that  during  the  prevalence  of  an  epidemic  of 
Cholera,  Diarrhoea,  or  looseness  of  bowels, 
which  is  free  from  pain,  is  more  dangerous — 
more  likely  to  be  the  first  stage  of  the  dis¬ 
ease — than  Diarrhoea  accompanied  with 
griping  or  pain.  Let  it  then  be  clearly  un¬ 
derstood,  that  when  the  epidemic  is  preva¬ 
lent,  mere  looseness  of  the  bowels  with  or 
•without  pain,  may  be  the  commencement  or 
first  stage  of  Cholera — that  the  disease  is 
generally  curable  in  this  stage — and  that 
not  a  moment  should  be  lost  in  applying 
for  relief. 

To  afford  this  immediate  relief,  the  Com¬ 
missioners  of  Health  recommend  that  every 
existing  Medical  Institution,  whether  Hos¬ 
pital  or  Dispensary,  should  be  open  day  and 
night,  during  the  prevalence  of  Cholera,  to 
all  applicants,  without  distinction,  where  all 
who  apply  should  obtain,  without  a  moment' s 
delay,  advice  and  medicine  ;  and  from  which 
all  the  poor,  who  may  be  unable  to  leave 
their  dwellings,  may  be  visited  with  promp¬ 


titude,  and  supplied  with  medicine  at  home, 
or  transferred,  if  requisite,  to  Hospital. 

To  effect  these  objects,  the  following  ar¬ 
rangements  are  recommended  : — 

Istly.  The  prescribing  room  of  every 
medical  institution,  whether  Hospital  or 
Dispensary,  should  be  open  day  and  night, 
without  intermission,  during  the  px-evalence 
of  Cholera,  and  a  Medical  Officer  should  be 
in  constant  attendance  to  prescribe  for  all 
applicants. 

2ndly.  Each  Hospital  and  Dispensary 
should  have  a  certain  district  allotted  to  it, 
and  the  attending  Porter  or  Clerk  should 
keep  a  book  in  which  he  should  enter  the 
names  and’  residences  of  all  applicants  for 
relief  within  the  district,  who  are  unable  to 
leave  their  homes.  The  book  should  show 
the  time  of  application,  and  the  name  and 
residence  of  the  patient. 

3rdly.  A  second  medical  officer  should  be 
constantly  in  readiness  to  receive  the  names 
of  all  such  applicants,  and  to  proceed,  with¬ 
out  delay,  to  visit  them.  The  visiting  phy¬ 
sician,  instead  of  writing  a  prescription  at 
the  residence  of  the  patient,  should  be  pro¬ 
vided  with  a  small  portable  pocket-medicine- 
box,  containing  the  medicines  most  generally 
required  made  up  in  such  a  form  as  to  render 
their  administration  as  speedy  and  as  simple 
as  possible.  Such  portable  medicine-boxes 
can  be  procured  at  a  very  small  cost,  or 
may  be  made  up,  on  an  emergency,  of  paste¬ 
board,  or  thin  board,  or  tin,  in  the  form  of 
a  book  about  seven  inches  long,  four  inches 
broad,  and  one  inch  deep,  with  one  of  the 
sides  to  fold  back,  or  open  on  hinges.  The 
services  of  an  Apothecary  will  be  required  to 
keep  up  a  constant  supply  of  the  medicines 
required,  made  up  ready  for  use.  The 
Medical  Officers  will  generally  give  formulae 
for  the  medicines  they  may  deem  best.  The 
following,  may,  however,  serve  as  an  ex¬ 
ample  of  what  should  be  generally  provided 
in  the  pocket-medicine-boxes.  The  most 
portable  forms  for  the  medicines  are  selected  ; 
the  directions  should,  as  far  as  practicable, 
be  printed  : — 

Powders. — Carbonate  of  Ammonia,  in 
waxed  papers,  each  paper  containing  40 
grains,  with  the  following  printed  directions 
on  the  outside  : — “  Dissolve  this  powder  in 
half  a  pint  of  water,  give  two  table-spoonfuls 
every  hour." 

Powders. — Compound  powder  of  Chalk 
with  Opium  ( Pulv .  Cretce  c.  Opio ),  in 
packets,  each  containing  6  papers,  each  paper 
containing  10  grains  of  the  Powder,  with 
printed  directions: — “One  Powder  every 
half-hour  until  the  looseness  ceases." 

Pills  of  Powdered  Opium,  each  contain¬ 
ing  one  quarter  of  a  grain  of  Opium,  and 
two  grains  of  Powdered  Ginger,  made  up 
with  Oil  of  Peppermint.  The  Pills  to  be  in 
boxes,  each  box  containing  6  Pills,  with  a 


INSTRUCTIONS  RESPECTING  THE  TREATMENT  OF  CHOLERA.  597 


printed  label : — “  Opium  Pills,  one  every 
half-hour  until  the  looseness  ceases.” 

Pills  of  Mercury  and  Opium,  each  con¬ 
taining  one  quarter  of  a  grain  of  Calomel, 
two  grains  of  Hydrargyrum  c.  Creta  (Mercury 
with  Chalk),  and  a  quarter  of  a  grain  of 
Opium,  made  up  with  Oil  of  Caraway 
(which  will  serve  to  distinguish  them  from 
the  plain  Opium  Pills),  in  Boxes,  each  con¬ 
taining  6  Pills,  with  a  printed  label : — 
“  Mercury  and  Opium  Pills,  one  every  half- 
hour.’  ’ 

Bottles  (one  or  two  ounce  phials,  with 
cork  stoppers), 

1.  Containing — Tincture  of  Opium  (Lau¬ 

danum), 

2.  “  Hoffman’s  Liquor, 

3.  “  Tincture  of  Rhatany, 

4.  “  Creosote. 

Along  with  the  box  should  be  carried  a  small 
jar  of  strong  brown  mustard. 

The  Visiting  Physician  should  also  be  fur¬ 
nished  with  printed  Forms,  for  the  removal 
to  Hospital  of  patients  who  are  destitute  of 
assistance  in  their  own  dwellings  ; — in  short, 
every  measure  should  be  adopted  that  will 
obviate  the  least  delay.  It  may  be  necessary 
in  some  instances  to  establish  Temporary 
District  Dispensaries,  but  it  is  most  de¬ 
sirable,  for  reasons  already  given,  that  the 
permanent  institutions  should  be  first  made 
available. 

It  is  not  within  the  purpose  of  a  commu¬ 
nication  such  as  this  to  go  into  details  of 
treatment.  There  are,  however,  two  points 
on  which  the  Commissioners  of  Health  feel 
it  will  not  be  out  of  place  to  give  an  opinion, 
viz.,  the  employment  of  frictions,  and  the  al¬ 
lowance  of  drinks  to  the  sick.  The  Com¬ 
missioners  cannot  recommend  that  fluid  ap¬ 
plications  of  any  kind  should  be  employed 
in  frictions  on  the  body  or  limbs,  as  the  cold 
consequent  on  prolonged  exposure  and  eva¬ 
poration  more  than  counterbalances  any 
supposed  good  effect  from  friction,  which,  if 
at  all  used,  should  be  made  merely  with  the 
warm  hand  without  disturbing  the  bed¬ 
clothes.  The  Commissioners  also  advise 
that  when  patients  suffer  from  thirst,  they 
should  in  general  be  permitted  to  drink 
freely,  as  experience  shows  that  the  denial  of 
drink  does  not  check  vomiting,  while  it  in¬ 
creases  very  much  the  suffering  of  the  patient 
from  the  burning  thirst  that  so  often  accom¬ 
panies  the  disease. 

It  is  scarcely  necessary  to  observe  that,  as 
far  as  empowered  by  Act  of  Parliament,  the 
Commissioners  of  Health  will  afford  all  the 
co-operation  and  advice  in  their  power  to 
Managing  Committees  of  Public  Institu¬ 
tions,  and  to  Voluntary  Sanitary  Associa¬ 
tions,  whose  aid  may  be  most  useful  in  carry¬ 
ing  out  the  above  measures.  To  fix  the 
necessary  precautions  and  instructions  in  the 
minds  of  the  people,  it  is  recommended  that 
copies  of  the  following  Circular  be  printed 


and  extensively  published  and  posted  unde 
the  directions  of  the  Local  Committees. 

CHOLERA. - PRECAUTIONS  AND  INSTRUC¬ 

TIONS  FROM  COMMISSIONERS  OF  HEALTH. 

Shun  damp  and  low  situations,  and,  if 
possible,  quit  dwellings  in  such  places  during 
the  prevalence  of  Cholera  ;  keep  your  houses 
and  rooms  dry,  and  the  windows  and  doors 
open  as  much  and  as  long  as  the  weather  will 
permit; — there  can  scarcely  be  too  much  ven¬ 
tilation.  An  abundant  supply  of  fresh  air  is 
as  necessary  during  the  night  as  in  the  day, 
and  pure  air  is  as  requisite  for  the  support 
of  life  and  health  as  good  food. 

Remove  all  stagnant  water  and  dung  heaps 
from  around  your  dwellings,  and  clean  out 
all  sewers  without  delay.  Do  these  things 
at  once,  without  waiting  for  the  outbreak  of 
the  disease.  It  will  be  unsafe,  and  it  will  be 
too  late  to  undertake  them,  when  Cholera 
shall  have  broken  out. 

Avoid  chills  ;  do  not  wear  wet  clothes  a 
moment  longer  than  can  be  avoided.  Wear 
a  flannel  belt  round  the  stomach  and  loins— 
make  use  of  plain  wholesome  food,  in  the 
solid  rather  than  in  the  liquid  form — abstain 
from  fruit,  raw  and  ill-cooked  vegetables, 
pastry,  smoked  and  hard  salted  meats,  and 
salted  fish,  pork,  cider,  stale  or  sour  malt 
drinks,  pickles,  and  all  articles  of  diet  that 
from  experience  are  known  to  have  a  purga¬ 
tive  effect. 

Avoid  purgative  medicines,  particularly 
Castor  Oil,  Seidlitz  Powders,  and  Salts. 

Be  very  careful  that  the  water  used  as 
drink  is  of  good  quality. 

Abstain  from  stimulants  unless  prescribed 
as  remedies  under  medical  advice.  In  for¬ 
mer  visitations  of  Cholera,  many  persons, 
both  rich  and  poor,  resorted  to  the  use  of 
stimulants — wine,  whiskey,  brandy,  &c., 
under  the  false  impression,  that  what  was 
sometimes  useful  as  a  cure,  was  also  good  as 
a  preventive.  This  is  a  great  error; — stimu¬ 
lants,  frequently  taken,  or  taken  in  excess, 
are  followed  by  collapse,  which  predisposes 
to  the  disease,  and  the  general  health,  more¬ 
over,  is  seriously  and  permanently  injured 
by  the  practice.  In  fine,  shun  damp  places, 
particularly  for  sleeping  ;  breathe  pure  air  ; 
observe  cleanliness  ;  keep  the  surface  of  the 
body  warm  ;  avoid  fatigues,  and  excesses  of 
all  kinds  ;  use  wholesome  plain  food  ;  live 
temperately  ;  preserve,  as  much  as  possible, 
a  state  of  general  good  health,  and  you  will 
have  adopted  the  best  safeguards  against 
Cholera. 

NOTICE. 

1st.  If  attacked  by  Diarrhoea  or  looseness 
of  the  bowels,  however  slight,  whether  with 
or  without  pain ,  apply,  without  A  mo¬ 
ment’s  delay,  at  the  Dispensary  in  , 
where  medical  relief  will  be  given  at  any 
hour  of  the  day  or  night. 


598 


REPORTED  APPEARANCE  OF  THE  CHOLERA  AT  HULL. 


2d.  Let  notice  be  given  without  delay,  at 
any  hour  of  the  day  or  night,  at  the  same 
place,  of  the  name  and  residence  of  any  pa¬ 
tient  affected  with  vomiting,  purging,  or 
cramps,  who  may  be  unable  to  go  out ;  im¬ 
mediate  attendance  will  be  given,  and,  if 
necessary,  the  patient  will  be  removed  to 
hospital. 

Should  you  be  attacked  with  Diarrhoea  or 
looseness  of  the  bowels,  with  or  without 
pain,  and  that  medical  advice  is  not  at  hand, 
go  at  once  to  bed,  wrap  yourself  in  warm 
blankets,  roll  a  swathe  of  warm  flannel, 
sprinkled  with  hot  spirits  of  turpentine  or 
whiskey,  closely  round  the  body,  extending 
from  the  chest  to  the  hips,  and  take  a  tea¬ 
spoonful  of  brandy  or  whiskey  in  a  little 
water,  with  fifteen  drops  of  laudanum,  re¬ 
peating  it  every  hour,  if  the  attack  be  not 
checked,  until  a  third  dose  has  been  taken, 
but  do  not  venture  further  in  the  use  of 
laudanum  without  medical  advice. 

By  Order  of  the  Commissioners, 

W.  H.  Hopper, 

Central  Board  of  Health,  Secretary. 

Dublin,  1st  Sept-,  1848. 

ORDER  IN  COUNCIL  IN  REFERENCE  TO  THE 
ENFORCEMENT  OF  TEE  CONTAGIOUS  AND 
EPIDEMIC  DISEASES  PREVENTION  ACT. 
llTH  AND  12TH  VICTORIA,  CAP.  123. 

The  following  order  in  Council,  enforcing 
the  provisions  contained  in  the  bill  passed 
last  session  for  the  prevention  of  contagious 
and  epidemic  diseases,  appeared  in  the  Ga¬ 
zette  on  Friday  last : — 

At  the  Council-chamber,  Whitehall,  the 
28th  day  of  September,  1848, 

By  the  Lords  of  Her  Majesty's  Most  Hon. 

Privy  Council. 

Whereas  by  an  act,  passed  in  the  last  ses¬ 
sion  of  Parliament,  entitled  “  An  Act  to  re¬ 
new  and  amend  an  Act  of  the  10th  year  of 
Her  present  Majesty,  for  the  more  speedy 
removal  of  certain  nuisances,  and  the  pre¬ 
vention  of  contagious  and  epidemic  diseases," 
after  reciting  that  it  is  expedient  that  when 
any  part  of  the  United  Kingdom  shall  appear 
to  be  threatened  with  or  affected  by  any  for¬ 
midable  epidemic,  endemic,  or  contagious 
disease,  measures  of  precaution  should  be 
taken  with  promptitude,  according  to  the 
exigency  of  the  case,  it  is  enacted,  that,  in 
Great  Britain,  the  Lords  and  others  of  Her 
Majesty’s  Most  Hon.  Privy  Council,  or  any 
three  or  more  of  them  (the  Lord  President 
of  the  Council,  or  one  of  Her  Majesty’s 
Principal  Secretaries  of  State,  being  one), 
may,  by  order  or  orders,  to  be  by  them  from 
time  to  time  made,  direct  that  the  provisions 
in  the  said  act  contained  for  the  prevention 
of  epidemic,  endemic,  and  contagious  diseases 
be  put  in  force  in  Great  Britain,  or  in  any 
such  parts  thereof,  or  in  such  places  therein 
respectively,  as  in  such  order  or  orders  re¬ 
spectively  may  be  expressed,  and  may  from 
time  to  time,  as  to  all  or  any  of  the  parts  or 


places  to  which  any  such  order  or  order s 
may  extend,  and  in  like  manner  revoke  o1 
renew  any  such  order,  and  subject  to  revo¬ 
cation  and  renewal  as  aforesaid,  every  such 
order  shall  be  in  force  for  six  calendar 
months,  or  for  such  shorter  period  as  in  such 
order  shall  be  expressed  ; 

And  whereas  the  United  Kingdom  appears 
to  be  threatened  with  a  formidable  epidemic 
disease,  in  consequence  of  the  progressive 
advance  of  such  a  disease  to  the  western 
portion  of  the  continent  of  Europe,  and  a 
case  has  arisen  for  putting  in  force  the  pro¬ 
visions  of  the  said  act ; 

Now,  therefore,  it  is  hereby  ordered  by 
the  Lords  and  others  of  Her  Majesty’s  Most 
Hon.  Privy  Council  (of  whom  the  Right 
Hon.  Viscount  Palmerston,  one  of  Her 
Majesty’s  Principal  Secretaries  of  State,  is 
one),  in  pursuance  and  exercise  of  the 
powers  so  vested  in  them  as  aforesaid,  that 
the  provisions  contained  in  the  said  herein- 
before-recited  act  for  the  prevention  of  epi¬ 
demic,  endemic,  and  contagious  diseases,  be 
put  in  force  throughout  the  whole  of  Great 
Britain  immediately  from  and  after  the  date 
of  this  order. 

And  it  is  further  ordered  that  this  order 
shall  continue  in  force  for  six  calendar 
months  from  and  after  the  date  hereof. 

C.  C.  Greville. 

REPORTED  APPEARANCE  OF  THE  CHOLERA 
AT  HULL. 

Three  cases  of  cholera  have  occurred  on 
board  of  a  vessel  now  lying  at  this  port.  A 
careful  inquiry  has  satisfied  us  that  the  pre¬ 
sent  are  bond  fide  cases  of  cholera.  For 
some  months  past,  during  the  continuance 
of  the  Danish  bombardment  of  the  Elbe  and 
Prussian  ports,  there  has  been  lying  in  the 
old  dock  at  this  port  a  Prussian  bark,  of 
some  500  tons  burden  or  upwards,  named 
the  Pallas,  of  Stettin,  of  which  Captain  Mul¬ 
ler  is  the  commander.  He  and  the  crew 
went  home  some  months  ago,  leaving  only 
the  carpenter  in  charge.  On  Friday  last  the 
captain,  with  a  crew  of  10  men,  from  Stral- 
sund,  Wismar,  and  the  neighbourhood,  ar¬ 
rived  here  by  one  of  the  steamers  which  left 
Hamburgh  yesterday  week.  It  is  known 
that  the  cholera  has  prevailed  in  tbe  latter 
city  for  some  weeks  past.  They  went  on 
board  the  Pallas  on  Friday.  The  same  night 
Carl  Petor,  one  of  the  crew,  was  seized  with 
a  bowel  complaint.  The  master  obtained 
the  assistance  of  Dr.  Cooper,  but  tbe  man 
expired  on  Sunday  morning.  Nicholas 
Rose,  the  cook,  began  to  be  similarly  ill  on 
Sunday  morning,  had  the  like  assistance,  and 
died  on  Monday.  The  steersman  (or  mate), 
William  Fisher,  began  to  be  ill  on  Monday 
morning,  and  expired  the  same  day.  Ano¬ 
ther  man  was  similarly  attacked,  but  is  re¬ 
covering.  We  mention  these  particulars  on 
the  authority  of  Dr.  Ayre,  who,  it  is  well 
known,  was  one  of  the  most  successful  prac- 


PROGRESS  OF  THE  CHOLERA  ON  THE  CONTINENT. 


599 


titioners  in  cases  of  cholera  when  it  appeared 
in  this  town  16  years  ago.  That  the  deaths 
now  named  were  produced  by  cholera  Ur. 
Ayre  has  no  doubt ;  other  medical  authori¬ 
ties  are  equally  satisfied  upon  the  point. 
Since  the  above  was  written,  the  Govern¬ 
ment  sent  down  Dr.  Sutherland  from  the 
General  Board  of  Health,  who  arrived  yes¬ 
terday  morning.  The  instructions  simply 
are,  that  Dr.  Sutherland  and  his  colleague, 
Mr.  Grainger,  who  were  to  arrive  yesterday 
evening,  were  to  make  medical  inquiry  and 
report  to  the  Board  of  Health,  while  the 
Customs  were  to  see  that  all  communication 
between  the  Pallas  and  the  shore,  excepting 
to  medical  men,  under  certain  restrictions, 
be  cut  off  until  six  days  expire  after  the  last 
death  or  the  last  recovery. 

***  The  following  additional  information 
respecting  these  cases  was  reported  in  the 
Times  of  October  4th  : — 

Three  sailors  on  board  a  ship  bound  from 
Hamburgh,  laden  with  fruit,  or  at  any  rate 
with  a  considerable  cargo  of  fruit  on  board, 
had  occupied  the  greater  portion  of  their 
time  during  the  voyage  in  eating  plums,  the 
very  fruit  of  all  others  most  likely  to  engen¬ 
der  the  disease  (?)  if  consumed  in  great 
quantities.  In  each  of  these  cases  a  porten¬ 
tous  number  of  these  plums  were  devoured, 
and,  to  make  matters  better,  the  three  men 
are  reported  to  have  washed  down  the  fruit, 
ripe  or  unripe,  as  the  case  might  be,  with 
copious  draughts  of  sour  beer.  We  will 
venture  to  say,  that  if  the  person  in  London 
least  predisposed  to  the  complaint  were  to 
indulge  himself  in  such  a  dietary  to  half  the 
extent  reported  of  these  three  sailors,  a  very 
few  hours  would  produce  the  same  results. 
We  must  therefore  set  aside  these  three 
cases  as  not  containing  the  slightest  legiti¬ 
mate  ground  for  apprehension. 

***  If  we  are  to  believe  this  statement, 
these  were  not  cases  of  Asiatic  cholera,  but 
simply  of  English  cholera  proving  fatal 
with  unusual  rapidity.  This  implies,  there¬ 
fore,  that  Dr.  Ayre  must  have  been  mis¬ 
taken  in  his  diagnosis  ;  for  plums  and  sour 
beer  swallowed  in  any  quantity  do  not  pro¬ 
duce  that  form  of  cholera  (Asiatic)  which 
has  excited  so  much  fear  in  the  public 
mind ;  nevertheless,  all  the  circumstances 
are  fraught  with  great  suspicion.  The  men 
who  died  had  recently  arrived  from  Ham¬ 
burgh,  where  the  cholera  is  prevailing,  and 
their  deaths  took  place  with  unusual  ra¬ 
pidity.  Although  the  symptoms  are  said 
to  have  been  satisfactorily  ti'aced  to  plums 
and  sour  beer,  the  Government  acted  with 
great  propriety  in  putting  the  crew  of  the 
vessel  under  some  restriction. 

PROGRESS  OF  THE  CHOLERA  ON  THE  CON¬ 
TINENT. 

St,  Petersburgh,  Sept.  21st. — From  the 
11th  to  the  16th  there  were  86  new  cases, 


and  32  deaths.  The  disease  is  sensibly  on 
the  decline.  The  total  number  of  cases  on 
the  17th  amounted  to  165. 

Syria  and  Egypt. — The  disease  has  con¬ 
siderably  abated  in  these  countries.  The 
number  of  deaths  is  estimated  to  have  been 
greater  than  in  1831. 

Riga. — The  disease  is  disappearing.  On 
September  7th,  there  were  only  seven  new 
cases.  The  total  number  of  persons  at¬ 
tacked  in  this  town  has  been  6680.  Of 
these,  there  were  4394  recoveries,  and  2115 
deaths.  There  were  still  171  persons  under 
treatment. 

Stettin,  Sept.  17th. — The  cholera  broke 
out  in  this  town  about  the  end  of  July.  The 
temperature  during  the  month  had  been  cold 
but  variable,  and  the  health  of  the  people 
good,  except  towards  the  close,  when  diar¬ 
rhoea  and  gastric  disorders  became  suddenly 
prevalent.  On  the  8th  August,  one  case  oc¬ 
curred  in  a  man  working  in  the  docks — the 
wind  being  cool,  and  from  the  north-west. 
It  is  remarkable  that  none  of  the  large 
towns  between  this  and  Russia  had  up  to 
that  time  suffered.  On  the  10th,  an  officer 
in  garrison  died.  The  disease  then  spread 
extensively  in  the  quarter  where  it  first  ap¬ 
peared,  which  is  surrounded  by  marshy 
swamps.  It  was  much  more  severe  than  in 
1831  ;  275  persons  died  from  it  in  three 
weeks,  i.  e.  as  many  as  died  in  seventeen 
weeks  on  the  former  invasion.  All  ages 
were  cut  off.  From  the  8th  August  to  the 
11th  September,  there  were  938  cases,  and 
611  deaths. 

Bucharest,  August  31. — The  disease  has 
perceptibly  declined  during  the  month.  The 
number  of  cases  has  been  3384,  and  853 
deaths.  In  the  surrounding  country,  the 
cases  amounted  to  35,881,  and  the  deaths 
to  10,719. 

Odessa,  Sept.  8th. — The  cholera  has 
totally  disappeared  from  this  city. 

Berlin,  Sept.  24. — The  cholera  is  fast  dis¬ 
appearing. 

Hamburgh.  —  The  latest  accounts  state 
that  the  disease  is  still  on  the  increase  at 
Hamburgh.  From  the  1st  of  September, 
when  it  broke  out,  to  the  26th,  there  were 
1,339  cases,  of  which  650  died,  302  reco¬ 
vered,  and  387  were  still  under  treatment. 
There  is  a  great  deal  of  sickness  on  board 
the  English  ships  lying  at  Hamburgh.  Two 
cases  of  cholera  have  appeared  in  the  port  of 
Sunderland.  One  of  them,  the  case  of  a 
sailor  on  board  of  a  vessel  recently  come 
from  Hamburgh,  was  investigated  by  Dr. 
Sutherland,  the  inspector,  who  was  sent  by 
the  General  Board  of  Health  to  examine  it, 
and  left  no  doubt  on  his  mind  as  to  its 
being  Asiatic  cholera ;  but  the  subject  was  a 
man  of  very  intemperate  habits,  who  had 
been  three  times  on  shore  at  Hamburgh, 
and  came  back  drunk. 


600 


CASE  OF  PERFORATING  ULCER  OF  THE  COLON. 


THE  CHOLERA  AT  TRIESTE. - IMPORTANCE 

AND  UTILITY  OF  QUARANTINE  RESTRIC¬ 
TIONS. 

Several  clever  essays  have  been  written  to 
prove  that  Asiatic  cholera  cannot  be  kept  out 
by  quarantine  restrictions.  The  appearance 
of  the  cholera  at  the  remote  port  of  Trieste,  on 
he  northern  part  of  the  Adriatic  sea,  is  now 
onfirmed ;  and  the  fact  is  deserving  of  the 
notice  of  those  medical  writers  who  have 
come  to  the  conclusion  that  no  quarantine 
restrictions  will  keep  out  the  disease.  A 
ship  recently  arrived  in  that  port  from  Con¬ 
stantinople,  where  cholera  was  raging,  and 
the  captain  was  seized  with  the  disease  on 
his  arrival.  The  appearance  of  cholera  in 
the  town  soon  after  this  event,  when  neither 
coast  of  the  Adriatic  had  suffered,  and  most 
of  the  places  situated  between  Trieste  and 
Constantinople  had  escaped,  is  sufficient  to 
render  the  transmission  of  the  disease  by  the 
ship  in  the  highest  degree  probable,  and  to 
justify  our  Government  in  detaining  all 
foreign  ships  arriving  on  our  coasts  from 
suspected  ports.  It  is,  we  think,  clear  that 
if  a  disease  may  be  introduced  by  want  of 
precaution,  it  may  be  kept  out  by  a  rigorous 
observance  of  quarantine. 

The  failure  of  quarantine  regulations  in  the 
Mediterranean  ports  is  commonly  owing  to 
the  venality  or  carelessness  of  those  who  have 
to  look  after  their  due  execution.  Quis  cus- 
todiet  ipsos  custodes  ?  Every  Health  officer 
has  his  bribe,  and  a  communication  with  the 
shore  at  night  may  easily  be  purchased  for  a 
few  scudi.  While  performing  quarantine 
in  one  of  these  ports,  having  arrived  with  a 
foul  bill  of  health  from  another  port,  where 
a  case  of  plague  had  recently  occurred,  we 
had  ample  opportunity  of  watching  the  pro¬ 
ceedings.  The  passports  were  taken  with 
great  precaution  at  the  end  of  a  long  stick, 
and  duly  singed.  Two  sanitary  officers  were 
put  on  board.  These  men  were  rendered 
thoroughly  intoxicated  in  the  evening,  so 
that  some  of  the  crew  were  enabled  to  row  to, 
and  have  free  communication  with,  the  shore. 
We  mention  this  fact  because  we  think  cir¬ 
cumstances  of  this  kind  will  often  account 
for  the  failure  of  quarantine.  The  difficulty 
really  consists  in  causing  the  rules  to  be 
strictly  obeyed — the  slightest  violation  of 
them  is  sufficient  to  render  all  other  proceed¬ 
ings  useless. 

We  are  glad  to  perceive  that  the  Govern¬ 
ment  are  acting  as  if  the  cholera  were  sus¬ 
ceptible  of  importation,  which  we  believe  it 
to  be,  and  that  suspected  vessels  are  to 
be  kept  in  seclusion  for  a  certain  period. 
This  is  as  it  should  be.  No  human  contri¬ 
vance  may  be  successful  in  averting  the 
outbreak  of  the  pestilence,  but  it  would  be 
culpable  to  neglect  any  precaution  that  ex¬ 
perience  would  suggest. 


^elections  from  journals. 


CASE  OF  PERFORATING  ULCER  OF  THE 

COLON  :  MECHANICAL  OCCLUSION  BY 

HARDENED  FASCES.  BY  MR.  CHARLES 

ANDERTON. 

Mr.  Anderton  has  lately  communicated 
the  following  interesting  case  to  the  Provin¬ 
cial  Journal : — 

I  was  called  to  visit  Miss  H.  J.  S - , 

aged  11  years,  in  September,  1847,  labour¬ 
ing  under  an  attack  of  measles,  which,  prior 
to  my  being  called  in,  were  well  and  fully 
developed,  but  at  this  particular  juncture  a 
retrocession  of  the  eruption  had  taken  place 
without  any  special  indications  of  mischief. 
After  the  lapse  of  a  short  time,  evident  symp¬ 
toms  of  abdominal  lesion  made  their  ap¬ 
pearance,  indicated  by  strong  and  almost 
uncontrollable  paroxysms  of  pain.  In  ad¬ 
dition,  we  had  in  this  case  the  rectum 
charged  to  an  amazing  extent  with  fiecal 
concretions,  resembling  masses  of  calcareous 
earth,  which  my  enfeebled  little  patient  could 
not,  per  vires  naturales,  part  with  ;  they 
therefore  required  to  be  remove  d  manually 
with  a  kind  of  scoop,  and  this,  indeed, 
required  much  force.  I  ought  to  observe 
that,  when  the  more  hardened  portions  had 
been  removed,  the  throwing  up  of  an  injec¬ 
tion  had  the  effect  of  encouraging  the 
bowels  to  relieve  themselves,  and  the  motions 
were  invariably  of  the  most  massy  character, 
both  in  point  of  consistence  as  well  as  quan¬ 
tity,  notwithstanding  the  extremely  atte¬ 
nuated  and  wasted  state  of  the  child.  This 
condition  of  matters  continued  unceasingly, 
with  the  abdominal  paroxysms  increasing  in 
frequency  and  severity,  notwithstanding  large 
doses  of  opiates,  until  death  happily  termi¬ 
nated  her  earthly  sufferings  on  the  16th  inst. 

The  post-mortem,  appearances  were  as  fol¬ 
lows  : — The  body  was  externally  wasted  to  a 
most  extreme  degree,  with  a  dry,  harsh,  and 
scabrous  condition  of  the  entire  integuments; 
the  latter  over  the  abdomen  of  a  dark  leaden 
•olour,  with  considerable  distension  from 
flatus ;  internally  the  peritoneum  insepara¬ 
bly  adherent  throughout  to  the  abdominal 
parietes  ;  the  mesentery  uniformly  and 
thickly  studded  with  enlarged  glands,  and 
darkened  from  congestion  ;  the  folds  of  the 
intestines  had  become  strongly  knitted  to¬ 
gether  by  adhesive  inflammation  throughout 
their  whole  course.  At  the  sigmoid  flexure 
of  the  colon,  a  large  perforating  ulcer ,  of 
the  diameter  of  a  shilling,  was  discovered  : 
this  portion  of  the  bowel,  with  the  rectum, 
was  enormously  distended  with  fgecal  m.atter, 
of  the  character  above  noticed.  Remarkable 
to  relate,  the  whole  superior  co»rse  of  the 
bowels  was  devoid  of  solid  ma^teiA  but  con-*. 


INFLUENCE  OF  CHOLERA  IN  CAUSING  A  VARIATION  OF  THE  SEXES.  601 


siderably  inflated ;  the  internal  lining  of  the 
colon  was  studded  with  small  circular  ulcers ; 
the  liver  of  a  dark  carbonaceous  colour,  and 
greatly  diminished  in  size ;  bladder  empty 
and  contracted. 

It  is  my  opinion  that,  owing  to  the  dis¬ 
tended  state  of  the  lower  part  of  the  colon 
and  rectum,  life  was  preserved  and  the  fatal 
event  protracted,  from  the  strong  mechanical 
occlusion  of  the  morbid  opening,  by  the 
indurated  faeces,  preventing  thereby  faecal 
effusion  into  the  abdominal  cavity. — Pro¬ 
vincial  Journal. 

ON  THE  MOVEMENTS  OF  THE  WHOLE 
LARYNX.  BY  M.  L.  A.  LEGOND. 

M.  Legond,  in  terminating  a  memoir  on  this 
subject,  arrives  at  the  following  conclusions. 

1.  The  movement  of  the  whole  of  the  la¬ 
rynx  adjusts  the  vocal  tube  to  fthe  different 
tones  produced  by  the  glottis  ;  but,  in  certain 
circumstances,  the  inferior  constrictor  of  the 
pharynx,  which  is  the  principal  agent  of  this 
movement,  may  combine  with  the  tensor 
muscles  of  the  glottis,  either  in  making  the 
thyroidea  angle  more  acute,  or  in  aiding  the 
movements  of  the  cricoid  upon  the  thyroid,  by 
means  of  its  lateral  attachment  to  the  first  of 
these  cartilages. 

2.  During  normal  vocalisation,  we  seethe 
larynx  ascend  gradually  in  the  successive 
production  of  tones,  while  passing  from  grave 
to  acute ;  we  see  it,  on  the  other  hand, 
descend  when  they  pass  from  acute  to  grave. 

3.  If  during  vocalisation,  the  performer 
uses  effort ,  the  larynx  fixes  itself  immediately, 
and  does  not  recover  mobility  until  the  effort 
ceases. 

4.  It  is  possible  that  the  larynx  may 
descend,  in  passing  from  any  sound  to  a  sound 
more  acute,  which  is  exactly  opposite  to  what 


takes  place  in  the  normal  state.  This  state 
presents  itself  when  the  larynx,  producing, 
for  instance,  do.3  without  violence — passes 
suddenly,  with  effort  to  fa.3  or  sol.3  ;  the 
organ,  obeying  the  depressor  muscles,  which 
tend  to  fix  it  vigorously,  descends  below  the 
point  at  which  it  was  placed  during  the  na¬ 
tural  production  of  do.3—Comptes  Rendus. 

2 

INFLUENCE  of  cholera  in  causing  a 

VARIATION  IN  THE  PROPORTION  OF  THE 

SEXES  AT  BIRTH.  BY  DR.  G.  EMERSON. 

In  estimating  the  births  in  Philadelphia 
for  the  months  of  April  and  May,  1833, 
it  was  found  that  the  males  amounted  to 
532,  and  the  females  to  590,  shewing  a 
female  excess  of  58,  or  about  10  per 
cent.  Now  these  months  included  a  pe¬ 
riod  nine  months  after  the  time  when  the 
cholera  prevailed,  namely,  August  and  Sep¬ 
tember,  1832.  It  must  be  borne  in  mind 
that  the  ordinary  average  excess  of  male 
births,  ascertained  by  former  calculations, 
amounts  to  about  7  per  cent.,  so  that  the 
diminution  of  male  conceptions  during  the 
cholera  was  at  the  rate  of  more  than  17  per 
cent. 

The  effects  of  this  epidemic  upon  the 
animal  economy  were  not  limited  to  those 
wrought  through  the  disease  alone,  but  in¬ 
cluded  many  strong,  moral,  and  depressing 
influences  exerted  during  most  of  the  year, 
embracing  the  painful  periods  of  anticipa¬ 
tion  and  presence  of  the  epidemic,  with  the 
secondary  effects  of  the  meagre  diet  generally 
adopted. 

The  amount  of  conceptions  during  six 
months  subsequent  to  the  commencement  of 
the  cholera,  exhibit  a  preponderance  of 
females. 


Thus,  the  conceptions  in  August,  1832,  as  shown  by 
the  births  in  April  1833,  were 
The  conceptions  in  September  1832,  by  the  births  of  May  1833,  were 


Males.  Females. 


272 

260 


289 

304 


19 

11 

October  1832, 

11 

June  1843, 

11 

285 

283 

11 

11 

November  1832, 

11 

July  1833, 
Aug.  1833, 

11 

304 

29fr 

19 

1 1 

December  1832, 

11 

11 

361 

330 

11 

11 

January  1833, 

11 

Sept.  1833, 

11 

334 

352 

1826 

1851 

It  is  proper 

to 

state  that  a  slight  visitation 

roboration  of  the  casual  observation  made  in 

A  - -  7 - J 

in  the  month  of  October,  and  that  the  re¬ 
turns  of  births  which  took  place  in  June  1835, 
show  a  considerable  falling  off  in  the  male 
births,  which,  instead  of  7,  amounted  to  only 
about  4  per  cent.  To  all  who  have  a  distinct 
recollection  of  the  two  occurrences,  it  must 
be  well  known,  that  the  solicitude  and  other 
depressing  agencies  operated  in  a  trifling  de¬ 


in 


the 


gree,  compared  with  what  they  did 
first  visitation. 

In  looking  abroad  to  see  whether  any  cor 


Philadelphia  was  furnished  by  other  places 
where  cholera  had  prevailed,  in  the  absence 
of  the  necessary  data  in  our  own  country,  we 
appealed  to  the  ample  and  accurate  records 
of  Paris,  where,  as  is  well  known,  the  malig¬ 
nant  cholera  committed  great  ravages  in 
1832.  Here  we  found,  in  a  mass  of  no  less 
than  33,367  births,  a  similar  reduction  in 
the  proportion  of  the  males,  discovered  in 
the  Philadelphia  reports. — American  Jour¬ 
nal  of  Med.  Sciences,  July  1848. 


602  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY,  ETC 


BIRTHS  &  DEATHS  in  the  Metropolis 
fyttriug  the  K/GgJc  ending  Saturday ,  Sept-  30- 


Births. 
Males....  630 
Females. .  597 

1227 


Deaths. 
Males....  669 
Females..  588 

1257 


Av.  of  5  Sum. 
Males ....  495 
Females..  477 

972 


Causes  of  Death.  : 

All  Causes .  1257j 

Specified  Causes . 1251 1 

1 .  .Zj/mof  ic(orEpidemic, Endemic, 

Contagious)  Diseases  . .  395 
Sporadic  "Diseases ,  viz. — 

2.  Dropsy,  Cancer,  &e.  of  uncer¬ 

tain  seat  .  54 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  .  135 

4.  Lung’s  and  other  Organs  of 

Respiration .  120 

5.  Heart  and  Bloodvessels .  43 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion  .  62 

7.  Diseases  of  the  Kidneys,  &c...  8 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c .  8 

9.  Rhematism,  Diseases  of  the 

Bones,  Joints,  &c .  8 

10.  Skin,  Cellular  Tissue,  &c .  1 

11.  Old  Age .  2S 

12.  Violence,  Privation,  Cold,  and 

Intemperance . !  146’ 


Av.  of 
5  Sum. 

972 

968 

257 

45 

120 

80 

28 

79 

8 

10 

7 
1 

50 

8 


The  following  is  a  selection  of  the  numbers  of 
Deaths  from  the  most  important  special  causes : 


Small-pox  .  30 

Measles  .  15 

Scarlatina  ......154 

Hooping-cough..  26 

Diarrhoea  .  44 

Cholera  .  4 

Typhus  .  69 

Dropsy .  22 

Sudden  deaths  . .  49 

Hydrocephalus..  25 
Apoplexy .  35 


Paralysis .  19 

Convulsions  ....  46 

Bronchitis .  39 

Pneumonia .  51 

Phthisis . 100 

Dis.  of  Lungs,  &c.  19 

Teething .  7 

Dis.  Stomach,  &c.  7 
Dis.  of  Liver,  &c.  12 

Childbirth .  1 

Dis.  of Uterus,&c.  4 


Remarks. — The  total  number  of  deaths  was 
285  above  the  weekly  summer  average  (see 
page  585.) 


METEOROLOGICAL  SUMMARY. 

Mean  Height  of  Barometer .  29*47 

“  “  Thermometer*  .  56  7 

Self-registermg  do> - max.  86’4  'min.  44*5 

“  in  the  Thames  water  —  58*5  —  57* 

a  From  12  observations  daily.  b  Sun. 

Rain,  in  inches,  1*89:  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological. — The  mean  temperature  of  the 
week  was  about  1°  below  the  mean  of  the  month. 


BOOKS  &  PERIODICALS  RECEIVED 

DURING  THE  WEEK. 

Pharmacopoeia  ad  usum  nosocomii  phthisicorum 
et  pectoris  morbis  segrotantium  accomodata. 

Pharmaceutical  Journal.  Oct.  1. 

Hints  on  the  probable  Approach  of  Cholera.  By 
T.  M.  Greenhow,  F.R.C.S.E.  &c. 

Plain  Directions  for  the  Prevention  and  Treat¬ 
ment  of  Cholera.  By  T.  Allen,  M.R.C.S.E.  &c. 

Cesper’s  Wochenschrift.  No.  37,  Sept.  9. 

Journal  de  Pharmacie  et  de  Chimie.  Sept.  1848. 

Journal  de  Chimie  M^dicale.  Sept.  1848. 

The  Edinburgh  Medical  and  Surgical  Journal. 
Oct.  1848. 

The  Veterinary  Record.  Oct.  184S. 

London,  Edinburgh,  and  Dublin  Philosophical 
Magazine.  Oct.  1848. 

Ethnological  Journal.  Oct.  1848. 

The  British  and  Foreign  Medico-Chirurgical 
Review.  Nov.  IV.  Oct.  1848. 

Edinburgh  Monthly  Journal.  Oct.  1848. 

Lectures  on  the  Diseases  of  Infancy  and  Child¬ 
hood.  By  Charles  West,  M.D. 

Gay  on  Femoral  Rupture. 

Dr.  Boggie  on  Hospital  Gangrene. 

Bulletin  g^ntrale  de  Thdrapeutique  M^dicale  et 
Chirurgicale. 

A  Letter  to  Lord  Morpeth.  Is  Cholera  conta¬ 
gious  or  not?  By  William  Reid,  M.D. 

Water-Cure  Journal.  No.  15,  October. 


NOTICES  to  CORRESPONDENTS. 

The  communications  of  several  correspondents 
have  been  unavoidably  postponed. 

Mr.  Perry  Dicken’s  letter  next  week. 

Dr.  Haden’s  Notes  on  a  Fatal  Case  of  Algide 
Cholera  will  be  inserted. 

Mr.  Swan’s  paper  will  be  inserted  in  the  follow¬ 
ing  number  if  possible. 

Received.— Dr.  S.  W.  Merriman— Mr.  Gay. 


Erratum.— In  our  last  number,  p.  535,  col.  1, 
1.  SO,  for  “falling”  read  “galling.” 


THE  GENERAL  INDEX. 

We  have  to  announce  to  our  Subscribers  that  a  General 
Index  to  the  first  40  Volumes  of  the  London  Medical  Gazette 
will,  it  is  calculated,  form  a  large  Yolume  of  about  700  pages. 
The  cost  of  the  Index  Yolume,  respecting  which  many  inquiries 
have  been  made,  will  be  Twenty-four  Shillings ;  and  it  is  proposed 
to  commence  it  so  soon  as  the  Names  of  Five  Hundred  Subscribers 
have  been  obtained. — The  printers,  Messrs.  Wilson  and  Ogilvy, 
57,  Skinner  Street,  will  receive  the  Names  of  Subscribers. 


603 


Scftuns* 


COURSE  OF  SURGERY, 
Delivered  in  the  years  1846  and  1847, 

By  Bransby  B.  Cooper,  F.R.S. 

Surgeon,  and  Lecturer  on  Surgery  at  Guy’s 

Hospital. 


Lecture  XXXIX. 

HERNIA — CONTINUED. 

Obturator  hernia — characters  of — difficulty 
of  detection  during  life — usual  course 
above  the  vessels.  Ischiatic  hernia — 
characters  of — difficulty  of  detection — 
case.  Perineal  hernia — characters  of — 
seldom  forms  external  projection — most 
frequent  in  female — case.  Opening  the 
sac  in  strangulated  hernia — operation — 
treatment.  Precautions  in  returning 
intestine — wound  of  intestine — treatment. 
Difficulty  in  returning  the  intestine  after 
the  sac  is  opened.  Omentum.  Sphacelated 
• — removal  of  dead  part — symptoms  of 
gangrene — treatment.  Difficulty  in  re¬ 
turning  the  intestine  in  congenital  bubono¬ 
cele — cases.  Strangulated  hernia,  com¬ 
plicated  with  hydrocele — case.  Necessity 
for  exploration — hernia  not  always  re¬ 
lieved  by  reduction — case.  Opening  the 
cavity  of  the  abdomen  for  exploration. 
Necessity  for  the  early  performance  of 
the  operation  for  strangulation.  Stran¬ 
gulation  within  the  abdomen — symptoms. 
Obstruction  may  exist  either  in  large  or 
small  intestines — case. 

Obturator  hernia  is  the  protrusion  of  any 
viscus  through  the  foramen  in  the  obturator 
ligament,  which  forms  a  pass.age  for  the  ob¬ 
turator  vessels.  This  opening,  in'  its  nor¬ 
mal  state,  is  very  minute,  and  the  tissue 
extremely  inextensible ;  the  hernial  pro¬ 
trusion  itself  can,  therefore,  be  but  small. 
And,  as  it  is  very  deeply  seated  on  the 
upper  part  of  the  thigh,  it  is  almost  im¬ 
possible  that  it  can  be  discovered  during 
life :  indeed,  I  do  no<?  think  that  any 
case  is  on  record  in  which  this  hernia  has 
been  discovered  before  the  death  of  the 
patient.  It  consecpiently  becomes  a  question 
as  to  the  course  tjae  surgeon  ought  to  adopt 
when  the  symptoms  of  hernia  remain  unsub¬ 
dued  by  the  application  of  the  usual  remedies, 
while  at  the  same  time  no  external  tumor 
can  be  found  to  indicate  the  seat  of  the  con¬ 
striction.  Even  if  upon  a  very  strict  exa¬ 
mination  of  the  seat  of  obturator  hernia,  a 
tenderness  or  any  other  circumstance  should 
induce  the  supposition  that  the  protrusion 
has  taken  place  at  this  point,  the  only  means 

xlii. — 1089.  Oct.  13,  1848. 


of  obtaining  the  proof  of  this  condition  would 
be  exploration,  and  this  would  be  almost  as 
dangerous  as  opening  the  abdomen  ;  but  in  , 
an  extreme  case  I  think  the  surgeon  ought 
to  decide  promptly  upon  doing  either  one  or 
other  to  afford  the  patient  the  only  chance 
of  his  life.  The  coverings  of  an  obturator 
hernia  consist  only,  strictly  speaking,  of  peri¬ 
toneum  and  internal  abdominal  fascia,  for  the 
skin  and  muscles  of  the  thigh  cannot  be 
correctly  considered  as  forming  any  part  of 
the  covering  of  this  hernia.  My  colleague, 
Mr.  Hilton,  lately  discovered  an  obturator 
hernia  in  a  subject  in  the  dissecting  room  : 
the  protrusion  was  found  to  have  passed  into 
the  sheath  of  the  obturator  vessels,  but  above 
them,  as  is  invariably  the  case  in  this  de¬ 
scription  of  hernia. 

Ischiatic  hernia  is  the  protrusion  of  a 
viscus  through  the  ischiatic  notch,  below  the 
pyriform  muscle  ;  accompanying,  therefore, 
the  great  sciatic  nerve.  I  believe  there  is  no 
case  known  in  which  such  a  hernia  has 
been  detected  during  life ;  but  Sir  Astley 
Cooper  describes  that  in  the  dissection  of  a 
subject  who  had  died  of  a  strangulated  her¬ 
nia  of  seven  days’  standing,  he  discovered  a 
portion  of  intestine  behind  the  gluteus  maxi- 
mus  muscle,  strangulated  at  the  point  of  its 
exit  from  the  ischiatic  notch  :  this  hernia, 
therefore,  resembles  in  one  respect  the  ob¬ 
turator  hernia  just  described — viz.,  in  being 
equally  difficult  of  detection.  A  tumor  of 
any  kind  situated  in  this  region  is  very  likely 
to  be  mistaken  for  a  hernia,  as  it  might  be 
capable  of  both  dilatation  and  motion  in  the 
act  of  coughing  ;  indeed,  the  presence  of  such 
a  tumor,  attended  by  interruption  to  the 
functions  of  the  bowels,  might  lead  to  great 
complication  and  difficulty  in  the  diagnosis. 
The  late  Dr.  Lubbock,  of  Norwich,  was 
consulted  by  a  patient  who  had  a  large  deep- 
seated  tumor  in  the  gluteal  region.  After 
examination  Dr.  Lubbock  determined  upon 
removing  the  tumor,  and  proceeded  to  the 
operation;  but,  on  making  the  first  incision, 
he  found  that  the  cries  of  the  patient  created 
such  an  influence  upon  the  tumor,  that 
he  was  induced  to  take  it  for  hernia,  and 
therefore  immediately  closed  the  wound. 
About  a  year  afterwards  I  removed  this 
identical  tumor,  and  then  found  that  it  was 
a  steatoma,  firmly  fixed  to  both  sacro- 
sciatic  ligaments,  and  projecting  partly 
into  the  ischiatic  notch,  which  w'as  sufficient 
to  account  for  the  effect  produced  in  it 
during  the  act  of  coughing.  If  a  hernia 
protrudes  through  the  ischiatic  notch,  it 
could  not  be  discovered  externally  during 
life,  and  the  only  plan  of  proceeding  would 
therefore  be  by  exploration,  as  in  cases  of 
obturator  and  internal  hernia. 

Perineal  hernia. — This  kind  of  hernia  does 
not  often  form  sufficient  external  projection 


604 


OPERATION  FOR  STRANGULATED  HERNIA. 


to  produce  a  tumor,  and  rarely  becomes  | 
strangulated;  but  it  interferes  with  the 
functions  of  the  rectum  and  vagina.  Some 
mechanical  arrangement  is  therefore  required 
to  diminish  this  inconvenience,  and  the 
pessary  or  bandages  are  generally  found  ef¬ 
fective.  I  have  myself,  however,  no  expe¬ 
rience  of  this  hernia,  and  believe,  that  as  it 
most  frequently  occurs  in  the  female,  it 
generally  falls  under  the  care  of  the  obstetric 
practitioner.  Perineal  hernia  may,  how¬ 
ever,  occur  in  the  male  subject,  when  the 
intestines  would  be  placed  in  the  pouch  of 
peritoneum  between  the  rectum  and  urinary 
bladder,  and  protruding  downwards  into  the 
perineum  would  there  form  a  hernial  tumor, 
but  still  this  might  not  produce  sufficient  ex¬ 
ternal  tumor  to  be  detectable  in  the  living 
subject.  Sir  A.  Cooper  states  in  his  work 
on  hernia,  that  he  had  once  an  opportunity 
of  dissecting  such  a  case,  and  found  the 
hernia  placed  between  the  anus  and  the 
prostate  gland.  In  that  case  the  perineum 
externally  presented  a  slight  abnormal  con¬ 
vexity,  but  not  a  distinct  tumor.  I  believe 
that  under  symptoms  of  strangulated  intes¬ 
tine,  concomitant  with  perineal  tumors,  the 
perineum  should  be  opened  to  seek  for  her¬ 
nia,  in  preference  to  proceeding  to  abdominal 
exploration,  as  in  this  case  the  hernia  would 
not  be  so  easily  reached.  Should  it,  however, 
happen,  by  any  possibility,  that  either  peri¬ 
neal  or  ischiatic  hernia  be  detected  during 
life,  and  effectual  means  employed  to  reduce 
them,  bandages  and  compresses  should  be 
applied  to  prevent  the  liability  to  their  re¬ 
currence. 

In  speaking  of  the  operation  for  strangu¬ 
lated  hernia,  I  have  hitherto  dwelt  chiefly 
upon  the  division  of  the  stricture  external 
to  the  peritoneal  sac,  my  object  being  to 
impress  strongly  upon  your  minds  the  ad¬ 
visability  of  always  attempting  that  method 
of  procedure  ;  but  this  may  not  always  be 
possible,  and  I  have  now  therefore  to  describe 
the  circumstances  under  which  the  opening 
of  the  sac  itself  becomes  imperative,  and  the 
difficulties  that  may  at  the  same  time  present 
themselves.  When  after  the  division  of  the 
stricture,  the  hernia  still  remains  irreducible, 
it  shews  that  the  contents  have  undergone 
some  change,  which  tends  to  maintain  them 
in  their  abnormal  situation.  To  overcome 
this  obstacle  to  the  reduction  of  the  hernia, 
the  sac  must  be  laid  open  :  this  operation 
requires  very  great  caution,  for  it  not  unfre- 
quently  happens  that  there  are  adhesions 
between  the  sac  and  its  contents.  When  the 
opening  is  made,  the  omentum  is  generally 
first  seen  ;  but  should  intestine  lie  in  front, 
it  is  judicious  to  cover  it  with  omentum,  so 
that  in  passing  the  finger  or  director  upwards 
towards  the  neck  of  the  sac,  the  intestine  is 
not  so  much  exposed  to  physical  injury.  If 
there  be  any  obstruction  to  the  passage  of 


the  finger  through  the  neck  of  the  sac  into 
the  cavity  of  the  abdomen,  it  is  evident  that 
the  stricture  has  produced  a  thickening  or 
constriction  of  the  sac  itself ;  this  might 
indeed  have  gone  on  to  such  an  extent  as  to 
require  division  by  the  knife,  which  in  that 
case  should  be  passed  upwards  into  the  ab¬ 
domen,  guarded  by  the  finger  or  with  the 
director.  In  this  operation  there  is  great 
danger  in  the  liability  to  wound  the  intestine 
in  passing  the  knife  through  the  constricted 
part  of  the  sac.  To  avoid  this,  I  invented  a 
knife,  the  cutting  edge  of  which  is  protected 
by  a  slide,  so  that  it  may  be  passed  with 
safety  through  the  constricted  neck  of  the 
sac,  and  then  being  exposed  by  withdrawing 
the  guard,  the  stricture  may  be  divided 
without  the  least  danger  to  the  intestine. 

When  the  constriction  in  the  neck  of  the 
sac  is  overcome,  it  must  be  ascertained  whe¬ 
ther  the  protruded  bowel  is  in  a  fit  condition 
to  be  returned  into  the  cavity  of  the  abdo¬ 
men  ;  if  it  be  of  a  dark  mulberry  colour,  and 
does  not  change  its  appearance  when  the 
constriction  is  removed,  the  blood  in  its 
vessels  must  have  become  coagulated,  and 
death  of  the  part  consequently  supervened 
if  this  be  the  case,  it  will  also  usually  be 
found  that  the  intestine  has  lost  its  natural 
elasticity,  and  pits  upon  pressure.  If  a 
bowel  were  in  such  a  state,  it  would  clearly 
be  unfit  to  be  returned  into  the  abdomen, 
but  at  the  same  time  I  should  hesitate 
before  I  laid  it  open,  and  should  apply  warm 
fomentations  or  a  slight  poultice,  in  the  hope 
that  restoration  may  be  effected.  Should, 
however,  this  hope  prove  abortive,  the 
bowel  must  of  necessity  be  opened,  and 
an  artificial  anus  established.  In  any  case 
in  which  there  existed  the  slightest  hope 
that  the  bowel  still  admitted  of  restoration, 
and  that  the  blood  in  its  vessels  remained 
fluid,  I  should  return  it  to  the  abdomen,  as 
the  restorative  process  is  much  more  likely 
to  proceed  when  it  is  in  its  natural  cavity, 
than  if  it  remained  in  the  hernial  sac ;  and 
even  should  it  subsequently  sphacelate,  ad¬ 
hesive  inflammation  would  be  set  up  from 
within,  and  preclude  the  liability  of  extrava¬ 
sation  of  the  contents  of  the  intestine  into  the 
peritoneal  cavity.  In  returning  an  intestine 
under  these  circumstances,  care  should  be 
taken  that  it  is  merely  placed  at  the  mouth 
of  the  neck  of  the  sac,  so  that  if  extravasation 
should  occur,  the  effused  matter  may  be  at 
once  propelled  through  that  outlet.  Should  it 
happen  in  the  division  of  a  stricture  that  the 
intestine  be  wounded,  notwithstanding  every 
precaution,  the  edges  of  the  wound  should 
be  taken  up  by  the  point  of  a  pair  of  forceps, 
and  a  silk  ligature  passed  round  the  small 
portion  thus  taken  up  ;  the  silk  will  soon  be 
covered  by  plastic  matter,  thrown  out  from 
the  peritoneal  coat,  while  the  inflammatory 
action  produces  ulceration  through  the  mu» 


OPERATION  FOR  STRANGULATED  HERNTA. 


605 


cous  membrane,  and  the  silk  is  discharged  by 
the  intestinal  canal.  Sir  A.  Cooper  mentions 
two  or  three  cases  where  recovery  was  com¬ 
plete  under  this  mode  of  treatment.  If,  how¬ 
ever,  the  opening  into  the  bowel  be  of  any 
extent,  it  would  not  be  safe  thus  to  include 
the  whole  of  it  in  a  ligature,  as  by  doing  so 
the  calibre  of  the  injured  intestine  would  be 
very  much  diminished.  When  the  wound 
is  therefore  too  large  to  be  thus  secured  by 
ligature,  it  should  be  closed  by  means  of  the 
uninterrupted  suture ;  but  I  should  in  that 
case  recommend  that  the  intestine  be  not 
returned  into  the  abdomen,  but  either  that 
it  be  left  in  the  sac  or  confined  by  a  stitch 
to  the  mouth  of  the  opening,  for  should  any 
portion  of  the  suture  give  way  before  the 
wound  is  covered  by  the  action  of  the  ad¬ 
hesive  inflammation,  extravasation  into  the 
abdominal  cavity,  and  consequent  death  of 
the  patient,  would  be  inevitable. 

Some  difficulty  occasionally  occurs  in  re¬ 
turning  the  intestine  into  the  abdomen, 
even  after  the  sac  is  opened,  owing  to  adhe- 
.sion  having  taken  place  between  it  and  the 
sac,  or  between  the  intestine  and  omentum, 
or  perhaps  both  :  when  this  is  the  case  the 
adhesions  must  be  carefully  separated  before 
the  bowel  can  be  returned.  Returning  the 
Intestine  and  omentum  together  should  al¬ 
ways  be  avoided,  as  their  adhesion  to  each 
other  may  prevent  the  bowel,  even  after  it  is 
returned,  from  being  capable  of  performing 
its  natural  function.  The  condition  of  the 
omentum  is  as  much  a  matter  for  the  consi¬ 
deration  of  the  surgeon  as  that  of  the  intes¬ 
tine  itself ;  for  by  inflammation,  the  former, 
which  is  naturally  a  delicate  and  attenuated 
membrane,  may  be  converted  into  a  solid 
mass,  totally  unfitted  to  be  returned  into 
the  abdomen.  It  then  becomes  a  question 
whether  the  portion  thus  altered  should  be 
removed  or  left  in  the  hernial  sac  :  I  am  an 
advocate  for  leaving  it  in  the  sac,  for  if  it  be 
removed  by  incision  it  will  be  necessary  to 
.apply  a  ligature  to  stop  the  bleeding  from 
the  divided  vessels,  and  that  process  is  very 
liable  to  produce  peritoneal  inflammation  ; 
a  further  advantage  is  also  derived  from 
leaving  the  omentum  in  the  sac,  as  it  some¬ 
times  becomes  adherent  to  the  aperture 
through  which  it  had  passed,  and  thus  pre¬ 
vents  the  future  descent  either  of  omentum 
or  intestine.  Should  the  omentum  have 
become  sphacelated,  the  dead  part  may  be 
.removed  with  safety,  provided  due  care  be 
■taken  to  avoid  the  division  of  the  vessels  of 
the  neighbouring  living  portion.  It  some¬ 
times  happens  that  when  living  omentum 
has  been  left  in  a  hernial  sac,  it  will  after¬ 
wards  pass  into  a  state  of  sphacelus,  even  al¬ 
though  the  external  ring  may  have  entirely 
minted,  This  change  is  marked  by  a  train 
■of  symptoms  that  clearly  indicate  the  altera¬ 
tion  which  is  taking  place  i.n  the  omentum  ; 


for  notwithstanding  that  the  bowels  continue 
to  perform  their  natural  office,  the  constitu- 
tutional  powers  of  the  patient  become  sud¬ 
denly  depressed,  the  pulse  feeble  and  irregu¬ 
lar,  often  attended  by  hiccup ;  and  the 
wound,  which  had  healed,  again  opens,  and  a 
foetid  odour  is  emitted  from  its  surface  :  poul¬ 
tices  should  be  immediately  applied  to  the 
part,  the  sloughing  omentum  removed,  and 
chloride  of  lime,  or  a  weak  solution  of  chloride 
of  zinc,  employed  to  destroy  the  foetor  and 
assist  in  the  separation  of  the  dead  part.  To¬ 
nics  must  also  be  administered,  and  if  there  be 
any  tendency  to  sickness,  carbonate  of  am¬ 
monia,  in  a  state  of  effervescence,  and  com¬ 
bined  with  some  narcotic,  may  be  given. 

A  difficulty  sometimes  occurs  in  congenital 
bubonocele  in  returning  the  intestine  into 
the  cavity  of  the  abdomen,  in  conse¬ 
quence  of  the  testicle  on  the  same  side  not 
having  descended  into  the  scrotum,  oc¬ 
cupying,  in  fact,  the  opening  in  the  vaginal 
canal  through  which  the  intestine  has  to  be 
pushed  back.  I  remember  in  operating, 
many  years  ago,  for  a  strangulated  bubono¬ 
cele,  meeting  with  gi'eat  difficulty  in  return¬ 
ing  the  intestine  into  the  abdomen,  although 
I  had  freely  divided  the  stricture ;  indeed, 
the  manipulation  was  so  much  protracted 
that  I  had  some  fear  for  the  life  of  my  pa¬ 
tient :  he  speedily  recovered,  however,  with¬ 
out  any  bad  symptoms.  Before  commencing 
the  operation  for  hernia  it  is  wise  always  to 
ascertain  whether  the  testicles  have  descended 
into  the  scrotum,  as  their  absence  from  their 
natural  situation  would  prepare  you  for  the 
many  difficulties  which  their  abnormal  po¬ 
sition  may  give  rise  to  during  the  operation. 
I  was  once  present  at  an  operation  for  stran¬ 
gulated  hernia,  where  the  surgeon,  finding  a 
second  protrusion  in  the  inguinal  canal,  per¬ 
sisted  for  some  time  in  attempting  to  push 
it  back  into  the  abdomen  ;  but  at  length  he 
found  that  it  was  an  undescended  testicle, 
and  that  he  had  already  returned  the  whole 
of  the  hernia. 

The  operation  for  strangulated  henna  may 
be  complicated  by  the  co-existence  of  a  hy¬ 
drocele  :  and  in  a  case  in  which  you  may 
have  carefully  dissected  down  to  the  tumor, 
an  escape  of  fluid,  and  the  sudden  disap¬ 
pearance  of  the  swelling,  may  lead  to  the 
supposition  that  a  hydrocele  had  been  mis¬ 
taken  for  a  hernia  ;  such  a  conclusion  ought 
not,  however,  to  prevent  your  further  inves¬ 
tigation,  but  the  finger  should  be  passed 
upwards  to  the  ring  to  examine  if  there  be 
not  some  other  tumor ;  as  it  may  occur  that 
a  hernia,  in  a  distant  peritoneal  sac,  may  be 
J  placed  in  front  of  the  tunica  vaginalis,  or 
may,  indeed,  have  passed  down  into  it :  in 
either  case  the  hernia,  unless  itwere  liberated, 
would  lead  to  the  destruction  of  life.  A  lady 
consulted  Mr.  Crosse,  of  Norwich,  being  tjie 

subjept  pf  a  swelling  in  the  right  inguinal 


606 


HERNIA  NOT  ALWAYS  RELIEVED  BY  REDUCTION. 


region,  and  suffering  at  the  same  time  from 
all  the  symptoms  of  hernia  ;  which  would  not 
yield  to  the  usual  remedies,  nor  could  the  tu¬ 
mor  be  reduced.  Mr.  Martineau  was  called 
in  consultation,  and  the  operation  for  stran¬ 
gulated  hernia  was  determined  upon :  on 
opening  the  membranous  covering  to  the 
tumor  by  careful  dissection,  a  quantity  of 
fluid  made  its  escape,  which  satisfied  the 
mind  of  Mr.  Crosse  that  the  swelling  was  not 
a  hernia,  and  therefore  he  desisted  from  fur¬ 
ther  exploration.  Mi\  Martineau,  however, 
strongly  recommended  him  to  continue  his 
search  ;  he  would  not,  however,  consent  to  do 
so,  and  the  patient  died  without  any  abatement 
of  the  symptoms.  On  a  post-mortem  exami¬ 
nation  it  was  found  that  a  hernia  existed  at 
the  internal  ring,  within  the  peritoneal  co¬ 
vering  of  the  round  ligament,  which  had  also 
contained  the  water  that  had  been  evacuated, 
constituting  a  hydrocele  of  the  round  liga¬ 
ment,  complicated  with  hernia — a  very  rare 
disease.  There  can  be  no  doubt  that  further 
exploration  should  have  been  made  in  this 
case,  as  the  liberation  of  the  strangulated  in¬ 
testine  would  have  offered  a  fair  chance  of 
this  patient’s  recovery. 

As  I  have  already  stated  in  a  former  lec¬ 
ture,  varicocele,  abscesses,  or  indeed  tumors 
of  any  kind,  in  the  situations  of  hernise,  may 
be  mistaken  for  those  protrusions,  especially 
when  disturbance  to  the  natural  funtions  of 
the  intestinal  canal  is  concomitant  with 
them.  Should  these  symptoms  prove  insu¬ 
perable,  however  dissimilar  the  physical 
conditions  of  the  tumor  may  be  to  hernia,  a 
minute  exploration  should  be  made,  in  order 
to  establish  beyond  question,  either  its  being 
connected  with  or  independent  of  any  abdo¬ 
minal  viscus. 

I  have  already  alluded  to  the  fact  that  the 
reduction  of  a  hernia  by  the  application  of 
the  taxis  does  not  invariably  relieve  the 
symptoms  ;  for  if  the  sac  be  pushed  back 
into  the  cavity  of  the  abdomen,  with  the  pro¬ 
truded  viscus  still  contained  within  it,  the 
only  change  which  has  taken  place  is  the 
conversion  of  an  external  into  an  internal  her¬ 
nia,  the  symptoms  remaining  unmitigated. 
I  attended  a  case  with  Mr.  Fred.  Toulmin, 
of  Hackney,  in  which  the  patient  was 
the  subject  of  a  reducible  hernia  in  both  in¬ 
guinal  regions,  and  suffering  from  symptoms 
of  strangulation.  We  returned  the  protru¬ 
sion  on  the  right  side  with  the  greatest  ease  ; 
but  on  the  left  side  some  thickening  still  re¬ 
mained  in  the  inguinal  canal,  even  after  the 
reduction  of  the  hernia  seemed  to  be  com¬ 
pleted,  and  therefore  it  was  determined  that 
an  exploration  should  be  made  to  ascertain 
the  cause  of  this  abnormal  condition.  The 
result  led  to  the  discovery  of  a  small  portion 
of  healthy  omentum  within  the  hernial  sac, 
but  it  was  easily  returned  into  the  cavity  of 
the  abdomen,  without  the  necessity  for  di¬ 


viding  the  internal  ring  ;  and  although  we 
had  no  reason  to  believe  that  this  portion  of 
omentum  could  have  produced  the  urgent 
symptoms  of  strangulated  hernia,  as  there 
was  no  other  tumor  in  the  right  inguinal 
region,  we  could  not  proceed  to  any  further 
exploration.  The  symptoms,  however,  re¬ 
mained  ;  indeed,  their  urgency  increased, 
and  the  next  day  the  patient  died. 

On  a  post-mortem  examination  being 
made,  it  was  found  that  the  left  hernia  upon 
which  we  had  operated,  presented  what  we 
had  already  discovered  in  the  operation,  but 
on  the  right  side  the  nature  of  the  case  be¬ 
came  perfectly  explained  by  the  existence  of 
a  double  protrusion,  the  posterior  position 
of  which  was  the  reducible  hernia,  the  sac 
still  remaining  in  the  inguinal  canal  and 
scrotum ;  but  within  the  abdomen  was 
found  a  second  hernia  enveloped  in  its  sac, 
and  still  strangulated  by  it,  and  which  no 
doubt  hac\  been  returned  “  en  bloc”  by  the 
application  of  the  taxis. 

I  have  published  a  full  description  of  this 
case  in  the  4th  vol.  of  Guy’s  Hospital  Reports. 
A  question  is  here  involved,  as  to  whether 
means  should  have  been  taken  to  reproduce 
the  descent  of  the  hernia  by  exciting  the  pa¬ 
tient  to  cough  while  in  the  erect  posture  ; 
and  if  the  attempt  had  succeeded,  whether 
an  operation  ought  not  to  have  been  per¬ 
formed,  for  the  full  investigation  of  the  con¬ 
dition  of  the  tumor :  this  might  also  have  been 
effected  by  opening  the  abdomen,  and  mak¬ 
ing  the  examination  from  within ;  but  the 
case  was  rendered  doubly  complicated  by 
the  existence  of  a  hernia  on  the  opposite 
side,  giving  the  idea  that  the  obstruction 
was  more  likely  to  be  external  than  internal 
to  the  cavity. 

The  circumstances  under  which  the  cavity 
of  the  abdomen  may  be  laid  open  to 
seek  for  an  internal  mechanical  cause  of 
obstruction  to  a  bowel,  may  be  considered 
as  a  matter  still  sub-judice ;  but  when  we 
consider  the  danger  inseparable  from  the  ope¬ 
ration  of  laying  open  the  abdominal  cavity, 
especially  with  an  inflamed  peritoneum,  we 
shall  perceive  that  it  should  be  only  had 
recourse  to  as  a  last  resource,  although  it  is 
quite  clear,  at  the  same  time,  that  the  chance 
of  success  must  be  diminished  in  proportion 
to  the  delay  ;  yet  the  surgeon  is  further 
justified  in  procrastinating  such  an  opera¬ 
tion,  as  many  cases  apparently  reduced  to 
the  last  extremity  have  recovered  under 
nature’s  own  reparative  efforts.  It  is  also  a 
matter  of  uncertainty  whether,  upon  laying 
open  the  abdomen,  you  may  succeed  in 
discovering  the  seat  and  cause  of  obstruc¬ 
tion  ;  for,  in  consequence  of  the  distension 
of  the  bowels,  and  the  adhesions  result¬ 
ing  from  the  inflamm  ation,  t  1  <  n  ••  i  a- 
tions  necessary  to  separate  these  adhesions, 
so  that  the  surgeon  may  arrive  at  the  object 


STRANGULATION  OF  THE  BOWELS  WITHIN  THE  ABDOMEN. 


of  his  search,  in  itself  would  be  sufficient  to 
aggravate  the  symptoms  to  a  degree  likely 
to  prove  rapidly  destructive  to  life.  When 
abdominal  exploration  is  determined  on, 
I  believe  that  the  linea  alba  ought  to  be 
the  point  chosen  for  the  performance  of  the 
operation  ;  for,  although  the  locality  of  the 
symptoms  may  lead  the  surgeon  to  guess  at 
the  precise  point  at  which  the  obstruction  is 
situated,  still,  as  you  avoid  the  necessity  for 
the  division  of  muscular  fibre,  and  the  liability 
to  haemorrhage,  as  well  as  deriving  the  ad¬ 
vantage  to  be  obtained  from  the  accurate 
knowledge  of  the  relative  position  of  the 
subjacent  parts,  acquired  by  commencing 
the  operation  from  one  precise  point,  this 
region  is  the  most  appropriate  for  the  opera¬ 
tion. 

When  obstructions  occur  to  the  large  in¬ 
testines,  as  from  stricture  in  the  rectum,  or 
in  the  sigmoid  flexure  of  the  colon,  the  ope¬ 
ration  necessary  for  the  relief  of  the  patient 
is  the  formation  of  an  artificial  anus.  This 
is  to  be  effected  by  opening  the  colon  in  the 
posterior  lumbar  region,  as  has  already  been 
described,  deviating  in  this  case  from  the 
practice  recommended  in  the  exploration, 
where  the  point  of  obstruction  is  doubtful. 
The  well-marked  symptoms  and  history  of 
the  case,  will,  however,  preclude  any  diffi¬ 
culty  in  forming  a  just  diagnosis. 

In  concluding  the  subject  of  hernia,  I 
ought,  perhaps,  to  remark  to  you,  gentle¬ 
men,  that  the  result  of  operation,  in  case  of 
strangulation  or  obstruction  in  irreducible 
hernia,  is  not  by  any  means  so  successful  as 
the  pathological  considerations  connected 
with  the  malady  would  lead  us  to  expect. 
In  a  great  measure  I  believe  this  want  of 
success  to  be  attributable,  firstly,  to  the  de¬ 
lay  on  the  part  of  the  patient  in  seeking 
surgical  relief ;  and,  secondly,  to  the  violence 
which  is  so  frequently  employed  in  the  at¬ 
tempt  to  reduce  the  hernia  prior  to  proceed¬ 
ing  to  the  operation.  It  is  a  matter,  there¬ 
fore,  of  the  greatest  importance,  that  before 
the  taxis  be  attempted,  the  patient  should  be 
so  prepared  by  constitutional  remedies,  and 
local  applications  and  position,  that  the  least 
effectual  degree  of  force  only  need  be  em¬ 
ployed  to  return  the  protruded  part.  The 
amount  of  force  which  may  be  safely 
tised  it  is  impossible  to  describe,  as  it 
varies  in  every  case,  and  can  only  be  learned 
from  an  accurate  knowledge  of  the  part 
involved :  it  also  depends  upon  the  con¬ 
ditions  of  those  parts,  and  the  constitutional 
peculiarities  of  the  patient.  Such  circum¬ 
stances  can  only  be  appreciated  by  the  expe¬ 
rience  gained  from  a  long  practical  acquaint¬ 
ance  with  the  subject.  When  the  attempt 
at  reduction  of  the  hernia  has  failed,  and  all 
the  force  it  is  considered  prudent  to  adopt 
hasbeenemployed,theoperation  should  be  re¬ 
sorted  to  without  further  delay, — as  by  pro¬ 


607 


crastination,  such  conditions  are  likely  to 
supervene  in  the  contents  of  the  hernia 
as  either  to  produce  adhesion  to  the  sac, 
or  to  render  them  unfitted  to  be  returned 
into  the  abdomen.  Either  of  these  condi¬ 
tions  would  lead  to  the  necessity  for  laying 
open  the  hernial  sac — an  operation  which  so 
much  enhances  the  danger  that  delay  in  the 
early  division  of  the  stricture  ought  always 
to  be  avoided. 

Strangulation  of  the  bowels  within  the 
abdomen — Internal  hernia. 

Such  an  occurrence  offers,  perhaps,  the 
greatest  difficulty  with  which  a  surgeon 
has  to  contend.  The  symptoms  commence 
with  little  to  alarm  the  patient.  Slight  un¬ 
easiness  in  the  bowels,  and  irregularity  in 
their  function,  alone  mark  the  deviation  from 
health,  and  gentle  purgative  medicine  is 
taken  by  the  patient’s  own  judgment,  or  if 
under  the  advice  of  a  surgeon,  it  is  prescribed 
often  without  a  suspicion  of  any  threatening 
danger.  The  medicine  probably  fails  in 
producing  its  desired  effect :  the  uneasiness 
in  the  bowels  increases ;  the  abdomen  be¬ 
comes  somewhat  distended  ;  nausea  super¬ 
venes  ;  and  the  constipation  remains  unre¬ 
lieved.  The  patient  now  becomes  anxious, 
and  the  medical  attendant  is  consulted  in 
good  earnest.  Another  kind  of  pnrgative  is 
prescribed,  probably  a  wrarm-bath  ordered, 
and  enemata  administered  ;  but  even  as  yet 
no  alarm  may  be  in  any  way  excited.  But 
still  the  bowels  may  remain  unmoved,  and 
the  distension  and  sickness  increase,  but  the 
patient  is  calmed  of  his  apprehension  by  the 
assurance  of  the  surgeon  that  three  or  four 
days’  constipation  is  a  matter  of  frequent  oc¬ 
currence,  and  generally  unattended  by 
danger.  The  next  symptom  is  probably  a 
fixed  pain  at  one  particular  point  within  the 
abdominal  cavity,  and  the  patient  attributes 
to  that  spot  the  “  error  loci leeches  are 
now  ordered,  and  the  warm-bath  also  re¬ 
peated.  Calomel  and  opium  are  prescribed  : 
and  if  the  patient  be  of  a  plethoric  habit, 
probably  a  small  quantity  of  blood  is  ab¬ 
stracted  from  the  arm,  and  a  saline  efferves¬ 
cent  draught  ordered  to  be  taken  every  three 
or  four  hours,  until  the  bowels  be  opened. 

This  desired  result  may  not,  however, 
occur  :  the  vomiting  now  becomes  more  and 
more  urgent,  and  the  matter  ejected  is  pro¬ 
bably  stercoraceous.  If  such  be  the  case, 
and  the  vomiting  be  the  most  urgent  symp¬ 
tom,  and  the  odour  of  the  ejected  contents 
of  the  stomach  foetid,  a  diagnosis  may,  in 
my  opinion,  at  once  be  formed,  that  the 
obstruction  is  seated  in  the  small  intestines ; 
for  when  the  larger  bowrels  are  subjected  to 
obstruction,  sickness  does  not  occur  until 
towards  the  approaching  sequel  of  the  dis¬ 
ease — not  until,  in  fact,  the  colon  becomes 
so  distended  between  the  point  of  obstruc- 


608  STRANGULATION  WITHIN  THE  ABDOMEN. 

—  .  —  -  -  -  '  ■  ■  :  —  .  -  >■ 


tion  and  the  ileo-colic  valve,  that  nothing 
can  pass  from  the  small  into  the  large  intes¬ 
tines,  and  then,  therefore,  they  reject  their 
accumulated  contents  ;  but,  as  T  have  re¬ 
marked  in  a  former  lecture,  no  regurgitation 
can,  I  think,  take  place  through  the  ileo¬ 
colic  valve,  unless  that  organ  be  subjected 
to  actual  lesion,  the  feculent  smell  of  the 
vomited  matter  merely  arising  from  its  re¬ 
tention  in  the  smaller  bowels. 

If,  therefore,  there  be  little  or  no  sickness 
with  this  obstinate  constipation,  it  is  to  be 
attributed  to  some  altered  condition  of  the 
large  intestine,  and  the  prognosis  may  be 
considered  more  favourable  than  when  the 
small  intestines  are  the  seat  of  the  disease. 
In  such  a  case  much  benefit  may  be  derived 
from  passing  a  long  flexible  tube  into 
the  rectum,  to  the  very  commencement  of 
the  sigmoid  flexure  of  the  colon,  and  large 
quantities  of  gruel  and  castor  oil  should  be 
thrown  up,  so  as  to  distend  the  arch  of  the 
colon.  This  may  have  the  effect  of  unfold¬ 
ing  some  unnatural  convolution  it  may  have 
formed,  or  of  softening  some  hardened  faeces 
which  it  may  retain  ;  and,  indeed,  many 
instances  are  recorded  by  Dr.  O’Beirne, 
of  Dublin,  in  which  this  mode  of  treat¬ 
ment  has  proved  effectual.  In  those  cases 
where  the  small  intestines  are  primarily 
affected,  such  means  should  not,  however, 
be  had  recourse  to,  as  they  would  only  tend 
to  irritate  the  intestinal  canal,  and  increase 
the  sickness. 

Should  the  sickness  and  constipation  re¬ 
main,  and  the  urgent  symptoms  still  resist 
all  the  remedies  which  had  been  adminis¬ 
tered,  what  further  is  to  be  done?  There 
is  now  every  reason  to  believe  that  the  ob¬ 
struction  is  the  result  of  some  internal 
mechanical  cause ;  and,  indeed,  in  post¬ 
mortem  examinations  of  cases  which  have 
terminated  fatally,  it  is  not  uncommon 
to  find  such  to  be  the  case.  Bands  of 
plastic  effusion  sometimes  surround  the 
intestines  so  as  to  constitute  an  internal  stran¬ 
gulation.  Portions  of  bowel  have  been 
found  protruding  through  openings  of  the 
omentum  and  mesentery ;  and  also  in  cases 
of  reducible  hernia,  adhesions  are  occasion¬ 
ally  formed  just  at  the  outlet  through  which 
the  protrusion  had  occurred.  Intussuscep¬ 
tion  may  also  lead  to  obstruction,  or  the 
vermiform  process  of  the  caput  coli  may  be¬ 
come  adherent  to  some  other  portion  of  the 
intestinal  canal,  leaving  an  opening  through 
which  a  portion  of  bowel  may  pass,  and 
become  the  cause  of  all  the  mischief.  But 
such  symptoms  may  arise  from  other  causes, 
and  from  those  w  hich  may  be  spontaneously 
removed  by  nature’s  processes — such  as  the 
presence  of  a  foreign  body  within  the  intes¬ 
tines,  hardened  faeces,  or  perhaps  spasmodic 
action  of  the  muscular  coat  of  the  intestines  ; 
and  it  is  on  this  account  that  surgeons  are 


so  little  inclined  early  to  propose  explora¬ 
tion  by  laying  open  the  cavity  of  the  abdo¬ 
men  .  therefore,  where  this  mode  of  pro¬ 
ceeding  has  been  had  recourse  to,  it  has 
generally  been  at  so  late  a  period  that  little 
or  no  hope  of  success  could  be  fairly  ex¬ 
pected. 

I  once  witnessed  the  restoration  of  a  pa¬ 
tient  to  health  after  all  the  symptoms  de¬ 
scribed  from  protracted  constipation  had 
existed  apparently  to  the  last  extremity. 
The  case  is  wrnrthy  of  being  related,  as  the 
cause  one  wrould  be  led  to  suppose  was  mere 
spasm  : — 

An  elderly  lady,  residing  at  Norwich, 
was  under  the  care  of  Mr.  Coleman,  of 
that  town,  suffering  from  constipated 
bowels,  having  had  no  evacuation  for  four 
days.  The  usual  purgative  remedies  were 
prescribed,  but  without  effect ;  enemata  and 
more  drastic  cathartics  were  tried,  but  still 
ineffectually ;  vomiting  and  immense  dis¬ 
tension  of  the  abdomen  supervened,  the 
symptoms  became  more  and  more  urgent, 
and  on  the  twelfth  day  from  her  attack  she 
had  had  no  relief  from  the  bowels.  Dr. 
Alderson  was  then  called  in,  and  was  asked, 
after  he  had  examined  the  patient,  what 
purgative  he  would  recommend  ;  to  which 
he  replied,  “None;  but  a  large  dose  of 
opium.”  It  was  given,  and  in  a  few  hours 
the  bowels  were  freely  opened,  and  the  pa¬ 
tient  recovered. 

Now  in  this  case,  had  exploration  been 
the  mode  of  procedure  adopted,  it  is  quite 
clear  not  only  that  no  benefit  could  have  been 
derived,  but  the  operation  would  almost 
inevitably  have  proved  fatal.  It  is  such 
cases  as  these,  therefore,  I  say,  which  tend 
to  induce  the  procrastination  of  surgical 
attempts  at  relief,  until  every  hope  is  passed 
of  nature  being  able  to  restore  the  function 
of  the  bowels,  and  until  the  operation  itself 
is  scarcely  admissible  ;  so  that  it  is  only  in 
cases  where  no  doubt  can  exist  as  to  the 
cause  of  obstruction  being  mechanical,  that 
laying  open  the  abdomen  should  ever  be 
recommended ;  and  then  the  sooner  it  is 
had  recourse  to,  the  better  for  the  patient. 

I  remember  the  case  of  an  individual  who 
was  suffering  under  insuperable  constipa¬ 
tion,  and  in  whom  a  swelling  of  considerable 
size  in  the  right  iliac  region  led  the  physician 
who  attended  him  to  suppose  that  the  source 
of  the  obstruction  was  in  the  ascending 
colon.  It  was  proposed  to  cut  down 
upon  the  swelling  through  the  abdomi¬ 
nal  muscles,  and  to  puncture  the  caecum, 
and  thus  establish  an  artificial  anus.  The 
surgeon  called  in  consultation  was  not, 
however,  convinced  that  the  tumor  was  the 
distended  caecum,  and  doubted  as  to  the 
propriety  of  making  the  incision  on  the 
tumor  itself,  but  proposed  to  open  the  abdo¬ 
men  by  an  incision  through  the  linea  alba, 


DR.  DAY  ON  CHEMISTRY  AND  THE  MICROSCOPE. 


609 


which  he  preferred,  in  consequence  of  the 
greater  room  he  would  acquire  for  explora¬ 
tion.  Ultimately,  however,  an  incision  was 
made  over  the  caecum,  according  to  the 
original  proposition,  when  it  was  found  that 
the  obstruction  was  not  in  the  colon,  but  in 
the  ileum,  and  produced  by  an  adventitious 
band  of  plastic  effusion — proving  how  diffi¬ 
cult  it  is  during  life  to  ascertain  the  precise 
seat  of  mischief.  The  patient  died  a  few 
hours  after  the  operation. 

Mr.  Hilton  was  called  in  consultation  on  a 
case  in  which  a  lady,  aged  36,  had  been  seized 
with  all  the  symptoms  of  strangulated  hernia, 
but  no  external  signs  of  hernial  protrusion 
could  be  detected.  Various  means  had  been 
ineffectually  tried  for  her  relief,  but  during  the 
period  of  eleven  days  she  suffered  under  all 
the  symptoms  of  strangulation,  and  on  the 
twelfth  day  Mr.  Hilton  opened  the  cavity 
of  the  abdomen,  making  his  incision  in  the 
linea  alba  between  the  umbilicus  and  the 
pubes,  whenhediscoveredan  obturatorhernia, 
which  there  had  been  no  reason  to  suspect, 
as  such  a  protrusion  had  already  been  most 
diligently  sought  for.  The  operation  was 
performed  under  the  influence  of  chloro¬ 
form.  The  patient  died,  however,  on  the 
same  day.  On  a  post-mortem  examination, 
the  portion  of  intestine  which  had  been  pro¬ 
truded  shewed  the  strongest  evidence  of  a 
condition  competent  to  restoration. 

Does  not  this  case  sufficiently  prove  the 
necessity  for  the  early  operation  for  the 
relief  of  obstructed  bowel,  whenever  that 
obstruction  depends  upon  a  mechanical 
cause  ?  For,  as  the  protruded  intestine  did 
not  manifest  any  signs  of  disorganization, 
it  necessarily  leads  to  the  belief  that  the 
general  effect  on  the  constitution  led  to  the 
fatal  result.  Such  effects,  however,  do  not 
seem  to  be  the  consequence  of  a  more  pro¬ 
tracted  alvine  accumulation  when  depending 
on  an  abnormal  change  in  the  function  of 
the  bowels  themselves — in  fact,  on  internal 
causes  ;  for  the  constitution  in  such  cases 
seems  better  capable  of  maintaining  some 
compensating  action,:  for  instance,  how 
does  it  occur  that  patients  will  suffer  con¬ 
stitutional  constipation  even  for  three  weeks 
and  more,  and  yet  ultimately  recover  upon 
the  restoration  of  the  natural  function  of 
defsecation  ? 

The  symptoms  which  lead  to  the  neces¬ 
sity  for  exploration  require  therefore  to  be 
more  accurately  observed  and  defined  ;  and 
I  believe  it  may  be  said,  that,  whenever 
severe  sickness  and  a  well-defined  local  pain 
constitute  the  early  symptoms  of  internal 
obstruction — that  is  to  say,  whenever  sudden 
and  acute  signs  of  strangulation  occur,  al¬ 
though  unattended  by  any  external  signs  of 
hernia — the  absence  of  the  physical  proofs 
alone  should  not  preclude  the  operation  of 


exploration  to  those  wrho  advocate  the  pro¬ 
priety  of  such  a  step  ;  for  I  believe,  if  the 
operation  ever  succeeds,  it  will  be  only  when 
it  has  been  performed  before  peritonitis  has 
set  in. 


CHEMISTRY  and  the  MICROSCOPE 

IN  RELATION  TO 

PRACTICAL  MEDICINE. 

By  George  E.  Day,  M.  A.  &L.  M.  Cantab. 

Fellow  of  the  Royal  College  of  Physicians, 
Lecturer  on  Animal  Chemistry  and  Histology 
at  the  Middlesex  Hospital  School,  and  Phy¬ 
sician  to  the  Western  General  Dispensary. 


Lecture  X. 

I.  (continued). — Action  of  acids  on  the  red 
corpuscles — action  of  alkalies  and  their 
carbonates  on  them, — action  of  various 
salts  on  them — Inutility  of  such  experi¬ 
ments.  Effects  of  urea,  bilin,  and  carbo¬ 
nic  acid  on  the  corpuscles.  Experiments 
of  Harless  on  the  action  of  various  gases 
on  the  corpuscles. 

The  colourless  corpuscles — their  microsco¬ 
pical  and  chemical  characters  —  Large 
lymph- corpuscles. 

II.  — The  process  of  coagulation — The  huffy 
coat — The  occasional  absence  of  a  clot — 
Fallacy  of  experiments  made  on  dying 
blood. 

III.  — The  composition  of  healthy  venous 
blood — Difference  between  the  blood  of 
males  and  females. 

We  proceed  to-day  with  the  consideration  of 
the  action  of  different  reagents  on  the  blood- 
corpuscles. 

The  vegetable  acids,  of  which  we  may  take 
acetic  acid  as  the  type,  act,  when  very  dilute, 
in  much  the  same  manner  as  water,  except¬ 
ing  that  the  changes  they  induce  are  more 
rapid.  In  a  more  concentrated  state  their 
action  is  almost  instantaneous. 

Nitric  and  hydrochloric  acids,  unless  mixed 
with  at  least  their  own  bulk  of  water,  cause 
a  diminution  in  the  size  of  the  blood-corpus¬ 
cles,  but  no  irregularity  in  form.  They  pre¬ 
sent,  however,  a  granular  appearance,  as 
if  their  contents  had  become  coagulated. 
When  much  diluted  the  acids  dissolve  the 
capsule. 

The  action  of  the  alkalies  on  the  blood- 
corpuscles  must  be  next  noticed.  A  mode¬ 
rately  strong  solution  of  caustic  potash  exerts 
a  very  rapid  solvent  action  on  the  corpuscles ; 
no  traces  of  any  solid  element  remaining  on 
the  field  of  the  microscope,  even  when  we 
examine  blood  in  which  the  nuclei  are  suffi¬ 
ciently  distinct.  Ammonia  and  the  alkaline 
carbonates  act  in  the  same  way,  but  with 


610 


DR.  DAY  ON  CHEMISTRY  AND  THE  MICROSCOPE 


less  rapidity ;  so  also  do  solutions  of  soda, 
lime,  and  baryta. 

The  action  of  various  salts  has  been  noted 
by  numerous  observers,  amongst  whom  we 
may  especially  mention  Muller,  Schultz, 
Hunefield,  Magendie,  and  Simon.  The  al¬ 
kaline  and  earthy  salts,  as,  for  instance, 
chloride  of  sodium,  sulphate  of  magnesia, 
phosphate  of  soda,  &c.,  appear  to  exert  no 
definite  chemical  action :  when  these  solu¬ 
tions  are  denser  than  serum  they  cause  a 
shrivelling  and  irregularity  in  the  form  of 
the  corpuscles. 

Some  of  the  metallic  salts  exert  a  strong 
chemical  action  on  the  corpuscles :  thus, 
nitrate  of  silver  causes  their  rapid  disintegra¬ 
tion.  It  would  be  unprofitable  to  enter  at 
any  length  into  the  history  of  this  class  of 
experiments,  for  the  following  reasons : — 
firstly,  in  consequence  of  the  difficulty  of 
distinguishing  between  the  results  of  purely 
physical  action  (endosmosis)  and  purely  che¬ 
mical  action ;  and  secondly,  because,  al¬ 
though  it  would  be  of  the  highest  importance 
in  a  therapeutical  point  of  view  to  recognise 
the  chemical  action  of  the  various  medicinal 
salts,  &c.  on  the  elements  of  the  blood,  we 
cannot  establish  corresponding  relations  un¬ 
der  our  microscopes,  and  we  should  argue 
from  false  premises  if  we  rashly  attempted 
to  draw  any  practical  conclusions  from  them. 
Such  experiments  may  be  regarded  as  sug¬ 
gestive,  but  nothing  further.  The  blood  in 
the  living  body  differs  from  the  blood  under 
the  microscope :  in  the  latter  there  are  alterna¬ 
tions  of  temperature,  and  changes  dependent 
on  evaporation  and  on  free  exposure  to  the 
air,  from  which  the  former  is  protected. 
How,  also,  can  we  estimate,  with  any  degree 
of  precision,  the  degree  of  dilution  which 
some  of  these  salts  must  undergo  before  they 
can  enter  the  blood  ?  Let  us  take,  for  in¬ 
stance,  a  salt  I  have  referred  to — nitrate  of 
silver.  I  have  told  you  that  this  salt  (in  the 
proportion  of  one  to  twenty  of  water)  causes 
a  rapid  disintegration  of  the  corpuscles.  But 
this  fact,  observed  under  the  microscope, 
does  not  in  any  degree  elucidate  the  medicinal 
action  of  the  salt.  For,  in  the  first  place, 
it  is  decomposed  by  the  alkaline  chlorides  of 
the  gastric  juice,  and  converted  into  an  in¬ 
soluble  chloride  of  silver,  which  we  should, 
a,  priori,  assume  could  not  be  absorbed  ;  and 
secondly,  our  assumption  is  proved  to  be 
apparently  correct  by  the  circumstance  that 
the  most  delicate  and  skilful  analysis  fails  to 
detect  a  trace  of  silver  in  the  blood. 

But,  that  our  reasoning  and  our  chemistry 
are  alike  imperfect,  is  sufficiently  attested 
by  the  unhappy,  slate- coloured  faces  you 
must,  most  of  you,  have  witnessed  about  our 
hospitals  and  dispensaries — wretched  victims 
of  epilepsy  and  nitrate  of  silver. 

You  are  perfectly  aware  that  when  the 


great  excreting  organs — the  kidneys,  liver, 
and  lungs — cease  to  discharge  their  func¬ 
tions,  the  blood  speedily  becomes  poisoned 
by  the  retention  of  effete  matters,  and  death 
rapidly  ensues.  We  may  regard  urea,  bilin, 
and  carbonic  acid,  as  the  types  of  the  pro¬ 
ducts  of  these  three  organs  ;  and  it  is  worthy 
of  remark  that  all  these  substances  act  with 
energy  on  the  corpuscles. 

Urea  slowly  dissolves  the  corpuscles, 
which  usually  assumes  an  irregular  form 
before  they  vanish.  The  irregular  appear¬ 
ance  of  the  corpuscles,  so  often  seen  in 
Bright’s  disease,  is  probably  in  part  depen¬ 
dent  on  this  cause,  and  in  part  on  the  dimi¬ 
nished  specific  gravity  of  the  fluid  portion  of 
the  blood. 

The  effects  of  bilin  on  the  corpuscles  have 
been  observed  by  Hiinefeidand  Simon.  The 
latter  writer  makes  the  following  observa¬ 
tions  on  this  subject : — 

“I  can  also  confirm  Hiinefeld’s  observa¬ 
tion  respecting  the  influence  of  bile  on  the 
blood.  On  the  addition  of  fresh  bile,  the 
blood  immediately  becomes  clear,  and  the 
corpuscles  disappear.  In  consequence  of 
the  viscidity  of  ordinary  bile  I  experimented 
with  pure  bilin.  Upon  the  addition  of  a 
little  partially  dried  bilin  to  the  blood  of 
man,  the  calf,  the  tench,  or  the  frog,  the 
fluid  becomes,  after  a  little  stirring,  thick, 
almost  gelatinous,  capable  of  being  drawn 
out  in  threads,  and  no  corpuscles  can  be  seen 
in  it.  If  a  minute  drop  of  frog’s  blood,  in 
which  the  corpuscles  have  been  thus  dis¬ 
solved,  be  brought  in  contact,  and  suf¬ 
fered  to  mix  with,  a  fresh  drop  of  blood 
from  the  same  animal,  an  interesting  micro¬ 
scopic  object  is  afforded.  After  the  first  in¬ 
tense  action  is  over,  the  corpuscles  are  seen 
to  move  about  slowly,  or  to  be  in  a  state  of 
rest,  and  gradually  to  disappear.  The  solu¬ 
tion  of  the  capsule  (not  of  the  nucleus)  occurs 
so  instantaneously  that  the  eye  cannot  trace 

the  reaction . In  those  instances  in 

which  the  corpuscles  resisted  the  solvent 
power  of  the  bilin  for  a  considerable  time 
(possibly  in  consequence  of- the  reagent  being 
applied  in  too  dilute  a  state),  they  often 
assumed  very  peculiar  forms  :  appearing  as 
if  they  were  twisted  and  extended  longitudi¬ 
nally  in  one  direction,  or  variously  coloured 
in  the  interior.” 

Now,  taking  Bright’s  disease  as  that  of  all 
others  in  which  an  excess  of  urea  is  most 
commonly  present  in  the  blood,  and  jaundice 
as  that  in  which  an  excess  of  biliary  consti¬ 
tuents  is  present,  it  is  worthy  of  remark  that 
in  these  two  affections  there  is  a  diminution 
in  the  amount  of  blood-corpuscles.  “The 
most  remarkable  character  of  the  blood  in 
the  advanced  stage  [of  Bright’s  disease]  is 
the  great  decrease  of  blood-corpuscles,  which 
frequently  amount  to  only  one-third  of  the 


IN  RELATION  TO  PRACTICAL  MEDICINE.  611 


normal  proportion.”  (Simon’s  Animal  Che¬ 
mistry,  vol.  i.  p.  322.)  In  reference  to  the 
blood  in  jaundice,  the  same  author  observes 
that  “  the  researches  of  Denis  and  Lecanu 
give,  to  a  certain  degree,  similar  results 
[with  his  own]  :  they  show  a  decrease  of  the 
blood-corpuscles.”  (Op.  cit.  p.  331.) 

Do  not  suppose,  that  in  noticing  the  co¬ 
existence  of  the  presence  of  an  excess  of 
urea  or  bilin,  and  a  deficiency  of  blood-cor¬ 
puscles,  I  mean  to  infer  that  the  diminu¬ 
tion  of  the  latter  is  altogether  or  even  prin¬ 
cipally  dependent  on  the  presence  and 
chemical  action  of  the  former.  But,  although 
there  are  other  causes  for  the  deficiency  of  the 
corpuscles  in  these  cases,  we  are  justified, 
from  the  experiments  I  have  mentioned,  in 
concluding,  that  the  retained  excretions  must 
have  a  share  in  effecting  this  alteration. 

The  only  physiologist  who  has  made  trust¬ 
worthy  observations  on  the  effect  of  carbonic 
acid  and  other  gases  on  the  corpuscles,  is 
Harless.*  Carbonic  acid  causes  the  blood- 
corpuscles  to  swell  and  become  perfectly 
transparent,  while  oxygen  diminishes  them, 
and  causes  them  to  assume  a  finely  granular 
appearance.  The  alternating  action  of  these 
gases  on  the  same  corpuscles  may  be  kept 
up  for  eight  or  ten  times  ;  the  experiment 
then  terminating  in  the  solution  of  the  cor¬ 
puscles.  Nitrogen  seems  from  his  experi¬ 
ments  to  exert  no  action  on  them. 

The  effects  noticed  by  Harless  are  most 
probably  dependent  on  exosmotic  and  endos- 
motic  currents. 

I  will  not  detain  you  any  further  with  the 
results  of  other  experiments  on  the  red  cor¬ 
puscles,  but  must  for  a  few  minutes  beg  of 
you  to  return  with  me  to  the  consideration 
of  the  white  or  colourless  corpuscles,  of 
which  we  made  mention  in  our  last  lecture. 

I  have  already  told  you,  that  when  seen 
in  the  living  vessels  they  are  mostly  close  to 
the  walls.  If,  however,  we  examine  a  drop  of 
recently  drawn  blood  under  the  microscope, 
we  find  them  scattered  amongst  the  red  cor¬ 
puscles,  from  which theymay  be  distinguished 
by  their  comparative  absence  of  colour,  by 
their  granular  appearance,  and  by  their 
greater  size.  There  is  no  fixed  relation  be¬ 
tween  the  number  of  coloured  and  colourless 
corpuscles  :  the  latter  are  most  abundant 
after  a  meal.  On  an  average,  we  may  say 
that  there  is  one  colourless  corpuscle  to  ten 
or  twelve  red  ones. 

Examined  in  perfectly  recent  blood,  they 
appear  as  solid,  and  partially  granular  bodies, 
usually  varying  in  diameter  from  awVoth  to 
TsVoth  of  an  inch.  When  exposed  for  a  few 
minutes  (three  to  five)  to  the  action  of 
water,  each  corpuscle  is  observed  to  separate 

*  Monographic  fiber  den  Einfluss  der  Gase 
auf  die  Form  der  Blut-korperclien  von  liana 
temporaria.  Erlangen,  1816. 


into  a  slightly  granular  roundish  nucleus, 
and  into  a  very  delicate  structureless  capsule. 
Sometimes  the  action  of  water  reveals  the 
existence  of  two  nuclei.  The  corpuscles  in 
these  instances  must  not  be  regarded  as  dis¬ 
tinct  or  peculiar  structures,  but  as  merely 
immature  forms  in  which  the  consolidation 
of  the  nucleus  is  not  perfected. 

We  occasionally  observe  corpuscles  con¬ 
siderably  larger  than  those  I  have  described, 
and  exhibiting  a  more  decidedly  granula 
appearance.  They  usually  present  a  well- 
marked  nucleus,  and  are  regarded  by  our 
best  microscopists  as  highly  developed 
lymph-corpuscles.  They  appear,  however, 
only  to  exist  in  the  blood,  and  not  to  be 
found  in  the  lymph. 

With  regard  to  the  chemical  reaction  of 
different  agents  on  the  colourless  corpuscles, 

I  may  observe,  that  dilute  acetic  acid  causes 
a  rapid  separation  into  nucleus  and  cap¬ 
sule  ;  but  while  water  usually  leaves  the 
nucleus  unacted  on,  acetic  acid  causes  its 
disintegration  into  two,  three,  or  sometimes 
four  parts.  This  reagent  renders  the  cap¬ 
sule  so  pale  that  it  often  requires  considerable 
management  to  detect  its  presence  under  the 
microscope.  A  dilute  solution  of  caustic 
potash  acts  on  the  colourless  in  just  the  same 
way  as  the  red  corpuscles,  rapidly  dissolving 
both. 

In  all  their  chemical  and  microscopical 
relations,  these  corpuscles  seem  to  be  per¬ 
fectly  identical  with  the  lymph-corpuscles 
noticed  in  our  last  lecture,  and,  as  I  then 
observed,  must  be  regarded  as  cells  in  a 
comparatively  early  stage  of  development. 
In  most  respects,  also,  they  approximate  in 
their  physical  and  chemical  characters  to 
pus-corpuscles  ;  and  I  am  convinced  that 
this  similarity  has  led  many  observers  into 
error.  I  shall  revert  to  this  subject  when 
speaking  of  pus  in  the  blood. 

I  believe  that  I  have  now  told  you  all  that 
it  is  necessary  for  you  to  know  regarding 
“  the  physical  and  microscopical  characters 
of  the  blood,  previously  to  its  coagulation.” 
There  are  other  points  connected  with  the 
corpuscles  which  will  be  briefly  noticed  when 
we  arrive  at  “  the  general  physiology  of  the 
blood ;”  as,  for  instance,  the  mode  of  for¬ 
mation  of  the  corpuscles,  both  in  the  foetus 
and  the  adult,  and  the  relation  between  the 
red  and  the  colourless  corpuscles. 

II.  The  process  of  coagulation  next  claims 
our  attention.  This  change  takes  place,  as  a 
general  rule,  whenever  the  blood  ceases  to 
circulate  through  the  vessels.  It  occurs, 
however,  most  rapidly,  and  the  process  is 
best  observed,  in  blood  abstracted  from  the 
living  body. 

In  blood  taken  from  a  vein  in  the  human 
subject,  the  coagulation  usually  occurs  in 
from  three  to  seven  minutes,  and  proceeds 


612 


DR.  DAY  ON  CHEMISTRY  AND  THE  MICROSCOPE 


in  the  following  manner  : — A  membrane  is 
observed  to  form  on  the  surface  of  the  blood  ; 
this  is,  however,  merely  the  external  mani¬ 
festation  of  a  change  that  the  fibrin  is  under¬ 
going  throughout  the  whole  mass  of  the  fluid. 
The  fibrin,  liquid  in  the  living  blood,  and 
the  most  highly  organized  constituent  of  that 
fluid,  removed  from  the  vitalizing  influences 
to  which  it  had  been  continuously  exposed, 
undergoes  a  change  expressive  of  the  death 
of  the  blood.  It  gradually  solidifies  in  de¬ 
licate  fibrils,  forming  a  minute  net-work, 
•which,  as  it  contracts,  entangles  the  cor¬ 
puscles,  and  gradually  expels  almost  the 
whole  of  the  serum  or  non-coagulable  fluid. 
The  clot  thus  formed  is  at  first  soft  and 
gelatinous,  but  gradually  becomes  firmer  as 
the  contraction  of  the  fibrinous  net-work 
advances,  and  ultimately  appears  as  a  red, 
solid  mass,  floating  in  the  clear  yellow 
serum. 

These  are  the  ordinary  changes  undergone 
by  blood  on  its  abstraction  from  the  living 
body. 

There  are,  however,  certain  pathological 
conditions  under  which  it  would  seem  that 
the  blood  cannot  perfectly  hold  the  corpus¬ 
cles  in  suspension.  The  corpuscles  then 
sink  to  a  greater  or  less  degree  from  the 
upper  surface  of  the  blood,  leaving  a  super¬ 
natant  layer  of  clear  yellow  plasma,  or  liquor 
sanguinis  (serum  +  fibrin  in  solution).  The 
fibrin  in  this  clear  plasma  undergoes  the 
change  I  have  already  mentioned ;  but,  as 
there  are  no  red  corpuscles  to  be  entangled 
in  its  meshes,  the  clot  becomes  invested 
superiorly  with  a  whitish  or  slightly  yellow 
coating.  This  peculiarity  is  most  common 
in  inflammatory  diseases  (although  it  is  by 
no  means  confined  to  them),  and  hence 
some  of  the  earlier  writers  termed  the  ap¬ 
pearance  I  have  described  as  the  crusta  in- 
fiammatoria.  It  is  now  commonly  known 
as  the  huffy  coat.  The  investigations  of 
Mulder  lead  to  the  belief  that  in  most  of 
the  cases  where  the  buffy  coat  occurs  there 
is  an  excess  of  oxyprotein  in  the  blood,  and 
that  it  is  this  compound,  rather  than  actual 
fibrin,  that  forms  its  chief  constituent.  It 
is  likewise  found  to  contain  fat  and  colour¬ 
less  blood-corpuscles. 

There  are,  again,  other  pathological  states 
in  which  the  blood  contains  either  mere 
traces  of  fibrin,  or  else  that  constituent  in  a 
very  imperfectly  elaborated  condition.  In 
these  cases  no  regular  clot  is  formed,  and 
we  merely  observe  the  separation  of  a  few 
dark  gelatiniform  flocculi. 

These  peculiarities  will  be  further  noticed 
in  the  consideration  of  the  morbid  conditions 
of  the  blood  under  which  they  occur. 

Numerous  experiments  have  been  insti¬ 
tuted  with  the  view  of  ascertaining  the  effects 
produced  by  various  agents  in  accelerating 


and  retarding  the  coagulation  of  the  blood  ; 
and  many  of  the  agents  thus  tried  have  been 
found  to  exert  a  very  decided  effect,  espe¬ 
cially  in  the  retardation,  or  even  the  pre¬ 
vention,  of  coagulation. 

It  must,  however,  be  borne  in  mind  that 
blood,  when  hindered  from  coagulating  by 
these  means,  is  in  a  very  different  condition 
from  that  in  which  it  previously  existed  and 
circulated  in  the  body  ;  the  fibrin,  and  pro¬ 
bably  some  of  the  other  elements  of  the 
blood,  having  undergone  important  chemical 
changes  altogether  unfitting  them  for  the 
functions  they  have  to  discharge  in  the 
iving  being.  For  my  own  part,  I  regard 
these  experiments  as  of  little  practical  thera¬ 
peutic  value  :  at  the  most,  as  I  have  already 
remarked  in  reference  to  the  action  of  re¬ 
agents  on  the  corpuscles,  they  should  be 
merely  suggestive.  If  you  desire  to  make 
yourselves  acquainted  with  the  experiments 
that  have  been  made  on  this  subject,  and 
the  discordant  results  that  have  been  ob¬ 
tained,  I  may  refer  you  to  Magendie’s 
Leconssur  le  Sang ;  to  Mr.  Ancell’s  seventh 
lecture  “  On  the  Physiology  and  Pathology 
of  the  Blood,”  in  the  Lancet  for  1840  ;  and 
to  Nasse’s  article  “Blut,”  in  Wagner’s 
Handworterbuch  der  Physiologic. 

III.  Numerous  analyses  of  healthy  venous 
blood  have  been  instituted  during  late  years. 
Those  ofLecanu,  Denis,  Simon,  Nasse,  and 
Becquerel  and  Rodier,  are  regarded  as 
amongst  the  most  accurate,  and  I  believe 
that  the  discrepancies  existing  between  them 
are  merely  those  which  must  naturally 
arise  from  the  differences  in  the  methods  of 
analysis  pursued  by  these  chemists.  I  be¬ 
lieve  it  to  be  utterly  impossible  to  deter¬ 
mine  a  formula  for  the  composition  of 
healthy  blood  that  would  serve  as  a  stan¬ 
dard  by  comparison  with  which  we  might 
detect  absolute  deviations  in  other  forms 
and  specimens  of  blood  ;  for  not  only  may 
we  conceive  that  there  are  changes  in  the 
blood  of  the  same  individual  at  different 
times  of  the  day,  according  to  the  amount 
of  pabulum  poured  into  the  circulating 
system,  and  that  different  methods  of  life 
and  various  modes  of  nourishment  would 
cause  such  changes,  but  we  know  by  actual 
analysis  that  sex,  age,  and  temperament,  do 
impress  peculiar  changes  on  it. 

All,  then,  that  we  can  venture  to  do  is  to 
give  the  maxima,  mean,  and  minima  values 
of  the  different  constituents  of  healthy 
blood,  and,  in  order  that  they  may  be  at  all 
trustworthy,  they  should  be  deduced  from  a 
large  number  of  analyses. 

The  following  table  is  drawn  up  by  Bec¬ 
querel  and  Rodier,  from  the  analyses  of  the 
blood  of  eleven  men,  all  of  whom  were 
considered  to  be  in  perfect  health,  and 
varying  in  age  from  21  to  56  years : — 


613 


0090HDTM  3HT  CTVT A  YTTTSIMflHO  MO  YAC 

IN  RELATION  TO  PRACTICAL  MEDICINE. 


- - - - ■■  - - - — - ' 

Mean. 

Maxima. 

Minima. 

Density  of  defibrinated  blood 

1060-2 

1062-0 

1058-0 

Density  of  serum  .  .  . 

1028-0 

1030-0 

1027-0 

Water  . 

799-0 

800-0 

760-0 

Solid  constituents 

201-0 

240-0 

200-0 

Fibrin  . 

2-2 

3*5 

1-5 

Fat . 

3-2 

6-6 

2-0 

Albumen  . 

69-4 

73-0 

62-0 

Blood-corpuscles  . 

141-1 

152-0 

131-0 

Extractive  matters  and  salts  . 

6*8 

8-0 

5-0 

1000  parts  of  incinerated  blood  contained— 

/ 

Chloride  of  sodium 

3-10 

4-20 

2-30 

Other  soluble  salts 

2-50 

320 

2-00 

Earthy  phosphates 

0-33 

0-70 

0-22 

Iron . 

0-56 

0-63 

0-51 

The  composition  of  the  blood  of  the  healthy  female,  as 

deduced  from 

eight  analyses,  is 

given  in  the  following  table  : — 

Mean. 

Maxima. 

Minima. 

Density  of  defibrinated  blood 

1057-5 

1060-0 

1054-0 

Density  of  serum  . 

1027-4 

1030-0 

1026-0 

Water.  . 

791-1 

813-3 

773-0 

Solid  constituents 

208-9 

227  0 

187-0 

Fibrin 

2-2 

2-5 

1-8 

Fat . 

2-2 

5-7 

2-0 

Albumen  . 

70-5 

75-5 

65-0 

Blood-corpuscles 

127*2 

137-5 

113-0 

Extractive  matters  and  salts 

7-4 

8-5 

6-2 

1000  parts  of  incinerated  blood  contained— 
Chloride  of  sodium 

3-90 

4-00 

3-50 

Other  soluble  salts 

2-90 

3-00 

2-50 

Earthy  phosphates 

0-35 

0-60 

0-25 

Iron . 

0-54 

0-57 

0-48 

From  these  tables,  Becquerel  and  Rodier 

respecting  the  deviations 

of  morbid  blood 

maintain  that  the  influence  of  sex  is  so 

from  the  healthy  standard,  diseased  male  and 

great,  especially  in  reference  to  the  amount 

female  blood  must  be 

always  contrasted 

of  water  and  of  blood-corpuscles,  that,  in 
order  to  arrive  at  any  correct  conclusions 

with  the  respective  male 

and  female  blood 

in  a  state  of  health. 

HEREDITARY  INSANITY. 

Is  mental  disease  transmitted  more  fre¬ 
quently  from  the  mother  than  the  father  ? 
This  question,  considered  in  its  strictest 
sense,  might  show  that  insanity  depends 
mostly  upon  conditions  which  are  either 
limited  to  the  mother  or  father  exclusively  ; 
that  it  is  connected  with  this  or  that  system 
and  organ  ;  or,  finally,  that  the  influence  of 
one  or  the  other  parent  predominated  in  the 
act  of  procreation.  We  thus  see  how  a 
question  of  this  nature  opens  the  way  to  a 
whole  series  of  others,  and  how  cautiously 
we  ought  to  proceed  in  giving  a  decisive 
reply,  lest  we  involve  ourselves  in  a  mass  of 
hypotheses,  in  our  attempt  to  explain  the 
subject  under  consideration.  Even  Esquirol 
established  the  proposition  that  mental  dis¬ 
ease  was  more  frequently  transmitted  from 
the  mother  than  the  father — an  opinion  that 
has  continued  in  force,  and  has  been  very 


nearly  considered  as  a  settled  fact  by  Bail- 
larger.  Another  point,  tolerably  well  at¬ 
tested  by  experience,  and  scarcely  to  be 
refuted  on  theoretical  principles,  has  again 
been  generally  advanced — namely,  that  in¬ 
sanity  is  not  so  frequently  transmitted  to 
the  offspring  when  it  does  not  shew  itself  in 
one  or  the  other  parent  until  after  the  birth 
of  the  former,  excepting  where  the  disease 
is  based  on  hereditary  disposition,  and 
appears  to  have  been  simply  retarded  in  its 
manifestation.  It  would  be  very  important 
to  learn  how  far  it  is  necessary  to  extend  our 
investigations  amongst  the  relatives  of  a 
patient,  and  through  how  many  generations 
the  disposition  may  be  transmitted ;  but 
these  are  points  into  which  statistical  in¬ 
quiries  do  not,  and  cannot,  enter. — From 
Dr.  Forbes  Winslow’s  Journal  of  Psycho¬ 
logical  Medicine. 


614 


PHENOMENA  ATTENDING  DEATH  FROM  CHLOROFORM. 


0itgtnal  0cmnumtcattong. 


ON 

NARCOTISM  by  the  INHALATION 
OF  VAPOURS. 

By  John  Snow,  M.D. 

Vice-President  of  the  Westminster  Medical 
Society. 

[Continued  from  page  416.] 


Phenomena  attending  death  from  Chlo¬ 
roform. —  Post-mortem  appearances. 

* — 7  he  fatal  cases  of  inhalation  of 
Chloroform. 

In  my  last  communication  it  was 
shewn,  that  when  an  animal  of  warm 
blood  is  made  to  breathe  the  vapour  of 
chloroform,  well  diluted  with  air,  until 
death  ensues,  the  heart  continues  to 
pulsate  for  some  time  after  the  respira¬ 
tion  has  ceased,  the  circulation  being 
arrested,  secondarily,  by  the  failure  of 
the  breathing.  It  was  also  shewn,  by 
some  experiments  on  frogs,  that  chloro¬ 
form  has  the  effect  of  directly  paralyzing 
the  heart,  when  it  is  absorbed  in  a 
somewhat  larger  quantity  than  is  re¬ 
quired  to  stop  the  respiratory  move¬ 
ments.  It  is  possible,  indeed,  to  narco¬ 
tise  the  heart  of  warm-blooded  animals 
by  chloroform.  When  the  vapour  is 
exhibited  to  them  in  a  concentrated 
form,  the  breathing  and  circulation  ap¬ 
pear  to  cease  nearly  together;  probably, 
because  the  quantity  of  vapour  in  the 
lungs,  at  the  time  the  breathing  stops, 
is  sufficient,  when  absorbed,  and  added 
to  that  already  in  the  blood,  to  narcotise 
the  heart.  The  two  following  experi¬ 
ments  confirm  this  view. 

Exp.  44. — 120  grains  of  chloroform 
were  put  into  a  jar  of  the  capacity  of 
600  cubic  inches,  which  was  kept  ac¬ 
curately  covered  with  a  piece  of  plate- 
glass,  and  moved  about  to  diffuse  the 
chloroform  over  its  sides.  In  a  few 
minutes  the  chloroform  was  all  con¬ 
verted  into  vapour.  The  temperature 
of  the  jar  was  65°;  the  air  in  it  was 
consequently  nearly  saturated  with 
vapour,  and  contained  20  grains  in  each 
100  cubic  inches.  A  young  rabbit  was 
put  into  the  jar.  It  was  very  quickly 
affected,  and  ceased  to  breathe  in  less 
than  a  minute.  It  was  taken  out  im¬ 
mediately  the  respiration  ceased,  and 
the  ear  was  applied  to  its  chest,  but  no 


motion  of  the  heart  was  audible.  The 
thorax  was  opened  as  quickly  as  pos¬ 
sible,  and  when  the  heart  was  first  ob¬ 
served  it  was  quite  motionless  ;  but  it 
had  not  been  exposed  to  the  air  for  a 
minute,  before  it  began  to  contract,  the 
auricles  beginning  to  move  first,  and 
shortly  afterwards  the  ventricles, — and 
in  three  or  four  minutes  it  was  con¬ 
tracting  vigorously.  This  recommence¬ 
ment  of  the  heart’s  action  no  doubt 
resulted  from  the  evaporation  of  the 
chloroform  from  its  surface,  and  the 
consequent  liberation  of  the  nerves 
there  situated  from  the  influence  of  the 
vapour.  Soon  after  the  chest  had  been 
opened,  a  drop  of  chloroform  was  al¬ 
lowed  to  fall  on  theheart,  and  its  motion 
instantly  ceased,  but  gradually  com¬ 
menced  again  in  the  course  of  a  few 
minutes,  and  it  continued  to  contract 
feebly  for  some  time.  The  lungs,  which 
collapsed  as  soon  as  the  chest  was 
opened,  were,  when  first  observed,  of  a 
vermilion  tint.  This  colour  of  the 
lungs  is  an  additional  proof  that  the 
circulation  had  not  continued  after  the 
respiration  ceased.  There  was  active 
vermicular  motion  of  the  intestines  of 
the  rabbit  when  they  were  exposed  to 
the  air,  soon  after  death,  and  a  drop  of 
chloroform  being  put  on  the  ileum  at 
once  stopped  the  contractions  at  the 
place  of  contact,  whilst  they  continued 
as  before  in  the  rest  of  the  intestine. 
The  next  morning  the  body  of  the 
rabbit  was  rigid,  and  the  blood  in  the 
heart  was  coagulated.  The  right  cavi¬ 
ties  were  nearly  full,  and  the  left  con¬ 
tained  a  small  quantity  of  blood.  The 
brain  was  quite  healthy,  its  vessels  not 
being  congested. 

Exp.  45.— Two  fluid  drachms  of 
chloroform  were  put  into  the  same  jar, 
which  was  placed  near  the  fire,  and 
moved  about  till  the  liquid  was  all  con¬ 
verted  into  vapour,  when  the  air  within 
w7as  of  the  temperature  of  75°,  saturated 
with  chloroform,  and  containing  about 
29  grains  in  each  100  cubic  inches.  A 
young  rabbit  was  put  in.  It  first  at¬ 
tempted  to  escape,  then  gave  a  little 
cry,  and  sank  dowrn  on  its  side,  and  wras 
dead  three  quarters  of  a  minute  after 
its  introduction.  It  was  immediately 
removed,  and  the  ear  applied  to  its 
chest,  but  no  sound  could  be  heard. 
The  thorax  was  opened  directly,  and 
the  heart  observed  to  be  perfectly  mo¬ 
tionless  ;  but  it  commenced  to  contract 
after  its  exposure,  as  in  the  former  ex- 


THE  FATAL  CASES  OF  INHALATION  OF  CHLOROFORM. 


615 


periment,  and  in  a  few  minutes  was 
contracting  vigorously.  The  rabbit  was 
placed  back  again  in  the  jar,  in  which 
the  vapour  was  still  retained,  except  a 
little  that  escaped  during  the  momen¬ 
tary  removal  of  the  cover,  and  the  heart 
became  quickly  affected  from  the  ab¬ 
sorption  of  the  vapour  bv  its  moist 
surface.  Its  contractions  became  more 
and  more  feeble,  and  at  the  end  of  four 
minutes  had  entirely  ceased,  and  could 
not  be  excited  by  pricking ;  yet  they 
commenced  again  spontaneously  about 
ten  minutes  after  the  removal  of  the 
rabbit  from  the  jar.  but  were  not  so 
strong  as  before.  The  lungs  of  this 
rabbit  were  of  a  vermilion  colour  when 
the  chest  was  opened,  and  the  appear¬ 
ances  on  examination  of  the  body  next 
day  were  precisely  the  same  as  in  the 
former  experiment. 

It  has  appeared  to  me  that  the  res¬ 
piration  and  circulation  cease  nearly 
together  in  those  instances,  also,  in 
which  an  animal  is  slowly  killed  by  the 
inhalation  of  vapour  of  chloroform  of 
moderate  strength.  One  experiment 
will  suffice  to  relate  in  illustration  of 
this. 

Exp.  46. — A  cat,  which  it  was  re¬ 
quisite  to  destroy,  was  placed  in  a  jar 
holding  800  cubic  inches,  and  a  fluid 
drachm  and  a  half  of  chloroform  was 
put  in,  and  the  jar  covered.  The  cat 
made  efforts  to  escape  for  the  first 
minute  ;  it  then  became  insensible,  and 
was  affected  with  spasmodic  movements 
for  about  half  a  minute,  after  which  it 
was  quite  motionless,  and  relaxed,  and 
the  breathing  ceased  about  two  minutes 
after  the  commencement  of  the  experi¬ 
ment.  It  was  taken  out,  and  the 
stethoscope  applied  to  the  chest,  and 
the  sounds  of  the  heart’s  action  were 
distinctly  heard.  At  this  moment  the 
breathing  began  again,  and  the  cat  was 
put  back  into  the  jar,  from  which,  how¬ 
ever,  the  greater  part  of  the  vapour  had 
escaped.  It  remained  insensible,  and 
the  breathing  after  a  time  became  very 
feeble,  except  at  intervals,  when  it  was 
laborious.  In  little  more  than  half  an 
hour  the  animal  died.  It  was  taken 
out  as  soon  as  the  respiration  ceased, 
but  no  movement  of  the  heart  could  be 
heard.  Next  day  the  body  was  very 
rigid,  the  right  cavities  of  the  heart  and 
the  two  cavee  were  full,  but  not  greatly 
distended  ;  the  left  cavities  of  the  heart 
were  nearly  empty.  All  the  blood  was 
dark  coloured  and  fluid.  The  lungs 


were  collapsed  and  of  a  bright  red 
colour.  They  were  not  congested. 

Post-mortem  appearances. 

As  might  be  expected  from  these  in¬ 
vestigations  concerning  the  mode  in 
which  chloroform  causes  death,  the 
post-mortem  appearances  resulting  from 
it  are  neither  constant  nor  striking.  I 
have  preserved  brief  notes  of  the  exa¬ 
mination  of  14  animals  killed  by  chlo¬ 
roform — 3  cats,  3  rabbits,  2  guinea  pigs, 
4  small  birds  (chaffinches  and  larks), 
and  2  mice.  In  every  instance  the 
right  cavities  of  the  heart  were  more 
or  less  filled  with  blood,  and  in  five 
cases  out  of  the  fourteen  they  were 
much  distended.  The  left  cavities  of 
the  heart  contained  a  little  blood  in 
every  instance  in  which  their  state  is 
mentioned.  The  blood  was  fluid  in 
one  instance — that  of  the  cat,  related 
above.  In  the  other  instances  it  was 
coagulated— generally  firmly,  but  in 
three  or  four  cases  only  loosely.  The 
lungs  were  quite  free  from  congestion 
in  ten  of  the  animals,  in  the  other  four 
they  were  congested  in  patches.  The 
head  was  examined  in  only  eight  in¬ 
stances,  and  in  these  the  substance  of 
the  brain  was  free  from  congestion,  and 
the  sinuses  were  not  particularly  dis¬ 
tended,  except  in  two. 

The  fatal  cases  o  f  inh  alation  of 
chloroform. 

After  seeing  how  rapidly  the  vapour 
of  chloroform  kills  animals  when  it 
pervades  to  a  certain  extent  the  air  they 
breathe,  and  when  we  recollect  that  it 
came  all  at  once  to  be  generally  ad¬ 
ministered  without  any  previous  teach¬ 
ing  on  the  subject  in  the  schools,  it 
ought  not  to  surprise  us,  however  much 
we  are  called  on  to  deplore  the  circum¬ 
stance,  that  a  few  cases  have  occurred, 
in  different  parts  of  the  world,  in  which 
the  exhibition  of  chloroform  has  been 
attended  with  fatal  results  ;  especially 
when  we  consider  that  the  vapour  has 
usually  been  so  administered  that  its 
strength  could  not  be  controlled.  Re¬ 
flecting,  indeed,  on  the  mildness  and 
uniformity  of  the  action  of  the  vapour 
on  animals,  when  more  diluted,  as 
shown  in  some  of  the  experiments  re¬ 
lated  in  the  first  part  of  these  papers, 
we  ought  to  feel  confident  that  it  is 
capable  of  being  used  with  perfect 
safety,  certainty,  and  precision ;  and 
this  viewr  of  the  subject  agrees  with  my 


616 


THE  FATAL  CASES  OF  INHALATION  OF  CHLOROFORM. 


experience,  which  has  extended  now 
over  a  great  number  of  cases. 

I  offered  some  remarks  at  the  time 
respecting  the  fatal  case  that  occurred 
near  Newcastle.*  The  next  case  re¬ 
corded  is  one  at  Cincinnati,  U.  S.  in 
February  last.f  The  remarks  I  made 
on  the  Newcastle  case  apply  in  a  great 
measure  to  this.  Although  the  chlo¬ 
roform  was  not  administered  on  a 
handkerchief,  the  vapour  seems  to  have 
been  inhaled  in  too  concentrated  a 
form,  as  its  effects  were  produced  very 
rapidly.  The  patient  inhaled  from  a 
glass  globe,  containing  a  sponge  of 
considerable  size  saturated  with  chlo¬ 
roform.  “  Breathing  at  first  slow  ;  in¬ 
haled  12  or  15  times,  occupying  from  a 
minute  to  75  seconds,”  and  some  stumps 
of  teeth  were  then  immediately  removed. 
Now,  it  takes  three  or  four  moderately 
deep  inspirations,  and  as  many  expira¬ 
tions,  to  replace  all  the  air  contained 
at  one  time  in  the  lungs.  Consequently, 
the  patient  was  made  sufficiently  in¬ 
sensible  for  the  operation  by  the 
effect  of  about  8  to  12  inspirations, 
whilst  the  chloroform  of  3  or  4  inspira¬ 
tions  more  was  in  the  lungs,  waiting  to 
be  absorbed  and  increase  the  effect. 
I  am  aware  that  part  of  this  would  be 
expired  again  unabsorbed  as  the  patient 
continued  to  breathe,  but  that  is  equally 
true  of  what  was  inhaled  at  the  previous 
inspirations;  so  the  fact  remains,  that 
the  patient  must  have  had  from  one- 
third  to  one-half  more  chloroform  than 
was  necessary  to  produce  what  was 
deemed  sufficient  insensibility.  And  ac¬ 
cording  towhat  I  have  observed, insensi¬ 
bility  to  paincannotbeobtained  inavery 
rapid  manner  without  considerable  nar¬ 
cotism  of  the  nervous  centres — the 
third  or  fourth  degree :  therefore,  that 
the  palient  should  be  in  a  dying  state 
a  few  moments  after  the  inhalation  was 
discontinued,  was  only  what  might  have 
been  expected.  The  female  friends  of 
the  patient  considered  that  she  died 
about  two  minutes  after  the  commence¬ 
ment  of  the  inhalation  ;  and  although 
the  dentists  who  administered  the  chlo¬ 
roform  thought  that  the  patient  lived  a 
few  minutes  longer,  yet,  even  according 
to  their  account,  she  was  during  this 
time  in  a  dying  condition.  According  to 
Mrs.  Pearson’s  account,  which  is  clear 
and  precise,  the  pulse  became  feeble 


*  Med.  Gaz.  vol  xli.  p.  277. 
f  See  Med.  Gaz.  p.  79,  present  vol. 


and  then  stopped,  and  the  breathing 
ceased  about  the  same  time.  This 
agrees  with  what  is  stated  above  re¬ 
specting  the  phenomena  of  death  when 
rapidly  caused  by  chloroform,  and  with 
what  was  observed  in  the  rabbits  in 
experiments  44  and  45. 

On  inspecting  the  body, the  brain  was 
found  to  be  in  a  normal  state,  but  the 
vessels  and  sinuses  of  the  dura  mater 
contained  a  larger  quantity  of  blood 
than  usual,  which  was  liquid,  and 
mixed  with  some  bubbles  of  air.  The 
lungs  were  considerably,  but  not  in¬ 
tensely,  congested.  The  heart  was 
flaccid,  and  all  its  cavities  entirely 
empty.  It  had  been  emptied,  un¬ 
doubtedly,  after  death.  Artificial  re¬ 
spiration  was  resorted  to,  and  Mr.  Sib- 
son  has  remarked*  that  he  has  often 
known  the  heart  to  be  emptied  after 
death  by  artificial  inflation  of  the  lungs. 
Or  if  the  head  was  first  opened,  as  ap¬ 
pears  by  the  order  in  which  the  inspec¬ 
tion  is  reported,  part  of  the  two  or  three 
ounces  of  fluid  blood  which  flowed  from 
the  sinuses  of  the  dura  mater  might 
have  come  from  the  right  side  of  the 
heart,  as  I  have-  seen  the  blood  flow 
from  the  chest  and  out  by  the  lateral 
sinuses  in  an  inspection  in  which  it  was 
liquid.  The  blood  in  the  case  under 
consideration  was  as  fluid  as  water  in 
every  part  of  the  body,  and  the  globules 
were  thought  to  be  altered  in  micro¬ 
scopic  appearance.  The  causes  which 
prevent  the  coagulation  of  the  blood 
after  death  are  not  yet  well  understood, 
and  although  it  is  not  correct,  as  was 
once  supposed,  that  fluidity  of  the  blood 
is  a  constant  rule  in  certain  kinds  of  sud¬ 
den  death,  yet  there  are  sufficient  cases 
recorded  where  it  was  so,  to  show  that 
it  is  not  uncommon  in  the  human  sub¬ 
ject  when  death  takes  place  suddenly. 
The  observations  on  animals,  recorded 
above,  as  well  as  numerous  others, 
show  that  it  is  not  a  characteristic  pro¬ 
perty  of  chloroform  to  prevent  the  co¬ 
agulation  of  the  blood  ;  and  I  think 
that  the  artificial  respiration  would 
assist,  in  more  ways  than  one,  to  pre¬ 
vent  its  coagulation  in  this  case,  and 
one  presently  to  be  mentioned. 

The  next  case  that  we  have  to  notice 
occurred  at  Hyderabad. j-  The  subject 
of  it  was  a  young  woman,  who  required 
to  have  the  distal  phalanx  of  one  of 


*  Med.  Gaz.  p.  216,  present  vol. 
t  See  Med.  Gaz.,  present  vol.  p.  84. 


THE  FATAL  CASES  OF  INHALATION  OF  CHLOROFORM. 


617 


her  fingers  amputated.  The  surgeon 
who  operated  says,  “  I  administered  a 
drachm  of  chloroform  in  the  usual  way 
• — namely,  by  sprinkling  it  on  a  pocket 
handkerchief,  and  causing  her  to  in¬ 
hale  the  vapour.  She  coughed  a  little, 
and  then  gave  a  few  convulsive  move¬ 
ments.”  When  these  subsided,  the 
operation  was  performed,  and  endea¬ 
vours  were  made  to  recover  the  patient, 
but  in  vain.  Scarcely  a  drop  of  blood 
escaped  during  the  operation,  and  the 
surgeon  remarks,  “  I  am  inclined  to 
think  that  death  was  almost  instanta¬ 
neous  ;  for,  after  the  convulsive  move¬ 
ments  above  described,  she  never 
moved,  or  exhibited  the  smallest  sign 
of  life.”  There  was  no  inspection  of 
the  body. 

The  case  which  occurred  at  Bou¬ 
logne,*  is  so  like  the  above,  that  we 
may  consider  the  two  together.  The 
patient  was  a  female,  about  30  years  of 
age,  and  took  chloroform  for  the  open¬ 
ing  of  an  abscess.  M.  Gorre,  the  ope¬ 
rator,  says,  “  I  placed  over  the  nostrils 
of  the  patient,  a  handkerchief  moistened 
with  from  fifteen  to  twenty  drops  at 
the  most  of  chloroform.  Scarcely  had 
she  taken  several  inspirations, when  she 
put  her  hand  on  the  handkerchief  to 
withdraw  it,  and  cried  with  a  plaintive 
voice,  “  I  choak !”  Immediately  the 
face  became  pale ;  [a  symptom  re¬ 
corded  also  of  the  Newcastle  case ; 
and  the  one  at  Cincinnati]  the  counte¬ 
nance  changed  ;  the  breathing  embar¬ 
rassed;  and  she  foamed  at  the  mouth. 
At  the  same  instant,  (and  that  certainly 
less  than  a  minute  after  the  beginning 
of  the  inhalation),  the  handkerchief 
moistened  with  chloroform  was  with¬ 
drawn.”  The  operation  was  performed, 
and  then  efforts  were  made  to  restore 
the  patient,  but  she  was  dead;  and  M. 
Gorre  remarks  that  the  death  was 
without  doubt  complete  at  the  moment 
when  he  made  the  incision. 

From  experiments  related  in  former 
parts  of  these  papers,  the  conclusion 
was  arrived  at,  that  to  produce  a  degree 
of  narcotism  that  would  arrest  the  re¬ 
spiration,  the  blood  must  contain  about 
one  twenty-second  part  as  much  chloro¬ 
form  as  it  would  dissolve  ;  and  that  to 
narcotise  the  heart  so  as  to  stop  its 
contractility,  the  blood  must  contain 
about  one-eighteenth  part  as  much  as 
it  would  dissolve.  By  a  calculation 

*  See  Med.  Gaz,,  present  vol.  p.  76  and  211. 


similar  to  that  made  before,*  I  find 
that  half  a  fluid  drachm  is  the  quantity 
that  there  should  be  in  the  whole  of 
the  blood  of  a  person  of  average  size, 
to  stop  the  respiration,  and  37  minims 
to  arrest  the  heart’s  action.  In  the 
case  which  occurred  in  India,  a  drachm 
of  chloroform  was  placed  on  the  hand¬ 
kerchief.  We  cannot  easily  suppose 
that  more  than  half  of  this  entered  the 
patient’s  lungs,  since  the  expired  air 
carries  away  a  portion  as  it  passes  over 
the  handkerchief.  And  since,  as  was 
estimated  before,  only  about  half  of 
what  enters  the  lungs  becomes  ab¬ 
sorbed,  the  remainder  being  expired 
again,  there  could  only  be  aboutfifteen 
minims  in  the  blood.  This  quantity, 
supposing  the  young  Hindoo  female 
was  but  half  the  average  size  of  the 
adult,  and  this  is  not  improbable, 
would  only  be  just  sufficient  to  cause 
death  by  arresting  the  respiration, 
without  immediately  stopping  the 
heart’s  action,  providing  the  chloro¬ 
form  were  equally  diffused  through  the 
whole  of  the  blood.  There  is  every 
reason,  however,  from  the  symptoms, 
to  believe  that  the  action  of  the  heart 
was  suddenly  arrested  ;  and  the  quan¬ 
tity  used  in  the  case  at  Boulogne 
would  not  have  sufficed  to  cause  death 
in  any  way,  if  it  had  been  equally 
mixed  with  the  blood.  But  it  was  not 
equally  diffused  through  the  circula¬ 
tion  in  either  case, — there  was  not 
time  for  it  to  be  so.  Mr.  Sibson,  in 
treating  the  subject  of  death  from  chlo¬ 
roform, f  makes  some  remarks  in  which 
I  entirely  agree.  He  says,  “  the  poison 
penetrates  to  the  heart  from  the  lungs 
in  a  single  pulsation,  and  at  the 
beginning  of  the  next  systole  the  blood 
is  sent  through  the  coronary  artery  to 
the  whole  muscular  tissue  of  the  heart. 
The  blood  passing  into  the  coronary 
artery  is  less  diluted — is  more  strongly 
impregnated  with  chloroform— than  is 
the  blood  in  any  other  part  of  the  sys¬ 
tem,  except  the  lungs.”  By  experi¬ 
ments  42  to  45  on  frogs  and  rabbits,  it 
has  been  shewn  that  chloroform  will 
act  locally  on  the  heart ;  consequently, 
if  the  blood  passing  from  the  lungs  to 
the  left  side  of  the  heart  should  hap¬ 
pen  to  contain  one-eighteenth  part  as 
much  vapour  as  it  would  dissolve,  the 
patient  might  be  suddenly  killed  before 


*  Med.  Gaz.  vol.  xli.  p.  894. 
f  Med.  Gaz.,  present  vol.,  p.  109. 


618 


THE  FATAL  CASES  OF  INHALATION  OF  CHLOROFORM. 


the  nervous  system  in  general  were 
brought  under  the  influence  of  the 
narcotic.  A  small  quantity  of  chloro¬ 
form  might  suffice  to  produce  this  re¬ 
sult,  if  the  vapour  were  mixed  with 
only  a  limited  portion  of  air. 

The  difficulty  of  inhaling  the  vapour 
in  a  concentrated  form,  on  account  of 
its  pungency,  and  the  further  dilution 
of  it  when  inhaled  with  the  air  already 
in  the  lungs,  no  doubt  would  usually 
prevent  this  kind  of  accident,  and  are 
in  fact  the  reasons  why  it  has  not  more 
often  occurred.  Still  I  believe  that  the 
patient  is  not  safe  unless  the  vapour  is 
systematically  mixed  with  so  much  air 
that  no  great  quantity  of  it  can  be  in 
the  lungs  at  one  time.  I  am  of  opinion 
that  ether  is  incapable  of  causing  this 
kind  of  accident ;  for  the  blood  may 
imbibe  with  safety  so  considerable  a 
volume  of  its  vapour,  that  the  quantity 
which  the  lungs  can  contain  at  once, 
adds  but  little  to  the  effect.  And  I 
consider  that  a  patient  could  only  lose 
his  life  by  ether,  from  its  careless  con¬ 
tinuance  for  several  inspirations  after 
well-marked  symptoms  of  danger  had 
set  in. 

M.  Gorre  says  that  he  poured  on 
the  handkerchief  not  more  than  fifteen 
to  twenty  drops.  The  drops  of  chlo¬ 
roform  are  very  small.  "When  dropped 
from  an  ordinary  phial,  nine  of  them 
are  equal  to  about  two  minims,  and 
twenty  drops  would  be  less  than  five 
minims — a  very  small  quantity.  But, 
as  the  chloroform  was  poured,  he  pro¬ 
bably  means  as  much  as  would  be 
equal  to  fifteen  or  twenty  drops  of 
water—in  fact,  about  as  many  minims  ; 
and,  indeed,  as  it  was  not  measured, 
we  have  no  means  of  being  certain 
that  there  was  not  more — say,  half  a 
fluid-drachm.  However,  fifteen  minims 
might  be  amply  sufficient  to  cause 
death  in  the  way  indicated  above,  even 
if  but  half  of  it  entered  the  lungs  ; 
and  the  sudden  paleness,' and  almost 
instantaneous  death,  clearly  indicate 
that  the  circulation  must  have  ceased 
suddenly. 

The  post-mortem  appearances  in  the 
case  at  Boulogne  were  very  nearly  the 
same  as  in  the  case  which  occurred  at 
Cincinnati,  previously  alluded  to.  Arti¬ 
ficial  respiration  had  been  resorted  to, 
and  carried  to  the  extent  of  perma¬ 
nently  dilating  the  pulmonary  vesicles. 
Air  was  met  with  in  the  sinuses  of  the 
dura  mater  in  the  American  case,  and 


in  this  case  a  good  deal  of  air  was 
mixed  with  the  blood  in  the  veins  of 
almost  all  parts  of  the  body.  There 
can  be  but  little  doubt  that  this  was  a 
result  of  the  artificial  respiration,  al¬ 
though  one  cannot  tell  precisely  in 
what  way  the  result  was  produced. 
The  peculiar  state  of  the  blood,  which 
was  very  fluid  and  dark-coloured,  as 
in  the  American  case,  must  have  de¬ 
pended  rather  on  the  suddenness  of 
the  death,  and  the  artificial  respira¬ 
tion,  than  on  any  immediate  action  of 
the  small  quantity  of  chloroform — a 
quantity  much  less  than  is  usually  in¬ 
haled  in  a  surgical  operation. 

A  patient  died  whilst  taking  chloro¬ 
form  during  an  amputation  at  the  hip- 
joint,  at  the  Hopital  Beaujon,  inParis^ 
But  the  death  in  this  instance  was  pro¬ 
bably  not  entirely  due  to  the  chloro¬ 
form  ;  for  although  the  patient  appa¬ 
rently  got  an  overdose  of  the  vapour 
when  it  was  repeated  during  the  ope¬ 
ration,  yet,  as  the  pulse  was  occasion¬ 
ally  appreciable  for  three-quarters  of 
an  hour  afterwards,  he  would  most 
likely  have  recovered,  had  it  not  been 
for  the  lesion  occasioned  by  the  opera¬ 
tion,  which  it  seems  w’as  never  finished. 
So  the  four  cases  previously  alluded  to, 
and  which  happened  at  Newcastle, 
Cincinnati,  Hyderabad,  and  Boulogne 
respectively,  comprise  the  whole  of  the 
instances  in  which  it  appears  to  me 
that  death  has  clearly  and  undoubtedly 
resulted  from  the  inhalation  of  chloro¬ 
form.  There  was  a  death  at  Aberdeen, 
but  not  from  the  professional  adminis¬ 
tration  of  the  agent.  There  is  another 
case,  however,  in  which  the  death  is 
generally  attributed  to  the  chloroform  ; 
and  occurring,  as  it  did,  in  the  practice 
of  Mr.  Robinson,  who  has  had  great 
experience,  and  deservedly  earned  a 
high  reputation,  connected  with  the 
administration  of  ether  and  chloroform, 
it  has  made  a  great  impression  both  on 
medical  men  and  the  public.  My 
reasons  for  doubting  that  death  w7as 
caused  by  chloroform  in  this  instance 
are  these: — Mr.  Robinson’s  servant 
states,  in  her  evidence,  that  the  inhaler 
was  not  applied  to  the  patient’s  face, 
but  held  at  a  little  distance  from  it; 
and,  with  the  kind  of  inhaler  Mr. 
Robinson  uses,  it  is  impossible  that 
the  air  the  patient  breathed  could  be¬ 
come  strongly  charged  with  vapour  in 
this  wray ;  tor  it  would  pass  into  the 
mouth  and  nostrils  by  the  side  of  the 


THE  FATAL  CASES  OF  INHALATION  OF  CHLOROFORM. 


619 


face-piece,  and  very  little  of  it  would 
pass  over  or  through  the  sponge. 
Again,  the  patient  was  remarking  that 
the  vapour  was  not  strong  enough,  just 
when  the  inhaler  was  removed,  and 
the  moment  before  he  suddenly  ex¬ 
pired.*  I  consider  that  he  would  have 
made  no  such  remark  if  there  had  been 
a  quantity  of  vapour  in  his  lungs 
capable  of  suddenly  paralysing  the 
heart.  This  condition  of  the  patient 
is  totally  unlike  the  coughing  and  con¬ 
vulsions  in  the  case  in  India,  or  the 
exclamation  “I  choke/’  in  that  at 
Boulogne.  I  am  not  inclined,  how¬ 
ever,  to  attribute  the  sudden  death  at 
that  moment  to  a  mere  coincidence,  as 
it  might  be  occasioned  by  mental  emo¬ 
tion.  Fainting  is  not  altogether  pecu¬ 
liar  to  the  female  sex  ;  and,  supposing 
syncope  to  occur  in  a  patient  who  has 
fatty  degeneration  of  the  substance  of 
the  heart,  and  an  enlarged  liver  greatly 
encroaching  on  the  space  of  the  tho¬ 
rax,  one  can  easily  understand  why  he 
should  not  recover.  In  some  of  the 
reports  it  was  stated  that  the  patient 
did  not  appear  alarmed,  for  he  was 
laughing  and  talking  the  moment 
before  he  died;  but  I  do  not  know  why 
a  patient  should  laugh  in  a  dentist’s 
operating  chair,  unless  to  disguise  or 
try  to  banish  his  apprehension.  He 
had  been  led  by  his  medical  attendant 
in  the  country  to  believe  that  the 
chloroform  would  be  attended  with 
danger  in  his  case  ;  and  again,  just  the 
moment  before  he  died,  Mr.  Robinson 
was  asking  him  to  have  his  teeth  taken 
out  without  proceeding’  further  with 
the  vapour.  The  post-mortem  appear¬ 
ances  are  quite  consistent  with  this 
cause  of  death;  and,  according  to  this 
view  of  the  subject,  the  disease  of  the 
internal  organs  assists  to  explain  the 
fatal  occurrence ;  but  I  do  not  see  how 
it  can  assist  in  explaining  it,  if  it  be 
attributed  to  chloroform,  although  I 
am  aware  that  it  is  usually  thought  to 
do  so. 

If  the  heart  were  so  thinned  that  it 
were  in  danger  of  being  ruptured  by 
the  least  distension,  or  if  some  of  its 
orifices  were  so  contracted  that  it 
could  not  maintain  the  circulation 
under  increased  exertion  or  excite- 


*  I  do  not  understand  why  Mr.  Robinson  was 
proceeding  to  add  more  chloroform,  having  pre¬ 
viously  put  a  drachm  and  a  half  on  the  sponge, 
as  applying  the  inhaler  closer  to  the  face  woult 
have  made  the  vapour  stronger. 


ment,  I  could  understand  how  the  in¬ 
halation  might  be  attended  with  dan¬ 
ger,  if  excitement  and  struggling  were 
produced  by  it,  as  sometimes  happens. 
And  on  these  grounds  I  always  looked 
on  extensive  disease  of  the  heart  as  a 
contra-indication,  to  a  certain  extent, 
of  inhalation,  and  have  expressed  opi¬ 
nions  to  that  effect ;  but  I  cannot  con¬ 
ceive  how  a  moderate  and  gradual 
inhalation  of  chloroform  should  cause 
any  person’s  heart,  however  diseased, 
suddenly  to  cease  beating.  There  are 
neither  facts  nor  analogies  in  support 
of  such  an  occurrence.  Mr.  Thomas 
Wakley,  having  met  with  great  con¬ 
gestion  of  the  heart  and  lungs  in  cer¬ 
tain  of  the  animals  that  he  killed  with 
chloroform,  and  mistaking,  in  my  opi¬ 
nion,  the  consequence  of  the  mode  of 
dying  for  the  cause  of  death,  had  ex¬ 
pressed  an  opinion  that  this  agent 
would  be  particularly  dangerous  in 
diseases  of  the  heart  and  lungs;  but 
this  case,  the  only  one  of  those  where 
death  was  attributed  to  chloroform,  in 
which  any  previous  disease  of  these 
organs  was  found,  cannot  be  consi¬ 
dered  to  support  an  opinion  founded 
on  these  grounds ;  for  here  there  was 
no  congestion  of  the  heart,  and  but 
very  little  of  the  lungs.  I  am  happy 
to  find  views  similar  to  my  own,  re¬ 
specting  chloroform  in  disease  of  the 
heart,  entertained  by  one  whose  opi¬ 
nion,  both  on  account  of  the  attention, 
he  has  paid  to  this  subject,  and  his 
great  merit  as  a  physiologist,  is  entitled 
to  so  much  respect  as  that  of  Mr. 
Sibson.  He  says*  that  “  persons  the 
subject  of  heart  disease,  when  the 
dread  of  a  severe  operation  is  great, 
may  sometimes  be  peculiarly  benefited 
by  the  careful  and  short  production  of 
aneesthesia  during  the  cutting  part  of 
an  operation.” 

[To  be  continued.] 


ROYAL  COLLEGE  OF  SURSGEON. 

Gentlemen  admitted  Members,  October 
6,  1848  : — J.  A.  Tapson — J.  Laity — J.  G. 
Symes— J.  O.  Fletcher— C.  E.  B.  Danson 
— T.  Whitehead— W.  Cox— W.  Patteson— 
R.  Barnwell.  T.  Hunter  and  T.  E.  Moulds- 
worth  passed  for  Naval  Surgeons. 


*  Loc.  cit. 


620  MR.  HARE  ON  LONG-EXISTING  CURVATURE  OF  THE  SPINE. 


ON  CASES  OF  LONG-EXISTING 
CURVATURE  of  the  SPINE. 

By  Samuel  Hare, 

Member  of  the  Royal  College  of  Surgeons,  &c. 

As  the  cases  of  spinal  disease  for  which 
the  profession  is  consulted  are  generally 
of  a  chronic  character,  I  beg  to  forward, 
for  insertion  in  the  Medical  Gazette, 
one  of  long  standing  and  of  extreme 
lateral  curvature,  complicated  with  ex¬ 
tensive  excurvation  of  the  spinal  column 
and  ribs. 

I  was  first  consulted  about  the  middle 
of  October,  1847,  on  the  case  of  Miss 
AV.,  aged  16^  years,  residing  in  the 
county  of  York,  and  obtained  the  fol¬ 
lowing  account  of  the  previous  state  of 
her  health,  and  of  the  progress  of  the 
disease  up  to  the  time  when  I  saw  her. 

History. — She  was  a  small  and  deli¬ 
cate  child  when  born,  and  during  in¬ 
fancy  was  frequently  ill  and  very  fret¬ 
ful  :  she  had  the  hooping-cough  severely 
when  three  years  old  ;  when  five,  she 
complained  of  great  pain  in  the  upper 
part  of  one  of  the  lower  extremities, 
especially  after  any  exertion,  as  in 
walking,  but  there  was  no  paralysis, 
nor  was  there  any  disease  of  the  spine 
known  to  exist;  at  the  age  of  six,  she 
had  the  measles,  accompanied  with 
severe  inflammation  of  the  lungs,  from 
which  period  her  growth  was  for  some 
time  suspended,  and  she  was  altogether 
delicate  afterwards ;  when  seven,  it 
was  noticed  that  she  bent  to  the  right 
side — that  the  right  shoulder  was  con¬ 
siderably  enlarged — that  she  was  soon 
fatigued,  and  frequently  fell  while 
walking.  Two  years  afterwards,  the 
curvature  to  the  right  side,  and  the 
projection  of  the  right  shoulder,  having 
increased  considerably,  her  medical 
adviser  recommended  her  to  have  a 
pair  of  steel  stays  made,  which  she  has 
continued  to  wear  to  the  present  time. 
When  eleven,  she  suffered,  and  had 
done  so  for  some  time,  from  a  severe 
cough,  attended  with  difficulty  of 
breathing,  and  palpitation  of  the 
heart :  her  debility,  w7hich  was  always 
considerable,  continued  to  increase, 
attended  with  bad  appetite  and  other 
symptoms  of  a  disordered  state  of  the 
digestive  organs. 

From  the  period  at  which  the  defor¬ 
mity  was  first  observed,  the  disease  and 


the  consequent  debility  have  gone  on 
increasing  to  the  present  time,  notwith¬ 
standing  the  use  of  the  stays  alluded 
to  and  the  anxious  care  of  her  parents. 

Present  state. — On  examining  this 
patient,  I  found  that  the  head  had 
fallen  so  considerably  forward  and  to  the 
left  side,  that  on  applying  a  plumb-line 
to  the  forehead  there  was  a  distance  of 
4f  inches  from  the  upper  end  of  the 
sternum  to  the  plumb-line:  the  neck  was 
consequently  so  short  as  to  be  scarcely 
visible,  and  the  chin  approached  very 
near  the  chest:  this  twisting  of  the 
neck  to  the  left  was  increased  by  the 
hunch  (presently  to  be  described) 
which  was  seen  projecting  considerably 
above  the  shoulder. 

The  whole  chest  was  greatly  con¬ 
tracted  in  front,  the  shoulders  being 
brought  very  forward,  and  the  sternum 
projecting  much,  and  pointing  to  the 
right  side.  The  ribs  were  considerably 
excurvated  on  the  right  side,  while  on 
the  left,  owing  to  the  compression  of 
the  ribs  by  the  stays,  and  to  the  pro¬ 
jection  of  the  hip,  and  the  depression 
of  the  shoulder  on  that  side,  a  consi¬ 
derable  space  or  arch,  to  the  extent  of 
rather  more  than  an  inch  and  a  half, 
existed  between  the  trunk  and  the 
arm.  The  integuments  of  the  chest 
and  abdomen  (especially  over  the  left 
half  of  the  latter)  were  much  wrinkled, 
and  the  mammae  flaccid  and  atrophied. 

The  dorsal  portion  of  the  spine  was 
not  only  curved  excessively  to  the 
right,  but  was  likewise  very  much  ex¬ 
curvated,  so  that  the  spine  and  the 
ribs — which  always  in  such  cases  par¬ 
ticipate  in  the  deformity — formed  a 
huge  projection,  backwards  and  up¬ 
wards,  to  the  right :  this  projecting 
mass  was  marked  by  two  ridges  nearly 
parallel  with  each  other — the  one  being 
formed  by  the  spinous  processes  of  the 
vertebrae  (which  looked  to  the  left  in¬ 
stead  of  directly  backwards) ;  and  the 
other  by  the  ribs  of  the  right  side, 
which  were  bent  upon  themselves,  at 
about  an  inch  and  half  from  their  spinal 
extremities,  into  a  sharp  angle,  so  as  to 
form  the  edge  or  most  projecting  por¬ 
tion  of  the  hump :  indeed,  this  curva¬ 
ture  of  the  ribs  was  one  of  the  most 
acute  or  angular  I  have  met  with, 
and  formed  a  narrow,  but  very  project¬ 
ing  ridge  (which  could  be  taken  be¬ 
tween  the  finger  and  the  thumb)  of  at 
least  fourteen  inches  in  length.  On 
the  outer  side  of  this  projecting  mass. 


MR.  HARE  ON  LONG-EXISTING  CURVATURE  OF  THE  SPINE.  621 


the  right  scapula  was  so  placed  that 
its  posterior  border  looked  almost  di¬ 
rectly  backwards,  while  the  left  scapula 
was  half  buried  in  a  kind  of  fossa  formed 
by  the  ribs  of  that  side  being  bent  in¬ 
wards  to  an  extent  almost  as  great  as 
that  to  which  the  right  ones  were  ex- 
curvated.  Three  of  the  vertebrae  (the 
2d,  3d,  and  4th  dorsal),  instead  of  being 
placed  perpendicularly,  formed  almost 
a  horizontal  line  at  the  upper  part  of 
the  dorsal  curve,  while  the  compensa¬ 
ting  one  in  the  lower  part  of  the  spine 
had  its  convexity  of  course  to  the  left 
side,  and  was  of  considerable  size  :  the 
left  hip  projected  exceedingly,  and  the 
same  space  described  as  seen  in  front, 
between  the  arm  and  side,  was  also 
seen  from  behind,  while  the  right  arm 
was  pushed  out  by  the  convexity  of 
the  dorsal  curve  being  towards  that 
side. 

Her  cast  of  countenance  was  heavy  ; 
her  complexion  not  clear,  there  being 
some  eruptions  of  acne  throughout  her 
face  and  on  her  back  also.  The  in¬ 
teguments  over  the  whole  of  the  left 
side,  from  the  clavicle  to  the  hip,  were 
exceedingly  sensitive,  so  that  she  could 
scarcely  bear  the  part  touching,  any 
pressure  causing  considerable  nervous 
pain  of  an  almost  indescribable  nature ; 
there  was  also  much  pain  in  the  lum¬ 
bar  region,  and  in  the  right  hip  as  well, 
which  was  increased  by  walking. 

The  shortness  of  breathing  and  pal¬ 
pitation  of  the  heart  had  become  much 
worse  for  some  years  past,  particularly 
in  going  upstairs,  or  using  any  other 
exertion,  as  in  walking ;  her  cough, 
also,  was  very  troublesome,  especially 
when  she  laid  down  :  indeed,  her  suf¬ 
ferings  were  altogether  very  distressing, 
and  her  unfavourable  symptoms  had 
made  so  much  progress  during  the  last 
few  months,  that  her  friends  thought 
her  life  in  imminent  danger. 

She  was  considered  to  have  entirely 
ceased  growing,  not  having  increased 
in  height  for  some  time,  though  she 
now  only  measured  4ft.-6|. 

Finding,  from  there  being  some 
slight  mobility  in  the  deformed  part  of 
the  spine,  that  anchylosis,  if  it  had 
taken  place,  which  was  most  probably 
the  case  in  some  degree,  had  only  done 
so  partially,  I  determined  to  rectify  the 
distortion  as  much  as  possible,  think¬ 
ing  that  the  case  offered  a  hope  of 
success,  notwithstanding  the  great 
length  of  time  which  it  had  existed. 


With  this  object  in  view,  it  was  of 
course  necessary  to  remove  the  weight 
of  the  head  and  shoulders  from  the  de¬ 
formed  spine — apian  which  could  only 
be  done  efficiently  by  the  use  of  the 
recumbent  position  for  some  hours  a 
day.  This  was  cheerfully  assented  to 
by  the  young  lady,  and  frictions  and 
firm  pressure  by  the  hand  were  em¬ 
ployed  three  or  four  times  a  day  in 
such  a  direction  as  to  place  the  dis¬ 
torted  parts  in  a  more  favourable  posi¬ 
tion  for  permanent  recovery.  After¬ 
wards,  I  applied  firmer  and  more  con¬ 
stant  pressure,  by  means  of  a  con¬ 
trivance  which  I  now  generally  em¬ 
ploy,  and  which  consists  of  a  pad 
placed  at  the  end  of  a  spring,  the 
power  of  which  can  be  exactly  regu¬ 
lated  so  as  to  suit  any  individual  case, 
by  raising  or  depressing,  at  the  side  of 
the  plane  on  which  the  patient  reclines, 
the  upright  piece  to  which  the  spring 
is  fixed  at  a  right  angle.  This  is  used 
at  first  for  a  short  time,  and  afterwards 
for  a  longer  period,  as  may  be  re¬ 
quired,  while  the  patient  is  in  a  prone 
position,  and  is  applied  in  such  a  direc¬ 
tion  as  gradually  to  press  those  por¬ 
tions  of  the  spine  which  still  retain 
their  mobility  towards  their  proper 
position.  A  constant  but  very  gentle 
extension  of  the  spine  is  likewise 
maintained  during  the  time  that  the 
patient  remains  in  the  recumbent  posi¬ 
tion,  by  the  application  of  moderate 
weights  to  the  head  and  extremities, 
according  to  the  plan  I  have  elsewhere* 
described. 

Close  attention  was  paid  to  the  state 
of  the  general  health,  and  mild  warm 
aperient  medicines  were  exhibited,  by 
which  its  condition  was  improved,  and 
the  eruption  on  the  skin  gradually  re¬ 
moved  :  tonics  were  afterwards  ad¬ 
ministered.  Under  the  foregoing  plan 
of  treatment,  the  slight  elasticity  or 
mobility  of  the  deformed  part  of  the 
spine,  which  has  been  alluded  to,  and 
which  gave  the  hope  of  benefit  being 
derived,  manifestly  increased.  This  is 
usually  one  of  the  earliest  signs  of  im¬ 
provement  taking  place ;  and  in  this 
case  it  was  soon  followed  by  an  obvious 
improvement  in  the  appearance  of  the 
deformity;  so  that,  by  the  end  of 
January,  on  examining  the  spine  and 
other  parts,  the  projecting  shoulder 


*  Practical  Observations  on  Curvatures  of  the 
Spine,  2d  edit.  18H. 


622  MU.  HARE  ON  LONG-EXISTING  CURVATURE  OF  THE  SPINE. 


was  evidently  less,  the  vertebrae  were 
in  a  more  perpendicular  line,  the  neck 
was  longer,  and  the  chest  was  more 
developed..  The  notes  I  took  on  25th 
April  were,  that  she  had  continued  to 
progress  most  satisfactorily,  not  having 
had  a  single  unpleasant  symptom  since 
she  commenced  treatment,  and  that 
the  direction  of  the  spinal  column  and 
projection  of  the  ribs  had  much  fur¬ 
ther  improved;  her  general  health  had 
likewise  become  very  considerably 
better,  as  was  also  her  breathing, 
which,  from  being  so  short  that  she 
could  not  read  aloud  longer  than  ten 
minutes  or  a  quarter  of  an  hour,  had 
become  so  much  improved  that  she 
was  able  to  read  for  any  length  of  time 
without  feeling  any  inconvenience 
from  it,  and  expressed  herself  as  feel¬ 
ing  to  have  “  more  room  in  her  chest 
to  breathe  with.”  I  need  not  detail 
the  progress  she  made  from  time  to 
time,  but  may  mention,  that  in  July 
both  scapulae  rested  upon  the  plane 
when  she  was  in  the  recumbent  posi¬ 
tion;  while,  at  first,  the  left  one  was 
at  a  considerable  •  distance  from  it 
when  she  was  in  that  position,  owing 
to  the  great  projection  of  the  spine, 
ribs  and  scapula  of  the  right  side. 


When  she  had  been  nearly  eleven 
months  under  treatment,  she  was  in 
the  following  improved  condition 
Her  head  was  quite  erect,  and  had  no 
perceptible  inclination  to  the  left  side, 
and  the  neck  was  much  longer,  and 
well  formed  ;  the  chest  was  more  ex¬ 
panded,  and  the  two  lateral  halves 
of  it  were  nearly  symmetrical,  and 
the  sternum  did  not  project  more 
than  in  an  ordinarily-formed  chest, 
while  the  spaces  between  the  ribs 
and  arms  were  very  much  filled  up. 
On  a  posterior  view,  the  spinal  co¬ 
lumn  was  much  more  perpendicular 
than  it  had  been  ;  scarcely  anything  of 
the  lumbar  curve  remained,  and  the 
upper  one  was  much  improved;  those 
portions  in  which  there  was  mobility 
before,  having  become  much  more 
straight,  and  the  marked  deformity 
only  remaining  in  that  part  where 
anchylosis  had  before  taken  place,  and 
which  it  would  of  course  be  impracti¬ 
cable  to  rectify ;  the  form  of  the  ribs 
had  improved  correspondingly  with 
that  of  the  spine.  With  this  altera¬ 
tion  in  her  figure,  her  health  and 
strength  had  likewise  increased:  she 
could  support  her  head  with  perfect 
ease,  and  walked  comfortably,  and 


MR.  HARE  ON  LONG-EXISTING  CURVATURE  OF  THE  SPINE.  623 


with  a  firmer  step  ;  while  before,  all  1 
motion  was  a  fatigue  and  pain  to  her.  < 
Her  appetite  and  spirits  were  excellent,  t 
As  stated  in  a  preceding  part  of  this  { 
paper,  she  had  lost  all  dyspncea,  and  i 
instead  of  being  able  to  expire  only  30  r 
cubic  inches,  as  was  the  case  when  she  ; 
first  same  under  treatment,  she  could  I 
then  breathe  as  much  as  69  cubic  ] 
inches.  She  had  also  increased  in  s 
weight  from  5st.  91b.  to  6st.  |lb. 

The  general  change  in  her  appear¬ 
ance,  however,  will  probably  be  better  ; 
understood  by  the  accompanying  en¬ 
gravings  than  by  any  description.  The 
first  is  a  copy  from  a  cast  of  her  taken 
when  she  commenced  treatment  ;  the 
other  represents  her  as  she  was  at  the 
period  of  the  last  report. 

Remarks. — The  foregoing  case,  on 
account  of  its  long  continuance, 
the  extensive  deformity  it  exhibited, 
and  the  benefit  it  has  received  from 
treatment,  is  one  of  much  interest.  Too 
many  of  such  instances  are,  from  their 
being  considered  irremediable,  left  to 
take  their  chance,  without  any  medical 
or  surgical  aid  being  sought,  and 
without,  therefore,  any  opportunity  of 
cure  being  afforded  ;  for  it  is  a  disease 
which  of  itself  has  little  or  no  tendency 
to  improvement,  but,  on  the  other  hand, 
its  tendency  is  generally  to  become 
gradually  worse.  The  earlier  such 
cases  come  under  treatment,  the  greater 
the  amount  of  benefit,  which,  as  a 
general  rule,  wall  be  obtained  there¬ 
from,  but  where  anchylosis  between 
the  vertebree  or  between  these  and  the 
ribs  has  not  taken  place,  a  very  consi¬ 
derable  amount  of  good  may  usually 
be  effected,  even  in  cases  of  very  long 
standing.  In  this  instance,  though 
a  very  severe  one,  I  felt  satisfied  from 
the  experience  1  had  had  in  similar 
cases,  that  by  perseverance  in  the  plan 
I  am  in  the  habit  of  adopting— in  a 
word,  by  pressure  in  a  proper  direction 
on  the  deformed  parts,  by  gentle  exten-  i 
sion  of  the  spine,  and  by  attention  to 
the  state  of  the  general  health,  (which 
must  be  treated  according  to  the  exi¬ 
gencies  of  the  respective  cases,)  very 
considerable  benefit  might  be  derived. 

As  l  have  already  stated  in  the  ac¬ 
count  of  the  case,  the  circumstance 
on  which  I  grounded  my  opinion  of 
the  practicability  of  improvement  being 
effected  was,  that  upon  the  spine  being 
firmly  pressed  upon  by  the  hand,  a 


little  mobility  of  the  vertebree  on  each 
other  was  perceptible  above  and  below 
the  most  prominent  part;  and  it  is 
gratifying  that  the  results  of  the  treat¬ 
ment  have  borne  out  the  opinion  given. 
The  curvature  in  the  dorsal  region  was, 
as  in  by  far  the  majority  of  instances, 
to  the  right  side  ;  but  the  case  was  not 
purely  one  of  lateral  deformity,  as  the 
spine  was  likewise  excurvated — a  com¬ 
plication  which  usually  renders  a  case 
more  difficult  to  treat,  owing  to  the 
great  deformity  of  the  ribs  which  gene¬ 
rally  accompanies  it,  and  which  did  so 
in  this  instance  :  indeed,  a  feature  in 
this  case,  as  remarkable  as  the  projec¬ 
tion  of  the  right  side  of  the  back,  was 
the  incurvation  of  the  ribs  to  the  left  of 
the  spine,  and  their  forming  a  hollow 
in  which  the  scapula  of  that  side  was 
imbedded.  I  have  seen,  however,  some 
other  instances  of  a  similar  kind,  and 
equally  severe,  and  believe  they  are 
often  caused,  or  at  any  rate  made  worse, 
by  the  pressure  of  stays,  wTorn  with  a 
view  of  hiding  the  deformity,  or  some¬ 
times  even  by  those  used  with  the  inten¬ 
tion  of  relieving  it ;  for  they  are  fre¬ 
quently  of  such  a  construction  as  to 
produce  the  most  serious  results  by 
preventing  the  proper  expansion  of 
the  chest,  and  thus  aggravating  the 
dyspnoea  caused  by  the  distortion, 
which  in  the  above  case  was,  when  the 
patient  first  came  under  my  care,  a  very 
troublesome  and  distressing  symptom. 

1  have  seen  not  a  few  instances  in 
which  the  curvature  has  been  stated  to 
have  got  gradually  but  considerably 
worse  during  the  time  they  have  been 
worn ;  besides  which,  it  not  unfre- 
quently  happens  that  the  same  stays 
are  worn  for  a  great  length  of  time  to¬ 
gether,  without  any  change  or  altera¬ 
tion  to  meet  the  natural  growth  of  the 
body.  I  was  recently  consulted  respect¬ 
ing  a  youth  of  twelve  years  of  age,  who 
had  thus  been  allowed  to  wear,  I  might 
almost  say,  to  live  in,  the  same  stays 
i  for  no  less  a  period  than  three  years, 
though  the  pressure  they  caused  was 
inconvenient,  and  L  scarcely  need  to 
add,  at  least  under  these  circumstances, 
injurious. 

But,  besides  the  improvement  which 
accrues  from  treatment  in  the  general 
appearance  of  the  figure,  the  correlative 
advantages  which  arise  from  it  are 
equally  important,  and  may  occur  in 
cases  where,  from  there  being  some 
amount  of  bony  union  between  the 


624  MR.  HARE  ON  LONG-EXISTING  CURVATURE  OF  THE  SPINE. 


vertebrae,  complete  cure  of  the  defor¬ 
mity  may  not  be  possible  :  I  allude 
especially  to  the  fact  of  the  patients 
usually  increasing  so  much  in  strength, 
to  their  becoming  stouter,  and  to  their 
restoration,  as  in  the  preceding  case, 
from  (frequently)  an  almost  helpless 
state  to  one  of  comfort  and  activity,  in 
which  they  are  able  to  fulfil  the  ordi¬ 
nary  duties  that  may  devolve  upon 
them,  and  consequently  cease  to  be 
that  cause  of  care  and  anxiety  to  them¬ 
selves  and  friends  which  they  have 
perhaps  been  for  years  before :  the  im¬ 
provement  also  which  occurs  under 
treatment  in  the  breathing  (amongst 
other  symptoms)  has  been  exemplified 
in  the  case  above  given — on  the  one 
hand,  by  the  dyspnoea  becoming  gra¬ 
dually  less  troublesome  on  exertion  or 
from  reading  aloud;  and,  on  the  other, 
by  the  increased  quantity  of  air  which 
the  patient  was  able  to  expire,  and 
which,  while  it  amounted,  when  I  first 
saw  her,  to  only  30  cubic  inches,  had 
increased  by  January  25th  to  50 
inches,  in  April  to  60,  in  July  to  67, 
while  on  the  last  occasion  on  which  J 
examined  her  there  was  a  little  further 
increase,  viz.  to  69  cubic  inches.  The 
breathing  capacity  of  the  lungs  is  as¬ 
certained  by  means  of  the  Pulmometer, 
an  instrument  I  have  been  in  the  habit 
of  using  since  1843  to  ascertain  the 
amount  of  air  which  could  be  expired 
at  different  times  during  the  treatment 
of  cases  such  as  these,  and  I  have  in¬ 
variably  found  the  quantity  increase  in 
proportion  as  the  deformity  of  the  spine 
(and  consequently  of  the  chest)  im¬ 
proved,  and  I  have  known  the  increase 
to  amount  to  upwards  of  50  cubic 
inches  during  the  time  the  patient  has 
been  under  treatment,  without  there 
having  been  any  disease  of  the  lungs 
or  other  cause,  except  the  deformity, 
to  account  for  the  small  quantity  ex¬ 
pired  in  the  first  instance. 

The  apparatus  consists  of  a  glass 
vessel  graduated  from  above  down¬ 
wards  in  cubic  inches,  accurately  sus¬ 
pended  in  a  circular  vessel  of  water, 
and  counter-balanced  by  means  of 
weights  attached  to  it  by  cords,  which 
pass  over  pullies  properly  arranged: 
the  patient  then  fills  his  chest,  and 
breathes  through  a  tube  passing  into 
the  meter,  the  rising  of  which  indicates 
at  the  level  of  the  water  the  number  of 
cubic  inches  of  air  he  can  expire. 

The  case  of  Miss  W,  is  only  one  out 


of  very  many  which  I  have  had,  prov¬ 
ing  the  efficiency  of  the  plan  of  treat¬ 
ment  pursued  in  the  cure  of  cases  of  a 
similar  character:  I  have  adopted  the 
same  principle  for  more  than  twenty 
years  past,  and  I  can  add' that  my  con¬ 
fidence  in  the  steady  and  persevering 
use  of  the  means  I  have  named  for  the 
relief  of  cases,  which  at  first  seem  to 
hold  out  but  little  prospect  of  success, 
increases  with  my  experience  of  it.  I 
have  stated,  and  all  who  consider  the 
pathology  of  the  disease  will  see,  that 
many  cases  will  occur  which  do  not 
admit  of  the  spine  being  got  into  a 
straight  direction  ;  but  there  are  few, 
if  any,  of  this  kind  even,  which  do  not 
admit  of  relief  being  afforded,  and  that 
of  a  most  important  kind,  and  in  a 
comparatively  short  space  of  time. 

As  regards  attention  to  the  treat¬ 
ment,  I  do  not  think  it  necessary  to 
lay  any  absolute  embargo  on  patients, 
as,  under  the  directions  of  their  medi¬ 
cal  advisers,  their  own  good  sense,  and 
the  feeling  resulting  from  the  con¬ 
sciousness  of  the  benefit  they  are 
deriving,  may  generally  be  trusted  to 
so  as  to  insure  their  perseverance,  es¬ 
pecially  as  not  the  least  pain  is  given 
throughout  the  whole  course  of  treat¬ 
ment.  I  have  already  stated,  that 
much  real  benefit  may  be  derived 
from  it  in  advanced  cases,  and  even 
where  the  patient  has  reached  the 
middle  period  of  life.  In  the  first 
edition  of  my  work  on  spinal  disease, 
I  published  the  history  and  two  engrav¬ 
ings  of  a  case  of  this  kind,  in  which 
the  lady  wTas  41  years  of  age  when  she 
came  under  treatment,  and  had  been 
entirely  confined  to  the  house  for  three 
years,  and  through  inability  to  walk 
was  obliged  to  be  carried  to  and  from 
her  room  ;  yet  her  deformity,  though 
it  had  been  a  very  extensive  one,  was. 
so  much  relieved  as  to  be  scarcely  per¬ 
ceptible  when  she  was  dressed :  she  sub¬ 
sequently  continued  exempt  from  any 
return  of  her  former  complaints,  and 
was  quite  competent  to  discharge  her 
domestic  duties  with  comfort  and  fa¬ 
cility.  If,  however,  the  treatment  were 
more  generally  adopted  in  incipient 
cases,  we  should  have  much  less  fre¬ 
quently  to  deplore  the  severe  ones 
which  are  to  be  met  w'ith  in  all  ranks 
of  society. 

9,  Langliam  Place,  London, 

Oct.  6th,  1848. 


ON  EXUDATION  AND  ELEMENTARY  FORMS  OF  MORBID  PRODUCTS.  625 


ANTICIPATION  OF  THE 

VIEWS  OF  REINHARDT 

ON  THE 

EXUDATION  CORPUSCLE, 

TOGETHER  WITH  SOME  PRELIMINARY  OB¬ 
SERVATIONS  ON 

EXUDATION  AND  THE  ELEMENTARY 
FORMS  of  MORBID  PRODUCTS. 

By  Andrew  Clark,  M.D. 

Assistant-Surgeon  in  tlie  Royal  Navy;  of  the 
Pathological  Department  of  the  Royal  Hospital 
at  Haslar,  &c. ;  formerly  Chief  Assistant  in  the 
Pathological  Theatre  of  the  Edinburgh  Royal 
Infirmary. 

[Continued  from  p.  418.] 


Description  of  the  figures  illustrative  of 
the  observations  contained  in  the  pro¬ 
legomena. 

Fig.  1. — Cellular  forms  from  serous  ex¬ 
udation  into  the  pericardial  sac. 


Fig.  1. 


a.  Patch  of  tesselated  epithelium; 
healthy. 

b.  Isolated  epithelial  cells  slightly 
enlarged,  tumid,  and  exhibiting  the 
presence  of  anormal  granules  within, 
and  exterior  to,  the  nucleus.  b  b  b. 
Represent  the  first  variety  of  cellular 
forms  described  as  peculiar  to  serous 
exudation. 

Fig.  2.— Represents  the  second  variety 
of  corpuscles,*  described  as  peculiar  to 
Fig.  2. 


*  For  the  sake  of  convenience,  I  shall  in  these 
and  subsequent  papers,  employ  the  terms,  cor¬ 
puscle  and  cell  indiscriminately  understanding 
the  ideas  associated  with  them  to  be  identical. 


serous  exudation.  The  ordinary  mole¬ 
cular  constituents  of  these  corpuscles 
have  become  more  or  less  resolved 
into  a  semifluid  homogeneous  mass, 
and  their  nuclei  appear  enlarged, 
spherical,  and  filled  with  granules. 

a.  Corpuscles,  the  nuclei  of  which 
are  represented  in  the  act  of  becoming 
enlarged  and  granular.  The  nucleus 
has  not  become  entirely  granular,  nor 
have  the  normal  molecular  constituents 
of  the  cell  become  fully  resolved, — for, 
between  the  complete  development  of 
the  former,  and  the  fusion  and  disap¬ 
pearance  of  the  latter,  there  appears  to 
obtain  a  pretty  constant  and  definite 
relation.  When  the  granular  develop¬ 
ment  of  the  nucleus  is  complete,  the 
optical  expression  of  a  double  marginal 
ring  disappears  :  its  outline  is  deter¬ 
mined  by  a  single  refractive  line, 
and  the  cell-wall  becomes  so  pale  and 
delicate,  that  its  presence  can  be  de¬ 
tected  only  by  means  of  a  minute  pen¬ 
cil  of  obliquely  applied  light. 

b.  The  second  variety  of  corpuscles 
described  as  peculiar  to  serous  exuda¬ 
tion. 

c  c  c.  Represent  the  fully  developed 
granular  nuclei,  in  the  act  of  escaping 
from  their  parent  cells.  The  escape  of 
the  nucleus,  in  these  cases,  rarely  pro¬ 
duces  rupture  of  the  cell-wall.  The 
latter,  after  fusion  of  the  molecules, 
becomes  not  only  more  solid,  but 
highly  tenacious,  and,  at  one  end,  is 
frequently  prolonged  into  a  narrow 
neck  before  complete  separation  of  the 
nucleus  is  effected.  There  is  every 
reason  to  believe,  that,  at  the  time  of 
its  escape,  the  nucleus  carries  along 
with  it  a  distinct  membranous  enve¬ 
lope;  but  we  have  never  been  able 
satisfactorily  to  demonstrate  its  pre¬ 
sence.  The  difficulty  arises  partly 
from  the  consistence  of  the  escaped 
body,  which  is  great,  and  partly  from 
its  refractive  properties,  which  are  con¬ 
siderable. 

Fig.  3. — Cells  in  which  the  nucleus 
has  become  obscured  by  the  develop¬ 
ment  of  anormal  granules.  The  mole¬ 
cular  constituents  of  these  cells  ap¬ 
pear  to  be  but  slightly  diminished.  The 
granules  are  analogous  to  those  de¬ 
scribed  as  “  exudation  granules”  ;  and 
had  the  molecular  constituents  been 
more  completely  resolved,  and  the 
number  of  the  granules  so  great  as  to 
occupy  the  whole  interior  of  the  cells, 


626 


DR.  CLARK  ON  EXUDATION  AND  THE  ELEMENTARY 


r-- - — 

they  would  have  formed  pretty  accu¬ 
rate  representations  of  the  “  exudation 
corpuscle.”  This  variety  of  corpuscle 
does  not  appear  to  form,  at  any  time, 
the  subject  of  those  changes  illustrated 
by  fig.  2. 

Fig.  3. 


Fig.  4. — a  a.  Escaped  nuclei  of  the 
cells  represented  in  fig.  2  (c  c  c  )  form¬ 
ing  the  third  variety  of  corpuscles  de¬ 
scribed  as  peculiar  to  serous  exudation. 

Fig.  4. 


b  b.  The  same  as  they  are  sometimes, 
but  rarely  observed  with  adherent 
membranous  shreds. 

The  presence  of  these  corpuscles  not 
unfrequently  constitutes  the  chief  his¬ 
tological  characters  of  thick,  yellowish, 
purulent-looking  deposits  in  the  lungs, 
liver,  and  kidneys.  The  unmixed  dis¬ 
charge  from  diseased  bronchial  carti¬ 
lages  consists  of  a  fluid  holding  in 
suspension  corpuscles,  larger,  but  in 
other  respects  similar  to  those  above 
described.  They  are  likewise  met  with 
abundantly  in  the  turbid  yellow  fluid  : 
found  occasionally  in  cysts ;  or,  to  speak 
more  correctly,  in  distended  secreting 
sacs  of  the  choroid  plexus. 

Fig.  5. — Exhibits  a  mode  of  the  dis¬ 
integration  of  epithelial  cells,  which 
tends  to  throw  light  on  the  histological 
relations  of  the  elements  composing 
them. 

a  a.  Cells  in  which  the  granular 
layer  appears  to  be  in  the  act  of  sliding 
off  the  subjacent  cell-wall,  carrying 
along  with  it  the  nucleus  seen  to  be 
imbedded  in  its  substance. 


Fig.  5. 


b.  Broken- up  layer  of  molecules  and 
granules,  after  its  removal  from  the 
cell.  The  nucleus  is  seen  to  have  be¬ 
come  granular. 

c.  Cell  deprived  of  its  granular  tunic, 
but  which  retains  its  nucleus,  adherent 
apparently  to  the  outer  surface  of  the 
cell-wall. 

d.  Cell  deprived  both  of  its  granular 
tunic  and  nucleus,  and  consisting 
simply  of  a  cell-wall  and  semifluid 
contents. 

The  fully-developed  normal  cell  ap¬ 
pears  to  consist  of  the  following  his¬ 
tological  elements  :  — 

a.  A  cell-wall. 

b.  Homogeneous  cell  contents. 

c.  Molecules  and  granules. 

d.  A  nucleus. 

Of  the  molecular  and  granular  con¬ 
stituents  of  the  normal  cell,  some 
occupy  its  interior,  and  are  either 
suspended  or  imbedded  in  the  cell 
contents,  according  to  the  degree  of 
their  consistence :  others  invest  the 
external  surface  of  the  cell-wall,  and 
form  a  continuous  envelope  around  it. 
This,  which  may  be  termed  the  gra¬ 
nular  coat,  in  the  healthy  condition  of 
the  cell  adheres  to  the  outer  surface  of 
the  cell-wall  through  the  medium  of  a 
kind  of  gelatinous  matrix,  in  which 
the  granules  are  imbedded,  and  which 
is  subservient  to  the  preservation  of 
the  union  of  these  granules  in  the  form 
of  a  continuous  layer.  Sometimes,  as 
in  the  case  illustrated  by  Fig.  5,  the 
connecting  matrix  becomes,  by  solu¬ 
tion  or  some  other  means,  loosened  at 
the  point  of  contact  with  the  external 
surface  of  the  cell-wall,  and  the  gra¬ 
nular  coat  is  thus  permitted  to  escape. 
In  at  least  seven  cases  out  of  ten,  the 
nucleus  is  removed  along  with  the 
layer  of  granules,  and,  until  further 
changes  take  place,  remains  imbedded 
in  its  substance.  In  the  remaining 
three  the  nucleus  continues  adherent 


v-:v  *7*-^ 


FORMS  OF  MORBID  PRODUCTS 


627 


to  the  outer  surface  of  the  cell-wall. 
The  particular  conditions  which  de¬ 
termine  the  loosening  of  the  granular 
tunic  of  the  cell  determine  also  the 
solution  of  the  molecules  and  granules 
contained  in  its  interior ;  and  thus  it 
is  that,  after  the  escape  of  the  granular 
coat  and  nucleus,  the  cell  appears  as  a 
simple  vesicle  enclosing  homogeneous 
contents. 

The  position  of  the  nucleus. — The 
position  of  the  nucleus  is  still  a  matter 
of  dispute  among  histologists.  Fig.  5, 
which  is  but  one  of  many  instances, 
appears  to  indicate  that  the  nucleus  is 
either  imbedded  in  the  substance  of 
the  cell-wall,  or  attached  to  its  external 
surface.  That  the  nucleus  occasion¬ 
ally  protrudes  a  little  beyond  the  out¬ 
line  of  the  cell-wall  is  unquestionable  ; 
but  that  it  is  placed  entirely  exterior 
to  the  surface  of  the  cell-walls,  seems, 
from  the  optical  expression  of  its  phy¬ 
sical  characters  under  the  microscope, 
impossible.  The  disappearance  of  the 
nucleus  along  with  the  granular  coat, 
and  its  occasional  retention  by  the 
cell-wall,  appear  to  prove  that  in  the 
healthy  cell  the  nucleus  is  imbedded 
in  the  substance  of  the  cell-wall ;  and 
that  what  Schleiden*  stated  to  be  uni¬ 
versally  true  of  the  position  of  the 
nuclei  in  the  cells  of  plants,  may  be 
predicated  generally  of  the  cells  of 
animals. f 

Fig.  6. — Cellular  constituents  of  a 
purulent-looking  fluid  from  a  tuber¬ 
cular  cavity  in  the  lung  of  Charles 
Galpin,  examined  2d  August. 

Fig.  6. 


*  Muller’s  Archives,  1838. 
t  This  subject  will  be  found  more  fully  en¬ 
larged  upon  in  the  context.  It  is  here  treated 
of  only  in  so  far  as  it  relates  to  the  figures. 


h  h.  Epithelial  cells  in  a  state  of 
disintegration. 

c  c.  Cells,  epithelial,  which  have 
undergone  similar  changes  to  those 
illustrated  by  Fig.  2. 

d.  Cell  in  which  the  granular 
nucleus  is  represented  in  the  act  of 
escaping  from  the  parent  cell. 

e  e.  Escaped  nuclei  of  the  cells  re¬ 
presented  in  Figs.  2,  b,  and  6,  c  c. 

The  other  histological  elements  of 
this  fluid  were — corrugated  blood  discs, 
pigment  cells,  shreds  of  the  walls  of 
capillaries,  elastic  fibrous  tissue  from 
the  openings  of  the  air-cells,  a  few  oil 
globules,  and  numerous  molecules  and 
granules. 


FATAL  CASE  of  ALGIDE  CHOLERA. 

By  F.  S.  Haden,  Esa. 

Sloane  Street. 


The  following  notes,  which  appear  to 
me  to  embody  an  instance  of  true  Algide 
Cholera,  have  been  already  detailed 
and  discussed  in  the  Western  Medical 
and  Surgical  Society;  but  I  am  induced 
to  give  them  a  wider  circulation,  in 
the  belief  that  observations,  scrupu¬ 
lously  made  in  our  own  country,  are 
likely  to  afford  us  more  useful  deduc¬ 
tions  for  practice  than  cases  sent  us 
from  the  banks  of  the  Ganges,  which 
must  differ  from  those  we  are  likely  to 
see  here,  in  proportion  as  they  are  in¬ 
fluenced  by  climate  and  other  condi¬ 
tions  opposite  to  those  which  we  are 
accustomed  to  meet  with. 

It  has  been  objected  to  the  following 
case  that  it  is  not  one  of  “  true  cho¬ 
lera;”  but,  in  seeking  to  establish  the 
diagnosis  of  this  disease,  it  seems  to 
me  unreasonable  to  expect  it  to  pre¬ 
sent  precisely  the  same  features  here, 
in  India,  and  at  St.  Petersburgh. 
There  is  enough  (unfortunately)  that 
is  typical  of  the  scourge  to  enable  us 
to  recognise  it  wherever  it  may  occur; 
but  we  are  not  to  deny  its  identity 
because  it  does  not  always  come  to  us 
by  the  same  route  and  in  the  same 
guise.  A  specific  disease — the  state  of 
the  atmosphere — the  peculiarities  of 
vegetation,  temperament,  and  race — are 
but  the  various  resultants  of  a  com¬ 
mon  law  applied  to  different  regions  of 
the  earth’s  surface  ;  but  we  should  not 
expect  to  find  the  same  conditions  of 
the  air,  the  same  vegetation,  the  same 


628 


MR.  HADEN’S  FATAL  CASE  OF  ALGIDE  CHOLERA. 


specific  character  of  race,  in  Asia  and 
in  Europe.  We  have  the  general  cha¬ 
racter  (which  is  the  type),  but  not  the 
same  aspect .  How,  then,  should  dis¬ 
ease,  or  any  other  phenomenon  purely 
natural ,  present  exactly  the  same  symp¬ 
toms  in  opposite  quarters  of  the  globe  ? 

For  myself,  I  am  of  opinion  that 
cholera*  is,  everywhere,  one  and  the 
same  disease  :  that  it  is  English  in  one 
place — Asiatic  in  another  ;  mild  here — 
severe  there  :  Algide  in  proportion  as 
the  local  congestion  is  great :  and  mul¬ 
tiform,  as  time,  place,  and  circumstance 
combine  to  make  it.  Nor  do  I  deny 
myself  the  hope  of  seeing  our  nosolo¬ 
gical  scale  still  more  curtailed ;  and 
many  diseases,  now  separated  by  an 
arbitrary  classification,  admitted  to  be 
essentially,  if  not  very  apparently,  the 
same. 

July  17:  half-past  11  a.m.— I  was 
sent  for  to  the  subject  of  the  pre¬ 
sent  case  :  stout  and  phlethoric  in  per¬ 
son,  of  active  habits  and  an  irritable 
temperament,  an  indiscriminate  eater, 
and  78  years  of  age. 

She  states  that  at  4  a.m.  she  was 
awakened  by  nausea,  purging,  and  a 
sensation  of  sinking,  which,  with  occa¬ 
sional  cramps  in  the  right  calf,  still 
continue :  but  she  has  nothing  else  to 
complain  of — no  pain  or  thirst.  Her 
countenance  is  slightly  anxious,  but 
the  pulse  is  good,  80 ;  the  skin  warm 
and  natural,  and  the  tongue  moist. 
The  dejections  shown  me  were  of  a 
greenish  colour,  fluid,  and  containing 
flocculi  and  feculent  matter.  I  consi¬ 
dered  the  case  to  be  one  of  simple  in¬ 
testinal  derangement,  and  the  flocculi 
as  portions  of  half-digested  lettuce, 
which,  with  bread  and  cheese,  porter, 
and  some  spirits  and  water,  she  had 
taken  for  supper  the  night  before  ;  nor 
did  I  see  anything  alarming  in  the 
presence  of  the  cramps,  inasmuch  as 
she  was  at  all  times  subject  to  them, 
and  occasionally  in  a  severe  degree. 

At  1  p.m.  a  messenger  came,  in  my 
absence  from  home,  to  say  that  she 
had  vomited  after  taking  what  I  had 
prescribed  for  her,  and  four  or  five 
times  since,  and  that  she  was  more 
purged,  and  altogether  worse  than  in 
the  morning.  I  could  not  attend,  and 


*  Cholara  would  be  the  right  way  of  spelling 
the  severe  form  of  the  disease ;  from  x°^a?>  pew, 
intestinal  flux.  Cholera  can  only  express  bilious 
flux,  from  \o\r),  pew,  and  stands  for  common 
bilious  diarrhoea. 


Mr.  Synnot,  of  Cadogan  Place,  was 
good  enough  to  see  her. 

At  2  p.m.  a  second  message  arrived 
to  the  effect  that  she  was  worse,  that 
the  vomiting  and  purging  were  more 
severe,  and  that,  in  getting  out  of  bed 
to  go  to  stool,  she  had  fainted.  I  was 
still  absent,  and  another  medical  gen¬ 
tleman  saw  her. 

At  3  p.m.  my  assistant  reports  that 
the  surface  was  becoming  cold ;  and 
Mr.  Seaton,  who  visited  her  shortly 
after  at  his  request,  found  it  necessary 
to  check  the  purging  on  account  of  its 
severity,  but  did  not,  l  believe,  even 
then  look  upon  the  case  in  any  other 
light  than  that  in  which  myself  in 
the  morning,  and  afterwards  Mr.  Syn¬ 
not,  had  regarded  it. 

At  half-past  10  p.m.  I  visited  her, 
and  found  her  in  the  following  condi¬ 
tion  : — General  aspect  collapsed ;  pulse 
93,  small,  but  not  remarkably  so  ;  res¬ 
piration  quickened  and  short;  surface 
cold  ;  tongue  white ;  thirst  urgent ; 
countenance  exceedingly  anxious  ;  in¬ 
tellect  clear.  Patient  very  restless  ; 
voice  sharp  and  raised,  expressing 
satisfaction  at  my  entrance,  but  a  con¬ 
viction,  nevertheless,  that  she  should 
die.  The  last  motion  shown  me  was 
of  the  true  congee  character,  about  two 
pints  and  a  half  in  quantity,  pale, 
serous,  charged  with  whitish  "flocculi. 
The  cramps,  which  were  now  severe, 
seemed  to  attack  her  before  each  motion , 
and  with  each  attempt  at  change  of 
position.  She  had  had,  since  morning, 
about  twenty  evacuations,  the  earlier 
ones,  it  was  stated,  greenish,  but  most 
of  them,  and  all  the  later  ones,  of  the 
character  described. 

At  11  p.m. — Pulse  96,  smaller;  res¬ 
piration  more  difficult  and  shorter, 
being  25  in  the  minute  ;  surface  colder, 
and  covered  with  a  peculiar  oily  per¬ 
spiration  ;  hands  cold  and  shrivelled, 
with  a  deep,  basic,  blue  halo  round  the 
nails,  themselves  brown  rather  than 
blue  ;  tongue  cold,  white,  moist  in  the 
centre,  and  a  little  shrivelled  round  the 
edges;  face  livid  and  much  shrunk, 
the  lips  and  a  circle  round  the  eyes 
being  of  a  deeper  colour  than  the  rest. 
There  is  nausea  but  no  purging ;  thirst 
continues  excessive,  and  small  pieces 
of  ice  put  into  the  mouth  are  swallowed 
with  avidity.  The  cramps  are  severe 
in  the  knees,  legs,  and  feet,  eliciting, 
when  they  come  on,  a  distressing  and 
sharp  cry.  The  appearance  is  wild  and 


MR.  HADEN’S  FATAL  CASE  OF  ALGIDE  CHOLERA. 


0  29 


anxious,  and  she  complains  of  noises  in 
her  head,  her  expression  being,  that 
“  cannons  go  off  in  her  head  with  each 
breath  she  takes.”  General  distress 
and  restlessness  alternate  with  a  dis¬ 
position  to  drowsiness,  and  the  hands 
are  tossed  to  and  fro. 

12  p.m.  —  Pulse  fluttering  ;  respi¬ 
ration  very  shallow  and  frequent,  28 
per  minute;  body  icy  cold,  and  bedewed 
with  the  peculiar  perspiration  men¬ 
tioned;  voice  much  lowered,  sharp, 
cracked,  and  without  tone  ;  no  purging 
or  vomiting,  but  the  cramps  continue, 
with  a  thirst  which  cannot  be  assuaged ; 
the  tcngue  is  whitish,  moist,  quite  cold 
to  the  touch  ;  and  the  breath,  allowed 
to  fall  on  the  back  of  the  hand,  is  also 
cold;  the  volumeof  air  inspired  and  ex¬ 
pired  being,  however,  so  small,  as  to 
make  this  symptom  difficult  to  appre¬ 
ciate.  Noises  in  the  head  continue. 

1  a.m.,  18th. — There  is  no  great 
change,  a  peculiar  faint  odour  is  ex¬ 
haled  by  the  body,  which,  within  an 
inch  of  the  hot  bottles,  is  of  a  marble 
coldness ;  the  countenance  is  shrunk 
and  livid,  as  is  the  whole  surface,  and 
the  eye,  strangely  altered  in  expression, 
imparts,  with  its  dark  areola  and  con¬ 
tracted  pupil,  an  aspect  pinched  and 
peculiarly  ghastly ;  the  voice,  more 
feeble,  is  lowered  into  a  whisper,  and 
yet,  when  the  cramps  come  on,  raised 
and  sharp  ;  and  the  same  greasy  sweat 
covers  the  surface,  except  the  face, 
which  is  simply  cool  and  pinched,  and 
of  a  dull  lead  colour.  The  demand 
for  ice  is  continual ;  the  arms  cannot 
be  kept  in  bed  ;  and  the  pulse,  though 
unsteady,  is  still  perceptible  in  the 
axilla. 

6  a.m. — Pulse  somewhat  restored, 
about  140  as  nearly  as  could  be 
counted ;  the  respiration  short,  but  less 
so ;  the  voice  more  raised,  but  still 
without  tone.  The  purging  and  vo¬ 
miting  have  entirely  ceased,  and  the 
cramps  are  less  severe,  except  on  at¬ 
tempts  at  motion. 

Half- past  10  a.m. — The  pulse  is  now 
120 ;  the  breathing  less  embarrassed  ; 
the  skin  of  the  hands  and  face  still  cold 
and  livid  ;  is  not  so  much  so  as  it 
was,  and  the  thorax  is  perceptibly 
warmer.  She  appears  as  if  she  would 
rally.  The  tongue  is  still  cold,  but  the 
breath  not  so ;  the  voice,  though 
cracked,  is  somewhat  stronger ;  and 
the  intellect  clear.  She  complained 
at  this  time  of  a  pain  across  her  loins, 


and  said  that,  if  she  were  allowed  to 
get  out  of  bed,  she  thought  she  might 
be  able  to  pass  water.  On  the  attempt 
being  made  in  my  presence,  however, 
her  feet  would  not  support  her,  and 
immediately  afterwards,  while  still  in 
the  arms  of  her  attendant,  she  appeared 
to  become  suddenly  unconscious  of 
where  she  was,  stared  two  or  three 
times  wildly  round  the  room,  and  was 
removed  to  bed  in  a  state  of  partial  in¬ 
sensibility,  from  which  she  never 
wholly  recovered. 

At  noon,  the  skin  was  warmer,  the 
breathing  deeper,  and  the  lividity  less, 
except  about  the  hands  and  face — the 
pulse  120,  irregular,  small  — the  pupils 
contracted,  and  insensible  to  light — 
and  the  comatose  state  more  pro¬ 
nounced. 

Half-past  2. — Pulse  120,  more  re¬ 
gular;  surface  warmer;  breathing 
easier.  No  urine  yet  passed;  the 
catheter  introduced  into  the  bladder, 
found  it  empty. 

Half-past  3. — In  the  same  state,  ex¬ 
cept  that  the  face  is  less  livid,  and  now 
almost  as  if  congested. 

Half-past  4. — The  same;  pulse  112; 
better. 

Half-past  5. — Some  delirious  ex¬ 
citement  ;  pulse  certainly  improved ; 

110. 

Half-past  6. — The  delirium  had  passed 
off,  and  the  coma  become  more  pro¬ 
found. 

Half-past  9.  — She  could  be  roused  to 
consciousness,  but  the  catheter  again 
p  assed  found  no  urine. 

Half-past  10. — The  same. 

Half-past  11. — Pulse  106,  stronger; 
breathing  more  natural;  warmth  re¬ 
turning  to  upper  part  of  the  body  ; 
capable  of  being  roused. 

Midnight  between  18th  and  19th. — 
The  warmth  of  head  and  chest  was 
now  considerable  ;  so  much  so,  that  it 
was  my  impression  the  case  would  run 
on  to  consecutive  fever.  Later  in  the 
night,  Dr.M'Lachlan  reports  that  the 
head  was  even  hot ,  and  the  face  turgid  ; 
the  coma  profound,  and  the  pupil  in¬ 
sensible. 

10  a.m.,  19th. — Dr.  M‘Lachlan  saw 
her  with  me.  The  pulse  was  then 
smaller  than  on  the  previous  night; 
easily  annihilated  by  pressure,  yet 
good  and  regular.  The  head  was 
cooler  ;  the  sopor  lessened  ;  5  ss.  of  con¬ 
centrated  urine  was  drawn  off  by  the 
catheter,  and  for  a  moment  she  could 


630  DR.  SHEARMAN  ON  THE  RATIONAL  TREATMENT  OF  CHOLERA. 


be  roused ;  the  pupils,  though  less  con¬ 
tracted,  still  remaining  insensible  to 
light. 

At  1  p.m.  I  found  her  moribund; 
leeches,  which  had  been  applied  to  the 
temples  two  hours  before,  were  still 
adherent,  but  not  filling,  nor  did  any 
blood  follow  their  removal.  The  tem¬ 
porary  heat  of  head  and  chest  had  gone 
off,  and  the  face  had  resumed  its 
collapsed  appearance ;  the  pulse  had  be¬ 
come  thready  ;  the  inspirations  short 
and  shallow;  and  the  air-passages  em¬ 
barrassed  with  mucus.  She  is  now 
sensible,  though  the  pupils  continue 
contracted,  and  is  acutely  alive  to  the 
slightest  touch,  crying  out  with  a  short 
and  feeble  cry,  as  if  from  pain,  when 
the  finger  is  placed  upon  her.  The 
pulse  from  this  time  continued  to  fall 
until  it  became  imperceptible.  The 
inspirations  more  imperfect,  and  with  a 
greater  interval  between  them,  and  at 
half-past  4  she  died. 

ISTo  post-mortem  allowed. 

[To  be  continued.] 


ON  THE 

RATIONAL  TREATMENT  OF 
ALGIDE  CHOLERA. 

By  E.  J.  Shearman,  M.D. 


I  have  been  much  delighted  and  in¬ 
structed  by  the  late  perusal  of  Dr. 
Parkes’  valuable  contribution  to  the 
little  stock  of  knowledge  we  possess  of 
the  pathology  of  cholera ;  and  cannot 
help  remarking,  that  to  me  his  infor¬ 
mation  appears  more  likely  to  be  cor¬ 
rect  than  that  of  any  other  author.  I 
saw  a  good  deal  of  the  disease  in  1832, 
and  there  is  a  truthfulness  about  his 
researches  which  carries  conviction 
with  them. 

Dr.  Parkes  distinctly  proves  that,  in 
the  stage  of  collapse,  the  right  side  of 
the  heart  does  not  empty  itself ;  all  the 
branches  of  the  pulmonary  artery  are 
gorged  to  the  greatest  extent ;  there  is 
no  blood  in  the  lungs;  and  the  left  side 
of  the  heart  and  arteries  are  empty. 
The  serous,  albuminous,  and  saline 
parts  of  the  blood  ooze  through  the 
different  tissues,  and  are  evacuated ; 
the  fi'brine  of  the  blood  alone  being 
found  in  the  intestines. 

Now,  this  must  be  owing  either  to 
the  choleraic  poison  having  so  chemi¬ 


cally  altered  the  blood  that  the  oxygen 
of  the  atmosphere  cannot  act  chemi¬ 
cally  upon  it,  and  the  venous  blood 
remains  in  the  pulmonary  artery  ;  or 
the  choleraic  atmosphere  is  of  such  a 
nature  as  to  prevent  the  chemical  com¬ 
bination  of  it  with  the  blood  of  the  in¬ 
dividual  in  respiration.  Unfortunately, 
Dr.  Parkes  had  not  the  means  of  che- 
micall)  and  pathologically  examining 
the  blood  of  his  cholera  patients  ;  but 
the  former  position  appears  the  most 
tenable,  from  the  immediate  good  effect 
produced  by  injecting  a  solution  of 
albumen  and  salts  into  the  veins, 
which,  unfortunately,  does  not  last 
long  enough  to  allow  nature  to  weather 
out  the  disease. 

Where  a  case  has  reached  this  period, 
it  is  almost  invariably  fatal,  for  no 
absorption  can  take  place  ;  the  venous 
system  is  full,  and  all  medicine  and 
nourishment  introduced  into  the  sto¬ 
mach  must  be  useless. 

But  may  not  the  red  globules  of  the 
blood  become  poisoned  and  useless  ? 
and  if  so,  what  use  would  the  albumen 
and  salts  be  if  there  were  no  oxygen 
carriers  ? 

Reflecting  on  this  subject  since  read¬ 
ing  Dr.  Parkes’  work,  I  have  made  up 
my  mind,  should  nothing  more  be 
discovered  respecting  the  pathology  of 
cholera,  and  considering  the  failure  of 
every  other  mode  of  treatment,  that  I 
will  treat  my  cases  verging  into  the 
stage  of  collapse,  by  first  taking  away 
as  much  blood  as  I  reasonably  can  from 
a  vein  in  the  arm  (no  easy  matter), 
and  then  immediately  transfuse  warm 
blood  from  the  most  healthy  subject  I 
can  meet  with,  and  keep  up  respiration 
as  long  as  possible  with  a  mixture  of 
equal  parts  of  oxygen  gas  and  atmo¬ 
spheric  air.  Although  this  will  not  dis¬ 
lodge  from  the  branches  of  the  pulmo¬ 
nary  artery  the  poisoned  blood,  it  must 
give  nature  a  better  chance  of  carrying 
on  circulation  and  respiration  than  by 
injecting  merely  albumen  and  salts 
without  any  healthy  red  globules. 

I  think  respiration  may  be  carried  on 
in  such  cases  by  using  a  modification 
of  my  friend  Sibson’s  mouth-piece, 
which  he  invented  for  the  inhalation 
of  chloroform.  And  oxygen  gas  can 
be  kept  ready  prepared  over  water  for 
a  great  length  of  time. 

The  first,  or  premonitory,  stage  of 
cholera  requires  merely  common  astrin¬ 
gent  remedies.  The  next  stage,  where 


CONTAGION  OF  CHOLERA - NOTIFICATION  OF  THE  BOARD  OF  HEALTH.  631 


the  vomiting  and  purging  are  accom¬ 
panied  by  cramps,  seems  to  admit  of 
two  grand  modes  of  treatment :  viz. 
tartar  emetic,  and  acetate  of  lead  with 
opium,  together  with  various  external 
remedies  to  relieve  particular  symp¬ 
toms.  In  1832  I  only  became  ac¬ 
quainted  with  Mr.  Stott’s  (of  Man¬ 
chester)  treatment  by  tartar  emetic 
when  the  disease  was  subsiding  ;  but 
all  the  cases  I  treated  with  it  certainly 
recovered.  In  the  Lancet  for  Sept.  16, 
1848,  there  is  a  valuable  communica¬ 
tion  from  my  friend,  Dr.  C.  Radclyffe 
Hall,  on  this  subject,  well  worth  pe¬ 
rusing  ;  and  1  can  add  my  testimony 
to  the  success  urhich  attended  that 
mode  of  treatment. 

I  am  not  aware  that  the  above 
method  of  treating  the  stage  of  col¬ 
lapse  has  ever  been  tried  ;  but,  until  the 
researches  of  those  most  conversant 
with  pathological  chemistry  shall  have 
decided  what  the  nature  of  the  poison 
of  cholera  is,  any  apparently  rational 
mode  of  preserving  life  for  a  few  hours 
cannot  be  deemed  unworthy  of  notice. 

Rotherham,  Oct.  1848. 


TREATMENT  OF  CHRONIC  LIPPITUDO. 

BY  ISAAC  HAYS. 

Ophthalmia  Tarsi  is  generally  a  manage¬ 
able  disease,  but  occasionally  cases  are  met 
with  in  which  the  affection,  in  consequence 
of  neglect  or  bad  management,  has  persisted 
for  years, — the  lids  have  become  puffy, 
their  lining  membrane  thickened  and  villous, 
causing  more  or  less  eversion  (ectropium) , 
their  edges  raw  and  sometimes  ulcerated,  the 
cilise  irregular  and  scanty,  or  entirely  lost ; 
with  photophobia,  lachrymation,  &c.  Two 
such  cases  came  under  our  charge  during 
our  recent  service  at  Wills  Hospital ;  and  as 
they  had  resisted  the  usual  remedies,  I  was 
induced  to  try  the  alternate  application  of 
tincture  of  iodine,  and  the  solid  sulphate  of 
copper,  at  intervals  of  three  days.  The 
external  surface  of  the  lids  was  painted 
with  the  former ;  and  three  days  after¬ 
wards  the  latter  was  freely  applied  over  the 
thickened  conjunctiva.  Under  this  treat¬ 
ment  both  cases,  one  of  them  of  twelve  or 
fourteen  years  continuance,  have  recovered, 
and  we  are  induced  to  communicate  the  cir¬ 
cumstance  in  hopes  that  this  course  may 
prove  equally  useful  in  the  hands  of  others.” 
— American  Journal. 


MEDICAL  GAZETTE. 


FRIDAY,  OCTOBER  13,  1848. 

The  attention  of  the  public  as  well  as 
of  the  profession  is  almost  exclusively 
fixed  on  the  Asiatic  Cholera.  We  have 
now  before  us  a  pile  of  pamphlets,  con¬ 
taining  all  kinds  of  suggestions  respect¬ 
ing  prophylactic  and  remedial  treat¬ 
ment;  and  the. columns  of  the  daily 
journals  are  filled  with  Instructions  to 
the  Public  from  Boards  of  Health,  or 
with  reports  of  the  progressive  advance 
of  this  formidable  disease. 

In  the  instructions  issued  to  the 
public,  the  members  of  the  Boards  of 
Health  of  England  and  Ireland  ap¬ 
pear  exceedingly  desirous  of  impressing 
upon  the  minds  of  persons  that  cholera 
is  not  communicable  from  one  person 
to  another ;  or,  to  use  a  common  term, 
that  it  is  not  infectious  or  contagious. 
The  Dublin  Board  asserts  that  it  is 
“  rarely,  if  ever,”  contagious* — a  du¬ 
bious  form  of  expression,  which  may, 
we  think,  be  fairly  taken  to  mean 
“sometimes.”  The  London  Board,  in 
a  notification  issued  on  Friday  last,  has 
entered  into  some  details  on  this  sub¬ 
ject.  Thus  the  report  states  : — 

“  The  extent,  uniform  tenor,  and 
undoubted  authority  of  the  evidence 
obtained  from  observers  of  all  classes 
in  different  countries  and  climates,  and 
amidst  all  varieties  of  the  physical, 
political,  and  social  conditions  of  the 
people,  appear  to  discredit  the  once 
prevalent  opinion  that  cholera  is,  in 
itself,  contagious;  an  opinion  which, 
if  fallacious,  must  be  mischievous,  since 
it  diverts  attention  from  the  true  source 
of  danger  and  the  real  means  of  protec¬ 
tion,  and  fixes  it  on  those  which  are 
imaginary  ;  creates  panic  ;  leads  to  the 
neglect  and  abandonment  of  the  sick ; 
occasions  great  expense  for  what  is 
worse  than  useless;  and  withdraws  at¬ 
tention  from  that  brief  but  important 


*  See  page  595  of  our  last  number. 


632  CONTAGION  OF  CHOLERA - NOTIFICATION  OF  THE  BOARD  OF  HEALTH, 


interval  between  the  commencement 
and  development  of  the  disease,  daring 
which  remedial  measures  are  most 
effective  in  its  cure. 

“  Although  it  is  so  far  true  that  cer¬ 
tain  conditions  may  favour  its  spread 
from  person  to  person,  as  when  great 
numbers  of  the  sick  are  crowded  toge¬ 
ther  in  close,  unventilated  apartments, 
yet  this  is  not  to  be  considered  as  affect¬ 
ing  the  general  principle  of  its  non- 
contagious  nature ;  nor  are  such  condi¬ 
tions  likely  to  occur  in  this  country  : 
moreover,  the  preventive  measures, 
founded  on  the  theory  of  contagion — 
namely,  internal  quarantine  regula¬ 
tions,  sanitary  cordons,  and  the  isola¬ 
tion  of  the  sick,  on  which  formerly  the 
strongest  reliance  was  placed,  have 
been  recently  abandoned  in  all  coun¬ 
tries  where  cholera  has  appeared,  from 
the  general  experience  of  their  ineffi¬ 
ciency.” 

The  Editor  of  the  Times,  in  comment- 
ting  upon  this  report,  goes  a  step  be¬ 
yond  the  members  of  the  Board  of 
Health,  who  are  exceedingly  cautious 
in  their  language,  and  endeavours  to 
satisfy  and  console  his  readers  by  the 
assurance  that  there  is  no  more  likeli¬ 
hood  of  the  communicability  of  cholera 
from  one  person  to  another  than  there 
is  of  a  broken  leg!  He  says  : — 

“  But  to  be  fully  persuaded,  as  every 
person  now  undoubtedly  may  be,  that 
no  contagion  whatever  accompanies  the 
epidemic,  is  a  circumstance  in  the 
highest  degree  re-assuring  and  consola¬ 
tory.  It  is  no  doubt  true,  that  when 
one  person  has  taken  the  cholera  ano¬ 
ther  may  take  it.  The  atmospheric 
conditions  which  produce  one  case  may 
produce  another;  just  as  when  our 
pavements  are  covered  with  ice  and 
snow,  if  half  a  dozen  men  fall  down 
and  fracture  their  ankles,  there  is,  of 
course,  a  probability  that  others  may 
fall  down  and  do  the  same.  But  as  to 
any  direct  communicability  of  the  acci¬ 
dents  from  one  person  to  another,  such 
a  thing  is  no  more  likely  in  the  case  of 
cholera  than  in  the  case  of  a  broken 
leg.  Both  cases,  indeed,  call  for  simi¬ 
lar  conduct  and  similar  precautions  : — 
for  prompt  and  fearless  attention  to 
the  sufferer  ;  for  greater  carefulness  on 
our  own  parts,  and  for  the  immediate 


removal  of  all  those  dangerous  agencies 
which  brought  the  misfortune  to  pass. 

“  It  is  not  to  be  supposed  that  consi¬ 
derations  of  contagion  may  be  altoge¬ 
ther  discarded.  In  the  strict  sense  of 
the  word— that  is  to  say,  as  implying 
a  communicability  of  the  disease  by 
touch  or  proximity,  it  may  indeed  be 
entirely  dismissed  from  thought— such 
a  property  has  been  proved  in  the  case 
of  cholera  not  to  exist.  But  in  the  case 
of  all  diseases  whatever,  if  by  want  of 
due  ventilation  and  cleanliness  the  at¬ 
mosphere  of  any  one  spot  be  allowed  to 
acquire  an  intensity  of  poison,  there  is 
no  doubt  thatsuch  atmosphere  could  not 
be  inhaled  with  impunity.  This  is  no 
characteristic  of  cholera;  any  known 
malady  will  produce  the  like  effects  : 
nay,  to  return  to  our  illustration — if 
six  men  with  broken  legs  were  crowded 
into  one  foul  and  ill-ventilated  cham¬ 
ber,  it  is  a  fact  well  known  to  every 
scientific  practitioner  that  their  wounds 
will  not  only  not  heal,  but  that  any 
attendant  exposed  to  the  atmosphere 
of  the  chamber  would  be  liable  to  the 
self-same  incurable  gangrene  if  he 
chanced  to  have  any  fleshwound  about 
his  person.  Any  disease  whatever  is 
contagious  under  such  conditions  as 
these.  Whether,  in  any  case,  the  poison 
of  the  atmosphere  can  be,  by  such 
neglect  as  we  have  been  describing,  so 
highly  concentrated,  and,  as  it  were, 
inspissated,  as  to  become  transmissible 
from  one  place  to  another,  not  only  by 
persons,  but  by  articles  of  clothing, 
furniture,  or  the  like,  is  a  point  on 
which  serious  doubts  are  now  altoge¬ 
ther  entertained ;  and  it  is  argued  with 
great  show  of  reason,  that  even  the 
black  plague  of  Cairo  can  claim  no 
such  terrific  powers.  In  the  case  of 
cholera,  however,  there  is  no  kind  of 
ground  for  any  such  suspicions,  nor 
can  it  be  made  infective  except  by  such 
extreme  neglect  as  would  make  con¬ 
sumption  just  as  dangerous.” 

The  vagueness  of  language  which 
characterizes  these  statements,  induces 
us  to  believe  that  they  have  been  made 
and  circulated  from  motives  of  expe¬ 
diency.  Say  that  a  disease  is  conta¬ 
gious,  and  you  frighten  persons  from 
approaching  to,  or  administering  to 
the  wants  of,  the  sick  ;  because  people 
will  always  exaggerate  the  degree  to 


NOTIFICATION  OF  THE  BOARD  OF  HEALTH.  633 


CONTAGION  OF  CHOLERA - 

which  a  disease  is  communicable  from 
one  person  to  another.  The  motive  is 
praiseworthy  enough  :  it  is  to  remove 
the  fear,  in  a  great  measure  groundless, 
under  which  timid  persons  would  la¬ 
bour,  if  it  were  authoritatively  declared 
that  the  disease  was  contagious.  We 
have,  however,  to  view  this  question  in 
a  medical  aspect,  and  not  to  allow  the 
truth  to  be  concealed  or  evasively  an¬ 
nounced,  merely  for  the  sake  of  soothing 
the  public  mind.  The  members  of  the 
Board  of  Health,  among  whom  there  is 
only  one  belonging  to  the  medical  pro¬ 
fession — namely,  Dr.  S.  Smith,  tell  us 
that  “  certain  conditions  may  favour  the 
spread  of  cholera  from  person  to  per¬ 
son,  as  when  great  numbers  of  the  sick 
are  crowded  together  in  close  unven¬ 
tilated  apartments,  yet  this  is  not  to  be 
considered  as  affecting  the  general  prin¬ 
ciple  of  its  non-contagious  nature .”  This 
admission,  it  will  be  seen,  applies  with 
equal  force  to  typhus  fever,  as  well  as 
to  that  severe  form  of  it  known  under 
the  name  of  Irish  fever,  so  that  we  pre¬ 
sume  in  future  the  same  fine-drawn 
destruction  will  be  made  with  respect 
to  this  disease.  “  It  is  not  contagious 
or  communicable,  but  certain  conditions 
favour  its  spreading  from  person  to 
person.”  We  do  not  like  this  plan  of 
dealing  with  medical  facts  and  doc¬ 
trines  for  the  sake  of  what  may  appear 
to  be  a  safe  method  of  preventing  a 
panic  in  the  public  mind.  Our  view  is 
that  the  truth  should  be  told,  for  sooner 
or  later  it  will  be  made  known  ;  and 
should  the  official  notification,  taken  in 
its  ostensible  meaning,  prove  to  be 
unfounded,  as  we  believe  it  will  be, 
it  must  have  the  effect  of  destroying 
all  confidence  in  Government  reports. 
Our  contemporary,  the  Times,  carries 
this  soothing  plan  to  an  extent  which 
must  appear  absurd  to  all  reasonable 
persons.  Foulness  and  filth  cannot 
create  the  choleraic  poison,  or  we 
should  have  had  it  constantly  with  us, 


and  not  now  have  had  occasion  to 
speak  of  its  second  progressive  advance 
from  east  to  west.  The  poison  is  gene¬ 
rated  in  the  bodies  of  the  affected,  and 
perfect  ventilation  and  cleanliness  have 
merely  the  effect  of  diluting  it,  and 
disarming  it  of  its  virulence.  In  fact, 
as  with  the  miasm  of  typhus,  it  is  ren¬ 
dered  inert  under  these  circumstances, 
and  will  not  reproduce  the  disease  in 
another  person.  The  Board  of  Health 
theory,  as  it  is  developed  in  the  Times, 
is,  that  there  are  no  emanations  from 
the  body  of  one  person  which  can  pro¬ 
duce  the  disease  in  another;  but  that 
when  many  individuals  are  crowded  to¬ 
gether,  and  there  is  a  wTant  of  due  ven¬ 
tilation  and  cleanliness,  then  a  poison 
is  generated.  The  proof,  however,  that 
the  diseased  body  has  some  share  in 
the  matter,  is  the  fact,  that  the  disease 
produced  by  the  neglect  of  these  hy¬ 
gienic  precautions,  is  always  identical 
in  characters  with  that  under  which  th 
individuals  are  labouring.  Typhus 
fever  does  not  arise  from  the  crowding 
of  cholera  patients,  nor  does  malignant 
cholera  proceed  from  the  foul  air  of 
wards  in  which  fever  patients  are 
crowded  together.  Yet  the  wTriter  in 
the  Times  argues  that  “  any  disease 
whatever  is  contagious  under  such  con¬ 
ditions  as  these;”  from  which  we  sup¬ 
pose  it  to  be  understood  that  crowding 
a  ward  with  gouty  or  dropsical  patients, 
would,  of  course,  produce  gout  or 
dropsy  in  any  person  who  happened  to 
enter  it ! 

Among  the  many  pamphlets  in  rela¬ 
tion  to  the  cholera  which  we  have 
lately  received,  there  is  one  which  deals 
with  this  question  in  a  more  rational 
manner  than  we  have  yet  found  it  treat¬ 
ed  by  medical  writers.*  The  writer 
considers  the  question  logically,  and  his 

*  A  Letter  to  Lord  Morpeth  and  the  Members 
of  the  Board  of  Health,  on  the  question,  “  Is 
Cholera  Contagious  or  not?”  by  William 
Reid,  M.D.  Fellow  of  the  Royal  College  of  Phy¬ 
sicians,  Edinburgh,  &c.  London  :  Highley. 


634  CONTAGION  OF  CHOLERA - NOTIFICATION  OF  THE  BOARD  OF  HEALTH. 


premises  are  based  on  facts  which  we 
think  will  be  admitted  by  all  expe¬ 
rienced  medical  practitioners.  Dr. 
Beid  observes — 

“At  the  present  conjuncture,  the 
question  of  contagion  or  non-contagion 
in  cholera  is  one  of  the  most  vital  pub¬ 
lic  interest;  and  hitherto  it  has  by  no 
means  been  answered  satisfactorily, 
either  in  the  negative  or  affirmative,  as 
the  conflicting  testimonies  of  boards  of 
health  collectively,  and  medical  autho¬ 
rities  individually,  abundantly  prove. 
It  is  a  subject,  further,  on  which  the 
public  at  large  is  highly  excited,  and 
on  which,  moreover,  we  conceive  it  is 
fully  competent  to  form  an  opinion,  or 
certainly  to  balance  the  probabilities  of 
evidence,  and  thence  determine  the 
] practical  line  of  conduct  to  be  pursued. 
May  we  add,  it  is  a  question,  besides, 
on  which  we  think  the  public  has  a 
right  to  demand  some  information,  and 
if  it  cannot  be  answered  directly  in  the 
affirmative,  or  unconditionally  and  ab¬ 
solutely  in  the  negative,  to  be  supplied 
with  the  grounds  for  such  an  unsettled 
state  of  the  proposition.” 

Using  the  terms  infectious  and  con¬ 
tagious  as  synonymous,  the  writer  pro¬ 
ceeds  to  say — 

“  That  any  disease  should  be  en¬ 
titled  to  be  designated  by  the  term  in¬ 
fectious  or  contagious,  it  is  not  requi¬ 
site  that  every  human  being  who  comes 
within  the  sphere  of  its  action  should 
sicken  thereby.  So,  evidently,  there 
are  certain  conditions  of  the  animal 
frame — whether  arising  from  the  vital 
actions  constantly  going  on  internally, 
or  proceeding  from  the  operation  of  ex¬ 
ternal  causes  affecting  it  (exclusive 
totally  of  the  action  of  the  pure  simple 
contagious  matter),  whose  separate  or 
conjoint  influences  enable  it  to  with¬ 
stand  the  assault  of  the  enemy  ;  while 
likewise  there  are  conditions  under 
which  it  yields  more  readily  to  the 
same.  This  daily,  experience  must 
have  taught  every  one.  As  then,  these 
states  of  the  body,  or  conditions  of  the 
animal  frame,  are  equally  requisite 
with  the  presence  of  the  poisonous 
effluvia,  it  is  apparent,  that  could  these 
former  be  avoided,  checked,  suspended, 
or  even  modified,  the  latter,  or  the 
noxious  agent,  would  no  longer  pro¬ 


duce  its  impression  or  effect  on  the  now 
unsusceptible  body. 

“  The  extremely  virulent  and  diffusive 
nature  of  the  poison  of  contagious 
fever  in  close  and  ill-ventilated  dwell¬ 
ings  is  well  known ;  but  the  same 
fever  occurring  in  the  person  of  a 
wealthy  individual,  whose  bed-room 
is  airy  and  spacious,  seems  at  once  dis¬ 
armed  of  that  most  characteristic  pro¬ 
perty — to  wit,  infection ;  so  that  it 
might  be  held  almost  as  a  totally  dis¬ 
tinct  and  different  disease.  Had  the 
dwellings  of  the  lower  order  of  society 
been  similarly  constituted,  it  is  more 
than  presumptive  that  the  disease 
typhus  might  never  have  received  the 
appellative  infectious 

The  controversy  which  so  long  ex¬ 
isted  regarding  the  contagious  propa¬ 
gation  of  typhus  is  now  settled  down 
into  a  general  admission,  that  the  dis¬ 
ease  is,  under  certain  conditions ,  propa¬ 
gated  by  proximity  to  the  sick.  The 
opposition  shown  by  the  late  Dr. 
Armstrong  to  the  admission  of  this 
theory,  must  be  fresh  in  the  recollection 
of  our  readers.  When  several  cases  oc¬ 
curred  successively  in  a  house  or  street, 
the  Doctor  was  always  ready  to  prove 
that  there  was  malaria  in  the  district, 
just  as  now  with  the  cholera,  plums  and 
sour  beer,  or  some  overflowing  cesspool, 
is  made  responsible  for  the  successive 
attacks  of  persons  who  have  been  in  a 
district  where  cholera  [was  extensively 
prevailing.  It  is  strange,  however,  that 
the  insufficiency  of  such  an  explanation 
is  not  made  apparent  to  every  reasonable 
mind,  when  the  first  cases  occur  among 
the  crews  of  vessels  which  have  recently 
arrived  from  a  port  where  the  disease 
is  prevailing.*  In  the  cases  which 
occurred  at  Hull  and  Sunderland,  the 
men  brought  the  disease  with  them  ;  of 
this  we  do  not  entertain  any  doubt, 
but  whether  it  will  spread  among  the 
inhabitants  of  these  towns  or  not, 

*  The  cases  at  Hull  occurred  on  board  a  vessel 
from  a  Prussian  port ;  and  two  cases,  more  re¬ 
cently  observed  by  Dr.  Sutherland,  occurred  on 
board  of  a  vessel  which  bad  recently  arrived  from 
Hamburgh.  See  page  641. 


CONTAGION  OF  CHOLERA - NOTIFICATION  OF  THE  BOARD  OF  HEALTH.  635 


must  depend  on  various  circumstances. 
If,  fortunately,  it  should  not  spread,  the 
fact  will  apparently  be  in  favour  of  the 
view  taken  by  the  Board  of  Health, 
that  cholera  is  not  contagious ;  but  on 
this  point  it  may  be  as  well  to  consider 
the  following  remarks  made  by  Dr. 
Reid: — 

“The  affection  commonly  named  the 
Rose,  or  St.  Anthony’s  fire  (the  erysi¬ 
pelas  of  systematic  writers),  has  from 
time  immemorial  been  classed  amongst 
the  non-contagious  order  or  group  of 
diseases ;  in  short,  it  has  generally 
been  considered  as  not  infectious. 
Three ,  however,  authentic,  uncontested, 
and*  indisputable  illustrations  of  the 
contrary  have  been  noticed  within  the 
last  thirty  or  forty  years,  respectively  in 
Montrose,  Edinburgh,  and  the  metro¬ 
polis.  Some  twenty  or  thirty  were 
affected  in  all,  and  if  we  recollect  aright, 
some  of  these  cases  terminated  fatally. 
But  that  does  not  in  the  least  affect  the 
question  of  infection. 

“The  corollary  or  inference,  then,  is 
self-evident ;  for  here  is  a  disease, 
usually  in  its  most  ordinary  form  (and, 
as  every  person  knows,  it  is  a  most 
prevalent  affection)  held  as  not  con¬ 
tagious,  propagated  by  contagion, 
distinctly  through  a  series  of  three 
different  groups  of  individuals,  ori¬ 
ginating  in  one  of  each  of  these 
groups,  in  whom  the  original  cause  was 
altogether  a  matter  of  pure  accident. 
What  holds  good,  then,  in  this  affec¬ 
tion,  may,  until  the  contrary  is  demon¬ 
strated,  hold  no  less  forcibly  in  any 
other  new  disease,  not  generally 
deemed  to  be  infectious.  The  produc¬ 
tion ,  apparently ,  of  a  disease  by  conta¬ 
gion,  does  not  preclude  its  origin  from 
causes  independent  of  any  animal  efflu¬ 
vium  ;  and  the  generation  of  a  disease 
from  natural  physical  causes,  would  not 
appear  to  prevent  the  possibility  of  that 
affection  subsequently  acquiring  infec¬ 
tious  properties.  So  that,  if  we  are 
brought  in  collision  with  a  disease  of 
such  a  double  nature  (if  this  expression 
be  permitted),  we  shall  have  at  once  to 
fortify  ourselves  against  the  agency  of 
the  physical  causes,  and  avoid,  at  the 
same  time,  free  intercourse  with  the  in¬ 
fected,  if  we  desire  to  live  secure  from 
the  disease.  No  one  denies  now  the 
occasional  production  of  erysipelas  by 
infection.  The  evidence  of  the  pro¬ 


duction  of  cholera  in  a  similar  mode  is 
fully  as  strong ;  still,  the  Cholera  may 
be,  and  in  all  probability  is,  very  much 
under  the  influence  of  atmospheric  and 
terrestial  agencies  ;  but  so,  likewise,  is 
common  continued  fever.  The  Cho¬ 
lera  is  not  always  infectious  ;  but  the 
fact  that  it  is  so  at  times ,  upholds  the 
necessity  of  always  being  on  our  guard 
against  that  contingency  occurring.” 

“We  consider  that  the  proposition, 
also,  may  be  held  as  established,  that 
the  identity  of  a  disease,  and  its  propa¬ 
gation  by  infection,  are  not  to  be  re¬ 
puted  as  absolutely  essential  in  every 
instance;  or,  in  other  terms,  it  will  be 
admitted,  we  conceive,  that  a  disease 
may  at  times  proceed  distinctly  and 
undoubtedly  from  infection ;  while 
under  other  circumstances,  causes  alto¬ 
gether  of  a  different  character  may 
contribute  to  its  generation.  In  the 
case  of  common  continued  fever  this 
seems  to  be  undoubtedly  the  actual 
statement  of  the  proposition.  And 
precisely  so  do  we  conceive  the 
evidence  holds  as  regards  the  Cholera. 

“  It  may  not  be  contagious  in  one 
locality,  while,  in  another,  it  displays 
that  property  in  an  exquisite  degree. 
In  the  large  and  spacious  dwellings  of 
the  rich  and  affluent,  it  may  never 
assume  that  mark  (analogous  to  typhus 
under  these  conditions) ;  while,  in 
humbler  and  crowded  abodes  of  the 
dwellings  of  the  poor,  infection  may  be 
its  most  distinctive  mark.  It  may 
likewise  (to  pursue  the  parallel)  never 
attack,  at  least  but  rarely,  the  wealthy 
(analogous  again  to  typhus  fever, 
which  rarely  affects  that  class  of 
society)  ;  while  the  poor,  impoverished, 
over-wrought,  ill-fed,  depressed  artizan, 
becomes  its  ready  prey,  as  is  sufficiently 
notorious  in  the  case  of  our  common 
fever.  It  may  have  one  character  in 
the  tropics,  and  display  another  within 
the  temperate  circles,  yet  continue  still 
the  same  affection.  It  not  being  con¬ 
tagious  in  one  district,  is  no  guarantee 
that  it  will  not  become  so  in  another; 
for  in  the  first  many  concurring  causes 
might  not  exist,  which  may  be  met  with, 
in  the  latter.” 

Dr.  Reid  differs  toto  ccelo  from  the 
Members  of  the  Board  of  Health  on 
the  expediency  of  stating  the  whole 
truth.  The  Board  appears  to  act  on 
the  principle  that  the  public  should  be 


IT  MX  ASSJOHO  OIlAiBA  atu 

- NOTIFICATION  OF  THE  BOARD  OF  HEALTH* 


636  CONTAGION  OF  CHOLERA 

kept  in  ignorance  of  the  fact,  that 
cholera  may  be,  and  is  sometimes,  com¬ 
municated  from  one  person  to  another. 
This  it  is  supposed  will  cause  indivi¬ 
duals  to  attend  with  more  zeal  and  con¬ 
fidence  to  each  other’s  wants  in  the 
event  of  an  attack.  This  may  be  ;  but, 
as  Dr.  Reid  observes,  there  is  the 
risk  of  lulling  the  minds  of  the 
people  into  a  false  security,  and  thus 
leading  to  the  unnecessary  sacrifice  of 
life.  To  act  strictly  upon  the  doctrine, 
would  be  to  incur  a  great  risk  of  admit¬ 
ting  the  cholera  by  importation,  just  as 
the  fever  was  imported  into  Canada  by 
the  Irish  emigrants. 

“From  the  data  now  enumerated, 
we  think  we  do  not  rush  precipitately 
to  a  conclusion  when  we  assert  that  we 
have  no  positive  evidence  that  cholera 
is  invariably  a  non-contagious  dis¬ 
order  ;  and  also  that,  on  the  other 
hand,  we  have  most  satisfactory  and 
indisputable  grounds  for  saying  that  it 
has  almost,  in  its  first  visitation  of  this 
country,  uniformly  affected  the  very 
same  localities  and  tracts  which  are 
the  unvarying  haunts  of  typhus.  In 
the  unbiassed  mind  these  facts  would 
certainly  be  sufficient  to  excite  sus¬ 
picion,  and  create  doubts  as  to  its  non- 
contagious  character.  This  suspicion 
would  be  eventually  converted  into  a 
direct  affirmative,  when  the  disease  is 
found  to  arrive  simultaneously  in  dif¬ 
ferent  districts  subsequently  to  the 
arrival  of  individuals  there  from  in¬ 
fected  localities,  and  who  finally  fell 
ill.  It  is  accordingly  lulling  the  minds 
of  the  people  into  a  false  security, 
maintaining  unreservedly  such  a  pro¬ 
position  ;  and,  if  qualified,  where  are 
you  to  stop  ?  where  do  you  end  ?  where 
do  you  begin  ?  where  is  the  exact  line 
of  demarcation  ?  at  what  point  do  you 
say — thus  far  and  no  farther  ?  The 
more  prudent,  the  more  safe,  and  the 
more  judicious  plan,  is  to  adopt  the 
precautionary  measures  connected  with 
such  an  assumption.  No  harm  can 
arise  therefrom  ;  on  the  contrary,  much 
good  may  result. 

“  Habits  of  cleanliness  will  be  en¬ 
joined  ;  free  ventilation  enforced. 
Along  with  which,  proper  diet  and 
occupation  will  disarm  the  pestiferous 
malady  of  much  of  its  virulence.  The 


act  of  knowing  we  are  occupied  in 
doing  what  is  sure  to  prevent  the  dis¬ 
ease  will  invigorate  and  confirm  the 
mind,  so  that  it  will  be  able  to  with¬ 
stand  the  assault.  Nothing  so  deadly 
in  epidemic  diseases  as  a  panic.  We 
have  witnessed  the  fatal  effects  of  such 
a  state  of  the  nervous  system  more 
than  once.  In  perils  of  whatever  kind 
there  is  no  greater  security  than  a  pre¬ 
cise  knowledge  of  the  exact  degree  of 
danger.  And  the  habitual  typhus,  to 
which  we  are  daily  and  hourly  ex¬ 
posed,  is,  by  universal  assent,  admitted 
to  be  a  disease  of  a  most  malignantly 
infectious  character  compared  with  the 
Cholera.  Be  it,  then,  attentively  ob¬ 
served,  that  the  lives  of  millions  will 
be  affected  by  the  tenor  of  the  regula¬ 
tions  you  enjoin.  And  beware,  lest  it 
be  proved  to  be  invariably  contagious; 
as  yet  the  reverse  has  not  been  deter¬ 
mined.” 

Many  will  agree  with  us  in  thinking 
that  it  was  decidedly  impolitic  to  make 
the  difficult  question  of  contagion  a 
subject  of  discussion  inofficial  instruc¬ 
tions  issued  to  the  public,  or  in  the 
daily  journals.  The  truth  should 
have  been  told  in  a  plain  and  un¬ 
equivocal  form,  or  the  matter  should 
have  been  left  altogether  unnoticed* 
As  it  is,  the  Boards  of  Health,  both  of 
London  and  Dublin,  have  adopted  a 
course  which  it  appears  to  us  cannot 
be  justified.  In  the  recent  documents 
they  have  not  shewn  the  courage  to 
affirm,  without  any  reservation,  that 
cholera  cannot,  under  any  circum¬ 
stances,  be  communicated  from  one 
person  to  another  :  they  say,  “  the 
extent  and  undoubted  authority  of  the 
evidence,  &c.  appear  to  discredit  the 
once  prevalent  opinion  that  cholera  is 
in  itse//’contagious— an  opinion  which, 
if  fallacious,  &  c.”  Then  we  are  told 
that  certain  conditions  “  may  favour 
its  spread  from  person  to  person,  &c. 
but  such  conditions  are  not  likely  to 
occur  in  this  country,  &c.  We  have 
already  commented  on  the  notification 
of  the  Irish  Board,  to  the  effect  that 
“  Cholera  is  rarely,  if  ever,  contagious.” 
“  Consequently”  (it  continues)  “  the 


IS  THE  ASIATIC  CHOLERA  IN  THE  METROPOLIS  ? 


637 


separation  of  the  sick  from  the  healthy 
— a  measure  so  essential  in  checking 
the  spread  of  fever — is  not  required  in 
Cholera.”  Further,  “  the  7ion- contagious 
character  of  Cholera  fortunately  re¬ 
moves  all  objection  to  the  receiving  of 
persons  suffering  under  the  disease 
into  the  ordinary  hospitals  of  the 
country,  &c.”  It  will  be  seen  that  the 
Government  Boards,  while  wishing  to 
impress  the  public  mind  with  the  idea 
that  the  disease  is  not  contagious,  have 
in  reality  adopted  a  qualified  admis¬ 
sion  of  the  doctrine  of  contagion  ;  and 
we  are  inclined  to  ask,  with  Dr.  Reid, 
where  are  wTe  to  begin,  and  where  to 
stop  ?  It  will,  wTe  think,  be  somewhat 
difficult  to  fix  the  line  of  demarcation  ; 
and,  if  this  be  not  fixed,  people  will  be 
more  frightened  at  the  uncertainty 
than  at  the  reality. 

The  truth  might  have  been  told  in  a 
few  words.  Cholera,  like  fever,  may 
prevail  in  an  epidemic  form  ;  and,  like 
this  disease,  it  may  be  communicated 
from  one  person  to  another;  but,  as  a 
general  rule,  this  will  happen  only  in 
those  cases  in  which  cleanliness  and 
ventilation,  &c.  are  wholly  neglected. 
This  statement,  while  it  would,  we 
believe,  have  been  consistent  with 
truth,  would  have  been  more  satisfac¬ 
tory  to  the  public  than  the  vague  form 
in  which  the  disease  has  been  officially 
pronounced  to  be  non-contagious. 


If  we  are  to  trust  to  the  observations 
of  some  practitioners  who  are  well  ac¬ 
quainted  with  the  characters  of  Asiatic 
cholera,  this  disease  has  shown  itself, 
but  as  yet  not  in  a  formidable  shape, 
in  the  metropolis.  The  notes  of  seve¬ 
ral  cases  have  reached  us  :  the  symp¬ 
toms  in  all  are  of  the  same  character, 
and  the  disease  is  marked  by  a  rapidly 
fatal  termination.  A  brief  account  of 
the  case  which  proved  fatal  in  St.  Bar¬ 
tholomew’s  Hospital  is  elsewhere  in¬ 


serted.*  We  do  not  mean  to  question 
the  judgment  of  those  gentlemen  who 
have  unhesitatingly  affirmed  that  the 
cases  belong  strictly  to  the  Asiatic 
variety  of  the  disease,  and  that  they 
are  not  cases  of  English  cholera  in  an 
aggravated  form  ;  but  we  entertain  no 
doubt  that  similar  cases,  although  not 
so  numerous,  have  occurred  in  the  me¬ 
tropolis  for  some  months  past.  In 
another  part  of  the  journal  f  will  be 
found  the  report  of  a  case,  by  Mr.  Ha- 
den  ,  which  occurred  in  August  last,  and 
which,  so  far  as  we  can  ascertain,  is 
identical  in  its  symptoms  and  progress 
with  those  which  have  been  reported 
recently.  The  question  whether  these 
cases  are  to  be  ascribed  to  autumnal 
cholera  in  a  severe  form,  or  to  the  pes¬ 
tilence  which  has  been  steadily  pro¬ 
gressing  westward,  is  likely  to  have  a 
speedy  solution.  The  number  of  per¬ 
sons  attacked,  the  intractable  nature  of 
the  cases,  and  their  rapid  progress  to  a 
fatal  termination,  are  circumstances 
which,  if  observed,  cannot  fail  to  iden¬ 
tify  the  malignant  form  of  disease. 
We  have  had  already  so  many  false 
alarms  on  the  subject,  that  it  will  be 
only  common  prudence  to  reserve  an 
opinion  until  some  further  observations 
are  made. 


In  addition  to  the  cases  reported  at 

page  640,  four  other  cases  are  reported 

to  have  occurred  on  Wednesday.  So 

* 

far  as  we  can  ascertain,  the  disease  has 
not  as  yet  manifested  any  tendency  to 
spread. 


We  elsewhere^  insert  a  letter  which 
will  illustrate  the  scandalous  treatment 
to  which  the  medical  officers  of  Poor 
Law  Unions  are  often  compelled  to  sub¬ 
mit.  The  main  object  of  some  of  these 


*  Page  640  t  Page  627.  %  Page  639. 


638  CLINICAL  MEMORANDUM  BOOK.  MERCURY  AND  ITS  EFFECTS. 


sub- officials  of  the  poor  law  appears  to 
be,  to  procure  medical  relief  without 
paying  for  it.  A  quasi-order  is  issued  : 
if  the  medical  officer  attend,  and  the 
case  goes  on  well,  payment  is  refused. 
Should  he  decline  to  attend,  and  the 
case  turn  out  unfavourably,  the  over¬ 
seer  or  other  parties  may  throw  the 
whole  of  the  blame  upon  him,  and 
appeal  to  the  order  as  a  proof  that  he 
had  legal  notice  to  attend !  Mr.  Buller, 
the  President  of  the  Poor  Law  Board, 
cannot  surely  be  aware  that  such  tricks 
as  these  are  played  by  overseers,  for 
the  purpose  of  cheating  the  medical 
officer  out  of  the  fair  value  of  his  ser¬ 
vices. 


The  Student’s  Clinical  Memorandum 
Book;  or,  Medical  Practitioner’s 
Remembrancer  and  Vade  Mecum. 
Highley,  Fleet  Street.  1848. 

We  commend  this  memorandum  book 
to  the  use  of  every  student  or  practi¬ 
tioner  who  is  desirous  of  keeping  a  re¬ 
cord  of  the  results  of  his  observation 
and  practice.  It  is  arranged  in  the  | 
form  of  an  oblong  note  book,  adapted 
to  the  pocket.  Four  pages,  with  ruled 
lines,  are  devoted  to  each  case,  and 
they  are  so  conveniently  sub-divided  as 
to  admit  of  the  introduction  of  every 
fact  of  interest  in  the  history  or  treat¬ 
ment  of  a  case.  To  the  frequenters  of 
the  clinical  wards  of  hospitals  it  will 
be  found  an  invaluable  companion. 
We  quite  agree  in  the  statement  of  Dr. 
Barlow,  inserted  in  the  preface,  that 
“  Exact  information  is  difficult  to  fur¬ 
nish,  chiefly  from  the  neglect  of  all  me¬ 
dical  reporting ;  and  this  arises  less 
from  indolence  or  want  of  zeal  than 
from  no  general  mode  being  devised 
that  all  may  adopt.”  As  far  as  our 
judgment  goes,  the  compiler  of  this 
book  has  succeeded  in  removing  this 
objection.  We  believe  that  it  is  to  be 
had  at  a  very  reasonable  price,  and  it 
will  be  found  far  more  serviceable  than 
the  blank  note-books  commonly  used 
by  students. 


The  Clinical  Repertory.  Synoptical 

Tabular  Form.  London  :  Highley. 
1848. 

This  Repertory,  which  is  in  a  large 
sheet  of  double  demy  folio,  is  so  con¬ 
structed  as  to  allow  of  the  tabulation 
of  a  vast  multitude  of  facts  on  all  sub¬ 
jects  connected  with  diseases  and  their 
treatment,  and  at  the  same  time  to 
afford  the  statistician  an  opportunity 
of  keeping  a  geographical  and  meteoro¬ 
logical  journal.  It  also  embraces  nu¬ 
merous  subjects  of  interest  in  a  sanitary 
view.  Nothing  seems  to  be  omitted  ; 
and  the  only  question  is  whether,  in 
respect  to  clearness  of  reference,  too 
much  may  not  have  been  introduced. 


Pharmacopoeia  ad  usum  Nosocomium 
phthisicorum  et  pectoris  morbis  oeg ro¬ 
ta  ntium  accomodata.  12mo.  pp.  37. 
Londini,  apud  Bradbury  and  Evans. 
1848. 

This  little  pharmacopoeia,  as  its  name 
implies,  is  especially  adapted  to  the 
use  of  the  Hospital  for  Consumption 
and  Diseases  of  the  Chest.  It  con¬ 
tains  rather  more  than  100  formulae, 
which  appear  to  have  been  very  judi¬ 
ciously  selected.  We  have  looked 
through  the  list,  and  believe  that  al¬ 
though  the  formulae  consist  chiefly  of 
new  combinations  of  well-known  com¬ 
pounds,  there  are  many  which  will  be 
found  serviceable  to  a  practitioner  who 
is  called  upon  to  treat  a  case  of  chest 
disease. 


of  j&octettes. 

MEDICAL  SOCIETY  OF  LONDON. 
Monday,  October  2,  1848. 

Mr.  Hancock,  President. 


Mercury  and  its  effects. 

Mr.  Hancock  inquired  if  any  members  had 
tried  the  plan  recommended  by  some  French 
surgeons,  of  giving  calomel  in  very  small 
doses  in  inflammatory  cases  ?  The  dose  re¬ 
commended  was  a  twentieth  part  of  a  grain 
every  hour,  day  and  night,  until  the  specific 
effect  of  the  medicine  was  produced.  He 
had  tried  this  plan  with  two  patients  in 
Charing-cross  Hospital,  both  of  whom  had 
been  admitted  with  inflammation  of  the  tes¬ 
ticle,  consequent  upon  gonorrhoea.  In  one 
case,  he  gave  a  twentieth  of  a  grain  of  calo- 


UNJUST  TREATMENT  OF  POOR-LAW  MEDICAL  OFFICERS.  639 


♦ 


mel  every  hour  ;  in  the  other,  a  twentieth  of 
a  grain  every  three  hours.  In  the  first  case, 
the  patient  was  salivated  in  thirty- six  hours  ; 
in  the  second  case,  in  forty-eight  hours.  The 
advantages  of  this  mode  of  producing  ptyalism 
were,  that  the  effect  was  milder  and  more 
controllable  than  where  larger  doses  were 
administered ;  the  bowels  were  also  un¬ 
affected.  The  mode  of  its  administration 
was  as  follows  : — Calomel,  one  grain  ;  con¬ 
fection  of  opium,  a  scruple;  divide  in 
twenty-pills — one  every  hour.  In  the  cases 
related,  the  effects  of  this  medicine  were 
most  decided. 

Mr.  Middleton  had  been  occasionally 
surprised  to  see  small  doses  of  the  mercury 
and  chalk  produce  ptyalism  in  children  of 
all  ages  when  given  merely  as  an  alterative. 
Large  doses  of  calomel  failed  to  produce 
any  such  effect.  He  had  seen  salivation 
produced  in  a  child  by  a  single  dose  of  the 
mercury  with  chalk. 

Dr.  Willshire  had  never  seen  ptyalism 
in  a  very  young  child,  though  he  had  ob¬ 
served  its  effects  on  the  mouth  from  the 
administration  of  this  medicine. 

Mr.  Hooper  had  never  seen  a  child  sali¬ 
vated  by  calomel.  With  respect  to  small 
doses  of  calomel  to  produce  the  specific  ef¬ 
fects  of  mercury  on  the  constitution,  he  had 
long  been  in  the  habit  of  employing  them. 
One  grain  every  three  or  four  hours  he  found 
more  effective  than  the  larger  doses. 

Mr.  Hird  said,  that  if  all  the  beneficial 
effects  of  mercury  could  be  obtained  from  the 
small  doses  mentioned  by  Mr.  Hancock, 
then,  indeed,  would  the  new  plan  be  very 
useful.  His  opinion,  however,  founded,  it 
was  true,  on  his  experience  of  the  small 
doses,  was,  that  in  acute  inflammatory  dis¬ 
eases  of  serous  membranes  they  would  be 
found  less  effective  in  lowering  the  heart’s 
action,  and  producing  the  other  specific 
effects  of  mercury,  than  the  more  commonly- 
employed  doses.  He  had  seen  the  worst 
effects  of  mercury  in  children  when  em¬ 
ployed  as  alteratives. 

Dr.  Willshire  admitted  that  the  speci¬ 
fics  of  mercury  were  exerted  most  benefi¬ 
cially.  In  cases  of  syphilis  in  young  chil¬ 
dren,  one  grain  of  the  mercury  with  chalk, 
and  two  grains  of  soda,  night  and  morning, 
generally,  in  ten  or  fourteen  days,  succeeded 
in  effecting  a  cure,  but  without  producing 
salivation.  He  threw  out  a  hint  that  mer¬ 
cury  in  inflammation  might  not  be  so  effec¬ 
tive  as  some  had  imagined,  and  appealed  to 
the  opinions  expressed  by  Dr.  Alison,  and 
by  a  reviewer  in  Forbes's  Journal,  on  this 
point. 

Mr.  Robarts  believed  that  the  effects  of 
mercury  were  influenced  and  modified  much 
by  the  period  of  year,  state  of  weather,  &c. , 
at  which  it  was  administered.  He  had  tried 
the  plan  of  treating  chronic  catarrh  with 


small  doses  of  blue-pill,  as  recommended  by 
Dr.  F.  Thompson,  and  published  in  The 
Lancet,  with  much  success. 

Mr.  Hancock  had  found,  in  cases  where 
it  was  thought  almost  impossible  to  produce 
salivation,  that  a  few  grains  of  iodide  of  po¬ 
tassium,  administered  in  the  intervals,  was 
most  effective. 

Mr.  Bishop  had  observed  the  same  cir¬ 
cumstances. 


©omgpontience. 


UNJUST  TREATMENT  OF  POOR-LAW  MEDI¬ 
CAL  OFFICERS.  ORDERS  ON  LOAN. 

• 

Sir, — I  shall  feel  obliged  by  your  answer¬ 
ing  in  your  columns  the  following,  or  giving 
me  your  advice  as  to  what  course  should  be 
adopted  under  the  circumstances  by  the  dis¬ 
trict  medical  officer  of  the  Poor-Law  Union. 

A  poor  man  ( not  a  pauper,  receiving 
parish  relief,  with  a  large  family ,  and  earn¬ 
ing  12s.  or  14s.  per  week),  applies  to  the 
Overseer  of  his  parish  for  medical  attendance 
on  his  wife,  who  is  hourly  expecting  her 
confinement :  this,  the  Overseer  refuses,  on 
the  ground  of  the  applicant  not  being  a 
pauper but  he  (the  Overseer),  being 
afraid  lest  any  accident  may  happen  to  the 
woman  during  labour,  sends  me  (being  the 
district  medical  officer)  the  following  order. 

“  To  Mr.  D., 

Medical  Officer,  Hartshorne. 

Sir, — Please  to  attend  A.  B.,  residing  in 
the  above  parish. — Signed, 

C.  D.,  Overseer. 

Sept.  20,  1848. 

P.S.  This  order  is  on  Loan.” 

In  accordance  with  this  order  from  the 
Overseer,  I  attend  the  patient  for  a  fort¬ 
night,  and  during  that  time  she  is  delivered 
under  my  care.  At  the  expiration  of  that 
time,  the  Board  of  Guardians  (who  hold 
their  meetings  every  two  weeks)  decide, 
“  that  the  case  was  not  for  the  parish  sur¬ 
geon,  and  that  they  cannot  allow  me  any¬ 
thing  for  my  attendance  on  her  during  that 
time,  she  not  being  considered  a  pauper.” 

I  shall  be  much  obliged  to  any  of  your 
correspondents,  who  will  advise  me  how  to 
act  in  such  a  case,  and  whether  the  Overseer 
has  the  right  of  compelling  my  attendance 
by  an  order  “  on  Loan,”  and  then  refusing 
to  pay  after  the  recovery  of  the  patient ;  or 
whether  I  can  compel  the  Board  of  Guar¬ 
dians  to  allow  me  for  my  extra  attendance 
on  such  patient. 

I  remain,  sir, 

Your  obedient  servant, 

Perry  Dicken,  M.R.C.S. 

Ashby-de-la-Zouch,  Oct.  2,  1848. 

***  The  Overseer  has  no  power  to  com- 


640 


FATAL  CASES  OF  CHOLERA  MEDICALLY  CERTIFIED. 


pel  the  medical  officer  to  attend  a  patient, 
except  by  an  order  which  justifies  a  demand 
for  payment.  The  law  knows  nothing  of 
orders  on  loan  ;  and  we  advise  our  corres¬ 
pondent  to  consult  a  solicitor,  as  to  the  form 
in  which  he  should' bring  his  plaint  before 
the  judge  of  the  County  Court. 


JMefctcal  Intelligence. 


FATAL  CASES  OF  CHOLERA  RETURNED  IN 
THE  WEEK  ENDING  SATURDAY  THE  7'1H. 
- (ALL  ARE  CERTIFIED  BY  MEDICAL  AT¬ 
TENDANTS.) 

In  Old  Street  (sub-district),  St,  Luke’s,  at 
39,  Rahere  Street,  wife  of  a  gentleman,  59 
years,  “  disease  of  the  bowels,  simulating 
Asiatic  cholera  (38  hours’  duration).”  In 
south  sub-district,  west  London,  F.  27  years, 
“  cholera  (13  hours’  duration).”  In  St.  Bar¬ 
tholomew’s  Hospital,  west  London,  M.  about 
40  years,  “  Asiatic  cholera.”  In  Town 
(sub -district),  Bethnal  Green,  at  4,  Cheshire 
Street,  a  weaver,  F.  21  years,  “  enlargement 
of  the  heart  (12  months’  duration),  cholera, 
spasmodic  (12  hours).”  In  Spitalfields, 
Whitechapel,  M.  23  years,  “  cholera  (12 
hours’  duration).”  In  Whitechapel  north, 
a  girl,  4  years,  “  English  sporadic  cholera 
(7  days’  duration).  In  St.  Paul  (sub-dis¬ 
trict),  St.  George  in  the  East,  M.  38  years, 
“  cholera  (2  days’  duration).”  In  Mile 
End  Old  Town,  Lower  Stepney,  M.  47 
years,  “  cholera  (36  hours’  duration).” 
Mr.  Castleden,  the  Registrar’s  Note.  Mr. 
Todd,  the  surgeon  in  this  case,  certifies  that 
the  above  was  a  case  of  Asiatic  cholera ;  and 
the  informant  states,  that  her  father  (the 
deceased)  got  up  on  Thursday  morning,  about 
4  o’clock,  with  a  bowel  complaint,  for  which 
he  took  some  gin  and  ginger,  and  then  went 
to  his  work  on  board  ship,  but  which  he  was 
compelled  to  relinquish  about  mid-day.  He 
returned  home  in  a  cab,  and  died  yesterday 
morning  at  4  o’clock.  The  medical  gentle¬ 
man  was  in  close  attendance  to  the  very 
last.”  In  Lambeth  Church,  2nd  part  (sub¬ 
district),  at  Orsett  Street,  daughter  of  a 
chairmaker,  11  months,  “  cholera  (3  days’ 
duration) :  convulsions,  (1  hour).”  Mr. 
W.  H.  Wheatley,  the  Registrar,  states, 
“  that  at  one  end  of  the  street  mentioned 
above,  in  the  centre  of  the  road  is  an  open 
drain,  which  is  very  offensive  at  times — 
drainage  to  houses  very  bad.  Scarlatina  has 
been  very  prevalent  there.”  In  Rotherhithe, 
a  boy  11  years,  “cholera  (19  hours’  dura¬ 
tion).”  In  same  sub-district,  F.  38  years, 
“  cholera  (19  hours’  duration).”  In  same 
sub-district,  a  girl  2  years,  “  cholera  (2  days’ 
duration).”  In  Greenwich  West  (sub¬ 


district)  F.  37  years,  “  cholera  (4  days’ 
duration).” 

THE  CHOLERA  IN  THE  METROPOLIS. 

Three  fatal  cases  of  Asiatic  cholera,  one  of 
them  the  termination  of  an  attack  of  cholera 
on  board  the  hulks,  were  reported  on  Oct. 
10th,  and  several  cases  of  dangerous  attacks, 
confidently  stated  to  be  of  Asiatic  cholera, 
were  also  reported.  Twelve  of  the  cases  re¬ 
ported  on  the  9th  occurred  subsequent  to 
he  thirteen  cases  reported  in  the  Registrar- 
General’s  report  of  last  week,  which  were  up 
to  Saturday  only.  Five  cases  have  occurred 
in  a  court  in  Chelsea  ;  three  at  Rotherhithe  ; 
two  in  the  city  of  London  ;  two  in  Spital¬ 
fields  ;  two  in  Whitechapel  ;  two  in  Ber¬ 
mondsey  ;  two  in  Horsleydown  :  inclusive 
of  those  at  Woolwich,  26  fatal  cases  have 
been  reported  during  the  week.  Dr.  Parkes, 
and  Mr.  Robert  Bowie,  surgeon,  who  gave 
evidence  on  the  river  side  cases  before  the 
Sanitary  Commissioners,  have  been  engaged, 
on  behalf  of  the  General  Board  of  Health, 
in  examining  the  cases  reported  to  them. 

ALLEGED  APPEARANCE  OF  THE  CHOLERA 
IN  EDINBURGH  AND  LONDON. 

A  notification  was  received  in  town  from 
Edinburgh  on  Friday  last,  announcing  the 
appearance  there  of  malignant  cholera  in 
five  cases — three  in  one  part  of  the  city,  and 
two  in  another.  Three  of  the  cases  had 
proved  fatal  within  twenty-four  hours.  The 
College  of  Surgeons  had  advised  the  imme¬ 
diate  formation  of  a  local  Board  of  Health. 
Dr.  Sutherland,  who  had  been  investigating 
two  cases  of  cholera  occurring  at  Sunder¬ 
land  on  board  a  vessel  from  Hamburgh, 
had,  on  Thursday,  been  directed  by  the 
General  Board  of  Health  to  proceed  to  Edin¬ 
burgh  and  take  steps  in  aid  of  the  organiza¬ 
tion  of  a  local  Board  of  Health,  and  mea¬ 
sures  of  prevention  or  alleviation. 

By  information  since  received,  we  learn 
that  other  cases,  considered  to  be  of  decided 
Asiatic  cholera,  had  appeared  at  Edinburgh. 
On  board  the  Justitia  hulk,  lying  off  Wool¬ 
wich,  two  cases  of  Asiatic  cholera  had  oc¬ 
curred  on  Saturday,  and  two  yesterday,  of 
which  three  had  proved  fatal.  Other  scat¬ 
tered  cases  have  been  reported  ;  but  two  de¬ 
cided  cases  were  reported  in  the  metropolis 
several  weeks  ago,  and  in  the  extraordinary 
state  of  the  weather  during  the  last  week, 
which  would  favour  the  propagation  of  the 
ordinary  English  cholera,  the  reported  cases 
must  be  received  with  caution. 

***  We  received,  but  too  late  for  publi¬ 
cation  in  our  last  number,  the  following  ac¬ 
count  of  a  case  of  Asiatic  cholera  which  had 
occurred  in  St.  Bartholomew’s  Hospital : — • 

A  man,  from  Lambeth,  was  brought  in 
on  the  4th  instant,  at  4  a.m.,  having  profuse 
vomiting  and  diarrhoea,  accompanied  by  the 


CHOLERA  AT  WOOLWICH,  HULL,  EDINBURGH,  AND  BERLIN.  641 


usual  dirty,  watery  evacuations ;  lividity, 
cramps  of  the  limbs  and  abdominal  muscles; 
no  pulse,  cold  skin,  and  other  marks  of  col¬ 
lapse.  He  died  in  the  course  of  the  evening. 
The  post-mortem  appearances,  as  common 
in  such  cases,  showed  little.  The  daughter 
(a  child)  of  the  patient  has  just  been  brought 
in  with  similar  symptoms,  though  of  a 
milder  nature.  She  recovered. 

THE  CHOLERA  AT  WOOLWICH. 

Woolwich,  Oct.  10. — It  is  gratifying  to 
be  able  to  state  that  there  have  been  no  new 
cases  amongst  the  convicts  to-day,  and  it  is 
the  general  opinion  that  the  prompt  mea¬ 
sures  which  were  adopted  on  its  first  ap¬ 
pearance  wfll  have  the  most  beneficial  re¬ 
sults.  At  all  events,  those  measures  have 
had  a  great  influence  on  the  minds  of  the 
inhabitants,  and  numerous  faces  that  on  the 
first  assurance  that  cases  of  cholera  had 
arrived  bore  a  most  serious  aspect,  now 
appear  quite  cheerful,  all  apprehension  of 
the  disease  increasing  having  ceased  to  exist. 
The  convicts  on  board  the  Justitia  are  still 
under  quarantine,  and  none  of  them  are 
permitted  on  shore  to  work  in  the  Royal 
Arsenal. 

THE  CHOLERA  AT  HULL. 

No  other  cases  of  cholera  have  occurred  in 
Hull  since  our  last ;  and  we  believe  that  the 
apprehensions  which  existed  last  week  have 
almost  entirely  subsided.  Mr.  Grainger, 
Dr.  Sutherland’s  colleague,  accompanied  by 
Dr.  Ayre,  proceeded  to  Hamburgh,  in  the 
Helen  Macgregor  steamer,  Captain  Frost, 
on  Saturday  last.  Dr.  Sutherland  remained 
in  Hull  throughout  Sunday  and  Monday. 
On  the  latter  day  he  expressed  his  entire 
conviction  that  there  was  not  any  cholera  in 
the  town.  On  Tuesday  morning  he  pro¬ 
ceeded  to  Sunderland,  but  is  expected  very 
shortly  to  return  to  Hull,  and  to  follow  his 
colleague,  Mr.  Grainger,  to  Hamburgh. 
Two  vessels  are  lying  in  Whitebooth  Roads, 
in  the  Humber,  with  the  quarantine  flag 
hoisted. 

A  vessel  arrived  from  Hamburgh  at  Hull 
on  Monday,  with  several  cases  of  attacks, 
and  one  fatal  case,  on  board.  Two  cases  of 
•cholera  had  occurred  in  the  town,  but  they 
were  positively  stated  to  be  cases  of  the 
common  English  cholera,  and  no  cases  of 
Asiatic  cholera  had  been  heard  of  there. 

THE  CHOLERA  AT  EDINBURGH. 

It  was  reported  on  Saturday  last  that  seven 
or  eight  cases  of  Asiatic  cholera  had  occurred 
in  Edinburgh  and  Newhaven  during  the 
week.  In  order  to  prevent  unnecessary 
alarm,  we  deem  it  right  to  state  that  we 
have  been  informed  that  several  of  the  cases 
included  in  those  referred  to  by  Dr.  Taylor 
are  considered  by  the  medical  gentlemen 


who  treated  them,  and  who  therefore  had 
the  best  opportunity  of  judging  of  their 
character,  to  be  merely  severe  cases  of  the 
ordinary  form  of  British  cholera,  so  preva¬ 
lent  at  this  season  of  the  year.  The  same 
parties  also  state  that,  if  these  cases  were 
real  cases  of  Asiatic  cholera,  they  have  met, 
in  the  course  of  their  practice,  with  many 
cases  of  the  same  kind  during  the  last  nine 
months.  At  the  same  time  that  we  would 
thus  warn  the  public  against  unnecessary 
alarm,  we  would  equally  deprecate  inatten¬ 
tion  to  the  means  prescribed  for  warding  off 
this  frightful  scourge,  which,  there  is  reason 
to  fear,  may  yet  ere  long  visit  our  land. 

A  correspondent  informs  us  that  there 
had  been  twelve  deaths  from  cholera  up  to 
Monday  last. 

THE  CHOLERA  AT  BERLIN. 

By  letters  received  from  Berlin  on  the  28th 
September,  it  appears  that  there  were  47 
fresh  cases  of  cholera  on  the  day  preceding. 
Up  to  this  date,  1601  persons  have  been 
attacked,  and  among  these  there  were  944 
deaths  and  260  recoveries  :  397  were  under 
treatment.  It  is  stated  that  in  this  city  the 
disease  has  committed  the  greatest  ravages 
among  the  middle  classes,  while  in  Russia 
the  lower  classes  chiefly  suffered.  In  the 
barracks  there  have  been  but  few  cases, 
while  they  have  been  very  numerous  in  the 
prisons. 

QUARANTINE  AND  CHOLERA. 

It  is  satisfactory  to  know  that  every  precau¬ 
tion  has  been  taken  by  Government  to  pre¬ 
vent  the  importation  of  cholera.  Instruc¬ 
tions  have  been  forwarded  from  the  Board 
of  Health  to  the  Customs  authorities  of 
Southampton,  to  impose  a  quarantine  of  six 
days  upon  all  steamers  arriving  from  fo¬ 
reign  ports  where  the  cholera  prevails.  The 
same  rules  are  enforced  at  other  ports. 

THE  GENERAL  BOARD  OF  HEALTH. 

The  Queen  has  been  pleased  to  appoint 
Thomas  Southwood  Smith,  M.D.,  to  be  the 
Medical  Member  of  the  General  Board  of 
Health. 

APPOINTMENT  OF  AN  OFFICER  OF  HEALTH 
IN  THE  CITY. 

The  following  discussion  on  the  propriety 
of  appointing  an  Officer  of  Health  recently 
took  place  in  the  Common  Council  : — 

The  Chairman  said,  that  he  held  in  his 
hand  a  report  from  the  select  committee  re¬ 
lative  to  the  desirableness  of  appointing  an 
Offioer  of  Health  as  early  as  possible  for  the 
months  which  have  to  come  before  their  new 
act  would  come  into  operation.  It  was  in¬ 
tended,  or  rathe^proposed,  to  ask  for  power 
at  the  next  Court  of  Common  Council  to 
appoint  such  an  officer.  As  it  did  seem  from 


642 


ON  THE  FREQUENCY  OF  INSANITY  AMONG  THE  POOR. 


the  public  papers  that  the  cholera  was  mak¬ 
ing  rapid  advances  towards  this  country,  it 
was  desirable  that  there  should  be  no  delay 
in  the  matter. 

Mr.  Williams. — Will  such  a  step  super¬ 
sede  the  necessity  for  such  parties  to  be  ap¬ 
pointed  in  the  several  parishes  ? 

The  Chairman. — Our  proposition  has 
nothing  at  all  to  do  with  any  merely  local 
arrangements. 

Mr.  Kemp  wished  to  remind  the  Court 
that  part  of  the  proposition  of  the  select 
committee  was  that  the  party  to  be  so  ap¬ 
pointed  was  also  to  be  allowed  to  attend  to 
his  private  practice  as  a  medical  man.  Cer¬ 
tain  he  (Mr.  Kemp)  was,  that,  according  at 
least  to  a  list  of  duties  such  an  officer  would 
have  to  perform  according  to  the  new  act  of 
Parliament,  it  was  inconsistent  for  them  to 
suppose  that  any  man  could  attend  to  his 
public  duty  and  his  private  practice  at  one 
time. 

Mr.  Blake  did  not  consider  that  it  was 
essentially  necessary  that  the  Officer  of 
Health  should  be  a  medical  man.  They 
wanted  a  party  who  could  distinguish  causes 
of  disease  in  this  case  rather  than  a  man  who 
could  supply  a  remedy  after  an  epidemic  had 
made  its  appearance. 

Mr.  H.  L.  Taylor  would  ask  the  com¬ 
missioners  whether  they  had  any  idea  what 
the  committee  proposed  to  give  this  Officer 
of  Health  ?  They  would  be  astonished  to 
find  that  the  sum  named  was  ^400  a-year. 
(Surprise.) 

Mr.  Kemp. — jg500. 

Mr.  Taylor. — Why,  it  ought  to  be  ten 
times  that  amount ;  and  I  am  satisfied  if 
^4,000  were  proposed  that  the  Court  would 
be  unanimous  upon  the  subject. 

Mr.  Blake  explained  that  the  idea  was, 
that  many  young  men  of  great  ability  might 
be  found,  possessing  the  necessary  talent, 
who  would  be  glad  of  the  opportunity  this 
appointment  would  give  to  them  of  rising 
in  their  profession  to  honourable  eminence. 

Mr.  Perkins  said,  that  to  the  honour  of 
the  profession  it  ought  to  be  said  that  the 
pay  was  a  secondary  consideration.  Upon 
the  last  visitation  by  cholera  these  men  had 
charged  nothing  for  their  valuable  services. 

Mr.  Deputy  Corney  moved,  and  Mr. 
Kemp  seconded,  that  the  clause  as  to  ex¬ 
pressing  an  opinion  as  to  the  “  private  prac¬ 
tice/  ’  be  expunged.  As  to  other  matters, 
they  would  be  discussed  in  full  at  the  Court 
of  Common  Council. 

The  report,  upon  a  division,  was  carried 
in  the  shape  it  was  brought  up,  the  amend¬ 
ment  being  lost — 17  voting  for  the  motion, 
and  13  for  the  erasure  of  the  line. 

ON  THE  FREQUENCY  OF  INSANITY  AMONG 
THE  POOR. 

The  following  communication  from  Mr.  T. 


Sidney,  in  reference  to  this  subject,  has  re¬ 
cently  appeared  in  the  Times  newspaper : — 
Much  has  been  said  and  written  to  show 
that  some  modes  of  prison  discipline  have  a 
greater  tendency  than  others  to  insanity 
among  criminals,  but  I  am  not  aware  that 
any  one  has  taken  the  trouble  to  ascertain  to 
what  extent  this  afflictive  malady  prevails 
among  the  lower  classes  of  the  community, 
from  which  the  criminal  population  itself  is 
chiefly  formed. 

I  have  extracted  from  the  latest  official 
documents  the  following  statistics  of  pau¬ 
perism  and  crime,  with  the  view  of  ascer¬ 
taining  the  relative  proportion  which  lunacy 
bears  to  each. 

From  “  the  Appendix  to  the  Annual  Re¬ 
port  of  the  Poor  Law  Commissioners”  I 
find — 

The  number  of  paupers  in  Eng¬ 
land  and  Wales  in  1846  was  1,330,557 

And  from  the  latest  official  publication  on 
lunacy  it  is  stated  that — 

The  number  of  pauper  lunatics 
in  England  and  Wales  in  1846 


was .  9,835 

And  of  idiots .  6,799 


Total .  16,634 

I  also  extract  from  the  “  Twelfth  Report 
of  the  Inspectors  of  Prisons  in  Great  Bri¬ 
tain/ '  that — 

The  total  criminal  population  in 

1846  was .  129,705 

The  number  of  lunatic  criminals 
under  confinement  at  the  same 
period  being .  337 

The  result  stands  thus  : — 

One  lunatic  for  every  .  .  385  criminals. 
One  lunatic  for  every  .  .  135  paupers. 
And  one  lunatic  or  idiot  for 

every . 80  paupers. 

Whilst  such  a  frightful  amount  of  lunacy 
and  idiotcy  prevails  amongst  the  poorer 
classes  (being  more  than  fourfold  greater 
than  exists  in  the  criminal  population),  and 
the  highest  medical  talent  is  very  properly 
called  forth  to  prevent  criminals  falling  vic¬ 
tims  to  its  ravages,  some  further  inquiry 
as  to  prevention  and  remedy  is  due  to  the 
honest  poor.  Justice  and  mercy  demand 
that  they  should  receive  a  proportionate 
share  of  sympathy. 

OBITUARY. 

On  the  2d  inst.,  at  Rye,  Francis  Henry 
Wilson,  surgeon,  aged  46. 

On  the  2d  ult.,  at  Nevis,  West  Indies, 
W.  T.  Nicholson,  Esq.,  M.D. 

On  Sunday,  the  8th  inst.,  at  his  residence 
in  Great  Surrey  Street,  Blackfriars,  in  the 
85th  year  of  his  age,  Robert  Mayhew 


ON  THE  CHEMICAL  CHANGES  OF  RESPIRATION. 


643 


Thompson,  Esq.,  late  Surgeon  to  the  14th 
Light  Dragoons. 

On  Saturday  the  7th  inst.,  Richard  Hicks, 
Esq.,  of  No.  7,  Argyle  Square,  King’s 
Cross,  surgeon,  in  the  35th  year  of  his  age. 


j&electtong  from  ^journals. 


ANIMAL  CHEMISTRY. 

ON  THE  CHEMICAL  CHANGES  OF  RESPIRA¬ 
TION.  BY  MM.  REGNAULT  AND  REISET.* 

It  is  agreed  by  all  experimenters  who  have 
investigated  the  chemical  process  of  respira¬ 
tion,  that  part  of  the  oxygen  of  the  air 
breathed  disappears,  and  a  certain  quantity 
of  carbonic  acid  is  formed.  According  to 
some,  however,  the  whole — according  to 
others,  only  part — of  the  absorbed  oxygen  is 
employed  in  forming  the  carbonic  acid. 
With  regard  to  the  changes  undergone  by 
the  nitrogen  of  the  air,  considerable  differ¬ 
ence  of  opinion  has  existed ;  some  believing 
that  this  gas  is  absorbed,  others  that  it  is 
exhaled. 

The  experiments  of  Dulong  and  Despretz, 
which  are  generally  regarded  as  the  most 
correct,  have  shown,  that  for  every  100 
parts,  by  volume,  of  oxygen  absorbed,  from 
65  to  75  parts  enter  into  the  carbonic  acid 
'  exhaled  ;  while  the  remaining  35  or  25  com¬ 
bine  with  a  corresponding  quantity  of  hydro¬ 
gen,  and  form  water.  They  shewed,  also, 
that  a  considerable  quantity  of  nitrogen  is 
disengaged  during  respiration,  sometimes  as 
much  as  one-fourth  of  the  quantity  of  oxygen 
absorbed.  It  is  manifest,  however,  that  the 
latter  statement  is  incorrect ;  for  not  only 
would  an  animal  thus  exhale  through  its 
lungs,  in  twenty-four  hours,  much  more 
nitrogen  than  exists  in  the  food  taken  during 
that  time,  but,  as  observed  by  Liebig, f  the 
quantity  thus  parted  with,  independent  of 
that  evacuated  by  the  other  excretions, 
would  in  a  few  days  exceed  the  quantity 
of  nitrogen  contained  in  its  whole  body. 

If,  now,  the  amount  of  nitrogen  shewn  by 
these  experiments  to  be  exhaled  through  the 
lungs  is  incorrect,  it  is  probable  that  the  re¬ 
lations  said  to  exist  between  the  quantities 
of  oxygen  absorbed,  and  of  carbonic  acid 
exhaled,  are  also  incorrect ;  for  all  the  pro¬ 
portions  of  the  gases  composing  the  respired 
air  were  determined  by  the  same  analy¬ 
sis.  A  new  and  very  extended  series  of 
experiments  on  the  subject  have  been  insti¬ 
tuted  by  MM.  Regnault  and  Reiset,  who 
give  minute  details  of  the  several  steps  of  the 
process  employed  by  them,  the  precautions 
taken,  and  the  kind  of  apparatus  used.  Their 
investigations,  which  are  still  in  progress, 
seem  to  be  performed  with  much  care  and 

*  Comptes  Rendus,  1848. 

t  Journal  de  Pharmacie,  t.  viii.  p.  24. 


exactness,  and  their  results  may  probably  be 
fully  relied  on.  The  most  important  of  these 
results  is,  that  nitrogen  is  invariably  exhaled 
through  the  lungs,  though  the  quantity  is 
small,  rarely  exceeding  -j-ig-th  °f  the  amount 
of  oxygen  consumed.  Hydrogen,  and  certain 
carburetted  gases,  usually  present  themselves 
in  small  quantity.  As  an  illustration  of  the 
changes  which  Regnault  and  Reiset  found  to 
occur  in  the  respired  air,  the  following  re¬ 
sults  of  an  experiment,  in  which  a  young 
dog  was  confined  in  the  apparatus  for  241- 
hours,  may  be  quoted  : — 

Grammes.* 

Oxygen  consumed .  182-288 

Carbonic  acid  produced  .  .  .  185*961 

Oxygen  contained  in  the  carbonic 

acid .  135*244 

Nitrogen  disengaged  ....  0*1820 

If  the  quantity  of  oxygen  consumed  be  re¬ 
presented  at  100,  then  the  results  may  be 
thus  stated  : — 

Oxygen  consumed  ' . 100 


Oxygen  in  the  carbonic  acid  .  .  74*191 

Oxygen  otherwise  disposed  of  .  25*809 

Nitrogen  disengaged  ....  0.0549 

Average  quantity  of  oxygen  con¬ 
sumed  in  an  hour  ....  7*44 


CASE  OF  HYDROPHOBIA.  EMPLOYMENT  OF 
CHLOROFORM. 

BY  THOMAS  T.  SMILEY,  M.D. 

March  9th,  1848. — Was  called  to  visit 
John  Henderson,  aged  14  years.  Symp¬ 
toms  -  Mind  perfectly  clear  and  collected, 
eyes  preternaturally  bright,  and  hearing 
morbidly  acute  ;  complained  of  heat  and  con¬ 
striction  about  the  throat,  and  pain  in  the 
lumbar  region.  Pulse  80,  small,  and  ex¬ 
hibiting  very  slight  indications  of  febrile 
action.  Tongue  slightly  furred,  white  and 
soft.  Spasms  about  the  muscles  of  the 
neck  supervened  every  two  or  three  minutes, 
and  continued  a  few  seconds.  After  each 
spasm  a  mouthful  of  white  froth  was  ejected, 
having  a  tenacious  appearance.  Could 
swallow,  by  a  strong  effort,  a  portion  of 
fluid  taken  into  the  mouth — a  part  also 
being  violently  ejected  by  the  effort  of  deglu¬ 
tition.  The  difficulty  of  swallowing  had 
been  first  observed  on  the  morning  of  the 
8th,  after  a  good  night’s  rest,  and  without 
any  previous  indications  of  indisposition. 
Had  been  bitten  on  the  chin  and  under  lip 
nine  weeks  previously,  by  a  dog  exhibiting 
symptoms  of  rabies  canina. 

Both  the  history  of  the  case  and  the  une¬ 
quivocal  character  of  the  symptoms  pointing 
clearly  to  the  nature  of  the  disease,  the  mode 
of  treatment  became  at  once  a  matter  of 
serious  consideration.  Reflecting  on  the 
acknowledged  inefficacy  of  venesection,  here¬ 
tofore  chiefly  relied  on  for  controlling  the 


*  A  gramme  equals  about  15£  grains  English. 


644  CASE  OF  HYDROPHOBIA - EMPLOYMENT  of  chloroform 


roost  prominent  symptoms  of  hydrophobia, 
and  no  symptoms  being  present  which  on 
general  principles  required  it,  I  determined 
not  to  resort  to  that  method  of  treating  the 
disease,  but  to  make  use  of  other  remedies 
which  had  at  least  an  equal  chance  of  being 
useful,  with  less  chance  of  being  injurious. 
For  the  purpose,  therefore,  of  removing  the 
muscular  contractions  and  spasms  of  the 
glottis,  I  prescribed  the  following  mixture  : 
— IL  Tart.  ant.  et  pot.  gr.  vi. ;  tinct.  tolu, 
f5i.,  aq.  fgvi.,  M.S.  A  table-spoonful  every 
five  minutes  till  vomiting  is  produced  ;  after¬ 
wards  to  be  continued  every  hour.  For  the 
other  most  prominent  symptoms  a  lini¬ 
ment  was  prescribed,  composed  of  Tinct. 
sapon.  camph.,  tinct.  canthar.,  and  liq. 
ammon.  To  be  well  rubbed  in  along 
the  whole  course  of  the  spine,  by  means  of 
a  soft  piece  of  flannel,  and  to  be  repeated 
until  the  skin  becomes  abraded.  No  means 
being  at  hand  for  general  bathing,  ordered  a 
hot  mustard  pediluvium. 

March  10th,  at  7  a.m.,  the  patient  had 
passed  a  dreadful  night,  requiring  the 
strength  of  several  persons  to  hold  him  dur¬ 
ing  the  spasms,  which  had  recurred  fre¬ 
quently.  The  tart.  ant.  had  all  been  taken 
without  producing  vomiting.  The  patient 
had  complained  of  a  little  nausea,  but  the 
distressing  symptoms  did  not  appear  to  have 
been  moderated,  or  in  any  way  controlled 
by  the  exhibition  of  this  medicine.  Dis¬ 
continued  the  further  use  of  the  tart,  ant., 
and  prescribed  the  following  mixture  . — 
24.  Spts.  xeth.,  sulph.  comp.,  f^ij.  ;  tinct. 
theb.,  f3j.;  aq.  camph.,  aq.  cinnam.  aq. 
pur.,  aa  f*ij.  M.  S.  A  table-spoonful  every 
hour.  Frictions  to  the  spine  to  be  continued 
as  before  directed. 

At  11  o’clock  a.m. ,  again  visited  the  pa¬ 
tient.  He  had  succeeded  in  swallowing  the 
mixture,  as  ordered  at  the  previous  visit, 
without  much  difficulty,  and  had  had  no 
spasms  since  he  commenced  taking  it.  Ap¬ 
pears  greatly  relieved,  and  laughs  and  talks 
fluently.  Sitting  up  on  a  stool  by  the  fire. 
On  entering  the  room  had  some  difficulty  in 
recognising  the  patient,  his  appearance  was 
so  much  improved. 

As  the  spts.  seth.  sulph.  comp,  appeared 
to  have  been  evidently  beneficial,  and  con¬ 
sidering  that,  from  the  constitution  of  chlo¬ 
roform,  it  must  possess  analogous,  if  not 
identical  properties,  with  a  more  powerful 
action  on  the  nervous  system,  directed  the 
mixture  to  be  continued  as  before,  and 
ordered  ten  drops  of  chloroform  on  a  piece 
of  sugar  of  suitable  size,  to  be  placed  in  the 
mouth,  and  inhaled  by  deep  inspirations ;  to 
be  repeated  at  intervals,  more  or  less  fre¬ 
quently,  according  to  the  exigency  of  the 
symptoms.  Tongue  moist,  but  heavily 
loaded,  having  a  bilious  appearance.  Pre¬ 
scribed  pulv.  jal.,  gr.  vi.  ;  mft.  chart.,  No. 


12,  S.  One  every  hour,  until  the  bowels  are 
freely  moved. 

March  11.  Morning. — Had  slept  a  little 
during  the  previous  night.  Was  sitting  up 
on  a  chair  before  the  fire,  the  floor  around 
him  covered  with  saliva  :  appears  to  be  a 
genuine  secretion  from  the  salivary  glands, 
being  colourless  and  not  frothy.  Cathartic 
had  operated  slightly.  Had  been  free  from 
spasms  during  the  night,  while  the  medicines 
acted;  afterwards,  more  distressed.  Articu¬ 
lation  a  little  thick  ;  mind  collected.  Con¬ 
versed  freely,  and  expressed  himself  greatly 
benefited  and  relieved  by  the  remedies  pre¬ 
scribed.  Asked  to  have  another  supply  of 
the  same,  especially  the  “  breathing  mix¬ 
ture.”  Pulse  90  ;  small,  and  less  forcible 
than  on  the  previous  day.  Directed  the 
medicines  to  be  continued  as  before. 

March  12. — He  had  been  nearly  free  from 
spasms  during  the  previous  day  and  night, 
and  the  difficulty  of  swallowing  had  greatly 
diminished.  Had  continued  to  take  the 
mixture  and  inhale  the  chloroform  as  di¬ 
rected.  In  the  morning  slept  for  an  hour 
or  two  ;  was  then  suddenly  roused  by  some 
person  knocking  violently  at  the  door  ;  com¬ 
plained  of  being  disturbed,  and  expressed  a 
desire  to  sleep  again.  Soon  after  told  his 
mother  to  “  bid  the  doctor  good  by  and 
expired  quietly,  without  spasm  or  any  vio¬ 
lent  effort. 

Remarks.  —  1.  The  spts.  seth.  sulph. 
comp.,  tinct.  theb.,  and  chloroform,  having 
been  prescribed  with  the  view  to  produce  a 
direct  action  on  the  symptoms  accompanying 
the  disease,  the  relative  proportion  and  total 
amount  of  each  exhibited  during  the  treat¬ 
ment  of  the  case,  are  worthy  of  being  noted. 
Of  the  first  and  second,  f5vi.  and  fjiij. 
respectively,  were  administered  by  the  sto¬ 
mach  ;  and  of  the  chloroform,  f^ij .  by  the 
lungs. 

2.  The  first  two,  administered  by  the 
stomach,  had  prevented  the  recurrence  of 
a  paroxysm  for  three  hours,  before  the  chlo¬ 
roform  w7as  given  by  the  lungs  ;  and  the 
combination  of  all  three,  when  given  as  di¬ 
rected,  prevented  the  recurrence  of  the  most 
distressing  symptoms  during  the  subsequent 
progress  of  the  case.  Whether  the  first  two 
would  have  continued  to  prevent  the  spasms, 
if  given  in  the  same  or  increased  doses,  would 
be  difficult  to  determine. 

3.  It  will  be  perceived  that  no  attempt 
was  made  to  give  the  chloroform  to  the  ex¬ 
tent  of  producing  insensibility  ;  nor  was  it 
considered  desirable  or  proper  to  do  so.  The 
attempt  to  keep  a  patient  for  hours  or  days 
constantly  under  the  influence  of  that  power¬ 
ful  remedy  to  such  an  extent  would  itself  in 
any  case  soon  produce  a  fatal  result;  and  the 
death  of  the  patient  might  then  be  fairly  re¬ 
ferred  to  the  remedy  instead  of  to  the  disease, 
A  constant  but  limited  effect,  just  sufficient 


DR.  BERNARD  ON  THE  LOCAL  TREATMENT  OF  BED-SORES.  945 


to  prevent  a  recurrence  of  the  spasms,  was 
the  object  in  view ;  and  for  this  purpose 
small  doses,  frequently  repeated,  were  di¬ 
rected. 

4.  The  general  result  of  the  treatment  in 
this  case  proves  that  the  remedies  used 
exerted  a  decided  influence  on  the  progress 
of  the  disease,  and  modified  the  symptoms 
to  such  an  extent  as  greatly  to  relieve  the 
distress,  though  it  failed  to  cure.  Possibly 
one  step  has  been  made  in  a  course  of  treat¬ 
ment  which  may  hereafter  render  hydropho¬ 
bia  a  curable  disease. 

5.  In  the  present  case,  circumstances  did 
not  admit  of  such  a  close  and  careful  super¬ 
vision  as  would  have  been  desirable.  The 
constant  presence  of  a  well  qualified  medical 
attendant,  who  could  increase  or  diminish 
doses,  and  regulate  the  time  of  giving  or 
withholding  remedies,  according  to  the  im¬ 
mediate  exigencies  of  the  case,  together  with 
the  use  of  all  the  collateral  means  neces¬ 
sary  to  give  the  fullest  efficacy  to  the  leading 
remedies,  might  have  a  great  influence  in 
producing  a  more  favourable  result. 

6.  It  may  be  asked  why  the  patient  did 
not  recover,  if  the  spasms  and  other  leading 
symptoms  were  under  the  control  of  reme¬ 
dies.  It  should  be  recollected  that  the  dis¬ 
ease  is  one  thing — the  symptoms  are  another. 
The  spasm  of  the  glottis,  and  other  pheno¬ 
mena  attending  the  disease,  are  only  symp¬ 
toms,  and  not  the  disease  itself.  These 
symptoms  are  the  manifestations  of  a  morbid 
condition  somewhere  else — probably  in  one 
of  the  nervous  centres — and  may  be  modified 
or  controlled  without  curing  the  morbid 
condition  on  which  they  depend. — Phil. 
Med.  Exam.,  April  1848. 


ON  THE  LOCAL  TREATMENT  OF  BED-SORES. 

BY  DR.  BERNARD. 

The  local  remedies  should  be  varied  accord¬ 
ing  to  the  different  stages  of  the  sores.  For 
practical  convenience,  we  may  divide  the 
progress  of  these  ulcers  towards  reparation 
into  three  stages.  In  the  first,  we  have  a 
deep  slough,  analogous  in  some  respects  to 
the  eschar  artificially  produced  by  caustic 
potash  ;  this  slough  (according  to  the  powers 
of  the  constitution)  will  take  two  or  three 
weeks  to  be  cast  off.  Whilst  this  process 
is  taking  place,  we  should  rather  assist  than 
interfere  with  the  salutary  efforts  of  nature. 
Stimulating  applications  will  now  be  found 
most  useful.  A  carrot-poultice  should  be 
applied  every  morning  and  evening.  A 
solution  of  chloride  of  soda  may  also  be 
sprinkled  on  the  poultice  to  decompose 
offensive  effluvia.  The  patient  should  be 
ordered  to  lie  on  the  face  to  take  off  pressure 
from  the  sore ;  if  this  is  not  practicable, 
bolsters,  air-cushions,  or  bladders,  inflated 


and  oiled,  must  be  used  with  a  similar 
intent. 

When  the  slough  falls  out,  a  deep  un¬ 
healthy-looking  ulcer  is  presented  to  our 
notice,  forming  the  second  stage  of  these 
sores.  This  ulcer  is  generally  round  or 
oval.  The  integuments  at  the  circumference 
are  undetermined,  so  that  you  can  readily 
pass  a  spatula  beneath  them,  showing  that 
the  subjacent  cellular  tissue  has  lost  its 
vitality  even  to  a  greater  extent  than  the 
cuticle.  The  margin  of  the  ulcer  is  con¬ 
sequently  found  to  overlap  its  base.  The 
base  presents  a  flabby,  uneven  surface  with¬ 
out  granulations,  and  interspersed  with 
shreds  of  adherent  slough.  From  this  sur¬ 
face  a  thin  sero-sanguineous  or  ichorous 
discharge  is  secreted,  having  a  most  foetid 
odour.  In  order  to  promote  healthy  granu¬ 
lations,  and  stimulate  the  parts  to  cast  off  the 
remaining  shreds  of  slough,  warm  dressings, 
consisting  either  of  equal  parts  of  gum  elemi 
and  spirits  of  turpentine,  or  of  castor  oil 
and  Peruvian  balsam,  may  be  applied,  dipped 
in  lint,  to  the  bottom  of  the  ulcer,  and  a 
linseed-meal  poultice,  spongio-piline,  or  a 
carrot  poultice,  placed  over  them.  After  a 
few  days,  the  ulcer  will  assume  a  more  florid 
appearance,  and  show  a  disposition  to  form, 
granulations.  It  will  now  be  necessary  to 
make  a  change  in  the  dressings.  At  this  par¬ 
ticular  stage  we  shall  hear  of  many  vaunted 
remedies  and  old  woman’s  cures  spoken  of  as 
specifics,  consisting  of  ointments  that  take 
twenty  days  to  make,  lotions,  and  poultices 
innumerable.  Suffice  it  to  say,  that  the 
simple  means  I  have  used  at  this  stage  have 
answered  all  my  expectations,  and  have 
added  more  to  my  patient’s  comfort  than  all 
the  greasy  applications  which  are  recom¬ 
mended  for  the  same  purpose.  It  consists 
in  applying  every  morning  with  a  camel’s- 
hair  brush  a  solution  of  nitrate  of  silver  (ten 
grains  to  an  ounce  of  distilled  water)  to  the 
flabby  granulations,  then  covering  the  sur¬ 
face  of  the  ulcer,  and  filling  it  up  with  fine 
carded  cotton.  A  piece  of  oiled  silk,  large 
enough  to  cover  both  hips  and  sacrum, 
should  then  be  placed  over  the  dressings. 
The  oil  silk  thus  applied  serves  a  double 
purpose  ; — it  will,  by  preventing  the  evapora¬ 
tion  of  the  discharge,  keep  the  cotton  soft, 
and  permit  its  easy  removal  at  each  dressing ; 
it  will  also  add  to  the  cleanliness  and  com¬ 
fort  of  our  patient,  by  preventing  the  bed¬ 
clothes  being  soiled.  Under  this  simple 
treatment,  the  surface  of  the  ulcer  soon  be¬ 
gins  to  assume  a  more  healthy  appearance, 
the  granulations  at  the  margin  become 
amalgamated  with  those  at  the  base,  until 
the  cavity  is  filled  up  by  luxuriant  granula¬ 
tions. 

We  have  now  the  third  stage  of  these  bed¬ 
sores  to  treat.  As,  in  the  second  stage,  our 
object  was  to  stimulate  the  surface  to  healthy 


646  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY,  ETC 


action,  we  have  in  this  to  control  inordinate 
action  and  repress  luxuriant  granulations.  A 
concentrated  solution  of  sulphate  of  copper 
(applied  every  morning)  will  be  found  most 
useful  for  this  purpose.  The  carded  cotton 
and  oil  silk,  as  above  recommended,  may 
be  also  continued  until  the  ulcer  is  perfectly 
healed. — Dublin  Medical  Press,  1848. 


BIRTHS  &  DEATHS  in  the  Metropolis 

During  the  week  ending  Saturday,  Oct.  7. 

Av.  of  5  Sum. 
Males....  581 
Females. .  573 


Births. 
Males ....  642 
Females. .  631 


1273 


Deaths. 
Males....  502 
Females..  503 


1005 


1154 


Causes  of  Death. 

All  Causes . 

Specified  Causes . 

1.  .Zym0ft'c(orEpidemic,Endemic, 

Contagious)  Diseases . . 
Sporadic  Diseases,  viz. — 

2.  Dropsy,  Cancer,  &c.  of  uncer¬ 

tain  seat  . 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  . 

4.  Lungs  and  other  Organs  of 

Respiration . 

5.  Heart  and  Bloodvessels  . . . 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion  . 

7.  Diseases  of  the  Kidneys,  &c. 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c . 

9.  Rhematism,  Diseases  of  the 
Bones,  Joints,  &c . 

10.  Shin,  Cellular  Tissue,  &c . 

11.  Old  Age . 

12.  Violence,  Privation,  Cold,  and 

Intemperance . 


Deaths  from  the  most  important  special  causes: 


Av.  of 
5  Aut. 

1005 

1154 

995 

1149 

430 

270 

48 

52 

82 

127 

107 

222 

36 

38 

45 

67 

9 

12 

6 

14 

6 

8 

0 

2 

42 

64 

16 

32 

Small-pox  .  31 

Measles  .  17 

Scarlatina  . 180 

Hooping-cough..  31 

Diarrhoea  .  47 

Cholera  .  13 

Typhus  .  65 

Dropsy .  28 

Sudden  deaths  ..  6 

Hydrocephalus..  17 
Apoplexy .  20 


Paralysis .  ]5 

Convulsions  ....  25 

Bronchitis .  32 

Pneumonia .  58 

Phthisis .  88 

Dis.  of  Lungs,  &c.  9 

Teething .  3 

Dis.  Stomach,  &c.  2 
Dis.  of  Liver,  &c.  6 

Childbirth .  4 

Di  s .  of  U  terus,  &c .  1 


-  - '  ■  ...  ~  ■  ■  ■■  ■■  - 

Remarks. — The  total  number  of  deaths  was 
149  below  the  weekly  autumnal  average.  This 
return  -would  have  been  still  more  favourable 
but  for  the  extraordinary  fatality  of  scarlatina. 
This  disease  alone  caused  180  deaths,  to  a  weekly 
average  of  47 :  and  175  of  these  deaths  were 
among  children.  The  fatal  cases  of  cholera  were 
13,  and  the  details  are  elsewhere  given,  see  p.  640. 


METEOROLOGICAL  SUMMARY. 

Mean  Height  of  Barometer .  29*79 

“  “  Thermometer3  .  60  3 

Self-registering  do.b _ max.  91*8  min.  34* 

“  in  the  Thames  water  —  60*8  —  57*2 

a  From  12  observations  daily.  b  Sun. 

Rain,  in  inches,  0*26:  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological. — The  mean  temperature  of  the 
week  was  no  less  than  11°*4  above  the  mean  of 
the  month. 


BOOKS  &  PERIODICALS  RECEIVED 

DURING  THE  WEEK. 

Anaesthetic  Midwifery.  Report  on  its  eai'ly  His¬ 
tory  and  Progress.  By  Dr.  J.  Y.  Simpson. 

Journal  of  Public  Health.  October  1848. 

Oesterreichische  medicinische  Wochenschrift. 
Nos.  23,  24,  25,  26.  Juin  1848. 

Medicinische  Jalirbucher.  Juin  1848. 

British  Record  of  Obstetric  Medicine  and  Sur¬ 
gery.  October  1848. 

Casper’s  Wochenschrift  der  gesammten  Heil- 
kunde.  No.  31.  Sept.  16,  1848. 

Neligan  on  Eruptions  of  the  Scalp. 

Zeitschrift  fiir  die  gesammte  Medicin.  Oppen- 
heim.  H.  4,  B.  38. 

The  Journal  of  Psychological  Medicine.  October 
1848. 

Guy’s  Hospital  Reports.  Vol.  VI.  Part  1, 
Oct.  1848. 

Hand-Book  of  Physiology.  By  William  Senhouse 
Kirkes,  M.D. ;  assisted  by  James  Paget,  Lec¬ 
turer  on  General  Anatomy  and  Physiology  at 
St.  Bartholomew’s  Hospital. 


NOTICES  to  CORRESPONDENTS. 

Dr.  Butler  Lane. — We  shall  feel  obliged  if  our 
correspondent  will  send  another  copy.  That 
which  has  been  forwarded  cannot  be  found. 

Received. — Dr.  Shearman — Mr.  Hayden — Mr. 
Hanks— M.  C.  F.  Cloan  (?)— Dr.  Barclay. 


THE  GENERAL  INDEX. 

We  have  to  announce  to  our  Subscribers  that  a  General 
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The  cost  of  the  Index  Volume;  respecting  which  many  inquiries 
have  been  made;  will  be  Twenty-four  Shillings ;  and  it  is  proposed 
to  commence  it  so  soon  as  the  Names  of  Five  Hundred  Subscribers 
have  been  obtained. — The  printers,  Messrs.  Wilson  and  Ogilvy, 
57,  Skinner  Street,  will  receive  the  Names  of  Subscribers. 


LECTURES 

ON 

PRETERNATURAL  AND  COMPLEX 
PARTURITION. 

By  Edward  W.  Murphy,  A.M.  M.D. 

Professor  of  Midwifery,  University  College, 
London. 

Lecture  II. 

PRETERNATURAL  LABOURS  :  BREECH,  FEET, 
KNEE  PRESENTATIONS. 

Prefer  natural  labours  —  definition  —  divi¬ 
sion.  Is#.  Tkeinvertedposition  of  the  child 
— breech ,  foot ,  knee  presentations.  2d. 
Transverse  positions — shoulder  and  arm 
presentations — mechanism  of  breech  pre¬ 
sentations — anterior  dorsal  positions — 
posterior  dorsal  positions — symptoms  and 
signs  of  breech  presentations — Treatment 
and  mode  of  delivery — rotation  of  the 
child  in  posterior  dorsal  positions — acci¬ 
dents  from  neglecting  it. 

Presentation  of  the  feet — symptoms — diag¬ 
nosis — Knee  presentations — diagnosis — 
sources  of  error — treatment.  Complica¬ 
tions — hand  and  foot — twins  locked  in 
each  other — Statistics. 

Gentlemen, — Preternatural  labours  are 
those  in  which  some  other  part  of  the  child 
than  the  head  presents :  they  form  another 
exception  to  Denman’s  definition  of  natural 
labour.  Speculative  writers  have  indulged 
in  the  opportunity  thus  allowed  them  to 
exercise  their  fancy,  and  have  figured  and 
described  an  endless  variety  of  preternatural 
positions  ;  in  fact,  there  is  no  part  of  the 
child  that  could  present  in  the  pelvis  that 
has  not  been  made  the  subject  of  descrip¬ 
tion  :  they  detail  not  only  presentations  of 
the  arm,  foot,  and  breech,  but  also  those  of 
the  back,  abdomen,  ribs,  &c.  I  have  never 
met  wfith  these  last  positions  unless  when 
the  disproportion  between  the  child  and  pel¬ 
vis  was  so  great,  in  consequence  of  the  small¬ 
ness  of  the  child,  as  to  account  for  so  unusual 
a  deviation.  If  the  pelvis  were  large,  a 
seven  months’  child,  or  a  putrid  child,  could 
be  forced  into  it  in  this  irregular  way.  It 
is,  however,  of  more  practical  importance  to 
direct  your  attention  to  those  varieties  of 
preternatural  positions  which  happen  when 
the  child  is  fully  grown,  and  the  pelvis  of  its 
ordinary  dimensions  :  it  is  in  such  cases  in¬ 
terference  is  most  frequently  required  ;  and 
upon  the  skill  of  the  operator  will  depend 
the  safety  of  the  child. 

>  Preternatural  presentations  may  be  di¬ 
vided  into  two  classes  : — 

1st.  Those  in  which  the  usual  position  of 
xlii.— 1090.  Oct.  20,  1848. 


the  child  is  reversed,  and  the  lower  part  of 
the  body  presents  at  the  pelvis  in  place  of 
the  head. 

2d.  Those  where  the  child  lies  trans¬ 
versely  across  the  uterus,  the  body  resting 
obliquely  on  the  brim  of  the  pelvis,  so  that 
the  shoulder  presents  in  place  of  the  head. 
This  is  called  in  popular  language  “  a  cross¬ 
birth.” 

In  the  first  division  we  find  presentations 
of  the  breech,  foot,  knee,  hip,  &c.  The  se¬ 
cond  is  confined  to  those  of  the  shoulder  and 
arm. 

Breech  presentations  afford  the  best  ex¬ 
amples  of  the  inverted  position  of  the  child, 
which  may,  nevertheless,  pass  safely  through 
the  pelvis,  although  the  chances  of  failure 
are  immeasurably  greater  than  when  the 
child  is  in  its  usual  situation  presenting  the 
head.  A  little  reflection  on  the  inverted 
position  of  the  child  in  the  uterus  is  suffi¬ 
cient  to  show  why  this  should  be  the  case. 
The  child  forms  on  oval  figure,  the  back 
strongly  curved,  the  head  resting  upon  the 
chest,  and  the  limbs  doubled  upon  the  ab¬ 
domen. 

When  the  head  presents,  the  widest  part 
of  the  oval  is  dependant,  and  the  efforts  of 
the  uterus  to  advance  the  child  tend  to  main¬ 
tain  this  form  :  the  head,  resisted  by  the 
pelvis,  is  pressed  more  against  the  chest, 
while  the  limbs  are  compressed  by  the  uterus 
against  the  abdomen  ;  but  when  the  position 
is  reversed  the  smaller  curve  of  the  oval  first 
enters  the  brim,  and,  therefore,  as  the  child 
advances,  its  passage  must  be  more  and  more 
difficult.  Besides  this,  there  is  the  constant 
risk  that  the  limbs  of  the  child,  as  they  enter 
the  pelvic  cavity,  may  drop  down,  the  oval 
disappear,  and  the  straightened  body  of  the 
child  act  like  a  long  and  narrow  wedge,  im¬ 
perfectly  dilating  the  passages ;  the  circula¬ 
tion  of  the  funis,  also,  may  be  interrupted, 
and  the  delivery  of  the  head  impeded,  if  not 
prevented,  in  consequence  of  the  passages 
being  so  insufficiently  prepared.  For  these 
reasons  interference  is  generally  necessary  to 
aid  the  delivery  of  the  child,  and  to  preserve 
it  from  injury.  In  too  many  instances  its 
life  has  been  needlessly  sacrificed  from  awk¬ 
wardness  ;  and  as  the  responsibility  of  any 
mismanagement  must  rest  on  the  practi¬ 
tioner,  it  becomes  a  matter  of  importance 
clearly  to  understand  these  positions,  to 
study  the  manner  in  which  they  pass  through 
the  pelvis,  and  to  have  a  correct  idea  of  the 
mechanism  of  their  delivery. 

The  child  may  enter  the  pelvis  with  the 
back  looking  forwards,  so  as  to  correspond 
to  its  anterior  or  pubic  segment,  or  the  ab¬ 
domen  and  limbs  of  the  child  may  occupy 
the  same  position.  It  passes  into  the  cavity 
either  in  the  right  or  left  oblique  measure¬ 
ment  of  the  pelvis.  Hence,  like  head  pre¬ 
sentations,  four  positions  of  the  breech  may 


648 


PRETERNATURAL  LABOURS - BREECH  PRESENTATIONS. 


be  described — the  right  and  left  anterior 
dorsal,  and  the  right  and  left  posterior  dor¬ 
sal  positions.  For  all  practical  purposes, 
however,  these  may  be  reduced  to  two — the 
anterior  dorsal  and  posterior  dorsal  posi¬ 
tions. 

The  anterior  dorsal  position  is  the  most 
frequent ;  and  when  the  breech  enters  the 


Fig.  3. 


Anterior  dorsal  position. 

brim  thus — if  it  pass  like  the  first  position  of 
the  head  in  the  right  oblique  measurement 
of  the  pelvis,  the  sacrum  will  correspond  to 
the  plane  of  the  left  ischium,  and  the  thighs 
and  genitals  to  the  right  sacro-iliac  synchon¬ 
drosis.  In  its  descent  the  breech  observes 
the  same  law  as  the  head  :  it  enters  the  pel¬ 
vic  cavity  obliquely — that  is,  the  side  of  the 
breech  next  to  the  pubis  descends  lower  than 
that  next  to  the  sacrum,  and  this  position 
is  I’etained  throughout.  If  the  limbs  are 
not  disturbed,  and  do  not  escape  from  the 
vagina,  the  lower  part  of  the  body  of  the 
child  will  pass  in  this  oblique  direction  safely 
over  the  perineum,  and  be  expelled.  The 
shoulders  then  enter  the  pelvic  cavity  in  the 
opposite  (the  left  oblique)  measurement,  the 
arms  folded,  and  corresponding  to  the  right 
sacro-iliac  synchondrosis.  If  the  action  of 
the  uterus  maintain  sufficient  pressime  on 
the  head  so  that  the  chin  continues  resting 
on  the  chest,  the  head  will  enter  the  brim  in 
the  same  measurement  as  the  breech,  having 
its  shortest  axis  (the  occipito-bregmatic)  co¬ 
incident  with  it.  Consequently,  the  head 
may  pass  through  and  be  delivered  in  this 
position  quite  as  safely  as  in  the  usual 
manner.  Assistance  is  not,  therefore,  abso¬ 
lutely  necessary  if  these  natural  laws  be  ob¬ 
served,  and  the  action  of  the  uterus  is  ade¬ 
quate  to  its  object ;  but  this  seldom  happens, 
since  there  are  many  causes  in  operation  to 


disturb  and  derange  the  order  of  delivery, 
which  we  shall  presently  consider.  The 
breech  may  also  enter  the  pelvic  cavity  at 
the  opposite  side,  having  the  sacrum  applied 
to  the  plane  of  the  right  ischium  (the  second 
anterior  dorsal  position).  In  this  case  the 
child  passes  through  it  in  a  similar  manner 
as  the  former  position,  the  relation  to  the 
pelvis  being  reversed. 

The  posterior  dorsal  position  may  enter 
the  pelvic  cavity  like  the  third  or  left  fronto- 

Fig.  4. 


cotyloid  position  of  the  head.  The  sacrum, 
then,  corresponds  to  the  right  sacro-iliac 
synchondrosis,  the  thighs  to  the  plane  of  the 
left  ischium,  and  the  nates  lie  obliquely  in 
the  cavity,  descending  more  on  the  pubic 
than  on  the  sacral  side  of  the  pelvis.  Here, 
also,  the  same  law  is  observed  as  in  third 
positions  of  the  head,  the  breech  rotates 
from  this  position  into  the  second  anterior 
dorsal — or,  in  other  words,  the  sacrum  of  the 
child  glides  from  the  sacro-iliac  synchon¬ 
drosis  to  the  plane  of  the  ischium  on  the 
same  side  of  the  pelvis,  and  is  delivered 
with  the  back  of  the  child  looking  forwards. 
The  same  rotation  takes  place  when  the 
breech  enters  the  left  side  of  the  pelvis  pos¬ 
teriorly  (the  left  posterior  dorsal  position)  ; 
and  thus  it  is  possible  for  the  child  to  pass 
through  and  be  delivered  without  assistance 
in  any  of  these  directions.  It  is,  however, 
much  more  exposed  to  accidents  in  the  latter 
than  in  the  former  (the  anterior  dorsal)  posi¬ 
tion.  Naegele,  to  whom  we  are  chiefly  in¬ 
debted  for  directing  attention  to  this  in¬ 
teresting  subject,  describes  a  remarkable 
exception  which  is  sometimes  met  with 
when  the  child  passes  down  with  the  abdo¬ 
men  forwards.  The  rotation  takes  place  in 
a  direction  the  reverse  of  what  is  usual ;  that 
is,  when  the  breech  descends,  having  the  sa- 


PRETERNATURAL  LABOURS - BREECH  PRESENTATIONS. 


049 


crum  corresponding  to  the  left  sacro-iliac 
synchondrosis,  and  the  thighs  to  the  plane 
of  the  right  ischium,  the  abdomen,  in  place 
of  turning  back  towards  the  right  sacro-iliac 
synchondrosis,  first  moves  forwards  behind 
the  pubis,  and  then  sweeps  completely  round 
to  the  left  sacro-iliac  synchondrosis,  and  is 
delivered  in  a  position  the  exact  converse  to 
that  in  which  it  first  descended.  I  believe 
that  these  curious  deviations  are  not  con¬ 
fined  to  breech  presentations.  I  have  met 
with  cases  where  the  head  entered  the  pelvis 
in  the  third  (left  fronto-cotyloid)  position, 
and  was  expelled,  not  in  the  second,  but  in 
the  first  position  ;  and  in  the  same  manner 
when  the  head  was  delivered  with  the  face 
looking  upwards  to  the  right  thigh  of  the 
mother  (the  first  position),  the  shoulders 
and  body,  as  they  descended,  rotated  so  com¬ 
pletely  that  the  face  turned  round  to  the 
opposite  direction,  and  looked  downwards  to 
the  left  thigh. 

This  brief  outline  of  the  manner  in  which 
breech  presentations  pass  through  the  pelvis 
is  sufficient  to  point  out  the  provisions  that 
Nature  has  made  to  secure  the  safety  of  the 
child,  independently  of  all  assistance,  and  to 
prove  the  importance  of  adhering  to  her 
principle  in  all  attempts  to  deliver  by 
manual  interference.  In  fact,  the  chief  cause 
of  infant  mortality,  in  cases  of  this  descrip¬ 
tion,  is  the  too  precipitate  intermeddling  with 
this  process,  by  which  means  the  position  of 
the  child,  and  the  whole  order  of  its  progress, 
is  completely  deranged.  If,  for  instance, 
the  limbs  of  the  child  are  prematurely  seized, 
and  brought  rapidly  down  for  the  purpose 
of  delivery,  the  whole  body  of  the  child  is 
straightened,  the  chin  leaves  the  chest,  the 
arms  are  thrown  up,  the  head  presents  per¬ 
haps  the  occipito  -  mental  (the  longest) 
measurement  to  the  brim  of  the  pelvis,  and 
the  arms  lying  at  each  side  of  the  head  may 
still  further  impede  its  advance,  and  render 
delivery  extremely  difficult :  the  delay  gene¬ 
rally  causes  the  death  of  the  child. 

The  symptoms  that  accompany  these  pre¬ 
sentations  —  and,  indeed,  preternatural 
labours  generally — differ  in  some  degree  from 
natural  labours.  The  pains  are  not  so 
powerful,  and  the  intervals  are  longer — the 
vagina  suffers  less  distension  than  when  the 
head  is  forcing  its  way  through  the  passages  : 
and  hence  the  stimulus  to  the  action  of 
the  uterus  which  arises  from  the  irritation 
of  the  vagina  being  diminished,  the  pains 
are  weaker.  Auscultation  also  gives  some, 
but  by  no  means  a  certain  indication  of  this 
presentation :  the  foetal  heart  is  heard 
higher  up,  more  in  the  neighbourhood  of  the 
umbilicus,  and  sometimes  in  the  lumbar  re¬ 
gion  :  the  meconium  may  also  be  observed 
colouring  the  vaginal  discharge. 

Digital  examination  is,  however,  the  only 
.accurate  means  of  determining  this  presenta¬ 


tion.  Usually  one  buttock,  the  most  depen¬ 
dant,  is  found  to  occupy  the  pelvis :  this  is 
smooth,  equal,  and  if  pressed  firmly,  bone  is 
felt  imbedded  in  the  soft  surface  ;  this  is  the 
tuber  of  the  ischium,  which  could  scarcely  be 
mistaken  for  the  vertex.  Still,  there  is  the 
possibility  of  mistaking  it  for  other  posi¬ 
tions.  For  instance,  the  shoulder  may  pre¬ 
sent  in  such  a  manner  as  to  resemble  the 
breech — the  same  soft,  smooth,  round  tumor 
is  felt  covering  a  point  of  bone;  and 
although  the  difference  in  size  between  the 
head  and  shoulder  might  be  sufficiently  ap¬ 
parent  to  prevent  mistake,  yet  in  some  cases 
it  is  not  so,  especially  when  the  presentation 
is  high  in  the  pelvis,  and  the  os  uteri  not 
much  dilated.  Some  diagnostic  mark  is 
necessary,  which  can  readily  be  obtained  by 
passing  the  finger  sufficiently  high  to  place 
it  within  the  fold  formed  by  the  limb  of  the 
child.  If  it  be  the  thigh,  the  genitals  are  im¬ 
mediately  felt,  which  proves  that  the  breech 
is  presenting.  If  the  arm,  the  ribs  may  be 
distinctly  traced  as  the  fmger  presses  the 
thorax.  Great  caution  is  necessary  in  mak¬ 
ing  such  examinations  lest  the  genitals  may 
be  injured  :  the  scrotum  frequently  suffers 
from  imprudence  on  the  part  of  the  practi¬ 
tioner  :  it  is  sometimes  so  compressed 
between  the  thighs  as  to  swell  up  to  a  very 
large  size  :  this  is  increased  by  frequent  ex¬ 
aminations,  which  are  repeated  because  the 
large  tumor  that  is  formed  is  too  often  an 
enigma;  extreme  congestion  is  the  result, 
and  in  some  instances  the  parts  have 
sloughed.  Some  awkward  blunders,  also, 
have  been  made.  I  have  been  told  by  a 
medical  friend  of  one  instance,  where  this 
swollen  scrotum  and  its  contents  had  been 
cut  away  in  mistake  for  a  tumor,  that  was 
supposed  to  prevent  the  delivery  of  the  child. 

Fig.  5. 


Swollen  scrotum  from  'pressure. 


650 


PRETERNATURAL  LABOURS - BREECH  PRESENTATIONS. 


Even  the  face  may  present  in  such  a  manner 
as  to  cause  some  little  embarrassment :  the 
cheek,  when  swollen,  communicates  the 
sensation  of  a  soft,  smooth  surface,  beneath 
which  the  malar  bone  is  felt,  just  like  the 
tuber  of  the  ischium.  This  can  only  happen, 
however,  in  the  beginning  of  labour,  because, 
as  the  os  uteri  dilates,  and  the  presentation 
descends,  the  remaining  features  may  be  as¬ 
certained,  and  remove  any  doubt.  When 
the  nature  of  the  case  is  ascertained,  the 
next  question  is 

The  treatment  and  mode  of  delivery. — It 
is  obvious  from  what  has  been  said,  that  all 
attempts  to  interfere  while  the  breech  is 
passing  through  the  pelvis  are  premature 
and  injudicious.  It  should  be  left  to  itself 
so  long  as  the  pains  are  advancing  the  pre¬ 
sentation,  until  it  arrives  at  the  vulva,  or 
even  passes  beyond  it.  There  is  here  the 
risk  that  the  perineum  may  be  torn  by  the 
sudden  expulsion  of  the  limbs  of  the  child  : 
when  they  are  delivered,  the  funis  may  be 
compressed  as  the  shoulders  and  head  pass 
through  the  brim  of  the  pelvis,  and  lastly, 
the  head  itself  may  change  its  position,  sepa¬ 
rate  from  the  chest,  and  become  fixed,  with 
its  longest  axis  lying  across  the  pelvis. 
Although  it  is  possible  that  the  child  may 
escape  all  these  accidents,  and  be  delivered 
without  aid,  still  it  is  generally  necessary  to 
assist,  and,  therefore,  we  shall  explain 

The  mode  of  delivery. —  As  soon  as  the 
breach  appears  beyond  the  vulva,  the  back  of 
the  child  should  be  grasped  by  one  hand 
just  above  the  pelvis,  while  the  other  is 
passed  between  the  perineum  and  the  limbs, 
in  order  to  bring  down  the  feet :  the  leg  or 
the  knee  may  be  brought  within  the  fingers, 
and  pressed  down  along  the  hand  in  such  a 
manner  that  it  escapes  from  the  vulva  with¬ 
out  touching  the  perineum  :  the  remaining 
leg  may  in  a  similar  manner  be  brought  out. 
When  this  is  accomplished,  the  next  object 
of  attention  is  the  funis,  which  should  be 
drawn  down  beyond  the  vulva  ;  the  coils  that 
lie  in  the  vagina  are  thus  removed,  and  the 
state  of  its  pulsations  can  be  more  con¬ 
veniently  examined.  It  would  be  advisable, 
also,  to  place  the  cord  as  nearly  as  possible 
over  either  sacro- iliac-synchondrosis,  in  order 
that  the  projecting  promontory  of  the 
sacrum  may  secure  it  from  the  pressure  of 
the  head.  The  body  of  the  child  should  now 
be  drawn  down  by  the  hand  that  has  grasped 
the  back  sufficiently  to  allow  the  opposite 
hand  to  reach  the  top  of  the  shoulder.  In 
order  to  do- so,  it  should  be  directed  along 
the  back  of  the  thorax,  ana  when  the 
shoulder  is  reached,  the  hand  should  be 
passed  over  it  to  the  front  of  the  thorax, 
carrying  the  arm  along  with  it  down  the 
body  of  the  child  and  out  of  the  vagina. 
Great  care  is  necessary  in  this  manipulation, 
lest  the  fragile  bones  of  the  infant  be  broken  : 


the  clavicle  and  humerus  have  sometimes 
been  fractured  through  violence.  When  the 
remaining  arm  and  shoulders  have  been 
extracted,  the  most  difficult  part  of  the  ope¬ 
ration,  the  delivery  of  the  head,  still  remains. 
In  order  to  remove  it  safely,  the  first  object 
should  be  to  correct  any  malposition  that 
may  have  occurred.  The  chin  must  be 
brought  down  upon  the  chest,  and  retained 
in  that  position.  This  is  generally  effected 
by  passing  the  finger  of  the  introduced  hand 
into  the  mouth  of  the  child,  but  this  alone  is 
not  sufficient :  the  opposite  hand  should  be 
passed  up  to  the  back  of  the  head,  so  as  to 
press  firmly  with  two  fingers  against  the  oc¬ 
ciput,  while  the  mouth  is  drawn  down  in  the 
manner  described. 

It  is  sometimes  difficult  to  alter  the  posi¬ 
tion  in  this  way,  and  it  may  be  necessary  to 
pass  the  fingers  along  the  face  towards  the 
forehead,  so  that  they  may  press  it  down 
like  a  vectis ;  but  this  is  seldom  required. 
The  head  should  be  extracted  as  quickly  as 
possible,  because  the  funis  is  now  exposed 
to  a  dangerous  pressure.  In  the  act  of  ex¬ 
traction,  the  direction  of  the  head  should  be 
changed  as  it  passes  through  the  pelvis. 
Before  the  head  presses  upon  the  perineum, 
the  direction  of  the  force  should  be  in  the 
axis  of  the  brim,  but  afterwards  in  the  axis 
of  the  outlet.  The  head,  as  it  descends, 
should  also  be  rotated  from  the  lateral 
towards  the  antero-posterior  measurement 
of  the  pelvis,  and  during  the  whole  of  this 
manipulation  the  perineum  must  be  carefully 
supported. 

The  chief  object  of  interference  in  breech 
presentations  is  the  preservation  of  the  child  : 
the  pulsation  of  the  funis  should,  therefore, 
be  carefully  observed  during  the  delivery.  If 
its  rate  be  much  increased,  or  if  the  arteries 
beat  feebly,  the  child  should  be  extracted  as 
rapidly  as  possible.  In  such  a  case,  there  is 
not  time  to  wait  for  the  return  of  the  pains — 
it  would  be  advisable,  therefore,  that  an  as¬ 
sistant  should  press  on  the  fundus  uteri 
firmly  with  both  hands,  in  order  to  cause  its 
more  efficient  contraction  as  the  child  is  being 
exhausted.  When  the  uterus  acts  strongly, 
the  head  is  less  likely  to  change  its  position, 
and  the  force  of  the  pain  should  be  as  much 
as  possible  increased,  to  prevent  the  straight¬ 
ening  of  the  head,  which  otherwise  would 
take  place  when  the  body  of  the  child  was 
drawn  rapidly  down. 

In  the  delivery  of  posterior-dorsal 
positions,  it  is  very  necessary  to  recollect 
the  rotation  of  the  child  as  it  passes  through 
the  pelvic  cavity ;  neglecting  to  aid  this 
change  of  position,  or  the  ignorance  of  the 
attendant  respecting  it,  has  been  a  frequent 
cause  of  the  child’s  death.  It  generally 
happens  that  the  child  is  drawn  down  very 
hastily,  but  in  the  wrong  direction, — the  head 
is  thrown  up,  and  the  chin  rests  on  the  linea 


PRETERNATURAL  LABOURS — FEET  PRESENTATIONS. 


651 


ileo-pectinea.  Further  efforts  to  extract 
have  only  the  effect  of  bringing  the  head  into 
such  a  position  that  the  face  looks  quite  up¬ 
wards,  and  the  occiput  descends  upon  the 
back  of  the  child  ;  and  although  it  is  possible 
that  the  head  may  be  so  delivered,  still  it  is 
very  unlikely  ;  it  is  far  more  probable  that  it 
becomes  fixed  in  the  brim  of  the  pelvis,  the 
longest  measurement  of  the  head  (the  occi- 
pito-mental)  being  drawn  into  its  oblique 
axis,  and  there  arrested :  the  death  of  the 
child  is  a  necessary  consequence,  the 
funis  being  so  long  compressed.  This  event 
may  be  hastened,  and  all  chance  of  saving 
the  child  lost,  by  further  mismanagement. 
An  attempt  is  often  made  to  alter  the  posi¬ 
tion  of  the  head,  by  twisting  the  body 
that  is  expelled,  so  that  the  back  may 
be  brought  round  to  the  anterior  side  of  the 
pelvis  :  the  head,  however,  refuses  to  move, 
and  the  child  is  strangled,  if  we  can  use  such 
a  term  where  there  is  no  respiration.  In 
this  dilemma  additional  aid  is  hastily  sum¬ 
moned,  and  the  consultant  finds  all  but  the 
head  of  the  child  delivered,  which  he  is  told 
every  effort  failed  to  remove,  in  consequence 
of  the  contraction  of  the  pelvis  !  In  such 
cases  the  first  object  of  attention  is  the 
funis ;  if  it  pulsate,  it  is  better  at  once  to 
apply  the  vectis  in  the  oblique  measurement 
of  the  pelvis,  opposite  to  that  in  which  the 
head  is  arrested,  to  raise  the  head  from  its 
situation,  and  to  turn  it  towards  the  sacro¬ 
iliac-synchondrosis  of  the  same  side  ;  when 
this  is  accomplished  the  vectis  may  be  with¬ 
drawn,  and  a  finger  passed  into  the  mouth 
of  the  child  to  bring  down  the  head  and 
complete  the  delivery.  If  this  be  done 
adroitly,  and  with  promptitude,  the  child 
may  yet  be  saved  :  sometimes  the  vectis  may 
be  dispensed  with.  It  is  sufficient  to  pass 
two  fingers  along  the  cheek  to  press  round 
the  head  towards  the  sacro-iliac  articulation, 
and  when  the  position  is  thus  changed  to 
deliver  as  before.  If  the  pulsation  in  the 
funis  have  ceased,  there  is  no  need  for  haste, 
the  head  may  be  extracted  by  the  hands 
alone,  or,  if  wedged  in  the  brim,  the  cranium 
may  be  perforated  behind  the  ear  or  through 
the  mouth,  the  crotchet  introduced,  and  the 
head  brought  down. 

We  have  stated  to  you  that  the  natural 
efforts  to  deliver  breech  presentations  should 
not  be  interrupted  until  there  was  some  risk 
of  injury  either  to  the  perineum  or  to  the 
child  :  the  time,  therefore,  for  interference,  is 
usually  when  the  breech  has  passed  the  vulva; 
but  there  are  exceptions  to  this  rule.  In 
some  cases  the  pains  are  feeble,  and  return 
at  long  intervals,  the  child  descends  very 
slowly  through  the  passages,  and  the  funis  is 
often  exposed  too  long  to  pressure  at  the 
brim  of  the  pelvis.  It  would  not,  therefore, 
be  advisable  to  allow  the  breech  to  continue 
to  move  so  slowly  through  the  vagina  ;  the 


action  of  the  foetal  heart  should  be  ascer¬ 
tained,  and,  if  necessary,  its  progress  should 
be  assisted — but  assisted  on  the  principle  we 
have  endeavoured  to  lay  down.  An  assistant 
should  press  firmly  over  the  fundus  uteri  to 
increase  the  effect  of  the  pains,  while  the 
practitioner,  placing  one  or  two  fingers  within 
the  fold  of  the  groin,  draws  it  gently  down 
with  the  pain  ;  a  moderate  dose  of  ergot  of 
rye  would  also  be  serviceable  to  stimulate 
the  action  of  the  uterus.  Tn  these  instances 
of  premature  interference,  the  difficulty  of 
delivery  is  always  increased,  because  the 
head  is  seldom  brought  into  the  pelvis  in  a 
position  so  favourable  as  it  would  have  been 
if  the  uterus  alone  expelled  the  child  ;  con¬ 
sequently  the  risk  to  it  is  greater,  and  its 
safety  will  depend  entirely  on  the  skill  and 
intelligence  of  the  practitioner  who  under¬ 
takes  the  operation  :  hence  may  be  inferred 
the  importance  of  studying  the  mechanism 
of  these  presentations. 

Presentations  of  the  feet  are  more 
hazardous  to  the  child  than  breech  positions, 


Fig.  6. 


Presentation  of  Feet. 


because  the  soft  parts  are  so  imperfectly 
dilated  by  them,  the  pains  are  weaker,  and 
the  funis  is  more  exposed  to  injury  during 
the  progress  of  delivery.  In  all  such  cases, 
therefore,  assistance  is  generally  required. 
One  or  both  may  present  sometimes  in  such 
a  manner  that  the  case  is  more  like  an  im¬ 
perfect  breech  presentation ;  that  is,  the 
breech  descending  with  the  feet  and  limbs, 
doubled  up  on  the  body  of  the  child,  is  ar¬ 
rested  by  the  brim  of  the  pelvis  :  the  action 
of  the  uterus  is  directed  from  the  breech  to 
the  limbs,  which  are  forced  down  into  the 
vagina,  and  thus  constitute  a  footling  pre¬ 
sentation.  They  may  be  divided  in  the  same 
manner  as  breech  presentations  into  anterior 
dorsal  positions,  in  which  the  toes  look 
towards  the  sacral  side,  and  posterior-dorsal 


652 


PRETERNATURAL  LABOURS - FEET  PRESENTATIONS. 


positions,  when  they  are  on  the  pubic  side 
of  the  pelvis. 

The  symptoms  that  accompany  these 
labours  are  also  similar  to  breech  cases  ;  the 
pains  are  short,  apparently  inefficient,  return 
slowly,  and  the  duration  of  labour  may  be 
consequently  protracted.  The  os  uteri  is 
less  perfectly  dilated  in  footling  than  in 
breech  cases,  and  before  the  membranes  are 
ruptured,  it  is  sometimes  very  difficult  to  feel 
the  presenting  part,  and  equally  so  to  deter¬ 
mine  what  it  is  when  it  comes  within  reach  ; 
the  foot  and  the  hand  may  be  easily  mistaken 
for  each  other,  because,  being  surrounded  by 
the  liquor  amnii  and  membranes,  an  accu¬ 
rate  examination  cannot  be  made.  It  is  very 
important,  therefore,  to  educate  the  sense  of 
touch  as  perfectly  as  possible,  to  take  every 
opportunity  of  feeling  the  hands  and  feet  of 
the  child,  so  as  to  accustom  the  fingers  to 
the  sensation  they  communicate,  and  thus  to 
acquire  a  facility  in  making  these  examina¬ 
tions.  This  may  be  practised  with  any  infant 
after  its  birth.  When  an  accurate  sense  of 
touch  is  acquired,  the  foot  may  be  detected 
through  the  membranes,  although  only  a 
small  part  of  it  is  felt,  but  otherwise  it  is 
very  difficult.  The  fingers  when  extended 
resemble  the  toes.  When  the  foot  is  pressed 
up  against  the  leg,  the  ankle  is  like  the 
elbow :  the  knee  and  elbow  also  resemble 
each  other.  The  diagnosis  is  best  made 
when  the  waters  are  discharged.  The  toes 
differ  from  the  fingers  in  being  shorter  and 
of  more  equal  length  ;  the  great  toe  is  not 
so  far  apart  from  the  others  as  the  thumb  is 
from  the  fingers  ;  but  the  most  certain  means 
of  distinguishing  one  from  the  other,  is  by 
folding,  or  attempting  to  fold,  the  phalanges  ; 
the  fingers  can  easily  be  doubled  and  the 
hand  closed,  but  the  toes  cannot.  The  con¬ 
dyles  of  the  ankle  and  elbow  joints  resemble 
each  other  very  much  ;  the  calcis  communi¬ 
cates  the  same  sensation  as  the  olecranon 
process,  and  the  foot  being  very  long  in 
proportion  to  the  leg  against  which  it  often 
lies  closely  applied,  resembles  in  some  degree 
the  fore-arm,  the  latter,  however,  being 
round  and  smaller  near  the  hand,  while  the 
sole  of  the  foot  is  flatter  and  broader  near 
the  toes  :  the  distinction  is  easy  if  the  finger 
be  passed  sufficiently  high  along  the  limb  to 
make  a  careful  examination  of  it. 

The  knee  joint  bears  a  closer  resemblance 
than  the  ankle  to  the  elbow  joint.  It  feels, 
however,  rounder,  and  is  without  any  pro¬ 
jecting  point  of  bone  like  either  the  calcis  or 
olecranon :  the  patella  may  be  felt,  but  it  is 
so  small,  and  is  often  so  imbedded  in  fat,  that 
it  is  not  easily  perceived. 

The  treatment  of  footling  cases  is  similar 
to  breech  presentations,  only  that  manual 
interference  is  more  absolutely  required  to 
save  the  child.  Before  any  attempt  to  deliver 
is  made,  the  presentation  should  be  carefully 


examined,  in  order  to  ascertain  whether  the 
breech  be  within  reach,  because  if  it  be  pos¬ 
sible  for  the  breech  to  descend  in  place  of 
the  foot,  a  great  advantage  would  be  gained. 
In  those  cases,  therefore,  where  the  breech  is 
found  resting  on  the  brim  of  the  pelvis,  the 
foot  should  be  prevented  descending  into  the 
vagina  ;  rather  press  up  the  foot  during  a 
pain,  so  as  to  get  the  breech  more  towards 
the  pelvic  cavity :  it  might  even  be  possible 
to  hook  a  finger  in  the  groin  and  bring  the 
breech  down.  So  long  as  the  funis  is  safe 
from  pressure,  it  would  be  advisable  to  delay 
the  delivery,  in  order  to  give  the  uterus  time 
to  effect  this  change ;  but  if  the  cord  comes 
down,  any  delay  is  dangerous  to  the  child. 

If  delivery  be  essential,  your  next  object 
is  to  convert  the  case,  if  possible,  into  a 
semi-breech  position ;  that  is,  to  bring  down 
one  foot  only,  and  to  prevent  the  other  leg 
descending  at  the  same  time.  This  will  have 
a  useful  effect  on  the  dilatation  of  the  pas¬ 
sages,  which  is  the  great  cause  of  difficulty  in 
the  safe  delivery  of  these  cases.  If  you 
cannot  succeed,  ' and  that  both  feet  come 
down,  the  child  must  be  extracted  as  soon 
as  possible  ;  and  to  aid  this  object  you  should 
endeavour  to  dilate  the  perineum  as  much  as 
possible  with  the  hand  that  is  introduced  into 
the  vagina.  This  may  be  done  by  pressing 
the  back  of  the  hand  firmly  against  the  floor 
of  the  vagina,  perineum,  and  coccyx,  while 
the  child  is  being  delivered  :  the  distension 
excites  the  uterus  to  more  powerful  action. 


Fig.  7. 


Knee  presentations  with  funis  prolapsed. 


Knee  presentations  are  less  frequently 
met  with  than  those  which  have  been  de¬ 
scribed,  and  when  they  occur,  the  funis  is 
more  likely  to  prolapse,  because  from  the 
position  of  the  child  it  receives  less  support. 
Only  one  knee  generally  presents,  which  may 
be  brought  down  while  the  remaining  limb 
is  left  within  the  uterus,  in  order  that  the 
child  may  be  delivered  as  nearly  as  possible 


PRETERNATURAL  LABOURS — HIP  PRESENTATIONS. 


653 


as  a  breech  case.  The  time  for  delivery  must 
be  determined  by  the  state  of  the  funis.  If 
it  is  safe,  the  more  time  that  is  allowed  for 
the  dilatation  of  the  os  uteri  the  better  ;  but 
if  it  prolapse,  you  cannot  wait  without  en¬ 
dangering  the  child. 

Fig.  8. 


Hip  presentations  rarely  occur;  they  are, 
in  fact,  only  a  variety  of  breech  positions, 
and  should  be  similarly  treated ;  the  child 
lies  with  the  hip  across  the  pelvis,  presenting 
a  round  soft  surface,  covering  a  bony  pro¬ 
minence  (the  trochanter):  the  fold  of  the 
thigh  on  the  abdomen,  and  the  spinous  pro¬ 
cess  of  the  ischium,  may  also  be  felt.  As 
labour  advances,  this  position  will  correct 
itself,  and  the  breech  descend  into  the  pelvic 
cavity. 

A  distorted  pelvis  may  accompany  any  of 
these  presentations,  which  greatly  increases 
the  difficulty  of  delivery,  especially  in  the 
extraction  of  the  head  ;  the  child  is  there¬ 
fore  generally  lost,  as  it  seldom  happens 
that  the  funis  escapes  pressure  ;  neverthe¬ 
less  this  is  possible  if  the  promontoi’y  of  the 
sacrum  project  much,  and  the  funis  is  placed 
near  the  sacro-iliac  synchondrosis.  If  this 
should  happen  in  the  ovate  pelvis,  it  is 
possible  that  steady  traction  in  the  axis  of 
the  brim  may  succeed  in  bringing  the  head 
through  it  before  the  pulsation  has  ceased ; 
and,  if  so,  it  may  be  easily  removed  from 
the  cavity  of  the  pelvis,  and  the  child  pre¬ 
served  ;  but  in  other  deformities  the  child 
seldom  escapes — the  pulsation  in  the  funis 
soon  ceases.  When  the  child  is  certainly 
dead,  it  is  better  to  perforate  behind  the  ear 
or  through  the  mouth,  to  evacuate  as  much 
of  the  brain  as  possible,  and  to  draw  down 
the  head  with  the  crotchet :  this  practice  is 
preferable  to  making  violent  efforts  to  ex¬ 
tract  the  head  by  pulling  at  the  body  with 
all  your  strength,  as  is  sometimes  done. 


Such  violence  is  especially  objectionable 
when  the  child  is  living,  because  it  is  the 
most  certain  means  of  destroying  it  that  can 
be  adopted.  At  this  tender  age  the  odon¬ 
toid  process  has  only  a  ligamentous  union 
with  the  vertebra  dentata :  it  may  easily  be 
broken  off,  and  death  thus  caused.  The 
effect  of  concussion  on  the  nervous  centres, 
also,  should  be  considered.  I  have  seen  (I 
could  almost  say  frequently)  cases  thus  de¬ 
livered  in  which  the  child  was  still-born, 
and,  from  its  appearance,  gave  every  evi¬ 
dence  that  death  was  caused,  not  by  pres¬ 
sure  on  the  funis,  but  by  nervous  shock  : 
the  heart  and  respiratory  nerves  were  para¬ 
lysed,  so  that  no  stimulus  could  excite 
them. 

Complications  sometimes  accompany  these 
presentations  that  require  notice.  The  hand 
and  foot  may  present  together  in  such  a 
manner  as  to  make  it  difficult  to  distinguish 
them.  When  the  membranes  are  ruptured, 
a  careful  examination  should  be  made,  and 
the  foot  brought  down,  in  order  to  convert 
the  case  more  completely  into  a  footling 
presentation  :  if  the  funis  is  safe,  it  is  better 
not  to  interfere  further,  but  to  leave  the 
case  for  some  time  to  the  natural  efforts,  in 
order  that  the  passages  may  be  better  pre¬ 
pared  for  delivery.  If  the  membranes  are 
entire,  no  accident  can  occur  so  long  as  the 
waters  are  retained  in  the  uterus ;  and, 
therefore,  interference  is  unnecessary.  A 
complication  of  a  singular  character  has 
been  recorded  in  which  delivery  was  ren¬ 
dered  extremely  difficult.  The  late  Dr. 
T.  Ferguson,  of  Dublin,  relates  a  case  of 
twins  in  which  the  first  child  presented  the 
foot,  and  was  delivered  without  any  unusual 
obstacle  in  the  progress  of  the  labour  until 
the  child’s  body  was  so  far  protruded  as  to 
enable  Dr.  Ferguson  to  ascertain,  by  the 
pulsation  of  the  funis,  then  without  the  os 
externum,  that  the  child  was  alive.  From 
this  stage  of  the  delivery  he  began  to  ex¬ 
perience  a  most  unusual  and  unaccountable 
resistance  to  the  further  descent  of  the 
child.*  This  difficulty  was  produced  by 
the  head  of  the  second  child  descending 
before  the  head  of  the  first,  so  that  each 
locked  in  the  other.  The  pulsation  in  the 
funis  of  the  first  child  continuing,  Dr.  Fer¬ 
guson  wished  to  perforate  the  head  of  the 
second,  that  caused  the  obstruction  :  there 
was  some  delay  in  obtaining  instruments ; 
and,  in  the  interval,  the  pulsation  of  the 
first  child  ceased  ;  but,  to  the  surprise  of 
Dr.  Ferguson,  powerful  expulsive  pains 
forced  down  the  heads  of  both  over  the  peri¬ 
neum,  and  the  second  child  was  born  living  ! 
Two  years  ago,  Mr.  Elton,  of  Windsor, 
related  a  similar  case.  The  feet  of  the  first 


*  Dub.  Med.  Trans,  vol.  i.  p.  146. 


654 


STATISTICS  OF  PRETERNATURAL  LABOURS. 


child  presented,  and  were  brought  down; 
hut,  “  after  the  thighs  had  passed,  the  de¬ 
livery  became  slow  and  increasingly  diffi¬ 
cult  ;  the  abdomen  suffered  great  compres¬ 
sion  in  passing ;  the  thorax  still  more  ;  the 
difficulty  became  greater  with  the  further 
progress  of  the  body  ;  the  arms  were  ex¬ 
tracted  with  much  trouble,  and,  it  then 
being  practicable,  an  examination  was  made. 

Fig.  9. 


I  (Mr.  Elton)  found  the  vertex  of  a  full- 
sized  head  presenting  immediately  over  the 
breast  in  the  position  where  there  should 
have  been  a  chin ;  the  anterior  base  of  the 
neck  could  be  traced  in  close  and  compressed 
contact  with  the  presenting  head,  the  latter 
firmly  impacted  in  the  pelvic  cavity.”* 
Mr.  Elton  divided  the  neck  of  the  first 
child;  and,  having  removed  the  truncated 
body,  applied  the  forceps  to  the  second 
child,  which  he  delivered,  but  could  not 


save,  although  attempts  “  to  restore  anima¬ 
tion  were  long  and  anxiously  continued.” 
What  is  to  be  done  in  such  a  case  as  this  ? 
I  certainly  should  not  be  disposed  to  destroy 
either  child.  Before  I  took  up  the  perfo¬ 
rator  or  the  amputating  knife,  I  should 
weigh  well  the  practicability  of  applying  the 
long  forceps  to  the  head  of  the  second  child, 
and  endeavour  to  imitate  nature  in  the 
effort  to  force  both  heads  over  the  perineum. 
If  you  succeeded,  its  laceration  might  be  the 
consequence ;  but  it  would  be  some  recom¬ 
pense  to  save  a  life  that  otherwise  you  must 
destroy. 

The  statistics  of  preternatural  labours 
prove  that  their  frequency  is  in  the  propor¬ 
tion  of  one  in  every  thirty  or  forty  labours  ; 
and  of  these,  presentations  of  the  breech  are 
the  most  frequent ;  those  of  the  feet  next  in 
order,  and  shoulder  positions  the  rarest. 
We  find,  also,  that  a  large  proportion  of  these 
cases  are  premature  deliveries,  many  of  the 
children  being  putrid.  Hence  we  would 
infer  that  in  many  instances  this  deviation 
from  the  natural  position  of  the  child  is 
caused  by  its  unusual  mobility  in  the  uterus 
at  the  time  of  labour.  The  child  being 
small  (premature),  and  the  liquor  amnii 
abundant,  its  position  is  liable  to  be  con¬ 
stantly  disturbed  by  the  action  of  the 
uterus ;  and  if  the  membranes  were  rup¬ 
tured  suddenly,  the  child  would  most  likely 
be  forced  down  into  the  pelvis  in  a  preter¬ 
natural  position.  A  full-grown  child  might 
also  be  displaced  by  any  sudden  and  violent 
action  of  the  uterine  fibres,  the  result  of 
shock,  during  pregnancy.  Putrid  children 
are  especially  liable  to  this  displacement, 
because  labour  is  generally  induced  because 
of  the  death  of  the  foetus,  and  not  in  con¬ 
sequence  of  the  descent  of  the  child  on  the 
cervix  uteri :  hence  the  uterus  protrudes  the 
inert  mass  from  its  cavity  through  the  pelvis 
in  whatever  form  it  may  have  assumed  at 
the  time  that  the  expulsive  action  of  the 
uterus  was  so  excited. 

The  following  statistical  results  are  taken 
from  tables  formed  by  Drs.  Collins,  Hardy 
and  M'Clintock,  and  derived  from  their  re¬ 
ports  of  the  Dublin  Lying-in  Hospital : — 


Total  Preternatural  Labours. 


Total 

cases. 

Preter¬ 

natural. 

1  in 

Breech. 

1  in 

Feet. 

1  in 

Shoul¬ 

der 

1  in 

Collins . 

16,414 

409 

40 

242 

68 

127 

1281 

40 

410 

Hardy  and  M‘Clintock 

6,634 

227 

29 

101 

654 

38 

174| 

26 

255 

23,048 

636 

362 

343 

67 

165 

1391 

66 

341 

*  Medical  Gazette,  July  24,  1846,  p.  152. 


655 


DR.  TODD  ON  THE  TREATMENT  OF  RHEUMATIC  FEVER. 


Breech  Presentations,  343. 


Premature. 

Living. 

Dead. 

Total. 

Putrid. 

r 

Living. 

Dead. 

Putrid.  ^ 

Boys  .  . 

131 

61 

192 

Girls  . 

102 

49 

* 

151 

233 

110 

343 

63 

18 

17 

39 

Feet  Presentations,  165. 


Living. 

.  Dead. 

Total. 

Putrid. 

Boys . 

42 

32 

74 

Girls  •  •  •  •  • 

43 

48 

91 

85 

80 

165 

54 

CLINICAL  LECTURE 

ON  THE 

TREATMENT  of  RHEUMATIC 
FEVER, 

Delivered  at  King's  College  Hospital, 

By  R.  B.  Todd,  M.D.  F.R.S. 

Physician  to  the  Hospital. 

(Reported  by  Mr.  H.  H.  Salter,  Med.  Schol. 
K.C.L.) 


Lecture  VI. 

In  my  last  lecture,  gentlemen,  after  having 
passed  in  review  six  different  methods  of 
treating  rheumatic  fever,  I  particularly  com¬ 
mended  to  your  attention  one  which  w*e  have 
been  in  the  habit  of  using  here,  the  objeet 
of  which  is  to  promote  as  much  as  possible 
the  elimination  of  morbid  matters  from  the 
system  through  the  natural  emunctories — 
through  the  skin,  through  the  kidneys, 
through  the  blood.  I  advised  you  to  use 
opium  freely,  and  nitre,  and  to  give  alkaline 
purgatives,  and  to  relieve  the  pain  and  swell¬ 
ing  of  the  joints  by  enveloping  them  in 
cotton  wool  surrounded  by  oiled  silk.  And 
all  this  I  ventured  to  recommend  to  you  in 
preference  either  to  the  plan  of  treatment  by 
venesection,  or  that  of  colchicum  or  guaia- 
cum,  or  that  by  calomel. 

Now  it  may  sometimes  happen  that  you 
will  have  to  deal  with  a  patient  who  is  unable 
to  take  opium.  What  are  you  to  do  under 
these  circumstances  ?  There  is  no  reason 
why  you  should  change  the  general  plan  of 
treatment — you  may  still  give  sudorifics — 
and  if  your  patient  will  bear  sedatives,  you 


can  give  hyoscyamus,  or  hop,  or  extract  of 
lettuce.  But  it  will,  I  believe,  very  seldom 
happen,  that  in  this  severe  and  painful 
malady,  patients  will  be  unable  to  bear 
opium  in  some  shape  or  other,  and  the  bene¬ 
fits  to  be  derived  from  the  proper  use  of 
this  drug  are  so  great  that  you  ought  to  try 
it  in  various  ways,  and  in  different  prepara¬ 
tions,  before  you  abandon  it  altogether.  I 
think  that  practitioners  often  fail  in  obtain¬ 
ing  all  the  good  effects  of  opium  from  being 
too  timid  in  the  use  of  it,  giving  it  in  too 
small  a  dose,  and  employing  it  in  a  vacillat¬ 
ing  manner  :  you  must  give  it  in  a  large 
dose,  not  less  than  a  grain,  frequently  re¬ 
peated,  taking  the  state  of  the  pupils  as  your 
guide  to  encourage  or  deter  you  from  pro¬ 
ceeding  with  it.  You  will  of  course  pro¬ 
ceed  with  great  caution  if  you  find  a  very 
contracted  pupil  in  addition  to  some  degree 
of  narcotism.  Before  you  abandon  the  use 
of  opium,  remember  that  you  have  a  great 
variety  of  forms  in  which  to  prescribe  it,— you 
have,  among  others,  the  compound  camphor 
tincture,  which  is  often  borne  when  the 
other  preparations  fail ;  the  acetate  and 
muriate  of  morphia;  Mr.  Battley’s  liquor 
opii  sedativus  ;  and  a  preparation  introduced 
by  Mr.  Squire,  the  solution  of  the  bime- 
conate  of  morphia,  which  may  be  given  in 
the  same  doses  as  laudanum. 

Again,  it  may  happen,  and  this  is  by 
no  means  of  unfrequent  occurrence,  that  the 
swollen  and  painful  state  of  the  joints  does 
not  yield  to  the  cotton  wool  and  oiled  silk 
only.  What  further  treatment  of  the  joints 
will  you  pursue  ?  I  have  no  hesitation  in 
advising  you  to  apply  blisters  ;  and  I  would 
recommend  you  to  use  every  means  in  your 
power  to  get  them  to  rise  well.  I  do  not 
think  it  advisable  to  apply  large  blisters  ; 
on  the  contrary,  they  are  injurious,  and 


656 


DR.  TODD  ON  THE  TREATMENT  OF  RHEUMATIC  FEVER. 


their  use  is  to  be  deprecated.  The  plan  I 
generally  follow  is  this  :  I  order  a  small 
mustard  cataplasm  to  be  applied  to  the 
affected  joint,  and  to  be  kept  on  for  half  an 
hour  to  redden  the  skin  ;  after  removal  of 
this,  the  skin  is  to  be  carefully  washed  and 
dried,  and  the  blister  may  then  be  applied  ; 
you  must  not  let  the  size  of  this  exceed  that 
of  a  crown-piece.  It  is  better  to  apply  two 
or  three  small  blisters  in  rapid  succession, 
and  to  different  parts  of  the  joint,  than  one 
large  blister.  After  the  blister  has  risen 
well,  if  the  swelling  of  the  joint  subsides 
quickly,  as  it  very  frequently  does,  you  may 
let  the  blister  heal  as  fast  as  it  will ;  but  if 
the  swelling  has  not  subsided,  then  you  had 
better  cut  away  the  cuticle  completely,  and 
promote  a  free  discharge  from  the  blistered 
surface  by  dressing  it  with  stimulating  oint¬ 
ments. 

You  need  not  be  afraid  to  apply  blisters 
in  the  early  stages  of  the  rheumatic  inflam¬ 
mation  of  the  joints.  I  believe  the  dread 
which  some  physicians  had,  and  have,  of  ap¬ 
plying  blisters  near  inflamed  parts — as  near 
an  inflamed  lung,  or  pleura,  or  pericardium — 
is  theoretical,  and  not  derived  from  any 
actual  mischief  which  they  had  witnessed 
from  the  practice.  I  have  applied  them 
very  early  to  rheumatic  joints  in  numerous 
cases,  and  always  withmore  or  less  advantage, 
provided  the  blisters  have  not  been  too 
large.  A  very  large  blister  is  extremely  apt 
to  do  mischief,  and  augment  the  inflamma¬ 
tion  of  the  joint ;  but  a  small  one,  ranging 
in  size  from  that  of  a  crown  to  a  half-crown, 
is  almost  invariably  beneficial.  When  a 
very  copious  effusion  has  taken  place  into  a 
joint,  the  plan  of  applying  two  or  three  small 
blisters  in  succession,  at  different  parts  of 
the  joint,  provided  the  first  should  fail  in 
getting  rid  of  the  effusion,  is  productive  of 
the  best  effects. 

I  have  seen  excellent  results  from  the  ap¬ 
plication  of  blisters  to  gouty  joints,  even  in 
the  most  acute  stage.  A  discharge  of  a  large 
quantity  of  serum  from  the  vessels  of  a  gouty 
joint,  has  all  the  good  effects  of  the  abstrac¬ 
tion  of  blood  from  it  without  any  of  the  evil 
consequences  of  that  mode  of  treatment. 

You  must  exercise  a  proper  caution  not 
to  carry  the  sweating  or  the  purging  process 
too  far  with  your  patients.  It  is  impossible 
to  lay  down  precise  general  rules  on  this 
subject :  the  state  of  the  patient’s  pulse,  his 
countenance,  the  mode  in  which  he  ex¬ 
presses  his  feelings,  will  sufficiently  indicate 
the  condition  of  his  general  powers  to  enable 
you  to  judge  whether  you  are  going  too  far 
or  not.  All  I  shall  say  on  this  point  is,  let 
this  be  your  motto  in  the  treatment  of  this 
disease,  ne  quid  nimis ;  neither  too  much 
sweating,  nor  too  much  purging,  nor  too 
much  opium.  I  need  not  caution  you 
against  too  much  bleeding,  as  I  advise  you 


to  omit  that  from  your  practice  altogether 
in  the  treatment  of  this  malady. 

All  the  world  now  knows  how  necessary 
it  is  in  acute  rheumatic  cases — and,  I  would 
add,  even  in  chronic  also — to  pay  the  closest 
attention  to  the  heart.  You  should  watch 
it  from  day  to  day,  and  from  the  very  com¬ 
mencement  of  the  attack  ;  and  if  you  find 
the  smallest  indication  of  a  departure  from 
its  normal  mode  of  action,  attack  it  spe¬ 
cially,  and  at  once.  Here  early  measures 
are  of  vital  importance — bis  dat,  qui  cito 
dat.  I  say  you  should  watch  the  heart 
from  the  very  first  moment  the  patient 
comes  under  your  charge ;  for  the  cardiac 
symptoms  are  apt  to  come  on  very  early, 
and  in  some  instances  they  precede  the 
articular  affection.  In  our  patient  Eliza¬ 
beth  Stocking,  the  cardiac  symptoms  must 
have  developed  themselves  very  early,  as 
they  were  already  well  developed  on  her 
admission  into  the  hospital. 

The  circumstances  that  will  denote  to  you 
that  the  heart  is  beginning  to  suffer,  are — 
irregularity  of  the  pulse  in  any  way,  either 
as  affecting  its  force  or  its  rhythm — i.  e. 
whether  the  intermission  be  partial  or  com¬ 
plete  :  or  its  becoming  suddenly  quicker  or 
slower.  Should  any  of  these  signs  present 
themselves,  you  should  at  once  institute  the 
most  minute  scrutiny  into  the  physical  signs 
of  the  heart’s  action,  and  if  you  should  find 
the  slightest  indication  of  a  rubbing  or 
bellows  sound,  you  may  infer  that  either  the 
pericardium  or  endocardium,  or  both,  are 
beginning  to  suffer.  Disease  of  the  endo¬ 
cardium  is  especially  to  be  feared  if  the 
bellows  sound  is  mitral  systolic,  i.  e.  if  it  be 
heard  most  distinctly  over  the  apex  of  the 
heart,  and  accompany  the  first  or  systolic 
sound  :  under  such  circumstances,  you  may 
he  sure  that  the  endocardium  is  suffering, 
and  that  some  portion  of  the  mitral  valve  is 
implicated  in  the  lesion.  If,  however,  the 
systolic  bellows  sound  be  heard  most  dis¬ 
tinctly  over  the  base  of  the  heart,  and  along 
the  course  of  the  great  vessels,  and  is  there¬ 
fore  aortic,  you  must  not  at  once  infer  that 
this  is  a  sure  sign  of  the  existence  of  endo¬ 
carditis  affecting  the  aortic  valves  :  you  must 
bear  in  mind  that  an  aortic  bellows  sound 
may,  and  very  frequently  does,  arise  from 
an  anaemic  state  of  the  system.  I  have  al¬ 
ready  told  you  that  the  rheumatic  state 
tends  to  diminish  very  much  the  proportion 
of  the  colouring  matter  of  the  blood  even  in 
patients  who  have  not  been  bled  or  other¬ 
wise  roughly  treated.  The  rheumatic  state 
itself,  then,  by  bleaching  the  blood,  may 
give  rise  to  aortic  and  even  venous  murmurs. 
How  much  more  likely  to  be  produced  is 
the  condition  favourable  to  these  murmurs 
when  bleeding  has  been  practised  ?  You  must 
be  very  careful  not  to  fail  into  the  mistake 
of  treating  an  aortic  murmur  as  due  to 


DR.  TODD  ON  THE  TREATMENT  OF  RHEUMATIC  FEVER. 


657 


endocarditis,  which  is  really  the  result  of 
the  already  bleached  state  of  the  blood. 
Such  a  mistake  is  not  unlikely  to  be  made, 
as  the  diagnosis  is  difficult  between  the 
anaemic  murmur  and  that  from  aortic  ob¬ 
struction  ;  and  you  can  readily  understand 
how  an  antiphlogistic  process,  especially  if 
it  included  bleeding,  would  make  matters 
infinitely  worse  in  a  case  where  the  murmur 
was  simply  of  the  anaemic  kind.  The  more 
you  proceeded  with  such  a  treatment,  the 
more,  of  course,  the  conditions  for  the  de¬ 
velopment  of  the  bellows  murmur  would  be 
developed,  and  the  louder  it  would  become. 
The  following  points  will  aid  you  in  de¬ 
ciding  upon  the  endocarditic  character  of  the 
murmur: — 1,  if  the  sound  come  on  very 
early  in  the  disease;  2,  if  it  be  rough  in 
character  ;  3,  if  it  be  not  accompanied  with 
venous  murmur  ;  4,  if  the  patient  has  not 
yet  displayed  much  anaemia;  lastly,  the  pro¬ 
bability  of  an  endocardial  affection  is  much 
increased  if  the  murmur  have  been  ushered 
in  with  some  disturbance  of  the  heart’s  ac¬ 
tion  such  as  I  have  already  referred  to. 

In  the  treatment  of  the  heart  affection,  I 
am  in  the  habit  of  acting  upon  much  the 
same  principles  as  in  the  treatment  of  the 
joints,  and  I  trust  to  free  vesication  and 
the  promotion  of  a  copious  discharge,  serous 
or  sero-purulent,  as  the  local  treatment.  I 
shall  describe  to  you  the  plan  I  am  in  the 
habit  of  following,  and  which  we  have  used 
with  the  most  satisfactory  results  in  Eliza¬ 
beth  Stocking’s  case.  On  the  first  indi¬ 
cation  or  suspicion  of  heart  affection,  a  large 
sinapism  made  with  flour  of  mustard  and 
hot  water,  is  applied  over  and  beyond 
the  region  of  the  heart.  This  is  to  be  kept 
on  as  long  as  possible:  after  its  removal, 
and  after  the  skin  has  been  properly  cleansed, 
put  on  a  blister  of  good  size,  and  you  must 
be  guided  as  to  the  dimensions  of  it  by  your 
opinion  of  the  extent  of  the  heart  which  is 
affected.  You  need  not  be  afraid  of  large 
blisters  here,  as  in  the  treatment  of  the  joints, 
because  the  inflamed  organ  is  much  more 
distant  from  the  surface  than  the  synovial  or 
other  articular  tissues. 

If  you  pursue  the  plan  which  I  have  thus 
pointed  out,  and  have  drawn  a  large  quantity 
of  blood  to  the  surface  by  the  long  continued 
stimulation  of  mustard,  you  will  generally 
succeed  in  producing  very  free  and  large 
vesication,  from  which  you  may  obtain  a 
considerable  quantity  of  serum,  or  rather,  I 
should  say,  of  liquor  sanguinis,  for  the 
fluid  of  the  blister  is  serum  containing 
more  or  less  fibrine.  If  you  examine 
the  fluid  from  blisters,  especially  when 
the  skin  had  been  previously  irritated  by 
mustard,  you  will  almost  invariably  find 
that  it  contains  more  or  less  of  fibrine.  In 
very  many  instances,  if  not  in  all,  the 
coagulated  fibrine  disposes  itself  as  a  mem¬ 


branous  layer  in  immediate  juxta- position 
with  the  deep  surface  of  the  elevated  cuticle. 
On  removing  the  cuticle  slowly  and  cau¬ 
tiously,  the  serum  will  not  flow  away  :  it  is 
still  retained  by  a  very  complete,  but  soft, 
moist,  and  almost  spongy  membrane.  This 
is  coagulated  fibrine,  which  has  entangled  in 
it  a  large  quantity  of  the  white  corpuscles. 
How  these  latter  escape  from  the  blood¬ 
vessels,  or  whether  they  are  not  the  result 
of  the  organizing  tendency  of  the  liquor 
sanguinis,  I  cannot  pretend  to  decide.  It  is 
clear,  however,  that  blisters  will  take  away 
the  liquor  sanguinis  with  its  dissolved  ele¬ 
ments  and  perhaps  the  white  corpuscles, 
which  constitute  more  than  four-fifths  of 
the  blood.  By  blistering,  you  take  away 
that  part  of  the  blood  which  is  the  great 
agent  in  the  development  of  new  formations, 
and  these  are  what  you  have  to  guard  against 
in  the  cardiac  inflammations.  Moreover, 
by  blistering,  you  spare  that  most  important 
part  of  the  blood,  the  colouring  matter, 
which  seems  especially  valuable  for  preserv¬ 
ing  the  nervous  functions  in  a  state  of 
integrity,  and  which  is  no  less  important  for 
maintaining  the  healthy  action  of  the  heart. 

But  some  of  you  will  say,  “  What !  do  you 
advise  us  to  lay  aside  that  which  has  so  long 
been  regarded  as  the  sheet-anchor  in  the 
treatment  of  inflammations— namely,  bleed¬ 
ing,  and  not  only  general  bleeding,  but 
topical  bleeding  likewise  ?  If  we  are  neither 
to  cup  nor  to  leech  in  pericarditis  or  endo¬ 
carditis,  what  security,  then,  shall  we  have 
against  the  progress  of  inflammation — 
against  the  formation  of  excrescences  on  the 
valves  —  against  ulcerative  or  suppurative 
processes  being  established  in  the  heart, 
destroying  its  valves,  and  infecting  the 
blood  ?”  I  am  quite  aware  that  the  doctrine 
which  I  recommend  for  your  adoption  is 
likely  to  be  regarded  as  extremely  heterodox 
by  many,  but  I  believe  the  number  of  those 
who  would  think  so  is  daily  diminishing. 
In  the  treatment  of  the  cardiac  affections 
which  accompany  rheumatic  fever,  you  have 
two  objects  to  keep  in  view  :  the  first  is  to 
check  the  morbid  process  completely,  or  to 
restrain  it  from  producing  such  changes  as 
may  prove  destructive  to  the  tissues,  and 
consequently  to  the  mechanism  of  the  heart ; 
and  secondly,  to  obviate  liquid  effusions 
which  may  distend  the  pericardium,  com¬ 
press  the  heart,  and  so  embarrass  its  actions, 
as  well  as  the  respiratory  movements,  as  to 
prove  seriously  detrimental  to  life.  Now, 
with  regard  to  the  first  point,  there  can  be 
little  doubt  that  bleeding  will  not  stop  or 
prevent  the  formation  of  those  fibrinous 
concretions  which  are  so  apt  to  form  upon 
the  valves.  The  formation  of  these  con¬ 
cretions  is  in  a  great  measure  mechanical, 
and  in  certain  states  of  the  blood  they  would 
form  around  or  upon  any  opposing  material 


658 


DR.  TODD  ON  THE  TREATMENT  OF  RHEUMATIC  FEVER. 


just  as  fibrin  will  coagulate  round  the  bunch 
of  twigs  by  which  blood  is  beaten  as  it  flows 
from  a  vein.  In  this  rheumatic  state,  the 
contractile  tendency  of  fibrin  is  apparently 
increased,  as  is  showrn  by  the  uniform  forma¬ 
tion  of  atough  buffy  coat  in  the  blood  removed 
from  rheumatic  subjects  ;  there  is  also  a 
considerable  increase  in  the  number  of  white 
corpuscles  ;  the  buffy  coat  is  formed  of  these 
two  constituents,  and  the  constancy  of  its 
formation  denotes  a  tendency  in  these  two 
elements  to  separate  from  the  other  elements 
of  the  blood  in  the  rheumatic  state.  Doubt¬ 
less,  a  disturbed  state  of  the  nutrition  of  the 
serous  membrane  or  the  endocardium,  or  of 
certain  parts  of  them,  precedes  the  formation 
of  fibrinous  deposits  upon  them  ;  and  this 
disturbance  of  nutrition  is  caused  by  the 
accumulation  of  the  rheumatic  matter  in  the 
vessels  of  the  part.  The  effect  of  this  is 
analogous  to,  if  not  identical  with,  that  pro¬ 
duced  by  a  blister  on  the  vessels  of  the  skin, 
which  I  have  just  now  described  to  you. 
The  liquor  sanguinis,  and  probably  the 
white  corpuscles,  transude  through  the 
parietes  of  the  bloodvessels,  and  the  plastic 
matter  coagulates  upon  the  surface  of  the 
endocardial  and  the  pericardial  membrane, 
forming  there  a  substance  identical,  or  nearly 
so,  with  the  buffy  coat  of  the  blood.  In  the 
endocardium,  which  is  in  contact  with  the 
blood  as  it  flows  through  the  heart,  this 
layer  of  plastic  matter  forms  a  nucleus, 
around  which  fibrin  from  the  blood  which 
flows  over  it  may  coagulate. 

Now,  if  this  be  a  correct  account  of  the 
manner  in  which  those  plastic  concretions 
develop  themselves  in  pericarditis  and  endo¬ 
carditis, — and  I  believe  it  is  that  which  is 
most  consistent  with  our  present  improved 
knowledgeofthe  bloodandof  inflammation — 
it  is  evident  that  the  object  of  the  practi¬ 
tioner  should  be  to  prevent  the  development 
of  that  altered  state  of  nutrition  which  pre¬ 
cedes  the  fibrinous  formations,  or  to  cut 
it  short  after  its  formation.  Then  comes  the 
question,  will  bleeding  do  this  ?  I  think 
our  experience  of  the  effects  of  bleeding  upon 
the  joints  ought  to  convince  us  that  it  will 
not :  for  bleeding  certainly  will  not  remove 
the  rheumatic  state  from  them  ;  for,  how¬ 
ever  it  may  relieve  for  a  short  time  by 
diminishing  hyperaemia,  the  flow  of  blood 
speedily  returns  with  greater  activity  than 
before.  I  apprehend  that  the  state  of  the 
joints  and  that  of  the  heart  are  as  nearly  as 
possible  the  same,  the  difference  being  that 
the  nature  of  the  synovial  secretion  offers  a 
complete  physical  impediment  to  the  forma¬ 
tion  of  fibrinous  or  plastic  concretions  in  the 
joints. 

And  I  would  put  another  question — will 
bleeding  cut  short  that  state  of  blood  which 
is  so  favourable  to  the  formation  of  the 
plastic  deposits  ?  To  this  I  answer  likewise 
in  the  negative.  Among  the  best  of 


!  the  recent  researches  upon  the  relative 
quantities  of  the  elements  of  the  blood  in 
various  conditions  of  that  fluid,  are  those  of 
Becquerel  and  Rodier :  what  do  these 
observers  say  as  to  the  influence  of 
bleeding  upon  the  blood  ?  Why,  that  it 
greatly  diminishes  the  red  particles,  that  it 
greatly  augments  the  proportion  of  water  ; 
and  that  it  affects  but  little  or  not  at  all  the 
fibrin  :  thus,  in  short,  you  get  a  thinner 
liquor  sanguinis  holding  in  solution  the  same 
or  nearly  the  same  amount  of  fibrine.  In 
other  words,  you  get  a  state  of  liquor  san¬ 
guinis  very  favourable  to  transudation,  and 
therefore  very  favourable  to  plastic  forma¬ 
tions. 

If,  then,  bleeding  will  not  stop  the  in¬ 
flammatory  state  which  creates-  the  undue 
determinations  of  the  blood  to  the  pericardial 
and  endocardial  surfaces,  and  if  it  will  not 
prevent  the  plastic  formations,  but  rather 
favour  them,  surely  it  is  not  the  remedy  for 
pericarditis  and  endocarditis.  And  if  the 
effects  of  venesection  be,  as  beyond  all  doubt 
they  are,  to  diminish  all  the  solids  of  the 
blood  but  the  fibrine,  and  to  augment  the 
water,  surely  the  employment  of  this  treat¬ 
ment  to  a  great  extent  is  fraught  with  the 
greatest  danger  of  creating  liquid  effusions 
into  the  serous  and  synovial  sacs,  which  are 
so  exposed  to  the  action  of  the  rheumatic 
matter. 

These  are,  as  concisely  as  I  can  put  them 
before  you,  the  theoretical  grounds  upon 
which  I  object  to  the  practice  of  bleeding, 
whether  local  or  general,  for  the  cardiac 
affections  of  rheumatic  fever.  And  my  ex¬ 
perience  confirms  me  in  the  belief  that  the 
practice  of  bleeding  is  altogether  unsatis¬ 
factory  in  its  remedial  results,  and  prejudi¬ 
cial  in  its  consequences:  and  that  the  practice 
of  abstaining  from  this  mode  of  treatment  is 
perfectly  safe,  and  tends  to  the  best  results. 
By  the  general  plan  of  elimination, — general 
through  the  sweating  and  other  augmented 
processes  of  secretion, — local,  by  blisters, — 
you  divert  the  rheumatic  matter  very  freely 
from  those  great  central  and  highly  vascular 
organs  which  we  are  so  anxious  to  protect 
from  mischief. 

Besides  the  local  treatment  that  I  have 
prescribed,  you  must,  when  the  heart  or  any 
of  the  great  internal  organs  is  affected,  avail 
yourselves  freely  of  the  antiphlogistic  powers 
of  mercury,  and  while  you  still  keep  up  the 
influence  of  opium  upon  your  patient, 
whereby  you  secure  a  powerful  means  of 
keeping  down  excessive  action  of  the  heart, 
you  might  conjoin  with  it  calomel,  in  two  or 
three  doses,  frequently  repeated  ;  and  in 
cases  where  you  desire  to  induce  ptyalism 
with  rapidity,  you  must  rub  in  mercurial 
ointment  into  the  groins  or  the  axillae,  and 
you  may  dress  the  blisters  in  the  cardiac 
with  mercurial  ointment. 

I  know  that  there  are  many  physicians 


DR.  TODD  ON  THE  TREATMENT  OF  RHEUMATIC  FEVER. 


659 


who  speak  lightly  of  the  remedial  powers  of 
mercury  in  these  rheumatic  affections.  But 
I  confess  to  you  that  I  am  not  prepared  to 
give  up  the  dogma  of  Dr.  Farre,  that  mer¬ 
cury  is  opposed  to,  and  breaks  down,  plastic 
fo  rmations.  Still  I  must  admit,  and  this  is 
satisfactory  for  patients  who  may  be  pre¬ 
vented  by  idiosyncrasy  from  the  use  of  mer¬ 
cury,  that  I  have  seen  patients  do  extremely 
well  without  having  taken  a  single  grain  of 
that  medicine. 

You  will  bear  in  mind  that  both  pneumo¬ 
nia  and  pleurisy  are  very  common  complica¬ 
tions  of  rheumatic  fever  :  but  for  the  treat¬ 
ment  of  these  affections  I  have  nothing  to 
add  to  what  I  have  said  respecting  the  treat¬ 
ment  of  the  cardiac  affections.  The  treat¬ 
ment  of  both  should  be  exactly  the  same, 
mutatis  locis. 

There  is  a  very  formidable  complication 
of  rheumatic  fever  respecting  which  I  must 
say  a  few  words.  I  allude  to  the  delirium 
which  is  apt  to  manifest  itself  in  the  course 
of  the  attack ;  sometimes  with  thoracic  in¬ 
flammation,  sometimes  without  it.  It  is 
very  important  that  you  should  be  prepared 
for  this  symptom  ;  and  that  you  should  un¬ 
derstand  its  nature,  and  its  proper  mode  of 
treatment :  it  is  not  in  itself  a  dangerous 
symptom,  unless  the  practitioner  fails  in 
taking  the  precautions  which  are  rendered 
imperative  by  its  occurrence. 

The  delirium  of  rheumatic  fever  some¬ 
times  comes  on  gradually,  the  patient  having 
been  a  little  talkative  and  wandering  for  two 
or  three  nights  ;  sometimes  it  comes  on  quite 
suddenly.  In  its  general  characters  it  re¬ 
sembles  delirium  tremens — generally,  how¬ 
ever,  exhibiting  less  of  the  nervous  tremor 
which  belongs  to  intemperance.  The  patient 
is  restless,  busy,  talkative,  picking  or  pulling 
the  bed-clothes,  frequently  rising  in  bed, 
and  wanting  to  get  out  of  bed,  reaching  out 
his  hand  as  if  to  catch  hold  of  some  object 
before  or  behind  him — and  sometimes,  a 
most  unfortunate  symptom,  obstinately  re¬ 
fusing  to  take  either  food  or  medicine. 

In  some  instances,  as  I  have  already  said, 
this  delirium  ushers  in  pericarditis,  pleurisy, 
or  pneumonia ;  frequently,  however,  it  oc¬ 
curs  after  one  or  other  of  these  maladies  has 
set  in,  and  sometimes  it  occurs  without  them. 
It  has,  therefore,  I  think,  no  necessary  con¬ 
nection  with  these  internal  inflammations, 
although  it  frequently  accompanies  them. 

Now,  what  is  the  nature  of  this  delirium  ? 

It  used  formerly  to  be  viewed  as  a  metastasis 
of  rheumatism  to  the  brain,  and  to  be  treated 
antiphlogistically.  I  have  treated  some  cases 
in  this  way,  and  on  this  hypothesis,  and  I  have 
had  the  opportunity,  inconsequence,  I  believe, 
of  this  treatment,  of  examining  the  state  of  the 
contents  of  the  cranium  in  a  few  such  cases  : 

I  can  therefore  assure  you  that  there  is  no 
more  inflammation,  either  of  the  brain  or  its 


membranes,  in  these  cases  than  in  delirium 
tremens.  The  membranes  are  perfectly  free 
from  abnormal  deposit,  the  pia  mater  is  pale, 
and  the  grey  matter  of  the  convolutions  re¬ 
markably  so,  and  the  subarachnoid  fluid  is 
increased  in  quantity.  These  signs  indicate, 
not  only  that  the  brain  has  been  imperfectly 
supplied  with  blood  during  life,  but  that  the 
vascular  pressure  upon  it  is  less  than  it 
ought  to  be,  and  that,  consequently,  an  in¬ 
crease  of  the  subarachnoid  fluid  has  taken 
place. 

When,  then,  we  consider  the  circum¬ 
stances  in  which  the  brain  is  placed  in  these 
cases,  we  cannot  wonder  at  its  functions 
being  disturbed.  In  the  first  place,  the 
organ  is  supplied  by  a  depraved  blood — a 
blood  deficient  in  its  most  important  stami- 
nal  principle,  its  colouring  matter  ;  a  blood 
infected  with  an  abnormal  material,  the 
rheumatic  virus,  whatever  that  maybe;  and 
if  the  patient,  as  is  very  often  the  case,  have 
been  treated  by  sanguineous  depletions,  a 
watery  blood.  Such  a  blood  is  ill  suited  for 
the  proper  stimulation  of  the  heart,  and, 
consequently,  it  is  not  propelled  by  that 
organ  with  its  proper  force,  although  the 
rapidity  of  the  heart’s  action  may  be  much 
increased.  And  if  the  heart  be  inflamed 
there  can  be  no  doubt  that  the  effect  of  that 
inflammation  will  be  to  weaken  its  power. 
Hence,  in  cases  of  this  kind,  the  brain  is 
feebly  furnished  with  a  blood,  poor  in  colour¬ 
ing  matter,  and  abounding  in  water. 

I  have  met  with  a  few  cases  in  which  the 
patient,  having  evinced  previously  little  or 
no  delirium,  has  become  rapidly  comatose, 
with  dilated  pupils,  and  sunk  quickly.  And 
it  sometimes  happens  that  patients  who  have 
been  actively  delirious  will  suddenly  fall  into 
coma  and  die ;  and  sometimes  they  die 
suddenly  while  making  some  effort,  beyond 
their  strength,  in  the  midst  of  their  deli¬ 
rious  ravings.  The  state  of  the  kidneys 
may  have  some  influence  in  determining  the 
mode  of  death  in  those  patients  who  pass 
quickly  into  coma,  as  we  know  that  defec¬ 
tive  action  of  that  organ  so  often  exercises  a 
baneful  influence  on  the  brain. 

You  will  find  a  valuable  collection  of  cases 
of  delirium  and  other  disturbances  of  the  ner¬ 
vous  system,  in  connection  with  rheumatic 
cardiac  affections,  in  Dr.  George  Burrows’  in¬ 
teresting  and  most  valuable  work  on  disorders 
of  the  cerebral  circulation.  The  evidence 
which  Dr.  Burrows  has  adduced  in  that 
work  should  teach  us,  that  whenever  we 
meet  with  a  case  of  delirium,  especially 
of  rheumatic  delirium,  we  should  diligently 
explore  the  region  of  the  heart,  and  watch 
the  condition  of  that  organ  most  carefully 
from  day  to  day. 

But  this  delirium,  as  I  said  before,  has  no 
necessary  connexion  with  the  heart  affec¬ 
tion — at  least,  with  endocarditis  and  peri- 


60  DR.  TODD  ON  THE  TREATMENT  OF  RHEUMATIC  FEVER. 


carditis,  for  it  occurs  in  cases  of  general 
gout,  in  which  there  are  no  such  heart  affec¬ 
tions  as  those  in  rheumatic  fever,  and  the 
delirium  of  gout  resembles  precisely  that 
which  I  have  described  to  you  as  belonging 
to  rheumatic  fever. 

I  have  seen,  indeed,  this  delirium  in  per¬ 
sons  of  strongly-marked  rheumatic  or  gouty 
diathesis,  accompanied  by  all  the  signs  of 
rheumatic  fever — the  sweats,  the  parched 
tongue,  and  the  lithic  urine,  but  without 
either  cardiac  or  articular  affection. 

I  may  make  this  further  remark  before  I 
refer  to  the  mode  of  treating  this  delirium, 
that  what  I  have  seen  of  it  has  strongly  im¬ 
pressed  me  with  the  belief  that  it  is  much 
more  apt  to  occur  after  bleeding,  and  in 
weakly  subjects,  than  when  depletion  by 
blood-letting  has  not  been  employed,  or  in 
sthenic  cases.  It  is  also,  at  times,  an  indi¬ 
cation  that  your  patient  is  being  reduced  too 
much  by  sweating,  or  purging,  or  some 
other  means. 

The  development  of  this  delirium  should 
be  the  signal  to  the  practitioner  to  exercise 
the  greatest  vigilance  in  looking  out  for  car¬ 
diac  or  other  internal  inflammations,  as 
pneumonia  or  pleurisy,  or  even  peritonitis, 
which  sometimes,  although  rarely,  occurs  in 
rheumatic  fever  :  if  such  have  not  been  pre¬ 
viously  detected.  But  it  should  likewise  be 
looked  upon  as  a  signal  of  distress,  denoting 
that  the  powers  of  the  constitution  are  un¬ 
equal  to  the  severe  trial  through  which  the 
patient  is  passing  ;  and  he  should  imme- 
•  dlately  come  to  the  patient’s  aid,  and  make 
instant  arrangements  for  having  him  con¬ 
stantly  watched  by  competent  nurses  or 
other  attendants,  taking  care  that  the  pa¬ 
tient  shall  never  be  left  alone.  If  he  have 
been  sweating  freely,  that  must  be  checked  ; 
the  amount  of  bed-clothes  may  be  reduced  : 
if  his  joints  have  been  enveloped  with  wool, 
it  must  be  removed.  In  like  manner  any 
other  too  free  evacuation  must  be  stopped, 
as  purging,  or  the  too  copious  discharge 
from  a  blister.  Nourishment  must  be  given 
very  frequently,  but  in  small  quantities,  so 
as  not  to  embarrass  the  stomach  ;  and  this 
should  consist  of  beef-tea,  arrow-root,  milk  ; 
and  frequently  it  will  be  necessary  to  conjoin 
with  this  wine  or  brandy,  or  porter  when 
that  has  been  an  habitual  beverage.  If  the 
patient  be  wakeful,  sleep  must  be  procured 
by  the  free  administration  of  opium.  These 
are  the  points  to  which  you  will  have  to 
direct  your  most  watchful  care ;  provide 
against  your  patient  being  allowed  to  exert 
himself  beyond  his  strength  ;  remember  that 
it  is  in  this  state  that  patients  often  die  sud¬ 
denly  by  syncope,  and  remember  to  nourish 
and  support  them  well.  Eschew  all  local 
treatment  to  the  head  ;  even  the  application 
of  ice  is  calculated  to  do  mischief,  by  de¬ 
pressing  the  heart’s  action. 


When,  however,  the  patient  evinces  a  ten¬ 
dency  to  coma,  then  of  course  you  will  not 
use  opium ;  then  I  would  advise  you  to 
shave  the  head,  and  to  counterirritate  it  and 
the  back  of  the  neck,  by  sinapisms  first, 
and  afterwards,  if  you  find  it  necessary,  by 
blisters,  pursuing  at  the  same  time  those 
measures  for  the  support  of  the  patient 
which  I  have  already  pointed  out,  and  which 
you  may  be  assured  are  not  less  necessary  in 
the  comatose  cases  than  in  those  in  which 
active  delirium  prevails. 

I  have  already  told  you  that  you  must  be 
careful  in  carrying  out  this  general  plan  of 
elimination  with  the  closest  attention  and 
regard  to  the  powers  of  your  patient’s  con¬ 
stitution.  I  allude  to  this  subject  again,  for 
the  purpose  of  mentioning  to  you  a  sign 
which  has  over  and  over  again  proved  most 
valuable  to  me,  in  leading  me  to  pursue  an 
altered  course  of  treatment.  When  the  pa¬ 
tient  has  begun  to  pass  pale  urine,  in  good 
quantity,  either  without  precipitate,  or  with 
a  greater  or  less  quantity  of  pale  lithates, 
you  will  almost  invariably  find  that  he  will 
be  the  better  for  a  more  generous  treatment, 
even  although  the  articular  affection  still 
continue  troublesome.  You  may  give  him 
ammonia,  or  quinine  and  sulphuric  acid,  and 
in  many  instances  you  may  give  wine  ;  and 
I  have  been  astonished  at  the  rapidity  of  the 
progress  of  cases  under  this  altered  treat¬ 
ment  :  cases  which  had  been  stationary  for 
two  or  three  days,  have,  under  the  circum¬ 
stances  and  treatment  I  have  described,  be¬ 
come  convalescent  in  little  more  than  forty- 
eight  hours. 

The  plan  of  treatment  which  I  have  now 
recommended  to  you  does  not  contain  any 
new  remedy,  nor  does  it  profess  to  point  io 
any  summary  method  of  treating  rheumatic 
fever  :  it  is  merely  the  application  of  old 
and  well-appreciated  remedies  to  the  treat¬ 
ment  of  this  formidable  malady,  in  further¬ 
ance  with  a  certain  determinate  object — -that 
of  eliminating  morbid  matter,  at  various 
points  and  through  different  channels,  from 
the  current  of  the  circulation.  Since  I  have 
adopted  this  mode  of  treatment  I  have  much 
more  rarely  met  with  those  accidents  qf  the 
disease — pneumonia,  pericarditis,  delirium, 
&c.  which  are  so  formidable  to  both  the 
patient  and  the  practitioner,  in  the  same 
severe  form  which  I  used  to  do  under  a 
more  depleting  treatment ;  and  when  such 
severe  cases  do  occur  in  the  hospital,  they 
are  generally  persons  who  have  suffered  from 
a  depleting  treatment  prior  to  their  admis¬ 
sion,  or  who  have  been  thrown  into  a  very 
reduced  state  from  other  causes.  Again,  I  find 
that  under  this  treatment  the  duration  of  the 
disease  does  not  exceed  from  ten  days  to  three 
weeks,  aud  that  relapses,  which  were  very 
frequent  under  the  treatment  by  bleeding, 
are  of  very  rare  occurrence  under  this.  New 


DR.  CARPENTER  ON  THE  OBJECTS  OF  MEDICAL  STUDY. 


661 


it  was  formerly  the  dictum  of  a  very  eminent 
physician,  “  that  the  only  cure  for  rheuma¬ 
tic  fever  was  six  weeks.”  By  this  he  meant 
that  the  disease  would  take  its  course,  that 
time  was  its  only  cure,  and  that  this  time 
was  not  less  than  six  weeks.  But  I  should 
not  attach  much  importance  to  a  plan  of 
treatment  which  failed  to  get  patients  into  a 
good  state  in  a  much  shorter  time  than  that. 
Our  patient,  Elizabeth  Stocking,  whose  case 
has  been  a  severe  one,  and  who  has  had 
pericarditis  and  slight  delirium,  has  been  in 
the  hospital  now  just  eleven  days,  and  had 
been  ill  three  days  prior  to  her  admission, 
and  you  see  that  she  is  convalescent  already. 
She  has  lost  every  rheumatic  symptom  ;  all 
the  pains  in  her  joints  have  ceased,  her 
tongue  is  clean,  and  I  have  no  doubt  that  in 
two  or  three  days  more  she  will  be  struck  off 
the  sick  list  altogether.  And,  as  the  last, 
though  not  least,  advantage  of  this  treatment, 
there  is  no  fear  of  those  unpleasant  conse¬ 
quences  which  are  so  prone  to  follow  in  the 
wake  of  this  disease ;  there  is  no  fear  of  a 
tardy  ansemic  convalescence,  for  her  blood 
has  been  spared ;  nor  of  a  state  of  chronic 
rheumatism,  for  there  is  every  indication 
that  the  whole  of  the  morbid  material  has 
been  eliminated  from  her  system. 


THE  OBJECTS  OF  MEDICAL  STUDY, 

AND  THE 

SPIRIT  IN  WHICH  THEY  SHOULD 
BE  PURSUED. 

Being  an  Introductory  Lecture  delivered  at 
the  Medical  School  attached  to  the  Lon¬ 
don  Hospital ,  October  2,  1848, 

By  W.  B.  Carpenter,  M.D.  F.R.S.  F.G.S. 

Examiner  in  Physiology  in  the  University 
of  London. 


Gentlemen, — When  honoured  by  the  re¬ 
quest  of  my  colleagues  that  I  should  de¬ 
liver  the  Introductory  Lecture  with  which 
our  Medical  Session  usually  opens,  I  deter¬ 
mined,  after  a  little  consideration,  not  to 
seek  any  other  topic  than  that  which  has 
been  customary,  and  which  seems  most 
appropriate,  on  such  occasions — namely, 
the  objects  of  medical  study,  and  the  spirit 
in  which  those  objects  should  be  pursued. 
For  I  reflected  that,  of  the  portion  of  my 
audience  to  which  my  discourse  should  be 
especially  addressed,  many  would  be  hearers 
for  the  first  time  on  such  an  occasion  ;  and 
it  seemed  right  that  every  student,  at  the 
commencement  of  his  career,  should  have 
his  attention  somewhat  formally  directed  to 
the  nature  of  the  labours  and  duties  in 
which  he  is  about  to  engage.  And  with  re¬ 
gard  to  those  to  whom  the  subject  has  be¬ 


come  hackneyed,  I  thought  that  even  they 
might  find  something  of  novelty  in  it,  arising 
from  the  freshness  of  the  source  from 
which  it  would  emanate,  and  from  the 
changes  in  its  aspect  which  are  the  conse¬ 
quence  of  the  progress  of  medical  know¬ 
ledge. 

Without  further  preface,  then,  I  shall  in¬ 
vite  your  attention,  in  the  first  instance,  to 
a  survey  of  the  principal  objects  of  medical 
study.  But  I  am  desirous  that,  before  we 
proceed  with  it,  you  should  possess  a  defi¬ 
nite  idea  of  the  relation  subsisting  between. 
science  and  art.  You  hear  medicine  and 
surgery  spoken  of,  sometimes  under  one  de¬ 
signation,  sometimes  under  the  other ;  as  if 
the  two  meant  nearly  the  same  thing,  or  as 
if  it  were  not  very  certain  which  was  the 
right  term  to  apply.  Now,  as  it  is  perfectly 
evident  to  every  one  who  thinks  himself  clear 
upon  the  subject,  that  these  two  terms  have 
very  distinct  meanings — that  it  is  not  a 
matter  of  indifference  which  we  employ— 
and  that  in  proportion  to  the  definiteness  of 
our  conceptions  will  be  our  success  in  realis¬ 
ing  them — I  shall  dwell  for  a  few  minutes  on 
the  inquiry  into  their  proper  acceptation,  and. 
their  relations  with  our  own  objects  of  pro¬ 
fessional  inquiry.  I  cannot  adopt  a  better 
definition  of  these  terms,  than  that  which  has 
been  recently  given  by  one  of  the  ablest 
rcasoners  of  our  time,  Mr.  John  Mill,  in  his 
Treatise  on  Political  Economy.  “  These 
two  ideas,"  he  says,  “  differ  from  one  ano¬ 
ther  as  the  understanding  differs  from  the 
will,  or  as  the  indicative  mood  in  grammar 
differs  from  the  imperative.  The  one  deals 
in  facts,  the  other  in  precepts.  Science  is 
a  collection  of  truths ;  art  a  body  of  rules 
or  directions  for  conduct.  The  language  of 
science  is — this  is,  or  this  is  not ;  this  does, 
or  does  not,  happen.  The  language  of  art 
is — do  this ;  avoid  that.  Science  takes  cog¬ 
nizance  of  a  phenomenon,  and  endeavours  to 
discover  its  law  ;  art  proposes  to  itself  an  end, 
and  looks  out  for  means  to  effect  it." 

Now  those  arts  or  collections  of  rules 
for  a  given  purpose,  are  the  most  complete 
and  the  most  perfect  in  their  application, 
which  are  built  up  on  the  most  secure  and 
extended  scientific  foundation.  Take,  for 
example,  the  art  of  navigation,  which  is 
founded  upon  the  science  of  astronomy. 
The  seaman  can  determine  the  exact  position 
of  his  vessel  with  a  precision  only  bounded 
by  the  limits  to  the  perfection  of  his  instru¬ 
ments,  by  observations  of  the  altitude  of 
the  sun,  which  fix  his  latitude ,  and  by  ob¬ 
servations  of  the  distance  of  the  moon  from 
the  sun  or  from  the  stars,  by  computations 
founded  upon  which  he  can  determine  his 
longitude.  Now,  whence  is  it  that  he  de¬ 
rives  the  knowledge  of  how  to  do  this — the 
rules  on  which  he  works — and  the  standards 
of  comparison  from  which  he  draws  the  re- 


662 


DR.  CAEPENTER  ON  THE  OBJECTS  OF  MEDICAL  STUDY, 


suits  of  his  computations;  so  that,  if  his 
vessel  have  been  driven  by  winds  and  cur¬ 
rents  into  seas  never  before  traversed  by  the 
mariner,  he  can  ascertain  its  place  with  the 
same  certainty  as  if  he  were  voyaging  along 
the  most  familiar  tracks  ?  Simply  because 
his  art  is  founded  on  a  science  so  perfect, 
that,  as  regards  this  application  of  it,  there 
is  nothing  wanting  to  make  its  predictions 
as  certain  as  if  the  events  had  actually  taken 
place.  The  astronomer  can  specify,  with 
the  utmost  exactitude,  the  changes  in  the 
sun’s  elevation  which  take  place  from  day  to 
day  in  every  latitude,  and  can  show  that  its 
height  above  the  horizon  must  depend  en¬ 
tirely  (allowance  being  made  for  these 
changes)  upon  the  observer’s  distance  from 
the  equator  ;  so  that,  if  the  height  be  deter¬ 
mined  by  observation,  the  latitude  can  be 
deduced  from  it  by.a  formula  of  the  sim¬ 
plest  kind.  The  determination  of  the  longi¬ 
tude  from  observations  of  “  lunar  distances” 
requires  a  computation  of  a  far  more  com¬ 
plex  nature,  and  one  in  which  the  triumphs 
of  science  are  still  more  apparent.*  For  it 
is  requisite  that  the  ever-changing  position 
of  the  moon  should  be  calculated  for  years 
beforehand  with  the  most  rigid  accuracy ; 
so  that  her  place  with  reference  to  the  sun 
or  the  fixed  stars,  at  a  given  observatory, 
may  be  set  down  in  tables,  which  shall  be 
carried  by  the  voyager  who  is  about  to  start 
on  a  distant  and  tedious  enterprise,  and 
shall  serve  as  his  guide  through  his  toilsome 
and  devious  way,  until  he  is  conducted  by 
them  in  safety  and  security  to  his  desired 
haven.  Such  tables  are  the  triumph  of  as¬ 
tronomical  science,  which  is  able  to  say, 
not  only  “  This  does  happen,”  but  “  This 
will  happen.”  And  thus  the  rules  of  navi¬ 
gation  are  as  certain  when  applied  to  any 
future  unknown  case,  as  they  have  been 
proved  to  be  in  regard  to  the  past. 

I  have  directed  your  attention  to  astro¬ 
nomy  as  the  most  perfect  of  sciences,  and  to 
navigation  as  the  most  perfect  of  arts ,  be¬ 
cause  I  desired — on  the  one  hand,  to  give  you 
a  clear  notion  of  the  relation  between  science 
and  art,  and  also  to  show  you  how  necessa¬ 
rily  the  certainty  of  the  rules  of  an  art  de¬ 
pends  upon  the  perfection  of  the  science 
upon  which  it  is  founded.  Thus,  if  there 
were  anything  wanting  to  the  completeness 
of  the  lunar  theory  ” — if  the  various  in¬ 
equalities  and  irregularities  of  the  moon’s 


*  This  method  is  quite  independent  of  chrono¬ 
meters,  since  it  furnishes  in  itself  a  means  of 
ascertaining  “  Greenwich  time,”  and  thus  of 
making  that  comparison  between  it  and  the  time 
of  the  observer’s  place,  by  which  his  longitude  is 
determined.  But  as  it  is  somewhat  difficult  to 
make  lunar  observations  at  sea  with  the  requisite 
precision,  and  as  the  computations  are  rather 
tedious,  they  are  chiefly  employed  as  an  occa¬ 
sional  check  upon  the  chronometers,  by  whose 
indications  the  navigator  ordinarily  works. 


motion  were  not  exactly  accounted  for  and 
referred  to  definite  causes — the  prediction 
would  lose  all  its  security,  and  would  be  re¬ 
duced  to  that  vague  probability  which  at¬ 
tends  the  prediction  of  the  return  of  comets , 
whose  movements  we  have  comparatively 
little  opportunity  of  observing,  and  the  ex¬ 
cessive  tenuity  of  whose  substance  renders 
them  liable  to  be  turned  aside  by  forces  so 
slight  as  not  to  produce  the  least  perceptible 
effect  upon  the  solid  masses  of  our  system. 

But  I  cannot  quit  this  subject  without 
drawing  your  attention  to  one  other  illustra¬ 
tion  of  the  wonderful  perfection  of  the  theo¬ 
retical  part  or  science  of  astronomy,  which 
must  be  fresh  in  the  minds  of  all  of  you — I 
refer,  of  course,  to  the  prediction,  not  merely 
of  the  existence,  but  of  the  probable  place, 
size,  and  distance  from  the  sun,  of  an  addi¬ 
tional  planet ;  founded  upon  calculations  of 
the  most  refined  and  abstruse  character,  as 
to  the  source  of  certain  irregularities  which 
had  been  observed  through  a  long  course  of 
years  in  the  movements  of  a  planet  that  was 
previously  considered  as  the  remotest  of  the 
mighty  orbs  that  circle  round  our  sun — ir¬ 
regularities  which  it  seemed  impossible  to 
account  for  on  any  other  supposition,  but 
for  which  the  action  of  an  additional  mass 
beyond  furnished  a  probable,  definite,  and 
therefore  satisfactory  explanation. 

Turn  we  now  to  our  own  department  of 
inquiry,  and  apply  to  it  the  definitions  I 
have  cited.  We  shall  find,  then,  that  medi¬ 
cal  science  embraces  all  that  is,  that  happens, 
in  the  human  body,  in  the  state  of  health  or 
disease.  On  the  other  hand,  the  healing 
art ,  as  exercised  by  the  physician  or  sur¬ 
geon,  consists  of  a  series  of  rules  which  may 
be  expressed  under  the  general  terms,  do 
this ,  avoid  that -  That  these  rules  are  far 
from  having  the  perfection  which  we  should 
desire — that  they  are  too  frequently  neither 
definite  in  their  nature  nor  certain  in  their 
results — is  a  truth  which  is  too  soon  forced 
upon  the  practitioner.  However  successful 
he  may  be  in  the  treatment  of  certain  classes 
of  disease  whose  nature  is  apparent  to  him, 
whose  causes  can  be  determined  with  exact¬ 
ness,  and  for  which  he  has  efficient  remedies 
which  rarely,  if  ever,  fail  in  their  operation, 
he  finds  that  the  larger  proportion  are  less 
clear  in  their  manifestations — that  their  causes 
are  more  obscure — the  indications  for  treat¬ 
ment  less  obvious — and  that  the  beneficial 
effect  of  his  remedies  is  uncertain.  To  many 
minds  this  state  of  things  is  not  a  little  dis¬ 
couraging.  I  shall  endeavour  to  show  you 
why  it  should  not  be  so  regarded.  We  can¬ 
not  but  lament  it.  We  cannot  but  desire, 
for  the  welfare  of  our  patients,  and  for  our 
own  satisfaction,  that  the  rules  of  our  art 
were  more  certain,  so  that  we  could  reckon 
more  surely  on  the  beneficial  result  of  our 
interference.  But,  on  the  other  hand,  if  we 


AND  THE  SPIRIT  IN  WHICH  THEY  SHOULD  BE  PURSUED. 


663 


take  a  careful  survey  of  the  present  condi¬ 
tion  of  the  science  on  which  it  is  based,  we 
shall  find  much — very  much — to  encourage 
us  in  the  belief  that  it  is  rapidly  advancing 
towards  this  wished- for  consummation.  And 
we  have  the  additional  satisfaction  of  feeling 
that  each  and  all  of  us  may  do  something  to 
bring  this  about.  The  success  of  our  la¬ 
bours,  however,  must  depend  in  a  great  de¬ 
gree  upon  the  nature  of  the  aim  which  we 
propose  to  ourselves,  and  the  steadiness 
with  which  we  pursue  it.  We  may  strive 
after  something  entirely  beyond  our  reach, 
and  encounter  much  toil  and  anxiety  with 
no  good  result.  We  may  see  our  purpose 
faintly  looming,  as  it  were,  through  an  inde¬ 
finite  mist,  and  may  waste  much  time  in 
gaining  a  distinct  view  of  its  real  direction. 
And  even  when  we  have  an  object  that  we 
can  clearly  discern,  and  that  we  feel  to  be 
within  our  apprehension,  we  may  be  led 
astray  from  it  by  attractions  which  may 
present  themselves  in  our  course — by  the 
desire  of  following  out  some  unprofitable, 
but  ingenious  speculation — the  temptation 
of  some  glittering  prize  that  we  seem  able  to 
reach  by  a  slight  deviation  from  our  onward 
course. 

I  propose,  then,  to  set  before  you  a  few 
considerations  as  to  the  chief  objects  which 
present  themselves  for  your  attainment ; 
such  as  may  tend  to  give  you  a  clearer  con¬ 
ception  of  their  nature,  and  greater  steadi¬ 
ness  of  purpose  in  the  pursuit  of  them. 
And  I  would  offer,  as  your  guiding  thread 
in  the  whole  inquiry,  this  general  principle — 
that  the  advancement  of  the  healing  art 
must  mainly  depend  upon  the  elevation  of 
medical  science.  In  other  words,  you  must 
know  what  is  and  what  happens  in  the  hu¬ 
man  body — still  more,  you  must  be  able  to 
predict  what  will  he,  what  will  happen — be¬ 
fore  the  rules,  do  this ,  avoid  that,  in  which 
the  healing  art  consists,  can  have  the  de¬ 
sired  definiteness  and  certainty. 

The  first  step  towards  this  knowledge  is 
an  acquaintance  with  the  anatomy  of  the 
body.  It  is  obvious  that  we  must  know  its 
structure,  before  we  can  understand  the 
changes  in  which  its  life  consists  ;  we  must 
be  fully  acquainted  with  its  condition  in 
health,  before  we  can  appreciate  the  altera¬ 
tions  which  disease  may  have  induced  in  it. 
But  whilst  it  is  right  that  the  student  should 
aim  at  obtaining  the  fullest  and  most  com¬ 
plete  knowledge  of  this  subject  that  it  is  in 
his  power  to  acquire,  there  are  certain  ob¬ 
jects  which  should  be  more  especially  kept 
in  si-ht,  with  a  view  to  the  most  profitable 
employment  of  the  facts  and  principles  of 
the  science.  On  the  one  hand,  you  should 
study  it  in  its  relation  to  Physiology ;  that 
is,  you  should  investigate  the  structure  of 
the  body  with  reference  to  the  normal  ac¬ 
tions  of  which  each  part  is  the  instrument ; 


without  the  knowledge  of  which  the  living 
body  is  to  you  nothing  else  than  a  mass  of 
inert  matter.  And  again,  you  must  study  it 
in  reference  to  Pathology  ;  that  is,  you  must 
make  yourselves  acquainted  with  the  liabili¬ 
ties  to  change  of  structure  and  to  perversion 
of  function  which  each  part  may  manifest  as 
the  result  of  disease  or  injury;  in  other 
words,  you  must  study  its  abnormal  or  mor¬ 
bid  phenomena.  In  this  manner  you  lay  a 
foundation  on  which  all  truly  scientific  no¬ 
tions  of  disease  (or  departure  from  normal 
action,  by  whatever  cause  induced)  must  be 
based.  But,  in  addition,  you  have  much  to 
learn  from  Anatomy  in  your  application  of 
the  rules  of  the  therapeutic  art.  You  will 
be  continually  baffled  in  your  attempts  at 
detecting  the  internal  causes  of  the  symp¬ 
toms  which  are  presented  to  your  observa¬ 
tion,  and  in  devising  remedies  for  these,  if 
you  have  not  a  clear  conception  of  the  posi¬ 
tion,  structure,  and  connections  of  all  the 
most  important  organs  of  the  body :  and  in 
the  performance  of  surgical  operations  of. 
every  class,  I  need  not  assure  you  of  the 
fundamental  importance  of  a  like  clear  con¬ 
ception  of  the  local  arrangement  of  even  the 
minuter  parts,  in  every  region  on  which  the 
interference  of  the  skilful  hand,  guided  by 
the  judgment  of  the  sagacious  head,  can  be 
advantageously  brought  to  bear. 

There  is  one  department  of  anatomy  which 
has  risen  into  increased  importance  within 
the  last  few  years,  and  which  is  now  univer¬ 
sally  recognised  as  forming  an  essential  part 
of  the  medical  education, — I  mean  General 
Anatomy,  or  the  minute  structure  and  com-- 
position  of  the  several  tissues  of  which  the. 
body  is  made  up.  This  has  most  important 
bearings  both  on  physiology  and  pathology. 
For  it  is  now  felt  that  our  fundamental  ideas, 
of  healthy  vital  action  must  rest  on  the 
knowledge  of  the  powers  and  capacities  of 
the  minutest  parts  of  the  fabric  ;  whilst,  in 
like  manner,  our  fundamental  notions  of  the 
changes  in  which  disease  essentially  consists 
are  coming  to  rest  more  and  more  upon  the 
knowdedge  of  the  perversions  which  the  ac¬ 
tions  of  these  undergo,  and  of  the  minute 
alterations  of  structure  which  hence  arise-s 
This  is  the  department  of  anatomy  which  is 
in  a  state  of  most  rapid  progress,  and  in 
which  the  greatest  opportunities  present 
themselves  for  making  additions  to  the  stock 
of  information  already  attained.  What  may' 
be  called  the  naked-eye  anatomy  of  the 
body  has  long  since  been  ascertained  with  a. 
completeness  which  leaves  very  little  to  de¬ 
sire.  But  in  all  that  relates  to  the  minute 
structure  and  connections  of  different  organs, 
there  are  wide  gaps  to  be  filled  up,  present¬ 
ing  attractive  objects  of  research  to  all  who 
may  feel  inclined  to  devote  themselves  to  the 
pursuit. 

And  now,  in  passing  on  to  Physiology,  I 


664 


DR.  CARPENTER  ON  THE  OBJECTS  OF  MEDICAL  STUDY, 


trust  that  I  shall  not  be  thought  to  magnify 
the  importance  of  my  own  department  of 
study,  if  I  urge  upon  you  reasons  for  giving 
it  more  special  attention  than  the  great  bulk 
of  medical  students  are  in  the  habit  of  be¬ 
stowing  upon  it.  To  say  that  it  is  impossi¬ 
ble  to  understand  the  diseased  operations  of 
our  system — impossible  to  apply  remedies 
with  anything  like  probable  success — impos¬ 
sible,  therefore,  to  exercise  the  healing  art  as 
it  ought  to  be  practised,  unless  we  are  ac¬ 
quainted  with  all  that  is  known  of  its  normal 
or  healthy  action — might  seem  a  truism  ;  and 
yet,  however  self-evident  the  truth  of  the 
assertion,  it  is  very  far  from  having  the 
weight  which  it  ought  to  possess.  The  phe¬ 
nomena  of  disease  have  been  too  much  iso¬ 
lated  in  idea  from  those  of  health,  and  have 
been  improperly  detached  as  objects  of  pro¬ 
fessional  study  from  the  changes  which  are 
continually  going  on  in  the  organism.  It 
has  been  too  much  lost  light  of,  that  every 
diseased  action  is  but  a  perversion,  by  ex¬ 
cess,  by  diminution ,  or  by  depravation ,  of 
some  natural  function ;  and  that  only 
through  an  acquaintance  with  the  latter  can 
the  former  be  understood,  either  as  to  its 
cause,  its  nature,  or  its  tendencies.  True  it 
is,  that  a  large  proportion  of  the  existing 
rules  of  the  therapeutic  art  have  no  definite 
physiological  foundation  :  in  other  words,  a 
great  deal  of  medical  and  surgical  treatment 
is  directed  on  no  other  foundation  than  that 
of  a  limited  experience.  Such  and  such  a 
method,  it  is  said,  will  probably  be  success¬ 
ful,  because  it  has  been  successful  in  cases 
that  appeared  similar ;  but  why  it  should 
succeed,  or  why  it  should  fail — what,  there¬ 
fore,  will  be  the  probability  of  success  or 
failure  in  new  cases — we  do  not  know,  and 
cannot  tell.  Now,  this  is  just  the  depart¬ 
ment  of  the  healing  art  which  all  feel  to  be 
most  unsatisfactory.  It  is  where  no  ra¬ 
tionale  of  treatment  can  be  given,  that  there 
has  been  the  least  connection  established 
between  the  phenomena  of  diseased  and 
those  of  healthy  action.  On  the  other  hand, 
it  is  where  this  connection  has  been  deve¬ 
loped — where  we  best  understand  the  nature 
and  causes  of  the  deviations  from  the  normal 
standard — that  we  can  most  definitely  mark 
out  the  ratio  medendi ,  and  can  most  confi¬ 
dently  predict  the  results  of  our  treatment. 

Now,  it  is  in  the  establishment  of  this  re¬ 
lation  between  the  healthy  and  morbid  con¬ 
ditions  of  the  system ,  and  in  the  detection  of 
those  first  departures  from  the  normal 
actions  which  frequently  constitute  the  es¬ 
sence  of  disease,  that  medical  science  is  at 
present  advancing.  And  I  do  not  hesitate 
to  affirm  that  this  progress  is  mainly  due  to 
the  more  clear  and  definite  aspect  under 
which  Physiological  Science  has  of  late  been 
presented,  through  the  combined  researches 
of  the  microscopist  and  the  chemist.  For 


whilst  the  one  has  been  devoting  himself  to 
the  patient  scrutiny  of  all  the  changes  which 
are  discernible  to  the  eye,  assisted  by  that 
wonderful  instrument  which  now  renders 
even  the  minutest  elements  of  the  bodily 
frame  clearly  discernible  in  all  their  parts 
and  actions,  the  other  traces  all  the  changes 
in  composition  which  the  materials  of  the 
fabric  undergo,  from  the  time  when  they  are 
first  received  into  it  as  food,  until  the  period 
of  their  expulsion  from  it  as  products  of 
death  and  decay.  He  seeks  to  know  all  the 
transformations  to  which  these  materials  are 
subjected,  the  uses  to  which  they  are  severally 
rendered  subservient,  the  circumstances 
which  govern  one  or  another  application  of 
them  ;  and  thus  to  be  able  to  give  a  definite 
account  of  the  chemical  actions  of  each  par¬ 
ticle  from  the  time  of  its  entering  the  body 
until  that  of  its  quitting  it,  which  shall  serve 
as  the  complement  to  that  which  the  micro¬ 
scopist  draws  from  his  observations  as  to  the 
visible  form,  structure,  and  operations  of  the 
tissues  into  whose  composition  it  enters. 

And  thus  we  are  led  to  view  the  construc¬ 
tive  part  of  the  living  system  under  two 
aspects,  dissimilar,  yet  harmonious ; — as  a 
manufactory  in  which  certain  materials  are 
worked  up  into  a  variety  of  forms,  each 
fabric  having  properties  of  its  own  ;  and  as 
a  laboratory  wherein  the  materials  themselves 
are  subjected  to  changes  of  composition,  by 
which  a  far  greater  variety  of  textures  may  be 
generated — a  far  greater  variety  of  forms  and 
properties  evolved.  Any  hindrance  or  per¬ 
version  of  either  process  will  mar  the  result ; 
that  result  being  the  development  and  main¬ 
tenance  of  the  perfect  organized  fabric,  en¬ 
dowed  with  those  wonderful  properties  which, 
(being  peculiar  to  living  beings)  we  denomi¬ 
nate  vital,  and  possessing  within  itself  the 
means  of  continual  renovation,  provided  the 
requisite  materials  be  supplied. 

But  there  are  not  merely  constructive 
agencies  at  work  in  the  living  body ;  it  is 
continually  liable  to  destructive  influences  ; 
and  these  arise  out  of  the  very  nature  of  its 
constitution.  It  is  a  great  mistake  to  suppose 
that  a  living  tissue  has,  simply  in  virtue  of 
its  life,  the  power  of  resisting  death  and  de¬ 
cay.  The  body  is  in  a  state  of  continual 
decomposition,  more  rapid  in  proportion  to 
the  activity  and  energy  of  the  exercise  of  its 
animal  functions ;  and  one  most  important 
class  of  its  operations  consists  of  the  means 
by  which  the  products  of  this  decay  are  eli¬ 
minated  from  the  system — namely,  the 
excretory  functions.  It  has  been  well  re¬ 
marked,  that  the  uninterrupted  exercise  of 
these  is  even  more  important  to  health  than 
the  uninterrupted  performance  of  the  con¬ 
structive  operations.  We  may  have  our 
supply  of  nutriment  suspended  for  a  time 
without  any  serious  injury ;  but  if  the  eli¬ 
mination  of  the  excretions  be  checked,  their 


AND  THE  SPIRIT  IN  WHICH  THEY  SHOULD  BE  PURSUED.  665  , 

'  -- . -  "  ■"  •"  - ; - ...  .  '  :  f  ] 


materials  speedily  accumulate  in  the  blood, 
and  act  as  the  most  deadly  poisons.  Fur¬ 
ther,  these  excretory  functions  serve  not 
merely  for  the  removal  of  the  poisons  which 
are  continually  being  generated  within  the 
healthy  system,  but  they  tend  also  to  draw 
off  those  which  are  abnormally  present;  whe¬ 
ther  these  have  been  altogether  introduced  from 
without,  as  in  cases  of  poisoning  by  opium, 
arsenic,  &c. ;  whether  they  have  been  intro¬ 
duced  from  without  in  the  first  instance,  and 
then  augmented  within  the  body  by  an  action 
resembling  fermentation,  as  seems  to  be  the 
case  in  regard  to  the  poison  of  fevers  of 
various  kinds ;  or  whether  they  have  been 
altogether  generated  within  the  system,  by  a 
perversion  of  the  ordinary  nutritive  opera¬ 
tions,  as  seems  to  be  the  case  with  the 
materies  morbi  of  gout  and  rheumatism. 

Now,  it  is  in  the  application  of  these  and 
other  such  general  principles  to  Surgery  and 
Medicine,  that  we  may  look  for  the  greatest 
improvement  in  the  healing  art.  The  sur¬ 
geon  is  mainly  concerned  with  the  construc¬ 
tive  operations.  It  is  his  business  to  repair 
the  breaches  occasioned  by  disease  or  injury  ; 
or  rather,  I  should  say,  to  place  Nature  in 
the  most  favourable  circumstances  for  re¬ 
pairing  them.  Although  it  may  seem  at 
first  sight  derogatory  to  the  dignity  of  the 
surgeon's  art  to  say  that  he  does  little  else 
than  this,  yet  I  believe  that  all  who  have 
well  considered  the  matter  will  agree  with 
me.  What  does  he  do  in  the  treatment  of 
fracture  but  bring  the  broken  bones  into 
apposition?  It  is  not  'he  that  forms  the 
callus.  All  that  he  can  do  is  to  take  care 
that  the  callus  shall  unite  the  disjoined  pieces. 
If  Nature  will  not  make  the  callus,  he  cannot 
doit.  He  may  give  her  a  little  stimulus  if 
she  be  inert,  and  may  sometimes  succeed  in 
getting  the  work  done,  where  it  would  not  be 
done  but  for  his  interference  ;  but  if  Nature 
perseveres  in  the  refusal,  he  cannot  do  it  in 
her  stead.  In  the  reduction  of  a  dislocation, 
his  share  in  the  cure  is  greater  ;  Nature  could 
not  have  done  it  without  him  ;  but  he  cannot 
here  do  without  Nature.  Who  repairs  the 
ruptured  ligaments,  the  torn  muscles,  the 
lacerated  capsules  ?  certainly  not  the  sur¬ 
geon,  but  Nature  again.  If  a  dislocation 
be  not  reduced,  Nature  often  makes  a  fresh 
joint;  the  surgeon  could  not  have  accom¬ 
plished  this  with  all  his  skill.  A  man  re¬ 
ceives  a  tremendous  wound  ;  a  clean  breach 
is  made  through  his  body.*  Who  repairs 


*  **  Captain  (now  General)  Macdonald,  of  the 
Royal  Artillery,  was  present  at  Buenos  Ayres, 
when  a  bombardier  of  that  corps  received  a  wound, 
from  a  two-pound  shot,  which  went  completely 
through  the  right  side,  so  thait  when  led  up  to  the 
General,  who  was  lying  on  the  ground,  he  saw 
the  light  quite  through  him,  and  supposed  he  was 
of  course  lost.  This,  however,  did  not  follow, 
and  some  months  afterwards  the  man  walked  in¬ 
to  Captain  Macdonald’s  room  so  far  recovered 


this  ?  clearly  not  the  surgeon.  All  he  can 
do  is  to  stand  by  and  watch ;  to  support  the 
strength  of  the  patient,  and  to  lower  inflam¬ 
matory  action  if  it  should  supervene  ;  in 
other  words,  to  give  nature  the  means  of 
reconstruction,  and  to  prevent  her  from  over- 
doing  the  work.  And  in  those  very  nice 
and  intricate  questions,  in  which  the  skill 
and  judgment  of  the  surgeon  are  shown  to 
the  greatest  advantage,  relating  to  the  con¬ 
servation  of  parts  that  have  undergone  in¬ 
juries  so  severe  as  to  render  it  questionable 
whether  the  safety  of  the  patient  does  not 
require  their  removal,  what  is  the  real  ques¬ 
tion  which  the  surgeon  has  to  decide  ?  It  is 
simply  this,  whether  the  probabilityis  greater 
that  nature  will  succeed  in  working  a  satis¬ 
factory  cure  ;  or  whether  the  risk  is  greater 
that,  by  failing  to  do  so,  the  patient’s  life 
will  be  endangered  by  the  constitutional 
disturbance  which  a  perversion  of  the  restora¬ 
tive  powers  may  excite.  The  question  is 
not,  whether  Nature  or  the  surgeon  will  ac¬ 
complish  the  work  better ;  but  whether  ■  ’ 
Nature  can  be  safely  left  to  herself ;  or  whe¬ 
ther  the  surgeon  had  better,  by  cutting  off 
the  injured  part,  make  shorter  and  more 
certain  work  of  the  process  of  cure,  at  the 
expense  of  a  maim  for  life.  ^  ..vo 

Thus  you  see  that  in  the  practice  of  Sur¬ 
gery,  a  full  appreciation  of  the  reparative  and 
preservative  powers  of  the  body  lies  at  the 
foundation  of  all  scientific  rules  of  treatment. 
The  knowledge  of  these  is  not  less  important 
in  medicine  ;  but  in  the  latter  we  have  also  ’ 
to  give  special  attention  to  the  destructive 
operations  constantly  going  on  in  the  sys¬ 
tem,  to  the  various  results  of  the  changes 
which  they  involve,  to  the  irregularities  to 
which  they  are  subject,  and  to  the  means  by 
which  these  may  best  be  counteracted.  In 
fact,  it  is  essential  to  the  perfection  of  me¬ 
dicine  as  a  science,  and  consequently  to  the 
most  successful  application  of  its  teachings 
to  the  art  of  healing,  that  we  should  have  a 
clear  conception  of  the  nature  of  every  one  ■ 
of  the  processes  by  which  the  body  is  built 
up  and  maintained  in  health  and  activity, 
and  of  all  the  perversions  which  each  of 
these  may  undergo,  whether  from  the  mor¬ 
bific  influence  of  external  agents,  or  from  ' 
causes  inherent  in  the  system  itself,  ^  i 

Thus  we  have  certain  classes  of  diseases  >  ’ 
which  are  dependent  upon  the  faulty  cha-  b 
racter  of  the  food  ;  the  excess  or  deficiency 
of  certain  of  its  proper  constituents  ;  or  the 
presence  of  substances  of  a  positively  inju-  -<•> 
rious  nature.  Then,  again,  we  have  other 
diseases  that  are  dependent  upon  some  im¬ 
perfection  in  the  processes,  by  which  even 
good  and  wholesome  food  is  prepared  for  the 

from  the  injury  that  he  was  able  to  undertake 
several  part's  of  his  duty  before  he  was  invalided.” 
—Guthrie’s  Lectures  on  Wounds  and  Injuries  of 
the  Chest,  p.  82. 


666  DR.  CARPENTER  ON  THE  OBJECTS  OF  MEDICAL  STUDY, 


nutritive  operations  by  conversion  into  the 
elements  of  blood.  There  can  be  no  ques¬ 
tion  that  many  disorders  of  nutrition  are  due 
to  causes  of  this  nature  ;  defects  in  the  'pri¬ 
mary  assimilating  and  elementary  organiz¬ 
ing  operations  by  which  the  circulating 
fluid  is  elaborated,  being  the  source  of  such 
departures  from  the  proper  proportions  of 
the  normal  ingredients,  and  of  such  a  depra¬ 
vation  in  the  quality  of  those  ingredients,  as 
may  give  rise  to  numerous  diseases,  which 
have  been  too  frequently  regarded  as  ori¬ 
ginating  in  a  perversion  of  the  normal  actions 
of  the  solid  tissues. 

But  even  supposing  that  the  blood  has 
been  most  completely  elaborated,  the  act  of 
nutrition  is  itself  liable  to  perversion,  arising 
from  the  abnormal  condition  of  the  solid 
tissues,  which  are,  equally  with  the  blood, 
participant  in  the  operation  ;  and  I  am  in¬ 
clined  to  believe  that  in  that  great  and  most 
important  class  of  diseases  ranked  under  the 
general  term  inflammation,  it  is  in  a  depressed 
functional  activity  of  the  solids  that  the 
disordered  condition  really  commences,  the 
changes  in  the  movement  and  constitution  of 
the  blood  being  secondary  to  this.*  At  any 
rate,  it  is  now  universally  admitted  by  sci-  I 
entific  pathologists,  that  inflammation  is  not 
a  distinct  and  independent  action,  superin¬ 
duced  upon  or  replacing  the  normal  opera¬ 
tions  of  nutrition ;  but  that  it  is  neither  more 
nor  less  than  a  perverted  condition  of  these. 
To  this  category,  again,  we  must  refer  those 
various  abnormal  growths,  which  are  not,  like 
tubercle,  the  result  of  the  imperfect  elabora¬ 
tion  of  the  organizable  materials  of  the  blood, 
hut  which  are  comparatively  high  in  their 
organization;  being  either,  like  fatty  tumors, 
composed  of  tissues  resembling  in  structure, 
composition,  and  mode  of  growth,  those 
which  are  normally  present  in  the  body ;  or 
else  being  made  up  of  forms  of  tissue  peculiar 
to  themselves,  and  leaving  in  many  in¬ 
stances  that  power  of  rapid  growth, 
appropriating  all  nutriment  to  themselves, 
and  destroying  everything  in  their  neigh¬ 
bourhood,  from  which  they  derive  their 
title  of  malignant.  I  cannot  see  any 
reason  for  regarding  these  disorders  as  having 
their  primary  seat  in  the  blood ;  although 
the  circulating  fluid  doubtless  becomes  se¬ 
condarily  affected  by  them. 

But  a  most  fertile  source  of  disease  is  to 
be  found  in  a  perversion  of  those  regular 
operations,  by  which  the  results  of  the  con¬ 
tinual  waste  or  disintegration  of  the  system 
are  eliminated  from  it.  If  this  process  go 
on  with  due  regularity,  those  debris  are 
carried  off  as  fast  as  they  are  formed,  having 
a  tendency  to  pass  into  new  combinations, 
for  the  removal  of  each  of  which  an  appro¬ 

*  See  British  and  Foreign  Medical  Review, 
VOl.  xviii.,  p.  91,  et  seq. 


priate  organ  is  provided.  Bnt  these  organs 
may  not  perform  their  normal  functions  ; 
and  thus  the  normal  products  may  accumu¬ 
late  in  the  blood,  and  may  act  as  poisons  of 
greater  or  less  virulence.  Or,  again,  from 
some  disorder  of  the  preliminary  actions,  or 
from  a  perversion  of  the  destructive  opera¬ 
tions  themselves,  an  abnormal  set  of  products 
may  be  formed,  giving  rise  to  a  series  of 
disorders  altogether  distinct  from  those 
which  I  have  just  named. 

It  is  not  only  our  business  to  ascertain 
the  existence  of  these  disorders,  but  also  to 
seek  for  remedies  for  them.  As  our  know¬ 
ledge  advances  of  the  real  nature  of  the 
morbid  operations  which  constitute  disease, 
so  does  our  acquaintance  improve  with  the 
power  of  remedies  in  modifying  them  and  in 
restoring  the  normal  condition.  And  I 
cannot  give  you  a  better  illustration  of  the 
increasing  precision  of  our  knowledge  on  this 
subject,  than  is  afforded  by  the  recent  an¬ 
nouncement  of  Dr.  Golding  Bird,  that, 
w’hilst  the  ordinary  diuretics  (squill,  digitalis, 
turpentine,  and  colchicum)  increase  the  dis¬ 
charge  of  water  without  augmenting  the  solid 
contents  of  the  urinary  excretion,  there  are 
certain  chemical  diuretics,  of  which  potass 
in  combination  with  vegetable  acids  seems  to 
be  (as  theory  would  predict)  the  most  effica¬ 
cious,  whose  agency  is  apparent  in  a  great 
increase  of  its  solid  matter,  especially  in 
thatmixture usually  setdown  as  “extractive,” 
and  which  promise,  therefore,  to  be  of  great 
efficiency  in  removing  effete  or  imperfectly 
organized  matter  from  the  system. 

I  have  thus  endeavoured  to  present  you 
with  a  glimpse  of  the  aspect  under  which 
medical  science  and  art  are  now  viewed  by 
intelligent  and  thoughtful  men,  who  look  to 
the  future  as  well  as  to  the  present,  and  who 
study  the  past  history  of  medicine  for  the 
hints  it  may  afford  as  to  the  means  and  op¬ 
portunities  of  onward  progress.  Now  it  is 
to  the  rising  generation  that  we  must  chiefly 
look  as  the  instruments  of  that  progress.  All 
experience  shows  that  the  younger  members 
of  our  profession  are  those  by  whom  scientific 
improvements  are  most  readily  carried  into 
practical  application  ;  by  whom  investiga¬ 
tions  for  the  discovery  of  new  truths  are  pro¬ 
secuted  with  most  zeal  ;  by  whom  errors  of 
doctrine  and  practice  are  most  quickly  de¬ 
tected  and  most  unreservedly  abandoned  ; 
by  whom,  in  a  word,  the  greatest  mental 
activity  is  displayed.  There  are  many  rea¬ 
sons  for  this.  As  age  advances,  the  habits 
of  thought  become  settled  ;  the  mind  tends 
to  move  in  the  beaten  track  ;  there  is  a  less 
eager  desire  for  professional  distinction  ;  and 
the  indisposition  to  new  acquirement  often 
induces  the  settled  belief  that  there  is  nothing 
new  worth  acquiring.  I  do  not  say  that  the 
superior  activity  of  the  youthful  aspirant  is 


AND  THE  SPIRIT  IN  WHICH  THEY  SHOULD  BE  PURSUED. 


667 


an  unmixed  good  ;  or  that  the  passive  con¬ 
servatism  of  his  less  mobile  senior  constitutes 
an  unmingled  evil.  Either  would  be  preju¬ 
dicial  if  it  existed  alone.  Without  such  a 
body  of  sober  experience  as  is  to  be  found 
amongst  men  of  mature  age  and  extensive 
opportunities  of  observation,  there  would  be 
little  of  permanence  in  medicine;  the  younger 
portion  of  our  community  would  be  carried 
about  by  every  wind  of  doctrine ;  every 
new  system  that  presented  a  fair  appearance 
would  enlist  a  band  of  enthusiastic  followers  ; 
and  exploded  errors  would  be  abandoned, 
only  to  be  replaced  by  a  new  set  of  fallacies, 
worse  perhaps  than  those  which  they  suc¬ 
ceeded.  On  the  other  hand,  if  it  were  not 
for  the  activity  of  our  younger  members, 
there  would  be  a  serious  danger  lest  cautious 
conservatism  should  lapse  into  utter  stagna¬ 
tion,  and  progress  become  a  dead  letter.  For 
although  it  is  not  by  the  young  alone  that 
discoveries  are  made,  that  the  search  for 
truth  is  diligently  carried  on,  that  error  is 
detected,  and  that  the  truths  of  science  are 
made  available  in  art,  yet  a  careful  survey  of 
the  past  history  and  present  state  of  the  pro¬ 
fession  can  leave  no  doubt  that  it  is  mainly 
through  them  that  improvements  in  know¬ 
ledge  or  practice  become  part  of  what  may 
be  termed  the  stock  in  trade  of  the  profession 
at  large. 

It  is  impossible,  then,  to  overrate  the  im¬ 
portance  of  the  acquirement  of  a  right  spirit 
on  the  part  of  those  who  are  entering  upon 
their  professional  career ;  for  upon  the 
spirit  with  which  they  set  out  will  they  gene¬ 
rally  proceed  ;  and  upon  their  future  course 
will  depend,  not  merely  their  own  worldly 
success,  but  the  welfare  of  the  entire  body 
of  which  they  are  members,  the  progress  of 
medical  science,  and  the  improvement  of  our 
benificent  art.  What,  then,  is  this  right 
spirit,  which  I  would  endeavour  to  impress 
upon  you  ?  I  cannot  better  explain  my  mean¬ 
ing  than  by  drawing  your  attention  to  the 
striking  parallel  instituted  by  the  immortal 
Schiller,  in  an  introductory  lecture  delivered 
at  the  University  of  Jena,  nearly  sixty  years 
ago,  between  the  “  trader  in  science,"  and 
the  “  philosopher"  or  “  lover  of  wisdom." 

“The  plan  of  study,'1  he  remarks, 
“  which  the  trader  in  science  proposes  to 
himself  is  one  thing  ;  that  of  the  philosopher 
is  another,  and  far  different.  The  former 
keeps  in  view  from  the  commencement  of 
his  academical  career  little  else  than  the  ac¬ 
quirement  of  such  knowledge  as  he  has  the 
prospect  of  rendering  directly  profitable  to 
himself ;  he  sets  the  powers  of  his  mind  in 
activity,  chiefly  or  solely  for  the  improve¬ 
ment  of  his  worldly  position ;  and  to  this 
object  is  his  ambition  limited.  Having 
stored  his  memory  with  a  certain  amount  of 
professional  lore,  he  goes  forth  into  the 
world  to  bring  it  into  practical  use ;  and  ere 


long  the  result  of  the  mental  habits  which 
he  has  cherished  begins  to  display  itself. 
Every  extension  of  the  boundaries  of  the 
science  by  which  he  earns  his  bread  is  re¬ 
garded  by  him  with  anxiety,  since  it  occa¬ 
sions  him  fresh  labour,  or  renders  his  former 
labours  useless.  Every  important  innova¬ 
tion  or  discovery  alarms  him  ;  for  it  breaks 
down  those  old  school  formulae  which  he 
had  taken  so  much  pains  to  acquire  :  it  en¬ 
dangers  the  entire  produce  of  the  toil  and 
trouble  of  his  whole  previous  life.  There 
are  none  who  raise  so  loud  an  outcry  against 
reformers,  who  so  carefully  and  effectually 
obstruct  the  progress  of  useful  revolutions  in 
science,  as  those  who  view  it  merely  as  an 
instrument  for  gaining  their  daily  bread. 
The  less  their  acquirements  reward  them  in 
and  for  themselves,  the  more  do  they  look 
for  remuneration  from  others.  Not  in  the 
deep  and  hidden  treasures  of  his  own 
thoughts  does  such  a  man  seek  his  recompense : 
he  looks  for  it  in  external  applause,  in  pro¬ 
fessional  honours,  in  the  accumulation  of 
wealth.  Is  he  disappointed  of  these  ?  Who 
is  more  unhappy  than  the  man  who  has  cul¬ 
tivated  knowledge  with  no  higher  and 
purer  aim  ?  He  has  lived,  he  has  watched, 
he  has  toiled  in  vain  :  in  vain  has  he 
searched  for  truth,  if  he  cannot  barter  her  in 
exchange  for  gold,  for  public  applause,  or  for 
the  favour  of  the  great.  Pitiable  man,"  says 
Schiller,  “who,  with  the  noblest  of  all  in¬ 
struments,  science  and  art,  can  design  and 
can  execute  nothing  higher  than  the  artizan 
with  the  meanest;  who,  in  the  empire  of 
perfect  freedom,  bears  about  him  the  soul  of 
a  slave  1  But  still  more  pitiable  is  the 
young  man  of  genius,  whose  natural  disposi¬ 
tion  is  turned  aside  by  pernicious  doctrine 
and  example,  into  these  miserable  byways  ; 
and  who  has  suffered  himself  to  be  per¬ 
suaded  to  concentrate  his  whole  mental  force 
upon  this  merely  professional  perfection  ? 
He  will  soon  regard  his  professional  attain¬ 
ments  as  a  mere  piece  of  botchwork  ;  wishes 
will  arise  within  him  which  can  never  be 
satisfied ;  his  genius  will  rebel  against  his 
destination  ;  everything  he  does  now  appears 
to  him  fragmental ;  he  sees  no  aim  to  his 
labours  ;  and  yet  he  cannot  endure  their 
aimlessness.  The  irksome,  the  insignificant 
in  his  employment,  press  him  to  the  earth, 
because  he  cannot  oppose  to  them  that  high 
and  cheerful  courage  which  accompanies  only 
a  clear  view  of  a  lofty  standard  of  eminence, 
and  a  confident  anticipation  of  in  some 
degree  attaining  to  it.  So  soon  as  his 
faith  in  the  infallibility  of  his  acquire¬ 
ments  is  shaken  by  important  failures  he 
becomes  disgusted  with  his  pursuit,  and  is 
disposed  to  relinquish  it  as  altogether  value¬ 
less,  instead  of  striving  hopefully  after  a 
more  certain  and  comprehensive  knowledge. 

“  How  far  different  is  the  spirit  of  the  real 


DR.  CARPENTER  ON  THE  OBJECTS  OF  MEDICAL  STUDY, 


668 


philosopher!  Just  as  sedulously  as  the 
trader  in  knowledge  severs  his  own  peculiar 
department  from  all  others,  does  the  lover 
of  wisdom  strive  to  extend  its  dominion  and 
restore  its  connexion  with  them.  All  his 
efforts  are  directed  towards  the  perfecting  of 
his  knowledge  :  his  noble  impatience  cannot 
be  restrained  until  all  his  conceptions  have 
arranged  themselves  into  one  harmonious 
whole — till  he  can  take  his  stand  on  the  sum¬ 
mit  of  the  hill  of  science,  and  overlook  the 
whole  extent  of  his  domain  with  a  satisfied 
glance.  New  discoveries  in  the  field  of  his 
activity,  which  depress  the  trader  in  science, 
enrapture  the  philosopher.  Perhaps  they 
fill  a  chasm,  which  the  growth  of  his  ideas 
had  rendered  more  and  more  unseemly, — or 
they  place  the  last  stone,  the  only  one 
wanting  to  the  completion  of  the  structure  of 
his  ideas.  But  even  should  they  shiver  it  into 
ruins — should  a  new  series  of  ideas — a  new 
aspect  of  nature — a  newly-discovered  law  in 
the  physical  world,  overthrow  the  whole 
fabric  of  his  knowledge — he  has  always 
loved  truth  letter  than  his  system — and 
gladly  will  he  exchange  her  old  and  defective 
form  for  a  new  and  fairer  one.  And  even 
if  no  external  shock  should  disturb  his  men¬ 
tal  structure,  yet  is  he  compelled  by  an  ever- 
active  impulse  towards  improvement,  to  be 
the  first  to  pull  it  down,  and  to  separate  all 
its  parts  that  he  may  rebuild  it  anew  in  a 
more  perfect  form  and  order  ?  The  philoso¬ 
phical  mind  passes  on  through  new  forms  of 
thought,  constantly  heightening  in  beauty, 
to  perfect  consummate  excellence  ;  while  the 
mere  trader  in  knowledge  hoards  the  barren 
sameness  of  his  school  attainments  in  a  mind 
eternally  stationary. 

“  There  is  no  more  equitable  judge  of  the 
merits  of  others  than  the  true  philosopher. 
Acute  and  inventive  enough  to  take  advan¬ 
tage  of  every  kind  of  active  power,  he  is  also 
reasonable  enough  to  honour  the  author  of 
the  minutest  discovery.  For  him,  all  spirits 
labour ;  to  the  trader  in  knowledge  their 
toils  are  hostile  and  ruinous.  The  former 
knows  how  to  make  all  that  is  thought  or 
done  around  him  his  own  ;  an  intimate  com¬ 
munity  of  all  intellectual  possessions  prevails 
among  real  thinkers  ;  whatever  one  conquers 
in  the  empire  of  truth,  he  shares  with  all : — 
while  the  man  whose  only  estimate  of  wisdom 
is  profit,  grudges  his  contemporaries  the 
light  and  sun  that  illumines  them  ;  he  guards 
with  jealous  care  the  tottering  barriers  vhich 
feebly  defend  him  from  the  incursions  of 
victorious  truth  ;  and  for  whatever  he  un¬ 
dertakes  he  is  compelled  to  borrow  sti¬ 
mulus  and  encouragement  from  without. 
The  man  of  philosophic  spirit  finds  in  the 
very  objects  of  his  search,  and  even  in  the 
toils  of  the  pursuit,  excitement  and  reward. 
"With  how  much  more  ardour  can  he  set 
about  his  work,  how  much  more  lively  is 


his  zeal,  how  much  more  persevering  his 
courage  and  activity,  since  each  labour  starts 
in  all  the  freshness  of  youth  from  the  bosom 
of  its  predecessor !  The  small  acquires 
magnitude  under  his  creative  hand,  for  he 
keeps  the  great  steadily  in  his  eye,  and  all 
his  conceptions  are  tinctured  by  it;  while 
the  trader  in  knowledge  sees  only  the  details 
— the  small  even  in  the  greatest.  Not, 
what  is  his  pursuit,  but  how  he  handles 
what  he  pursues,  distinguishes  the  man  of 
philosophic  mind.  Wherever  he  takes  his 
station — whatever  is  the  field  of  his  activity 
— he  always  stands  in  the  centre  of  the 
whole ;  and,  however  widely  the  object  of 
his  pursuit  may  detach  him  from  his 
brethren,  he  is  near  and  allied  to  them  by  a 
mind  working  in  harmony  with  theirs.  He 
meets  them  on  that  point  where  all  bright 
spirits  find  each  other."* 

Such,  gentlemen,  are  the  sentiments  left 
to  us  by  one  of  the  master-minds  of  his  age, 
who  nobly  exemplified  in  his  own  life  the 
spirit  which  he  thus  inculcated  on  his 
followers.  I  need  not,  I  trust,  ask  you, 
which  of  the  two  characters  thus  depicted 
you  feel  to  be  most  worthy  of  imitation. 
None  but  the  mind  essentially  mean  and 
sordid  could  hesitate  in  the  choice,  when 
they  are  thus  presented  to  it  as  objects  of 
which  both  are  equally  within  its  grasp. 
“  But,"youmay  not  unreasonably  reply,  “  we 
are  to  be,  by  the  very  nature  of  our  position, 
‘  traders  in  knowledge  we  must  live  by  the 
profession  we  have  chosen  ;  we  must  now 
learn  that  which  we  may  apply  hereafter  to 
the  procuring  for  ourselves,  and  for  those 
dependant  on  us,  our  daily  bread."  I  freely 
admit  this :  but  the  fact  should  supply  a  still 
stronger  motive  for  the  culture  and  en¬ 
couragement  of  a  spirit  which  shall  prevent 
your  minds  from  being  debased  by  the  acci¬ 
dent  of  your  position.  If  you  must  be 
“  traders  in  knowledge,"  let  it  be  after  the 
fashion  of  the  enterprising  and  liberal  mer¬ 
chant,  ever  ready  to  take  advantage  of  new 
openings  for  his  operations,  willing  to  make 
temporary  sacrifices  for  the  prospect  of 
ulterior  benefit,  and  measuring  his  profits  by 
the  balance  of  the  sum  total,  instead  of  by 
individual  items  :  rather  than  in  the  manner 
of  the  petty  retail- shopkeeper,  who  depends 
for  his  success  upon  dealings  of  the  most 
limited  nature  —  who  estimates  the  im¬ 
portance  of  each  division  of  his  business 
solely  by  the  returns  which  it  brings  to  his 
counter — who  tries  to  make  inferior  goods 
answer  the  purpose  of  the  best  - —  and 
who  refuses  to  have  anything  to  do  with 
an  article,  however  useful  it  might  prove 
to  his  customers,  and  profitable  to  himself— 


*  Abridged  from  a  translation  in  the  New 
Monthly  Magazine,  vol.  xxix. 


AND  THE  SPIRIT  IN  WHICH  THEY  SHOULD  BE  PURSUED.  669 


if  it  had  been  introduced  by  a  rival.  The 
greater  the  tendency  of  your  occupation  to 
lower  your  standard,  the  more  you  should 
struggle  to  keep  an  elevated  aim  in  view.  If 
you  feel  tempted  to  confine  your  attention 
during  the  periods  of  your  pupillage  to  that 
alone  which  will  serve  your  purpose  as 
routine  practitioners,  you  should  consider 
well  whether  you  are  discharging  your  duty 
to  your  Creator,  to  humanity,  to  your  pro¬ 
fession,  to  yourselves,  in  thus  descending  to 
the  level  of  mere  ‘traders  in  knowledge.’ 
And  if  you  seriously  ponder  on  this  momen¬ 
tous  question,  and  honestly  act  up  to  the  re¬ 
solutions  which  I  trust  that  your  sober 
judgment  and  sense  of  right  will  lead  you  to 
form,  it  will  be  much  easier  than  you  may 
at  present  imagine  to  cherish  a  genuine 
philosophic  spirit,  even  when  you  are  im¬ 
mersed  in  the  cares  and  responsibilities  of 
practice, — a  spirit  which  shall  be  quick  to 
pursue  whatever  may  tend  to  the  advance¬ 
ment  of  medical  science  and  the  improve¬ 
ment  of  the  healing  art,  but  not  less  quick 
to  discern  the  bounds  that  limit  every  human 
inquiry, — a  spirit  that  shall  discriminate 
between  those  cases  of  disease  which  may  be 
treated  on  scientific  principles,  in  the  full 
confidence  that  no  other  plan  has  the  least 
claim  to  adoption,  from  those  which  must  be 
mainly  left  to  Nature,  or  in  which  a  rational 
empiricism  alone  must  be  the  guide, — a 
spirit  which  shall  know  how  to  distinguish 
what  is  just  in  itself,  from  what  is  merely 
accredited  by  illustrious  names, — a  spirit 
which  can  recognize  the  merits,  and  appre¬ 
ciate  the  discoveries  of  a  rival,  not  ‘  damning 
with  faint  praise,’  but  giving  a  hearty  tribute 
of  applause  to  whatever  is  worthy  of  admira¬ 
tion. 

Such,  gentlemen,  is  the  philosophic  spirit 
which  has  been  well  said  to  be  more  valuable 
than  any  limited  attainments  in  philosophy ; 
and  such  are  the  desires  with  which  all,  who  are 
engaged  in  the  momentous  duties  of  medical 
education,  must  strive,  if  they  be  faithful  to 
their  trust,  to  animate  their  pupils.  But 
their  fulfilment  must  rest  with  yourselves. 
There  cannot  be  a  greater  mistake  than  to 
suppose  that  for  the  formation  of  your  pro¬ 
fessional  characters  your  teachers  are  respon¬ 
sible.  The  very  best  instructions,  falling 
upon  a  barren  soil,  are  perfectly  fruitless. 
The  most  accomplished  lecturer  may  as 
well  discourse  to  empty  benches  as  to  the 
careless  inattentive  student.  The  sagacious 
physician,  the  dexterous  surgeon,  may  work 
any  number  of  miracles  of  science  before  the 
eyes  of  a  crowd  of  pupils  with  no  good  re¬ 
sult,  except  to  the  patient,  if  you  do  not 
strive  to  understand  the  rationale  of  their 
proceedings,  and  to  acquire  the  knowledge 
by  which  you  may  yourselves  be  equally 
successful.  On  the  other  hand,  the  earnest 
and  discriminating  student  is  comparatively 


little  dependent  upon  the  guidance  of  the 
teacher  under  whom  he  may  chance  to  be 
placed  ;  but  draws  from  the  dissecting-room, 
from  the  hospital  wards,  and  the  dead-house, 
and  from  the  works  of  the  masters  of  their 
respective  departments,  that  information 
which  the  inefficiency  of  the  lecturers  on 
whom  he  attends,  or  the  unskilfulness  of  the 
practitioners  whom  he  follows,  may.  fail  to 
afford  him.  In  almost  every  walk  of  life, 
the  knowledge  which  a  man  gains  by  his 
own  exertions  is  that  which  he  most  prizes, 
and  which  is  most  fruitful  in  all  good  re¬ 
sults  ;  and  in  no  case  is  this  more  evident 
than  in  our  own  profession.  Those  indivi¬ 
duals  in  whom  the  advantages  of  a  superior 
education  are  most  evident,  will  be  found  to 
have  derived  their  superiority,  not  from  the 
amount  of  direct  instruction  which  they  have 
received  from  their  teachers  during  the  period 
of  their  pupillage,  but  from  the  mental  dis¬ 
cipline  to  which  they  were  subjected  (or 
wisely  subjected  themselves),  and  from  the 
habits  of  correct  observation  and  correct 
reasoning  which  they  had  imbibed. 

And  now,  in  conclusion,  gentlemen,  let 
me  lead  your  thoughts  to  the  motives  which 
should  animate  you  to  the  pursuit  of  your 
professional  studies,  in  that  elevated  and 
liberal  spirit  which  I  have  been  endea¬ 
vouring  to  inculcate.  In  the  first  place, 
you  owe  it  to  your  Creator  to  make  the 
most  advantageous  use  in  your  power  of 
those  gifts  and  opportunities  wherewith 
he  has  endowed  you.  Surely  he  did  not 
give  you  the  powers  of  observation,  the 
insight  into  the  mysteries  of  organization, 
the  capacity  for  scientific  research,  and  the 
intelligence  to  use  the  knowledge  already 
acquired,  that  these  should  be  allowed  to 
rust  and  decay  in  stupid  inactivity.  They 
are  all  talents  entrusted  to  your  charge, 
of  which  a  rigorous  account  will  be  ex¬ 
pected  from  you.  They  are  not  equally  dis¬ 
tributed.  The  one  has  many,  the  other  few. 
But  of  all  alike  must  an  account  be  ren¬ 
dered.  To  whom  much  is  given,  of  him 
will  be  much  required ;  and  even  he  that 
has  received  least,  if  he  hide  his  single  talent 
in  a  napkin,  instead  of  turning  it  to  profit¬ 
able  use,  will  be  accounted  a  wicked  and 
slothful  servant.  And  let  it  not  be  thought 
that  this  momentous  warning  has  a  limited 
application.  Our  mental  capacity  —  our 
time — our  opportunities  of  improvement — 
our  means  of  extending  knowledge  —  our 
ability  to  bring  it  into  useful  employment — 
are  all  talents ;  and  the  inquiry  will  not  be 
merely  whether  we  have  made  use  of  them, 
but  whether  we  have  made  the  best  use  of 
them  that  circumstances  permitted.  Now, 
if  we  look  thoughtfully  abroad  into  the 
world,  we  discern  a  most  wonderful  rela¬ 
tion — a  relation  that  is,  to  my  own  mind, 


670  DR.  CARPENTER  ON  THE  OBJECTS  OF  MEDICAL  STUDY, 


one  of  the  most  convincing  of  all  proofs  of 
order  and  design  in  the  existing  constitu¬ 
tion  of  the  universe,  mental  as  well  as  phy¬ 
sical — betvi  een  the  variety  of  objects  of  pur¬ 
suit  in  which  the  wants  and  desires  of  man 
have  caused  him  to  engage,  and  the  diversity 
of  capacities  and  tastes  which  provides  for 
the  filling  up  of  every  department  in  a 
manner  most  suitable  to  it.  There  is  to  me 
a  sacredness  about  any  special  gift  or  en¬ 
dowment  :  I  cannot  but  believe  that  it  was 
bestowed  for  a  good  and  wise  purpose,  and 
that  it  is  our  business  to  find  out  that  pur¬ 
pose  if  we  may,  and  to  allow  the  gift  to 
work  for  the  welfare  of  its  possessor,  and 
for  the  benefit  of  the  race.  You  must  all 
remember  the  cogent  train  of  reasoning  by 
which  the  Apostle  to  the  Gentiles  urges 
upon  his  Corinthian  converts  the  discreet 
and  harmonious  use  of  the  “  spiritual  gifts” 
with  which  they  were  severally  endowed. 
The  analogy  which  he  draws  between  the 
animal  body  and  the  Church  he  is  address¬ 
ing,  is  not  less  applicable  to  society  at 
large.  “  As  the  body  is  one,  and  hath 
many  members,  and  all  the  members  of  that 
one  body,  being  many,  are  one  body,”  and 
“  as  the  eye  cannot  say  to  the  hand,  I  have 
no  need  of  thee,  nor  again  the  head  to  the 
feet,  I  have  no  need  of  thee,” — so  is  our 
common  race  made  up  of  individuals  de¬ 
pendent  upon  each  other,  like  the  members 
and  organs  of  our  corporeal  frame,  for 
mutual  aid  and  co-operation.  Every  one, 
therefore,  who  misuses  his  powers,  whether 
by  idleness  or  misapplication,  not  merely 
leaves  the  purposes  of  the  Creator  un¬ 
fulfilled  so  far  as  he  is  individually  concerned, 
but  does  what  in  him  lies  to  disarrange  the 
vast  scheme  of  Providence,  which  has  united 
men  in  the  bonds  of  mutual  dependence — a 
chain  which,  instead  of  becoming  more 
galling  the  tighter  it  is  drawn,  has  its  pres¬ 
sure  replaced  by  the  mutual  attraction 
which  springs  up  between  those  whom  it 
has  brought  together,  when  they  allow  free 
play  to  the  kindly  sympathies  implanted  n 
their  hearts. 

And  thus  I  am  led  to  remark  upon  the 
motives  which  should  arise  from  the  feeling 
of  human  brotherhood — the  desire  to  mi¬ 
nister  to  the  wants  of  our  common  humanity, 
—which  has  had  its  share,  I  trust,  with  all 
of  you  in  directing  your  choice  of  a  profes¬ 
sion.  It  is  the  glory  of  our  calling,  that, 
whilst  others  are  engaged  in  the  destruction 
of  life  and  property,  and  in  the  infliction  of 
all  those  dire  miseries  which  result  from  the 
unprofitable  struggle  between  two  nations 
as  to  which  can  do  the  other  the  most  harm, 
it  is  our  office,  though  we  cannot  restore 
the  dead  to  life,  to  do  all  that  science  can 
effect  to  keep  death  at  bay,  to  mitigate 
suffering,  and  to  repair  injury.  Whilst 
Others  obtain  their  livelihood  by  taking  part 


in  the  quarrels  of  the  litigious,  in  bringing 
to  punishment  offenders  against  the  laws,  or 
(still  worse)  in  shielding  them  from  it,  it  is 
our  more  pleasing  duty  to  soothe  the  spirit 
made  irritable  by  bodily  disorder,  to  put  a 
wholesome  check  upon  tendencies  which,  if 
indulged,  would  be  alike  injurious  to  society 
and  to  the  individual,  and  to  point  out 
where  the  existence  of  mental  infirmity  re¬ 
quires  that  justice  should  be  tempered  by 
mercy,  and  corrective  restraint  substituted 
for  criminal  punishment.  Whilst  the  occu¬ 
pations  of  many  others  minister  to  nothing 
better  than  the  follies  or  luxuries  of  society, 
and  too  frequently  become  sources,  direct 
or  indirect,  of  human  misery  and  even  of 
depravity, — we  can  cherish  the  delightful 
consciousness  that  all  our  ministrations  tend 
directly  to  human  welfare ;  and  that  it  is 
not  merely  in  the  prevention  and  cure  of 
bodily  disease  that  our  power  consists  and 
our  duty  lies,  but  also  in  the  demonstration 
of  the  causes  of  that  debasement  of  the  in¬ 
tellect  and  morals,  which  is,  no  less  than 
physical  malady,  the  inevitable  result  of 
inattention  to  the  conditions  requisite  for 
the  healthful  performance  of  the  bodily 
functions.  And  if  we  feel  it  to  be  the 
glory  of  our  profession  that  we  can  thus 
look  for  our  reward,  not  solely  in  wealth 
acquired  or  dignity  obtained,  but  in  the 
happy  consciousness  of  duty  to  humanity 
discharged, — in  the  earnest  gratitude  of  the 
sufferer  restored  by  our  means  to  ease  and 
vigour, — in  the  blessing  of  him  that  was 
ready  to  perish  but  for  our  intervention, — 
can  any  thoughtful  student  enter  upon  the 
preparation  for  it  without  an  earnest  desire 
to  qualify  himself  to  the  best  of  his  ability 
for  the  discharge  of  its  responsible  duties  ? 

And  thus,  again,  I  am  carried  onwards  to 
speak  of  the  claim  which  the  profession 
itself  has  upon  you,  that  you  should  put 
forth  your  best  endeavours  to  sustain  and 
elevate  its  character.  There  never  was  a 
time,  perhaps,  when  this  claim  was  so 
strong  as  it  is  at  the  present  day.  On  the 
one  hand,  the  progressive  tendency  of  the 
age,  the  love  of  novelty,  and  the  decreasing 
tendency  to  rely  upon  prescription  and  au¬ 
thority,  are  weakening  the  hold  which  the 
profession  has  possessed  over  the  public 
mind.  We  do  not  now  see  the  ignorant  and 
gullible  alone  deserting  our  standard  and 
enlisting  themselves  among  the  followers  of 
empirics  :  it  is  the  astounding  fact  that 
among  the  votaries  of  quackery  at  the  pre¬ 
sent  time  are  to  be  found  some  of  the  most 
intelligent  and  highly  educated  of  the  com¬ 
munity  ;  and  that  even  most  respectable 
and  well-informed  members  of  our  own  pro¬ 
fession  have  become  advocates  of  systems 
opposed  not  merely  to  the  current  doctrines 
of  medical  science,  but  (as  appears  to  most 
of  us)  to  the  simplest  dictates  of  common 


AND  THE  SPIRIT  IN  WHICH  THEY  SHOULD  BE  PURSUED.  671 


sense.  On  the  other  hand,  if  the  progress 
of  scientific  inquiry  has  overturned  some 
ancient  fallacies,  it  has  built  up  a  solid 
foundation  for  a  far  more  substantial  and 
permanent  edifice, — if  it  has  shown  us  that 
much  of  what  we  thought  we  knew  was  far 
from  being  the  truth  we  believed  it  to  be, — 
it  has  given  us  a  number  of  more  substantial 
truths  in  its  stead;  and,  what  is  yet  more 
than  the  benefits  it  has  as  yet  actually  con¬ 
ferred  upon  us,  it  has  pointed  out  to  us  the 
direction  in  which  we  may  seek  for  fresh 
acquisitions,  with  a  full  confidence  of  suc¬ 
cess. 

Thus,  then,  whilst  the  present  position  of 
the  profession  with  the  public  urgently  calls 
upon  yuu  to  bear  your  part  to  rescue  it 
from  the  discredit  into  which  it  is  falling, 
the  condition  of  medical  science  is  such  as 
to  afford  you  opportunities  of  doing  so,  more 
fertile  than  have  been  presented  at  any  pre¬ 
ceding  period  in  professional  history.  And 
I  make  no  doubt  that,  so  soon  as  the  public 
shall  be  satisfied  that  we  are  sedulously 
applying  ourselves  to  the  advancement  of 
our  science,  and  to  the  improvement  of  our 
art, — that  we  are  carefully  examining  into 
the  foundations  of  the  doctrines  current 
amongst  us,  with  a  perfect  freedom  from  all 
disposition  to  cling  too  closely  to  the  “  wis¬ 
dom  of  our  ancestors/'  and  with  a  readiness 
to  examine,  in  a  fair  and  candid  spirit,  all 
and  any  suggestions,  however  they  may 
arise,  and  from  whatsoever  quarter  they 
may  come, — it  will  return  to  its  ancient 
allegiance,  and  will  trust  its  health  to  our 
keeping,  as  in  old  time. 

Now  the  elevation  of  the  status  of  the 
profession  in  the  aggregate,  depends  entirely 
upon  the  exertions  of  the  individuals  who 
compose  it.  I  cannot  imagine  that  any 
plan  of  medical  reform — any  alteration  in 
the  existing  constitution  of  our  corporate 
bodies — will  have  the  effect  of  improving 
our  position  with  the  public,  otherwise  than 
as  it  may  tend  to  raise  the  standard  of  pro¬ 
fessional  qualification,  and  to  cherish  and 
encourage  attainments  of  a  much  higher 
order  than  are  now  required.  But  it  is  in 
your  own  power,  gentlemen,  to  contribute 
towards  this  most  desirable  result  by  your 
own  voluntary  exertions.  Every  one  of  you 
who  goes  forth  into  the  world  with  the 
spirit  of  the  philosopher  triumphant  over 
the  mean  ambition  of  the  “  trader  in  know¬ 
ledge,"  is  thereby  qualified,  not  merely  for 
more  extended  usefulness  to  others,  and  for 
the  attainment  of  the  most  solid  and  dura¬ 
ble  happiness  for  himself,  but  also  for  bear¬ 
ing  his  part  in  the  elevation  of  the  profes¬ 
sion  to  that  place  in  social  consideration  to 
which  its  inherent  nobility  so  well  entitles 
it.  And  is  not  this  a  duty  which  you  owe 
to  the  community  you  are  now  seeking  to 
enter  ?  You  have  entrusted  to  you  the 


accumulated  treasures  of  ages.  You  are 
allowed  freely  to  participate  in  the  stores 
laid  up  by  the  disinterested  labours,  the 
self-denying  toil,  the  persevering  devotion, 
through  evil  report  and  good  report,  of  men 
who  have  sacrificed  their  time,  their  health, 
their  ease,  their  worldly  prospects,  for  the 
good  of  their  race,  for  the  discovery  of 
truth,  for  the  enlightenment  of  the  genera¬ 
tions  that  should  succeed  them.  And  will 
you  be  satisfied  with  sharing  all  these,  with 
enjoying  the  fruits  of  their  labours,  without 
adding  anything  to  the  pile, — without  even 
putting  the  seed  into  the  ground  from  which 
others  who  come  after  you  may  reap  the 
harvest  ?  Do  not  they,  though  dead,  yet 
speak  to  you,  and  urge  you,  by  all  the  ties 
of  gratitude,  to  repay  the  obligations  they 
have  conferred  upon  you,  by  labouring  in 
like  manner  for  the  benefit  of  your  succes¬ 
sors  ?  Sui'ely,  then,  we  all  have  motives 
enough,  in  the  present  aspect  and  in  the 
past  history  of  our  profession,  to  animate 
us,  as  honourable  and  faithful  men,  in  the 
effort  to  carry  forwards  that  which  they 
have  so  gloriously  begun,  and  to  encourage 
us  in  the  conviction  that  no  such  effort  will 
be  fruitless,  even  if  it  bring  to  us  no  other 
immediate  reward  than  that  of  an  approving 
conscience. 

And  now,  having  spoken  of  your  respon¬ 
sibilities  to  your  Creator  for  the  right  use 
of  the  endowments  entrusted  to  your  care, 
— of  your  social  duties  to  the  race  of  which 
you  are  individuals. — and  of  your  obligations 
to  that  profession  in  which  you  desire  to  be 
enrolled, — let  me,  in  the  last  place,  suggest 
to  you  the  consideration,  whether  there  be 
not  in  knowledye  itself,  when  sought  in  a 
right  manner,  and  with  right  ends,  some¬ 
thing  that  supplies  a  want  in  your  own 
spiritual  nature — that  ministers  to  a  mental 
appetite  which  requires  food  as  much  as 
bodily  hunger,  and  in  the  gratification  of 
which  there  is  an  analogous  but  a  far  nobler 
enjoyment.  The  love  of  knowledge  for  its 
own  sake  is,  of  all  the  motives  which  can 
influence  man  in  the  pursuit  of  it,  one  of  the 
noblest,  the  purest,  and  most  stable.  It  is 
among  the  noblest,  because  it  is,  as  Sir  H. 
Davy  has  beautifully  observed,  “in  its  ulti¬ 
mate  and  perfect  development,  the  love  of 
infinite  wisdom  and  unbounded  power,  or 
the  love  of  God."  It  is  among  the  purest, 
because  it  is  incapable  of  being  tarnished  by 
the  alloy  of  those  baser  feelings  which  may 
intermingle  in  a  greater  or  less  degree  with 
almost  every  other.  It  is  one  of  the  most 
stable,  because,  unlike  all  those  which  have 
reference  to  our  worldly  position,  it  may  be 
carried  to  a  spiritual  existence  without  a 
change  in  its  character.  To  the  man 
who  is  under  its  influence,  what  does  it 
matter  whether  he  alone  has  attained  the 
elevation,  or  whether  he  shares  it  with 


672 


DR.  CARPENTER  ON  THE  OBJECTS  OF  MEDICAL  STUDY. 


others  ?  The  prospect  below,  around,  and 
above  him  is  the  same.  He  has  the  same 
animating  satisfaction  in  the  review  of  diffi¬ 
culties  overcome, — the  same  expansion  of 
feeling  as  he  surveys  the  extent  of  the  do 
main  beneath  his  feet, — the  same  delight  in 
the  glimpses  he  discovers  of  paths  which 
may  conduct  him  to  new  and  yet  more 
valuable  acquirements.  It  is  among  those 
in  whom  the  mere  love  of  fame  is  the 
strongest — who  seek  most  strongly  for  the 
applause,  not  so  much  of  the  master-spirits 
of  their  age  as  of  the  world  at  large,  and  for 
the  substantial  advantages  which  this  brings 
with  it, — that  we  observe  the  keenest  sensi¬ 
tiveness  to  detraction  in  regard  to  the  value 
of  their  attainments — the  greatest  disap¬ 
pointment  if  it  can  be  proved  that  they  have 
been  at  all  anticipated  in  them.  Such  a 
seeker  after  truth  can  bear  the  proximity  of 
no  other :  he  must  stand  alone.  He  looks  at 
the  pinnacle  of  knowledge,  not  as  the  com¬ 
manding  eminence  from  which  he  may  take 
a  wider  survey  of  its  glorious  domain,  but 
as  the  pedestal  on  which  he  may  elevate 
himself  above  his  fellows,  that  they  may  fall 
down  and  worship  him  around  its  base. 
He  carries  into  the  domain  of  philosophy 
the  sordid  spirit  of  the  mere  “trader;” 
considers  all  who  are  engaged  in  similar 
pursuits  as  rivals  rather  than  as  comrades, 
and  looks  at  every  man  as  a  personal  enemy 
who  ventures  to  express  a  doubt  of  the 
merit  of  his  discoveries.  To  such  a  man 
truth  cannot  be,  as  it  ought,  “  its  own  ex¬ 
ceeding  great  reward.”  To  the  prevalence 
of  such  a  spirit  amongst  those  who  profess 
themselves  her  followers,  do  we  owe  those 
manifestations  of  envy,  hatred,  malice,  and 
all  uncharitableness,  which  disturb  the  peace 
of  the  philosopher,  and  drag  him  down  to 
eatth,  whilst  he  was  rising  in  elevated  con¬ 
templation  towards  that  region  of  light 
where  no  darkness  intervenes  to  hide  our 
comprehension  of  the  Creator’s  works. 
And  so  it  must  be,  until  it  comes  to  be  felt 
that  the  most  valuable  of  all  the  prizes 
which  can  be  offered  to  tl\e  aspirant  is  that 
which  every  one  can  attain ;  and  that,  in 
dwelling  too  strongly  on  the  direct  advan¬ 
tages  of  knowledge,  there  is  a  danger  lest 
this -prize  be  lost  sight  of,  just  as  (to  use 
Bacon’s  most  apposite  simile)  Atalanta  lost 
her  race  through  stooping  down  to  pick  up 
the  golden  applS?^ 

And  what  is  this  prize  which  I  would 
hold  out  as  that  which  each  one  of  you  may 
grasp,  without  being  distracted  by  the  rivalry 
of  selfish  interests,  or  disappointed  through 
the  superior  address  or  ability  of  the  most 
honourable  opponents  ?  It  is  the  pleasure 
which  attends  the  acquisition  and  the 
possession  of  knowledge,  if  it  be  made 
the  object  of  pursuit  for  its  own  sake , 
rather  than  with  a  view  to  the  worldly  ad¬ 


vantages  which  its  possession  may  bring 
with  it.  If  this  be  the  cherished  aim,  every 
step  towards  it  becomes  a  source  of  most 
legitimate  enjoyment.  The  pleasure  that  is 
experienced  in  the  act  of  acquiring  know¬ 
ledge,  is  felt  by  its  true-hearted  votary  to  be 
worth  far  more  than  that  derived  from  the 
accumulation  of  pecuniary  wealth.  There 
is  a  pleasure  in  encountering  toils,  and 
rising  superior  to  difficulties,  with  so  noble 
a  reward  in  view.  There  is  a  pleasure  in 
looking  upon  its  growing  stores,  and  in 
feeling  the  mind  expand  itself  to  receive 
them,  far  above  that  which  the  miser  can 
feel  in  the  grovelling  contemplation  of  his 
hard-sought  pelf.  There  is  a  delight  to  be 
experienced  in  following  out  a  beautifully- 
connected  chain  of  reasoning,  which  termi¬ 
nates  in  evolving  a  simple  principle  adapted 
to  explain  a  great  variety  of  complex  phe¬ 
nomena,  or  in  recognising  an  analogy  be¬ 
tween  facts  apparently  remote,  which  shall 
become  the  foundation  of  some  comprehen¬ 
sive  generalization — fully  as  keen  as  that 
which  the  most  successful  man  of  business 
can  enjoy  in  grasping  the  lucrative  results  of 
a  bold  and  well-arranged  speculation.  There 
is  a  pleasure,  which  becomes  greater  the 
more  we  open  our  minds  to  the  enjoyment 
of  it,  in  the  contemplation  of  beauty  and 
harmony  wherever  presented  to  us;  and  is 
not  this  pleasure  increased  when  we  are 
made  aware — as  in  the  study  of  Nature  we 
soon  become — that  the  sources  of  them  are 
never  ending,  and  that  our  enjoyment  of 
them  becomes  more  intense  in  proportion  to 
the  comprehensiveness  of  our  knowledge  ? 
We  need  never  fear  that  we  shall  exhaust 
the  sources  of  this  pleasure.  Alexander 
wept  because  he  had  no  more  worlds  to 
conquer;  and  I  have  heard  of  successful 
physicians  who  began  to  feel  their  profes¬ 
sional  labours  burdensome,  so  soon  as  it  be¬ 
came  apparent,  from  the  complete  occupa¬ 
tion  of  their  time,  that  they  could  not  extend 
the  sphere  of  their  exertions.  You  need 
have  no  such  fear  in  the  pursuit  of  know¬ 
ledge.  Every  step  you  take  only  gives  you 
a  wider  view  of  the  unexplored  country 
beyond  ;  every  elevation  you  gain  only  gives 
you  a  more  distinct  glimpse  of  heights 
above.  You  feel  more  and  more  that  there 
is  no  limit  to  human  attainment,  but  the 
duration  of  life  and  activity;  and  you  be¬ 
come  more  and  more  assured  that  it  is  not 
with  this  life  that  our  mental  expansion 
shall  end,  but  that  in  the  life  beyond  the 
grave  our  pi’Ogress  shall  be  continued  with 
the  aid  of  higher  faculties  and  clearer  vision, 
and  that  through  the  endless  ages  of  eter¬ 
nity  we  shall  be  receiviug  ever  new  delights 
in  the  extension  of  our  survey  of  the  grand 
scheme  of  creation,  and  in  the  gradual  ap¬ 
proach  towards  the  perfections  of  the  infi¬ 
nite  Creator,  of  which  He  has  graciously 


MR.  HADEN’S  FATAL  CASE  OF  ALGIDE  CHOLERA. 


673 


made  our  nature  capable.  And  then  shall 
we  estimate  our  terrestrial  attainments  at 
their  true  value.  We  shall  measure  every¬ 
thing,  not  according  to  the  worldly  pros¬ 
perity  which  it  has  brought  us,  but  according 
as  it  has  tended  to  develope  the  Divine  idea 
within  our  souls, — to  expand  our  intellec¬ 
tual  capacity  towards  the  comprehension 
of  the  wisdom  and  power  of  the  Creator, — 
to  purify  our  moral  nature  by  the  contem¬ 
plation  of  his  perfect  goodness, — and  to 
afford  us  the  power  of  in  some  degree  imi¬ 
tating  that  goodness,  by  the  benificent  exer¬ 
tion  of  our  faculties  for  the  welfare  of  our 
race.  And  then  we  shall  recognise,  in  its 
fullest  meaning,  the  truth  of  the  saying  of 
the  religious  philosopher  of  old,  that  “  Wis¬ 
dom  is  more  precious  than  rubies,  and  all 
the  things  thou  canst  desire  are  not  to  be 
compared  unto  her.” 


Original  ©ommuntcatton?. 

FATAL  CASE  of  ALGIDE  CHOLERA. 

By  F.  S.  Haden,  Esq. 

Sloane  Street. 

[Concluded  from  page  630.] 

Treatment. — On  a  revision  of  the 
symptoms  detailed  above,*  some  very 
opposite  conditions  are  observable. 
For  several  hours  there  was  nothing  to 
distinguish  the  case  from  one  of  the 
commonest  diarrhoea,  dependent  upon 
an  error  of  diet ;  in  a  short  time  it 
was  one  of  algide  cholera  ;  and,  before 
death,  a  condition  of  very  positive  re¬ 
action.  The  diarrhoea,  it  will  be  ob¬ 
served,  lasted  from  the  morning  until 
the  evening  of  the  first  day  (as  I  am  led 
to  understand,  having  myself  been 
absent  during  the  greater  part  of  this 
day) ;  the  algide  symptoms  com¬ 
menced  at  about  8  p.m.  of  the  same 
day,  and  had  gone  off  at  nooh  on  the 
18th ;  and  the  period  of  reaction 
was  at  its  height  at  midnight,  and  had 
terminated  at  noon  on  the  following 
day.  The  treatment  was  simply 
opposed  to  the  apparent  exigencies  of 
the  case.  In  the  first  period — that  of 
simple  diarrhoea — the  prescription  of 
Dr.  Synnot  and  myself  was  nearly  the 
same,  a  presumptive  proof  that  our 
opinion  was  the  same  with  respect  to 


*  See  the  case  of  cholera  published  in  last 
number. 


the  then  nature  of  the  disease.  We 
both  prescribed  Hydr.  c.  Cretd,  as  an 
alterative  and  evacuant,  in  considera¬ 
tion  of  the  supper  of  the  night  before. 
Mr.  Seaton,  who  visited  the  case 
several  hours  later  —  in  short,  just 
before  it  passed  into  the  algide  stage — 
saw  the  necessity  of  arresting  the 
purging,  and  ordered  Plumbi  Diaceta- 
tis,  3j.;  Pulvis  Opii,  gr.  ij. ;  Cons, 
Rosse,  q.  s.  to  make  six  pills  ;  of  which 
he  directed  one  to  be  given  hourly 
until  the  purging  had  abated,  and  then 
every  two  or  three  hours,  with  a  fourth 
part  of  the  following  mixture  : — Acet, 
Distillatse,  ^ss. ;  Syrupi,  ^ss. ;  Mist. 
Camp.  ^iij.  He  also  ordered  a  liniment 
to  be  rubbed  upon  the  legs  composed 
of  Lin.  Saponis,  giss. ;  Tinct.  Opii,  ^ss. 
This  treatment  had  the  almost  im¬ 
mediate  effect  of  checking  the  purging, 
and  was  persevered  in  until  towards 
the  latter  end  of  the  algide  stage, 
when,  appearances  becoming  hopeless, 
and  the  prostration  greater,  I  changed 
it  for  what  I  thought  might  prove  a 
more  restorative  plan. 

The  opium  had  accomplished  its  end„ 
when,  with  the  acetate  of  lead,  it  had 
arrested  the  purging  and  vomiting  j 
and  to  have  continued,  during  the 
Algide  stage,  a  remedy  whose  opera¬ 
tion  is  supposed  to  consist  in  diminu¬ 
tion  of  the  nervous  energy,  was  to 
insure,  as  its  effect,  nothing  short  of  a 
still  greater  collapse;  it  was,  therefore, 
discarded  at  this  stage  of  the  case,  and 
a  remedy  sought  for  which  should,  if 
possible,  interfere  with  the  morbid 
processes  said  to  be  going  on  during 
the  Algide  state.  Though  the  purging 
had  ceased,  it  was  fair  to  believe  that 
effusion  into  the  small  intestine  con¬ 
tinued,  and,  in  the  absence  of  a  better 
explanation,  that  this  depended  upon 
the  separation  of  the  serous  from  the 
solid  constituents  of  the  blood,  and  of 
the  transudation  of  the  former  through 
atonized  vascular  parietes.  It  also 
appeared  clear,  from  the  livid  surface 
and  from  what  has  been  found  on 
post-mortem  examination  of  that  por¬ 
tion  of  the  blood  which  remains  in  the 
vascular  cavities,  that  it  was  deprived 
of  its  oxygen,  and  that  this  itself  might 
be  owing  to  defective  action  of  the 
lungs.  The  kidneys,  too,  had  sus¬ 
pended  their  function,  and  it  was  not 
impossible  that  the  same  d6faillance  of 
the  nervous  centres  which  paralysed 
the  lung,  operated  also  upon  them. 


674 


MR.  HADEN’S  FATAL  CASE  OF  ALGIDE  CHOLERA. 


At  all  events,  this  was  the  view  of  the 
moment ;  and  the  desideratum  was  a 
remedy  which,  while  it  should  act  as 
an  astringent  upon  the  vessels  and  in¬ 
testinal  walls,  should  be  capable  of 
restoring  that  vivifying  agent  to  the 
blood,  which  it  was  supposed  to  have 
lost,  as  well  as  of  stimulating  the  kid¬ 
neys  to  a  renewal  of  their  action.  The 
hydrochloride  of  iron*  seemed  to  com¬ 
bine  these  qualities  in  the  greatest  de¬ 
gree,  and  I  therefore  gave  it— at  first, 
in  drachm  doses,  and  afterwards  half¬ 
drachm — every  half  hour,  alternating 
its  exhibition  (in  the  hope  of  awaken¬ 
ing  nervous  energy  and  restoring  the 
respiratory  function),  with  ammonia 
and  camphor,  in  the  proportion  of  six 
grains  of  the  former  to  four  of  the 
latter.  Frictions  were  also  employed, 
and  mustard  poultices  about  the  chest 
and  diaphragm.  This  change  in  the 
treatment  was  followed  (1  will  not  pre¬ 
sume  to  say  as  a  consequence)  by  re¬ 
action  ;  but  as  this  was  of  a  very 
decided  character,  it  is  within  the 
bounds  of  possibility  that  the  iron  did, 
in  some  degree,  conduce  to  it.  Never¬ 
theless,  it  is  just  as  proper  to  admit 
that  this  supposition  is  contradictory 
to  the  opinion  held  by  that  very  accu¬ 
rate  observer,  Dr.  Parkes,  as  to  the 
conduct  of  remedies  in  the  algide 
stage  of  cholera;  it  being  his  belief 
that  they  are  altogether  inert.  But 
to  resume.  With  this  reaction,  the 
continued  exhibition  of  ammonia 
and  iron  seemed  as  little  desirable 
as  the  persevering  employment  of 
opium  had  been  in  the  algide  stage  ; 
they  were,  therefore,  replaced  by  a  mode 
of  treatment  altogether  directed  to  the 
kidneys  and  liver.  No  urine  had  been 
secreted  since  the  onset  of  the  disease  ; 
and  it  was  surmised — in  presence  of 
the  reaction— that  this  was  now  the 
only  stumbling-block  to  recovery. 
Turpentine  fomentations  were  accord¬ 
ingly  applied  to  the  loins,  and  small 
doses  of  calomel,  with  large  ones  of 
acetate  of  potash,  given  frequently. 
Leeches  were  also  applied  to  the  tem¬ 
ples,  and  a  blister  to  the  nape  of  the 
neck,  it  being  Dr.  M‘Lachlun’s  opinion 
that  the  stupor  depended  as  much  upon 
cerebral  congestion  as  upon  the  sup¬ 
pression  of  urine.  A  slight  return  of 
consciousness,  and  a  scanty  secretion 

*  The  hydrochloride  of  iron,  when  this  case 
occurred,  was  not  known  to  the  writer  as  a  pro¬ 
posed  remedy  in  cholera. 


of  urine,  took  place  before  death ;  but 
whether  in  consequence  of  any  of  these 
means,  must,  with  the  operation  of  the 
ammonia  and  iron,  remain  a  matter  of 
conjecture.  The  patient  died, — arid  we 
are  still  left  to  seek,  in  the  observation 
of  future  cases,  that  philosopher’s  stone 
which  eluded  our  grasp  in  the  present 
instance. 

There  is  but  one  practical  point  in 
the  above  treatment  which  seems  to 
invite  especial  notice,  but  it  is,  I  appre¬ 
hend,  a  point  of  the  greatest  impor¬ 
tance.  Opium  was  persevered  in  until 
a  late  period  of  the  algide  stage,  and 
long  after  the  purging  had  ceased, 
and  though  the  amount  administered 
altogether  was  not  more  than  three 
grains,  I  am  now  convinced  that,  after 
sufficient  had  been  taken  to  arrest 
the  purging,  we  should  have  done 
better  to  have  withdrawn  it ;  nay,  I 
am  almost  convinced  that  opium  is  in¬ 
admissible  as  a  remedy  in  cholera. 
Congestion,  stupor,  and  diminution  of 
the  vis  vitcc,  are  among  the  most  for¬ 
midable  symptoms  of  the  disease, — 
symptoms,  I  should  think,  highly  con¬ 
tra-indicative  of  the  use  of  opium.  It 
may  be  exceedingly  proper  to  give  it 
in  the  earlier  stage  of  the  disease ;  but 
it  is  to  be  remembered,  that  should  the 
case  run  into  collapse,  the  difficulties 
of  treatment  are  thereby  increased  two¬ 
fold.  There  is  then  not  only  the  im¬ 
pairment  of  vital  energy  characteristic 
of  the  malady  to  be  combated,  but  the 
parallel  effects  of  the  opium  itself;  and 
we  must  he  still  less  surprised  if  the 
stomach  should,  under  its  influence  (as 
Dr.  Parkes  believes,  however,  it  would 
do  without  it),  resist  the  action  of  re¬ 
medies. 

But  too  little  is  at  present  known 
of  the  pathology  of  cholera  to  make 
any  preconcerted  scheme  useful.  We 
have  yet  to  assure  ourselves  that  the 
drugs  most  in  reputation  are  not  posi¬ 
tively  injurious;  and  it  is  clear  that  we 
can  arrive  at  nothing  worth  affirmation 
on  the  score  of  treatment,  until  the  way 
is  divested  of  these  negative  obstacles. 

62,  Sloane  St.,  Oct.  6, 1848. 

Since  writing  the  above,  I  have  been 
favoured,  by  Mr.  Keen,  of  the  King’s 
Road,  Chelsea,  with  an  opportunity  of 
examining  seven  cases  of  the  same 
disease  as  that  I  have  attempted  to 
describe,  and  of  witnessing  the  post¬ 
mortem  examinations  in  three  out  of  the 


ON  THE  CONTAGION  OF  TYPHUS  FEVER  AND  ASIATIC  CHOLERA.  675 


four  which  have  as  yet  died.  The 
particulars  of  these  cases  I  do  not  feel 
at  liberty  to  record,  but  no  one  who 
has  seen  them  can  doubt,  I  imagine, 
that  they  are  cases  of  malignant  cho¬ 
lera. 

9th  October. 


ON 

CONTAGION, 

IN  REFERENCE  TO  TYPHUS  FEVER  AND 
ASIATIC  CHOLERA. 

By  John  George  French,  Esq,. 
Surgeon  to  St.  James’s  Infirmary. 


The  mode  in  which  disease  is  propa¬ 
gated,  whether  by  communication 
with,  or  contiguity  to,  the  sick,  or  by 
other  causes  alone,  must  necessarily 
be  a  subject  of  some  difficulty,  since 
the  most  opposite  opinions  have  been 
entertained  by  those  who  have  had 
the  best  opportunities  of  forming  a 
judgment  upon  it.  The  late  Dr.  Arm¬ 
strong,  for  many  years  physician  to 
the  Fever  Hospital,  did  not  believe 
that  typhus  was  contagious;  and  I 
recently  inquired  of  an  eminent  phy¬ 
sician,  for  many  years  attached  to  a 
metropolitan  hospital,  his  opinion  of 
the  contagion  of  typhus.  He  replied, 
“  Before  18361  should  have  said  ‘  No;’ 
since  that  year  I  should  answer  ‘Yes,’ 
from  evidence  which  that  period 
afforded  me.” 

My  own  experience  in  1831  leaves 
me  in  no  doubt  on  the  subject.  In 
March  in  that  year  a  family  was  passed 
from  Water  Lane,  Fleet  Street,  into 
St.  James’s  Workhouse,  affected  with 
fever.  No  case  of  fever  existed  within 
the  walls  of  the  workhouse  previously, 
nor  was  any  such  disease  known  to 
exist  in  any  part  of  the  parish.  The 
man  died  two  days  after  admission, 
and,  on  the  third  day  after  his  death, 
the  nurse  who  attended  him  died  of 
the  disease.  Within  a  week,  two  con¬ 
valescent  patients  who  had  assisted  the 
nurse  in  the  care  of  the  first  patient, 
had  the  fever,  and  died  also;  other 
inmates  of  the  same  ward  then  be¬ 
came  affected  with  the  disease,  among 
whom  was  the  surgery-man,  who,  al¬ 
though  not  a  patient,  slept  in  this 
ward  ;  then  some  patients  in  the  ad¬ 
joining  ward  became  affected ;  next 
some  of  the  laundresses  who  washed  l  he 
linen  of  the  deceased;  then  their  bed¬ 


fellows  and  neighbours ;  and,  finally, 
the  watchmen  of  the  premises.  The 
number  of  cases  was  22:  the  disease 
was  of  unexampled  severity.  Dr. 
Tweedie,  who  saw  the  cases,  and  also 
received  many  of  them  into  the 
Fever  Hospital,  expressed  himself  very 
strongly  on  this  point.  My  belief  is, 
that  had  this  family  remained  in 
Water  Lane,  instead  of  coming  into 
St.  James’s  Workhouse,  these  22  cases 
of  fever  would  not  have  occurred. 

During  last  year,  repeated  instances 
of  the  following  kind  occurred  under 
my  observation  :  —  A  large  family, 
occupying  a  single  apartment,  received 
as  their  guest  or  lodger  an  inmate  just 
arrived  from  Ireland.  A  day  or  two 
afterwards  they  applied  for  his  removal 
to  the  Fever  Hospital ;  and  shortly 
after  this,  a  portion,  and  in  some  in¬ 
stances  the  whole  family,  became 
affected  with  fever.  The  disease  often 
spread  to  the  families  on  the  neigh¬ 
bouring  floors  and  houses.  On  such 
evidence  as  this,  then,  I  believe  that 
typhus  fever  is  a  contagious  disease. 

In  1832,  1  had  the  charge  of  St. 
James’s  Cholera  Hospital.  A  matron 
was  engaged, — selected,  among  other 
qualifications,  for  the  vigour  of  her 
constitution,  and  temperate  habits. 
She  was  40  years  of  age.  Her  duties 
were  those  of  housekeeper,  not  of 
attendant  on  the  sick.  She  had  re¬ 
sided  in  the  hospital  for  some  weeks 
previously  to  the  admission  of  any 
cases.  The  first  case  which  was  ad¬ 
mitted  was  Mary  Lee  (aged  30)  on  the 
6th  July.  The  journal  of  the  hospitaL 
states  that  she  had  been  nursing  her 
mother,  who  had  died  the  day  pre¬ 
viously  of  cholera,  and  was  seized  in 
the  churchyard  at  her  funeral.  This 
patient  died  seventeen  hours  after  ad¬ 
mission,  and  was  not  seen  by  the 
matron. 

The  second  case  was  Margaret  Lid- 
gate,  aged  9,  admitted  on  the  8th  July, 
from  the  Burlington  School,  at  1  p.m. 
The  matron  immediately  visited  this 
child,  sat  with  her,  and  rubbed  her 
legs  while  she  was  in  a  state  of  col¬ 
lapse.  At  half-past  5  o’clock  the 
matron  (previously  in  excellent  health) 
was  attacked  with  cholera,  and  died  in 
thirteen  hours  and  a  half. 

I  believe  that  the  communication 
which  the  matron  had  with  this  patient 
was  the  real  cause  of  her  attack. 

John  Foy,  a  labouring  man,  was 


676  ON  THE  CONTAGION  OF  TYPHUS  FEVER  AND  ASIATIC  CHOLERA. 


attacked  while  at  work  at  Paddington, 
at  2  p.m.  in  August  1833.  Some  of  his 
comrades  had  become  affected  in  this 
locality,  and  died.  He  was  brought 
home  to  Ham  Yard,  Windmill  Street. 
His  wife  was  attacked  after  nursing 
him  two  days,  and  subsequently  three 
cases  occurred  on  the  floor  above  that 
on  which  he  resided.  This  is  pre¬ 
cisely  the  same  kind  of  evidence  as 
that  on  which  the  contagious  nature  of 
typhus  rests. 

Although  these  cases  afford  ample 
evidence,  to  my  mind,  of  their  conta¬ 
gious  origin,  I  am  by  no  means  dis¬ 
posed  to  doubt  that  other  and  more 
numerous  cases  might  claim  their 
origin  from  other  causes. 

It  may,  however,  here  be  remarked, 
with  reference  to  the  general  question 
of  prevention  as  contemplated  by  qua¬ 
rantine  regulations,  that  it  is  highly 
doubtful  whether  any  known  or  prac¬ 
tised  system  of  quarantine  would  pre¬ 
vent  the  introduction  of  a  disease  so 
universally  admitted  to  be  exclusively 
contagious  as  syphilis,  should  a  new 
form  of  that  disease,  for  the  sake  of 
argument,  be  the  object  of  its  laws. 

The  ideas,  indeed,  commonly  at¬ 
tached  to  contagion  are  so  exaggerated, 
that  when  diseases,  supposed  to  be  of 
this  nature,  are  observed  under  ordi¬ 
nary  circumstances,  the  evidence  is  so 
weak  and  doubtful,  that  men  of  consi¬ 
derable  experience  are  led  to  form  the 
strongest  opinions  that  these  diseases 
are  incommunicable  from  one  indivi¬ 
dual  to  another.  Thus,  the  facts  elicited 
by  a  careful  inquiry  into  the  history 
of  the  Eclair,  were  in  direct  opposition 
to  the  numerous  opinions  formed  by 
men  who  had  observed  the  disease, 
which  was  the  object  of  inquiry,  at 
different  times  and  places.  So,  al¬ 
though  Dr.  Armstrong  denied  the  con¬ 
tagion  of  typhus,  the  Commissioners  of 
Health,  in  a  recent  circular,  declare  it 
to  be  a  “  highly  contagious  disease.’' 

The  degree  in  which  diseases  are 
contagious  is  a  question,  indeed,  of 
very  great  difficulty ;  but  it  is  certain 
that  the  principal  circumstances  con¬ 
nected  with  it  are,  the  denseness  of  the 
population,  and  the  number  of  cases  of 
the  same  disease  crowded  together, 
although  it  is  a  part  of  the  history  of 
disease  that  occasional  outbreaks  of 
unusual  virulence  will  occur  which 
defy  all  calculation. 

The  chief  practical  question,  indeed, 


is,  if  diseases  are  deemed  contagious, 
how  are  they  to  be  disposed  of. 

It  has  been  my  practice  for  many 
years  to  separate,  as  widely  as  possible, 
cases  of  the  same  disease  which  are 
deemed  contagious,  and,  l  believe,  with, 
an  undoubtedly  good  result.  So,  if 
there  are  more  cases  than  one  of  erysi¬ 
pelas,  or  other  contagious  disease,  I 
place  them  in  different  wards ;  and  I 
am  satisfied,  from  experience,  that 
there  is  less  danger  of  infection  from 
increasing,  as  it  were,  a  malarious  area, 
than  from  the  more  concentrated  taint 
occupying  possibly  a  smaller  space  ; 
and  also  that  the  cases  themselves  pro¬ 
ceed  more  favourably. 

In  1836,  by  order  of  the  Board  of 
Directors,  typhus  cases  were  not  per¬ 
mitted  to  be  received  into  the  Infir¬ 
mary  ;  but  the  building  which  was 
used  for  the  Cholera  Hospital  in  1832, 
being  a  house  situated  in  Marshall 
Street,  Golden  Square,  was  appro¬ 
priated  to  the  reception  of  typhus  cases. 
The  number  of  patients  received  there 
amounted  only  to  three,  all  of  whom 
recovered ;  but  the  two  nurses  who 
attended  them  during  their  protracted 
illness  had  the  fever,  and  died.  The 
Board,  consequently,  directed  that  all 
cases  of  typhus  should  be  sent  to  the 
Fever  Hospital. 

Last  year  the  number  of  fever  cases 
was  so  great  that  the  hospital  was 
filled,  and  many  cases  of  houseless 
poor  required  accommodation.  Ten 
cases  were  treated  at  the  Infirmary, 
and  there  was  not  any  spreading  of  the 
disease  whatever.  There  was  gene¬ 
rally  but  one  case  in  a  large  ward  at  a 
time ;  and  if  there  were  more  they 
were  placed  in  beds  as  far  as  possible 
from  each  other,  with  other  patients 
intervening:  while  in  the  lodging- 
houses,  containing  about  fifty  inhabi¬ 
tants,  which  contained  really  accommo¬ 
dation  for  six  or  eight,  the  disease 
spread  in  such  a  manner  as  to  justify 
my  belief  that  if  hospitals  received 
cholera  patients  into  their  wards  as 
ordinary  cases,  there  would  certainly 
not  be  more  danger  than  exists  from 
erysipelas  in  every  case  of  accident; 
and  that  the  cases  themselves  would 
do  better  than  if  collected  together. 

Again,  I  think  it  highly  desirable 
that  every  locality  should  have  some 
reasonable  accommodation  for  casual 
cases,  and  for  emergencies;  as,  for  in¬ 
stance,  in  order  to  thin  the  number  of 


THE  'CONTAGIOUS  DISEASES  PREVENTION  ACT.  677 


cases  where  they  should  occur  in 
crowded  houses — well  recollecting  the 
relief  from  anxiety  which  the  thinning 
of  the  number  of  fever  cases  afforded 
me  in  1831. 

It  will  be  observed,  that  this  view 
of  the  subject  is  founded  on  the  sup¬ 
position  that  the  general  idea  attached 
to  contagion  is  greatly  exaggerated 
with  regard  to  the  chances  of  propaga¬ 
tion,  and  also  of  the  importance  of 
contagious  diseases  (instead  of  being 
collected  together)  being  as  much  as 
possible  separated,  both  as  regards  the 
well-doing  of  the  cases  themselves  and 
lessening  the  virulence  of  the  conta¬ 
gious  virus;  for  it  must  be  remem¬ 
bered  that  such  remarkable  instances 
of  propagation  by  contagion  as  those 
afforded  by  the  epidemic  on  board  the 
Eclair,  as  well  as  those  which  occurred 
in  St.  James’s  Infirmary,  in  1831,  are 
of  such  uncommon  occurrence  as  to  be 
regarded  as  the  exception  rather  than 
the  rule. 


OBITUARY  NOTICE  OF  THE  LATE  DR.  WILLS, 
OF  CUMNOCK. 

We  have  to  record  the  death  of  Douglas 
Wills,  Esq.,  surgeon,  Cumnock,  under  the 
following  melancholy  circumstances  : — On 
the  14th  ult.  he  was  called,  in  the  discharge 
of  ‘his  professional  duty,  to  amputate  the 
leg  of  a  man  who  some  time  previously  had 
his  foot  mutilated  on  the  Grasswater  Rail¬ 
way.  During  the  operation  he  punctured 
his  hand  slightly  with  the  instrument  he 
used  ;  but  this  was  little  regarded  at  the 
time.*  In  the  course  of  a  few  days  symp¬ 
toms  of  absorbed  poison  became  manifest, 
which  speedily  assumed  an  alarming  aspect. 
The  highest  professional  skill  was  promptly 
in  attendance,  but  every  effort  was  utterly 
baffled  by  the  virulence  of  the  malady.  It 
was  his  own  firm,  calm,  melancholy  convic¬ 
tion,  which  he  expressed  from  the  beginning, 
that  he  should  not  recover.  His  death  took 
place  on  the  afternoon  of  Saturday  last,  after 
a  week  of  great  suffering.  The  deceased 
gentleman  was  a  native  of  New  Cumnock. 
On  the  completion  of  his  education,  while 
yet  a  very  young  man,  he  Settled  in  Cum¬ 
nock  as  a  regular  practitioner.  He  prose¬ 
cuted  his  calling  with  the  utmost  diligence 
and  most  distinguished  success  for  the  long 
period  of  30  years  ;  yet  he  was  still  in  the 
very  zenith  of  his  popularity  when  he  was 
thus  unexpectedly  and  prematurely  cut  off. 

*  We  are  informed  |that  it  was  during  his 
attendance  on  a  case  of  phlegmonous  erysipelas 
that  he  accidentally  inoculated  himself  with  the 
poisonous  matter. ' 


MEDICAL  GAZETTE. 


FRIDAY,  OCTOBER  20,  1848. 


We  have  not  hitherto  noticed  the 
provisions  of  the  Nuisances  Removal, 
and  Diseases  Prevention  Act,  passed 
towards  the  close  of  the  last  Session  of 
Parliament.*  The  fact  that  it  is  likely 
to  have  a  most  important  influence  on 
the  sanitary  condition  of  crowded  popu¬ 
lations,  and  that  by  a  recent  order  in 
Council  its  provisions  are  directed  to  be 
put  in  force  throughout  the  United 
Kingdom,  are  circumstances  sufficient 
to  j  ustify  a  brief  reference  to  it.  This  act 
is  a  considerable  improvement  on  that 
which  was  passed  in  a  previous  session, f 
the  efficient  operation  of  which  was 
very  soon  found  to  be  impeded  by 
numerous  technicalities.  The  differ¬ 
ences  between  the  present  and  the 
former  Nuisances  Prevention  Act,  will 
be  apparent  from  the  following  state¬ 
ment  : — 

“By  the  present  act  a  notice  from 
two  householders  is  sufficient  to  enable 
the  guardians  of  the  poor  to  act ;  by 
the  late  act  a  certificate  signed  by  two 
duly  qualified  medical  practitioners 
was  needed,  before  the  guardians  could 
act.  By  the  present  act  it  is  made  im¬ 
perative  on  the  guardians  or  other 
bodies  to  whom  notice  is  given  to  pro¬ 
ceed  forthwith  in  the  manner  pre¬ 
scribed  ;  by  the  late  act  it  was  discre¬ 
tionary  with  the  guardians  and  other 
bodies  whether  they  would  take  the 
proceedings  for  the  abatement  of  the 
nuisance.  By  the  present  act  a  penalty 
of  10s.  is  imposed  upon  the  owner  or 
occupier  who  disobeys  an  order  of 
justices  for  every  day  he  makes  default; 
by  the  late  act  no  such  pecuniary 
penalty  was  imposed  ;  by  the  present 
act,  to  enable  the  guardians  or  other 
bodies  to  determine  whether  proceed- 


*  llth  and  1 2th  Victoria,  cap.  cxxiii.  An 
Act  to  renew  and  amend  an  Act  of  the  tenth  year 
of  her  present  Majesty,  for  the  more  speedy  re¬ 
moval  of  certain  nuisances,  and  the  prevention 
of  contagious  and  epidemic  diseases, 
f  9th  and  10th  Victoria,  chap.  96. 


678 


THE  CONTAGIOUS  DISEASES  PREVENTION  ACT, 


ings  ought  to  be  taken  or  not,  an  entry 
of  the  premises  for  the  purpose  of  ex¬ 
amination  is  authorized  ;  by  the  late 
act  a  right  of  entry  only  was  given  to 
enforce  the  order  of  justices  when 
made.  Under  the  present  act  express 
powers  are  given  for  distraining  a  de¬ 
faulter’s  goods  wherever  they  may  be 
found.  The  act  also  authorizes  dung, 
&c.,  found  on  the  premises  to  be  de¬ 
stroyed  or  sold.  These  powers  were 
not  given  by  the  late  act;  the  present 
act  distinctly  assigns  duties  to  the 
Guardians  and  Poor-Law  Officers,  as 
well  as  to  surveyors  and  others  charged 
with  the  management  of  roads  and 
surface  cleansing.  The  provision  for 
this  purpose  is  new.  The  former  was 
a  temporary  act ;  the  present  is  per¬ 
manent.  The  present,  like  the  former 
act,  is  applicable  to  the  whole  of  the 
united  kingdom.  The  only  exception  is 
in  the  cases  of  ‘  districts’  formed  under 
the  Public  Health  Act,  where,  in  order 
to  prevent  conflicting  jurisdiction,  a 
discretion  will  be  exercised  by  the 
General  Board  of  Health  as  to  how  far 
the  present  act  shall  be  applied.”* 

We  regard  this  as  more  of  a  Public 
Health  Bill  than  that  which  is  so 
called;  and  if  its  provisions  be  only 
carried  out  in  the  spirit  in  which  they 
have  been  conceived,  we  have  every 
reason  to  believe  that  the  spread  of 
cholera,  typhus  fever,  and  other  dis¬ 
eases  rendered  infectious  by  the  accu¬ 
mulation  of  filth  in  the  crowded  quar¬ 
ters  inhabited  by  the  poor,  will  be 
speedily  arrested. 

The  present  act,  it  will  be  seen,  does 
not  dispense  with  the  aid  of  medical 
practitioners;  it  merely  gives  equal 
force  to  a  certificate  signed  by  two 
householders ;  a  provision  rendered 
necessary  for  the  more  speedy  working 
of  the  act,  under  the  apprehended  dif¬ 
fusion  of  cholera.  The  following  is  a 
short  summary  of  its  provisions  : — 

“  The  object  of  the  statute  is  two¬ 
fold.  It  provides  (1)  for  the  more 
speedy  removal  of  certain  nuisances  ; 
and  (2)  for  the  prevention  of  conta¬ 


*  Circular  of  the  Poor-Law  Board,  Somerset 
House,  October  6th. 


gious  and  epidemic  diseases  :  but  the 
provisions  for  the  latter  object  do  not 
take  effect  till  called  into  action  by  an 
order  from  the  Privy  Council. 

“  The  first  section  enacts  that,  upon 
receipt  (or  as  soon  afterwards  as  can 
be)  by  certain  bodies  therein  enume¬ 
rated,  or  by  any  guardians  of  the  poor, 
of  a  notice,  in  a  form  set  forth  in  a 
schedule  to  the  act,  or  to  the  like  effect, 
signed  hy  two  or  more  inhabitant 
householders  of  the  parish  or  place  to 
which  the  notice  relates,  stating — - 
‘  That,  to  the  best  of  their  knowledge 
and  belief,  any  dwelling-house  or 
building  in  any  city,  town,  borough, 
parish,  or  place  within  or  over  which 
the  jurisdiction  or  authority  of  such 
bodies  or  guardians  extends,  is  in  such 
a  filthy  and  unwholesome  condition  as 
to  be  a  nuisance  to,  or  injurious  to  the 
health  of  any  person  ;  Or  that  upon 
any  premises  wfithin  such  jurisdiction 
or  authority  there  is  any  foul  and 
offensive  ditch,  gutter,  drain,  privy, 
cesspool,  or  ash-pit,  or  any  ditch,  &c., 
kept  or  constructed  so  as  to  be  a  nui¬ 
sance  to,  or  injurious  to  the  health  of 
any  person ;  Or  that  upon  any  such 
premises  swine,  or  an  accumulation  of 
dung,  manure,  offal,  filth,  refuse,  or 
other  matter  or  thing  are  or  is  kept  so 
as  to  be  a  nuisance  to,  or  injurious  to 
the  health  of  any  person ;  Or  that 
upon  any  such  premises  (being  a  build¬ 
ing  used  wholly  or  in  part  as  a  dwell¬ 
ing-house),  or  being  premises  under¬ 
neath  any  such  dwelling,  any  cattle  or 
animal  are  or  is  kept  so  as  to  be  a  nui¬ 
sance  to,  or  injurious  to  the  health  of 
any  person.’ 

“  Such  bodies  or  guardians,  or  some 
committee  thereof,  shall,  after  twenty- 
four  hours’  notice  in  writing  delivered 
to  some  person  on  the  premises,  or,  if 
there  be  no  person  there,  affixed  on 
some  part  of  the  premises  (or  in  case 
of  emergency  without  notice)  by  them¬ 
selves,  their  servants,  or  agents,  with 
or  without  medical  or  other  assistants, 
enter  and  examine  the  premises  with 
reference  to  the  matters  alleged  in  the 
notice  of  the  complainants,  and  do  all 
that  may  be  necessary  for  such  pur¬ 
pose  ;  and  if,  upon  such  examination, 
or  upon  the  certificate  of  two  legally 
qualified  medical  practitioners,  the 
existence  of  the  nuisance  appears,  such 
body  or  guardians  shall  thereupon  lay 
a  complaint  before  a  justice  of  the 
peace,  who  shall  summon  the  owner  or 


IN  -REFERENCE  TO  THE  MEDICAL  PROFESSION. 


679 


occupier  to  appear  before  two  justices 
to  answer  such  complaint.  Such  jus¬ 
tices  are  then  required,  if  the  existence 
of  the  nuisance  is  proved  to  their  satis¬ 
faction,  to  make  an  order  for  cleansing, 
whitewashing,  or  purifying  such  dwell¬ 
ing  house  or  building,  or  for  the  re¬ 
moval  or  abatement  of  the  cause  of 
complaint  in  such  manner  and  within 
such  time  as  shall  be  appointed. 

“This  order  is  to  be  served  in  the 
same  manner  as  the  summons,  and  if 
not  complied  with,  the  owner  or  occu¬ 
pier  against  wThom  it  is  made  will  lie 
liable  to  a  penalty  not  exceeding  10s. 
for  each  day  of  default,  and  the  guar¬ 
dians,  or  other  body  mentioned  therein, 
shall  themselves,  or  by  their  servants, 
enter  the  premises  and  cleanse  them 
or  remove  the  cause  of  complaint,  and 
do  all  that  may  be  necessary  for  carry¬ 
ing  such  order  into  effect. 

“Any  dung,  manure,  or  other  thing 
which  is  removed  may  be  destroyed  or 
sold,  and  if  sold  the  proceeds  shall  be 
paid  to  or  retained  by  the  guardians, 
and  shall  be  applied  by  them  in  aid  of 
the  poor  rate  of  the  place  in  which  the 
removal  shall  have  been  made. 

“  The  statute  provides,  in  section  16, 
that  whosoever  shall  wilfully  obstruct 
any  person  acting  under  the  authority 
or  employed  in  the  execution  of  the 
act  shall  be  liable  to  a  penalty  not 
exceeding  £5  for  each  offence. 

“  Section  3  provides  that  the  costs 
and  expenses  reasonably  incurred  in 
obtaining  the  order,  or  carrying  it  into 
effect,  may  be  recovered  from  the 
owner  or  occupier  of  the  premises  in 
respect  whereof  they  have  been  in¬ 
curred  as  a  debt  in  the  county  court, 
or  by  summary  process  before  two 
justices,  unless  such  justices  shall  think 
fit  to  excuse  such  person  upon  the 
ground  of  poverty  or  other  special  cir¬ 
cumstances. 

“By  section  7,  the  drainage  of  filth, 
&c.  from  houses  not  occupied  before 
the  4th  of  September,  1848,  into  open 
ditches  so  as  to  occasion  a  nuisance  to 
or  to  be  injurious  to  the  health  of  any 
person,  w  11  subject  the  occupier  to  a 
penalty  of  £5  per  day  during  the  con¬ 
tinuance  of  the  offence,  and  he  may 
also  be  indicted  for  a  misdemeanour. 
There  is  a  like  provision  with  respect 
to  drainage  from  waterclosets  or  privies 
constructed  after  the  4th  of  September, 
1848,  and  the  penalties  in  that  case 
will  attach  whether  the  privy  or 


watercloset  so  constructed  be  attached 
to  a  house  occupied  before  or  after  that 
day.”* 

The  eighth  section  introduces  a  new 
provision  in  reference  to  Hospitals  and 
Infirmaries.  No  hospital  can  be  here¬ 
after  built  or  opened  for  the  reception 
of  patients  labouring  under  contagious 
diseases,  until  due  notice  has  been 
given  to  the  General  Board  of  Health, 
and  it  will  rest  with  this  Board  to  de¬ 
termine  whether  they  will  grant  per¬ 
mission  that  the  hospital  shall  be  used 
for  such  a  purpose.  Considering  that 
the  lay  members  of  a  Board  of  Health 
can  hardly  be  competent  to  decide  a 
question  of  this  kind,  we  are  not  sur¬ 
prised  to  find  that,  by  the  eleventh 
section  of  the  Act,  there  is  a  power  of 
appointing  temporarily  one  fit  person 
to  be  a  medical  member  of  the  General 
Board  of  Health.  Our  readers  know 
that  this  appointment  has  been  already 
conferred  on  Dr.  Southwood  Smith; 
therefore  the  entire  responsibility  of 
working  the  Act  efficiently,  is  now 
thrown  upon  this  gentleman.  We 
think  it  would  have  been  more  credit¬ 
able  to  the  Government,  and  more 
satisfactory  to  the  profession,  had  the 
new  Board  of  Health  been  constituted 
solely  of  men  who  had  attained  emi¬ 
nence  in  the  medical  profession.  It 
wrould  be  regarded  as  preposterous  to 
appoint  a  committee  of  medical  men, 
assisted  by  one  military  member,  to 
superintend  the  affairs  of  the  Ordnance 
department ;  and  yet  the  present  con¬ 
stitution  of  the  General  Board  of 
Health  is  just  as  anomalous.  It  follows 
that  either  the  work  must  be  done 
badly,  or  a  very  undue  portion  of  it 
must  fall  on  the  solitary  medical  mem¬ 
ber.  In  either  case  the  objects  of  the 
act,  so  far  as  the  interests  of  the  public 
are  concerned,  are  likely  to  be  defeated 
by  the  adoption  of  such  an  unwise  and 
false  system  of  economy. 

*  Circular  of  the  Poor  Law  Board,  Somerset 
House,  Oct.  6th. 


680  STATE  OF  HEALTH  OF  THE  METROPOLIS — ZYMOTIC  DISEASES. 


The  fact  is,  the  Government  is  de¬ 
sirous  of  receiving  on  this,  as  on  other 
occasions,  the  gratuitous  services  of  the 
medical  profession.  There  appears  to 
be  a  mortal  aversion  on  the  part  of  our 
legislators  to  giving  well-paid  appoint¬ 
ments  to  medical  men,  even  when  cir¬ 
cumstances  may  fairly  justify  their 
creation.  Such  ill-paid  offices  as  those 
which  constitute  the  disgrace  of  the 
Poor  Lawr,  are  liberally  thrown  open  to 
them,  and  they  are  invited  to  compete 
until  their  salaries  reach  the  point  at 
which  starvation  begins.  Sanitary  acts 
are  passed,  and  the  chief  appointments, 
with  one  exception,  are  conferred  on 
men  who  are  unacquainted  with  those 
two  important  branches  of  medicine — 
hygiene,  and  medical  police,  without 
which  no  sanitary  legislation  can  be 
effectual. 

In  the  meantime,  the  following  let¬ 
ter,  recently  addressed  by  Dr.  Paris  to 
the  Lord  Mayor,  shews  that  the  Royal 
College  of  Physicians  is  now  perform¬ 
ing,  as  its  own  spontaneous  act,  that 
duty  which  should  have  been  at  once 
assigned  to  its  members  by  the  Govern¬ 
ment.  oj 

“  Dover  Street,  Oct.  12. 

“  My  Lord  Mayor, — Your  Lordship, 
I  feel  assured,  will  learn  with  satis¬ 
faction  that  the  College  of  Physicians 
has  appointed  a  standing  committee, 
consisting  of  the  physicians  of  the  great 
metropolitan  hospitals,  and  other  emi¬ 
nent  persons,  for  the  purpose  of  inviting 
and  considering  communications  on  the 
subject  of  cholera,  and,  if  necessary,  of 
suggesting  such  measures  and  precau¬ 
tions  as  may  appear  expedient  to  insure 
the  confidence  and  safety  of  the  public. 
I  have  the  honour  to  be,  my  Lord, 
Your  Lordship’s  obedient  servant, 
.8*>1A  lo  tioiJo 

President  of  the  Royal  College 
n  •»!  >ba  i 

To  the  Right  Hon.  the  Lord  Mayor.” 

It  would  appear  invidious  to  mention 
names,  but  there  are  many  connected 
with  this  College  who  should  have  been 
selected  as  paid  members  of  the  Gene¬ 
ral  Board  of  Health  in  preference  to 

■ 


the  unpaid  laymen  who  now  form  the 
majority  of  the  Board. 


The  fact  that  Asiatic  Cholera  is  noW 
in  the  metropolis  appears  to  be  placed 
beyond  doubt  by  the  united  testi¬ 
mony  of  many  competent  observers. 
It  cannot  be  said,  however,  as  yet  to 
have  manifested  any  epidemic  ten¬ 
dency.  The  cases,  considering  the 
denseness  of' the  population,  have  been 
comparatively  few,  and  almost  exclu¬ 
sively  confined  to  the  banks  of  the 
Thames  in  the  eastern  parts  of  London. 
It  is,  however,  satisfactory  to  know 
that,  if  we  have  this  formidable  disease 
superadded  to  those  which  may  be  con¬ 
sidered  as  located  among  us,  the  weekly 
mortality  is  far  below  the  autumnal 
average.  The  dreaded  scourge  does 
not  even  make  up  for  the  diminished 
fatality  of  more  common  diseases. 
The  deaths  in  the  week  ending  Octo¬ 
ber  14  were  991,  to  a  weekly  average 
of  1154 — a  difference  of  163  on  the 
total  mortality  in  favour  of  the  healthy 
condition  of  the  metropolis.  When, 
we  look  to  the  special  causes,  we  find 
that  zymotic  diseases  are  unusually 
prevalent.  The  deaths  were  448,  to 
an  average  of  270  ;  and  among  diseases 
of  this  class,  the  following  were  the 
most  fatal: — 


Scarlatina 

Deaths. 

.  .  188 

Weekly  av. 

47 

Small  Pox 

*  .  47 

19 

Diarrhoea 

.  .  37 

21 

Cholera  . 

.  .  30 

1 

Typhus  . 

.  .  80 

50 

Of  the  188 

deaths 

from 

Scarlet 

Fever ,  181  occurred  at 

the 

infantile 

period  of  life. 

The  majority  of  the 

deaths  from  Small- pox  and  Diarrhoea 
occurred  at  the  same  period.  But  with 
regard  to  Cholera  and  Typhus ,  the 
deaths  were  more  numerous  at  the 
adult  period  of  life.  Thus,  of  the  30 
fatal  cases  of  cholera,  20  took  place 
among  adults;  and  of  the  80  fatal 


CHART  OF  THE  PUBLIC  HEALTH.  THE  PREVENTION  OF  CHOLERA.  681 


cases  of  typhus,  47  were  registered  at 
this  period  of  life. 

In  looking  over  the  details  of  the 
cases  of  cholera,  we  find  that  those 
which  proved  most  rapidly  fatal  oc¬ 
curred  among  the  convicts  at  the 
Hulks.  The  shortest  of  these  termi¬ 
nated  fatally  in  four  hours  from  the 
time  of  seizure.  In  spite  of  these 
alarming  indications,  there  is  some 
consolation  in  knowing  that  the  fatality 
of  other  diseases  has  considerably 
abated. 

"We  have  elsewhere*  given  all  the 
details  which  have  reached  us  respect¬ 
ing  the  cholera  up  to  the  time  of  going 
to  press.  We  have  only  to  add,  that 
since  the  12th  inst.,  nine  cases  have 
occurred  at  Hull :  seven  of  these  proved 
fatal ;  two  on  board  of  vessels  lying  in 
the  river,  and  the  remaining  five  in 
the  town. 


jtfUbiefog, 

Chart  of  the  Public  Health  Act,  1848. 
By  C.  E.  Bernard,  C.E.  Bradbury 
and  Evans.  1848. 

A  most  useful  table,  in  one  sheet,  of 
all  the  provisions  of  this  important 
Act.  Medical  readers  are,  we  know, 
most  unwilling  to  wade  through  the 
verbose  technicalities  of  any  Act  of 
Parliament ;  and  they  will  here  find, 
in  an  intelligible  form,  all  the  informa¬ 
tion  which  they  require.  The  sheet  is 
divided  into  sections  of  clauses,  with 
titles  printed  in  red  letter,  and  the 
object  of  each  clause  is  plainly  marked 
in  distinct  black  letter,  so  that  refer¬ 
ence  to  any  part  of  the  Act  is  rendered 
remarkably  easy.  This  Chart  will  be 
of  great  service  to  all  who  are  in¬ 
terested  in  sanitary  reform. 

Plain  Rules  for  Preventing  and  Treat¬ 
ing  the  Cholera.  Drawn  up  by  R. 
Druitt,  F.R.C.S.  London  :  Ren- 
shaw.  1848. 

Mr.  Druitt  has  here  placed  on  a  few 
square  inches  of  paper,  some  hygienic 


rules  regarding  self-management  and 
treatment  during  the  prevalence  of 
cholera.  It  is  adapted  for  popular 
readers.  We  are  glad  to  perceive  that 
the  first  rule  is  to  “  send  for  the 
doctor.” 

An  Inquiry  into  the  Proximate  Cause  of 

Gout,  and  its  rational  Treatment.  By 

Anthony  White,  Esq.,  M.B.,  Cam¬ 
bridge,  late  President  of  the  Royal 

College  of  Surgeons  of  England. 

Pamphlet,  8vo.  London,  pp.  20 : 
Churchill.  1848. 

Dr.  White  has  here  reprinted,  in  the 
form  of  a  pamphlet,  an  article  which 
has  only  recently  appeared  in  our 
pages.  Under  common  circumstances, 
it  would  not  be  necessary  for  us  to  do 
more  than  announce  its  publication ; 
but  we  are  induced  to  call  the  attention 
of  our  readers  to  the  subject,  as  the 
author  challenges  inquiry  with  respect 
to  his  theory  of  the  cause  of  gout,  and 
the  action  of  remedies  in  its  treatment. 
Dr.  White’s  suggestions  are  also  deserv¬ 
ing  of  especial  notice,  if  only  for  the 
fact  that  he  has  himself  been  a  martyr 
to  this  disease,  and  has  gone  through 
all  kinds  of  medical  discipline  to  re¬ 
move  its  attacks.  He  states,  that  so 
far  as  his  own  experience  is  concerned, 
the  only  plan  which  has  proved  suc¬ 
cessful  has  consisted  in  the  use  of 
those  remedies  which  tend  to  increase 
the  flow  of  bile.  He  believes  that  the 
proximate  cause  of  gout  consists  in  a 
functional  disturbance  of  the  liver,  and 
that  unless  this  be  removed  by  the  free 
administration  of  calomel  and  similar 
medicines,  the  disease  will  not  be  cured. 
He  has  long  exclusively  relied  for  the 
cure  of  gout  on  the  following  prescrip¬ 
tion  : — Hyd.  Chloridi;  Ext.  Colch. 
Acet.;  Ext.  Aloes  purif. ;  Pulv.  Ipeca¬ 
cuanha,  aa.  gr.  i.  M.  ut  fiat  pil. 
4tis  horis  sumenda.  Two  or  three  of 
these  pills  are  generally  enough  to  act 
freely  on  the  liver,  and  this  action  is 
then  aided  by  one  or  two  doses  of  the 
compound  Decoction  of  Aloes.  As  the 
symptoms  become  abated,  the  pills  may 
be  administered  at  intervals  of  from 
eight  to  twenty-four  hours.  The  good 
effects  of  all  the  preparations  of  colchi- 
cum  he  ascribes  entirely  to  the  action 
of  this  medicine  in  increasing  the 
hepatic  secretion. 

Both  the  theory  and  mode  of  treat¬ 
ment  are  simple.  The  real  question 
is,  how  far  the  views  of  the  author  will 


*  Fage6fc5, 


682 


DISCUSSION  ON  THE  TREATMENT  OF  CHOLERA. 


be  corroborated  by  the  experience  of 
others.  His  plan  is  certainly  deserving 
of  a  trial. 

The  pamphlet  is  sensibly  written, 
concise,  logical,  and  to  the  purpose. 
Dr.  White  deserves  great  credit  for 
compressing  what  he  has  to  say  in 
twenty  pages.  We  feel  certain  that 
many  medical  gentlemen,  beginning 
practice,  would,  w7ith  no  larger  stock 
of  materials,  have  contrived  to  expand 
their  thoughts  and  opinions  into  a 
good-sized  octavo  volume. 


^romtitngs  of  jfeodetteg. 

MEDICAL  SOCIETY  OF  LONDON. 
Monday,  October  9,  1848. 

Mr.  Hancock,  President. 


Cholera. 

Dr.  Clutterbuck  said  he  had  been  in¬ 
formed  by  Dr.  Pereira  that  a  decided  case 
of  cholera  had  occurred  in  the  London  Hos¬ 
pital,  he  therefore  did  not  question  that  the 
disease  now  existed  in  London.  He  should 
be  glad  to  hear  the  opinion  of  fellows  of  the 
Society  as  to  the  best  mode  of  treatment : 
he  had  himself  seen  many  plans  tried,  but 
had  never  satisfied  himself  of  their  success. 
He  was  inclined  to  take  a  common  sense 
view  of  the  subject  and  palliate  the  symp¬ 
toms,  and  trust  to  time  for  the  result :  as 
to  any  remedies  being  specific,  he  was  scep¬ 
tical.  If  the  patient  were  cold,  he  should 
apply  heat,  and  give  stimulants,  as  brandy, 
ammonia,  &c. ;  if  there  was  vascular  excite¬ 
ment,  he  should  treat  it  on  a  moderate  anti¬ 
phlogistic  plan  ;  if  there  was  pain,  he  should 
give  opium,  as  under  other  circumstances. 
As  to  attempting  to  cure  the  disease 
by  calomel  and  opium,  by  oil  of  turpen¬ 
tine,  naphtha,  &c.,  he  should  not  be  inclined 
to  resort  to  them,  as  no  pathological  view 
was  given  as  a  reason  for  their  use.  He  was 
inclined  to  think  that  cholera  was  not  con¬ 
tagious,  as  scarlatina  or  small-pox,  but 
caused  by  an  atmospheric  influence.  The 
organs  principally  affected  were  those  con¬ 
nected  with  the  spinal  nervous  system ;  the 
effect  was  something  like  that  of  strychnine, 
appearing  to  affect  the  spinal,  in  contradis¬ 
tinction  to  the  central,  nervous  system. 

Dr.  Leonard  Stewart  said  the  most 
staggering  objection  to  the  non-contagion  of 
cholera  was,  that  it  always  appeared  first  in 
seaports,  although,  at  the  same  time,  local 
circumstances  might  occur  to  cause  it  in 


seaports  as  well  as  in  other  places.  He  had 
seen  one  plan  of  treatment  successful,  which 
was  suggested  to  him  by  a  friend  who  had 
been  long  in  the  East  Indies  ;  he  tried  it  in 
one  decided  case.  Six  grains  of  tartarized 
antimony  were  dissolved  in  warm  water,  and 
half  given,  and  repeated  in  half  an  hour: 
the  first  dose  increased  the  symptoms,  the 
second  threw  the  patient  into  a  violent  heat 
and  perspiration,  and  in  ten  minutes  he  was 
a  changed  man,  and  got  quite  well  without 
further  treatment.  This  was  the  only  case 
he  had  treated  on  this  plan,  but  his  friend 
had  used  it  frequently.  As  to  opium,  and 
other  plans  of  treatment,  he  had  no  faith  in 
them. 

Dr.  Chowne  had  seen  much  of  cholera, 
and  thought  cases  were  likely  to  occur, 
owing  to  the  damp  weather,  and  the  un¬ 
natural  temperature  which  had  existed  for 
some  time ;  but  he  hoped  the  cases  alluded 
to  were  only  cases  of  the  cholera  of  this 
country.  He  wished  to  know  if  Dr.  Clut¬ 
terbuck  had  seen  cold  water  tried.  At  the 
close  of  the  disease  it  appeared  more  cases 
recovered  under  that  plan  than  any  other. 

Dr.  Clutterbuck  said,  the  period  at 
which  it  was  tried  might  account  for  this, 
these  maladies  coming  on  and  going  off  gra¬ 
dually. 

Mr.  Hird  inquired  if  the  tartarized 
antimony  increased  the  vomiting  in  Dr. 
Stewart’s  cases. 

Dr.  Stewart  said  it  did  at  first,  so  much 
so  that  the  man  said,  “You’ve  killed  me;” 
but  it  afterwards  threw  him  into  a  profuse 
perspiration,  and  he  merely  directed  warm 
tea  to  be  given  occasionally  ;  no  other  treat¬ 
ment  was  required. 

Mr.  Hird  had  seen  much  of  cholera  on  a 
former  occasion,  in  the  north  of  England  and 
in  Dublin,  and  it  appeared  to  him  to  be 
contagious  under  certain  circumstances;  he 
had  seen  cold  water  tried  very  largely,  and 
in  these  cases  the  disease  did  not  seem  to  be 
followed  by  the  consecutive  fever  which 
killed  so  many  of  the  patients  treated  by 
calomel  and  opium.  He  should  be  inclined 
to  try  mustard  emetics,  repeated  every  hour 
or  half-hour,  as  they  did  not  depress  the  sys¬ 
tem  like  tartarized  antimony.  He  should 
also  apply  mustard  poultices,  hot  bottles, 
and  frictions  of  warm  turpentine,  in  the  later 
stages,  to  check  the  enormous  secretion  from 
the  bowels.  He  should  give  two  grains  of 
acetate  of  lead,  and  half  a  grain  of  opium, 
every  hour  or  two,  for  a  few  times.  He 
never  saw  calomel  do  any  good.  A  friend  of 
his  had  recommended  carbon  in  these  cases; 
and  it  was  a  fact  that  the  cholera  did  not 
visit  many  of  the  places  where  there  were 
springs  containing  carbonic  acid  gas.  He 
had  certainly  seen  great  relief  from  effer¬ 
vescing  draughts  containing  carbonic  acid 
gas. 


STATE  OF  THE  SECRETIONS  IN  CHOLERA. 


688 


Mr.  Pilcher  said  that  drainage  had  a 
great  effect  in  preventing  cholera,  and  con¬ 
trasted  Birmingham,  which  was  well  drained, 
and  escaped  easily,  with  Walsall,  which  was 
low,  and  ill  drained,  where  great  numbers 
perished.  He  did  not  consider  cholera  con¬ 
tagious,  it  was  rather  epidemic.  He  had 
found  opium  the  best  remedy — without  de¬ 
pressing  or  narcotizing  the  system — but 
given  to  arrest  purging,  and  assist  the  secre¬ 
tion  of  the  kidneys.  He  had  often  observed 
that  there  was  a  peculiar  expression  in  the 
countenances  of  cholera  patients,  indicating 
whether  the  patient  would  die  or  not.  There 
was  no  pain  in  severe  cases,  the  nervous  sys¬ 
tem  being  too  much  depressed.  The  saline 
treatment  with  oxymuriate  of  potassa  and 
opium  seemed  to  arrest  purging,  and  restore 
the  secretion  of  the  kidneys.  Where  urine 
was  secreted,  the  patient  generally  did  well. 
Jeremy’s  specific — a  valuable  preparation  of 
opium,  made  with  water — was  considered  a 
specific  in  India.  He  soon  gave  up  giving 
calomel,  as  he  thought  it  always  injurious. 

Mr.  Hird  mentioned  that  petroleum  had 
been  stated  to  be  a  specific. 

Dr.  Chowne  considered  cholera  was  con¬ 
tagious,  but  not  very  contagious.  He  men¬ 
tioned  a  case  which  supported  the  views  of 
the  contagionists.  A  person  spent  the  night 
at  an  hotel  in  Newcastle,  where  a  commer¬ 
cial  traveller  had  died  of  cholera.  He 
returned  home,  next  day,  to  a  healthy  dis¬ 
trict,  where  the  cholera  had  not  appeared. 
He  took  the  disease,  and  his  brother,  and 
four  or  five  other  persons  in  the  same  house. 
A  passage  to  a  manufactory  ran  through  his 
house,  and  many  persons  who  were  in  the 
habit  of  passing  this  passage  took  the  disease, 
and  no  one  in  the  village  took  the  cholera 
who  had  not  come  in  contact  with  some  of 
them. 


ACADEMY  OF  SCIENCES,  PARIS. 

State  of  the  Secretions  in  Cholera. 

M.  Burguieres,  sanitary  physician  at 
Smyrna,  communicated  to  the  Academy  a 
notice  of  the  remarks  he  had  the  opportunity 
of  making  on  the  alkaline  state  of  certain 
liquids  of  the  human  body  in  cholera  morbus. 
M.  Andral  communicated  to  the  Academy, 
in  the  month  of  June  last,  a  notice  of  his 
researches,  from  which  it  would  appear  to 
result  that  the  different  liquids  of  the  animal 
economy,  present  in  the  nature  of  their  reac¬ 
tion,  whether  acid  or  alkaline,  a  constancy 
greater  than  had  been  supposed. 

M.  Andral  considered  himself  justified 
in  establishing,  as  a  principle,  that,  “  the 
immutability  of  the  secretion  of  the  alkaline 
and  acid  principles  of  the  animal  humours, 
is  a  law  of  the  physiological,  as  well  as  of  the 
pathological  state.”  Having  at  the  present 
time  an  opportunity  of  observing  the  cholera 


at  Smyrna,  M.  Burguieres  hastened  to  ex¬ 
amine  if  the  law  established  by  M.  Andral 
found  a  confirmation  in  that  disease:  this 
examination  has  led  to  certain  results,  which 
we  now  proceed  to  point  out. 

The  blood  taken  from  the  vessels  during 
life,  or  examined  in  the  bodies  a  few  hours 
after  death,  did  not  appear  to  him  to  vary  in 
its  reaction,  which  was  evidently  alkaline. 

In  the  earlier  stage  of  the  cholera,  the 
perspiration  is  almost  suppressed.  In 
the  subsequent  stage,  it  assumes  the  charac¬ 
ter  of  a  cold  viscous  coating ;  this  viscous 
perspiration  loses  its  normal  acidity,  but 
does  not  become  alkaline  :  it  has  constantly 
been  found  neutral.  In  the  period  of  reac¬ 
tion,  the  perspiration  becomes  acid  :  this  is 
usually  a  good  sign.  The  liquids  from  the 
stomach,  and  the  mucous  membrane  which 
spreads  over  that  organ,  presented  to  M. 
Burguieres  notable  modifications  in  the 
mode  of  reaction. 

M.  Andral  has  almost  constantly  found 
the  vomited  matters  to  be  acid,  as  well  as 
the  mucous  membrane  itself :  very  rarely 
this  membrane  appeared  to  him  neutral : 
never  did  it  offer  an  alkaline  reaction. 

M.  Burguieres  has  observed,  that  from 
the  very  first  the  vomited  matters  were  evi¬ 
dently  acid :  these  matters  contained  in 
every  case  remains  of  food  which  had  under¬ 
gone  the  commencement  of  digestion.  When 
the  patients  had  vomited  three  or  four  times, 
the  natural  acidity  of  the  matters  vomited 
disappeared,  and  gave  place  to  a  reaction 
manifestly  alkaline.  This  reaction  existed 
in  the  case  where  the  vomited  matters  as¬ 
sumed  the]  white  and  flocculent  appearance, 
which  characterizes  in  an  especial  manner 
the  evacuations  of  cholera  patients.  When, 
after  death,  he  examined  the  liquids  found 
in  the  stomach,  M.  Burguieres  found  them  to 
be  equally  alkaline,  even  though  it  some¬ 
times  happened  that  there  were  remains  of 
food  in  the  midst  of  these  liquids.  As  to 
the  mucous  membrane  of  the  stomach  itself, 
M.  Burguieres  has  observed  that,  amongst 
the  patients  which  fell  victims  to  the  cholera, 
that  membrane  presented,  instead  of  its  nor¬ 
mal  acid  reaction,  a  reaction  clearly  alka¬ 
line. 

The  alvine  evacuations,  as  well  also  as  the 
matters  found  in  the  intestines  after  death, 
were  alkaline.  M.  Burguieres  has  found 
the  same  reaction  in  different  parts  of  the 
intestinal  canal.  It  is  well  known  that  the 
secretion  of  urine  is  almost  always  suppressed 
in  cholera.  M.  Burguieres  has  examined 
the  urine  found  in  the  bladder  after  death : 
it  possessed  its  normal  acidity.  In  one  case 
he  found  in  the  bladder,  instead  of  urine,  a 
small  quantity  of  whitish  mucous  matter. 

“  En  resume,”  says  M.  Burguieres,  “I 
have  found  in  cholera  patients  the  normal 
acid  reaction  suspended  at  the  surface  of  the 


684  ATTEMPT  TO  POISON  BY  PHOSPHURETTED  HYDROGEN  GAS. 


skin,  and  replaced  in  the  stomach  by  an  al¬ 
kaline  reaction.  It  is,  without  doubt,  the 
index  of  a  great  disturbance  in  the  equilibrium 
of  the  secretions — a  disturbance  which  does 
not  appear  to  be  found  in  any  other  disease.” 
“  I  would  not  hastily,”  continues  M.  Bur¬ 
guieres,  “  base  on  these  results  a  chemico- 
pathological  theory,  and  deduce  from  it  a 
special  mode  of  treatment ;  but  I  think 
that  the  facts  I  have  observed  indicate  the 
utility  of  the  administration  of  acid  drinks 
in  cholera.  It  may  also  be,  that  the  modi¬ 
fications  which  operate  in  the  mode  of  re¬ 
action  of  such  liquids  of  the  body,  are  only  a 
very  secondary  effect  of  the  cholera  poison. 
To  speak  only  of  the  remarkable  change 
which  I  have  met  with  in  the  stomach,  a 
completely  physiological  explanation  may  be 
given  to  it ;  that  which  principally  prevails 
in  the  cholera  is  a  morbid  determination 
towards  the  digestive  apparatus.  This  deter¬ 
mination,  whatever  may  be  its  nature,  is  the 
same  through  all  parts  of  the  digestive  appa¬ 
ratus.  The  result  is,  that  the  special  func¬ 
tional  reactions  are  suspended  and  replaced 
by  the  uniform  secretion  of  a  liquid  which 
is  probably  nothing  more  than  the  serum  of 
the  blood,  and  which  possesses  an  alkaline 
reaction.  It  may  readily  be  understood 
that  this  reaction  is  communicated  to  the 
membrane,  which,  throughout  its  whole  ex¬ 
tent,  allows  the  exudation  of  a  liquid  in  all 
respects  identical. 

On  the  other  hand,  and  in  opposition  to 
the  idea  started  by  M.  Burguieres,  a  letter 
was  received  by  the  Academy,  at  the  same 
sitting  (the  illegible  signature  to  which  ren¬ 
ders  it  impossible  to  give  the  author’s  name), 
maintaining  an  observation  which  would 
appear  to  confirm  those  already  related  by 
M.  Baudrimont,  and  from  which  he  has 
considered  himself  authorized  to  recommend 
the  employment  of  bicarbonate  of  soda,  as 
giving  useful  results  in  the  treatment  of 
cholera.  In  the  case  mentioned  in  this 
letter,  2  or  3  grammes  (30  to  45  grains)  of 
bicarbonate  of  soda,  in  a  glass  of  water,  had 
arrested  at  Ispahan,  in  October  1847,  an 
attack  of  cholera  already  arrived  at  the  icy 
cold  state.  The  communication  of  M. 
Baudrimont  above  referred  to  was  presented 
to  the  Academy  a  few  weeks  since.  In  this 
communication,  M.  Baudrimont  mentioned 
the  great  success  which  he  had  found  to 
follow  the  undermentioned  mode  of  treat¬ 
ment  during  the  prevalence  of  the  cholera  in 
the  neighbourhood  of  Valenciennes,  in  1832. 

For  internal  use. — A  hot  and  copious  in¬ 
fusion  of  the  flowers  of  the  lime  or  linden 
tree,  with  4  to  8  grammes  (60  to  120  grains) 
of  bicarbonate  of  soda  in  each  quart. 

For  external  application.  —  Extensive 
mustard  poultices  to  the  lower  extremities, 
and  continued  friction  with  a  liniment 
formed  of  equal  parts  of  oil  and  ammonia. 


At  the  sitting  of  last  Monday,  M.  Pap- 
penheim  addressed  a  note  to  the  Academy, 
disputing  the  proposition  of  M.  Burguieres, 
that  in  cholera  morbus  the  secretions  of  the 
mucous  membrane  entirely  change  the  na¬ 
ture  of  their  chemical  reactions. 


J&etucal  trials  sub  Inquests. 


TRIAL  FOR  ATTEMPTING  TO  POISON  A  FA¬ 
MILY  BY  PHOSPHURETTED  HYDROGEN 

GAS. 

Middlesex  Sessions,  Oct.  14. 

John  Dolby,  a  practical  chemist  at  298, 
Strand,  was  indicted  for  a  misdemeanour, 
“  by  placing  certain  noxious  matter  near  the 
door  of  a  certain  room  occupied  by  Sarah 
Wild  and  her  children,  whereby  they  were 
rendered  ill,”  &c. 

Mr.  Prendergast  conducted  the  prosecu¬ 
tion,  and  Mr.  O’Brien  appeared  for  the  de¬ 
fendant. 

It  appeared  that  the  defendant  had  suc¬ 
ceeded  to  the  business,  as  a  practical  che¬ 
mist,  of  a  Mr.  Maclachlan,  at  the  house  in 
question,  in  which  the  prosecutor,  a  wood- 
engraver,  and  his  wife,  with  their  family, 
took  apartments  in  the  month  of  June  last. 
In  the  early  part  of  the  past  month  some 
differences  arose  between  the  wives  of  the 
respective  parties,  in  the  course  of  which  it 
was  stated  Mrs.  Wild  had  applied  the  epi¬ 
thet  “  scum”  to  Mrs.  Dolby,  which,  coupled 
with  causes  of  a  pecuniary  character,  deter¬ 
mined  Mr.  Dolby  to  endeavour  to  get  rid  of 
these  lodgers.  Finding  that  no  other  means 
succeeded,  the  defendant  caused  his  appren¬ 
tice  to  put  some  chemical  matters  into  a  pot, 
and  having  set  it  on  fire,  then  to  place  it 
close  to  the  door  of  the  room  which  was  in 
the  occupation  of  the  prosecutor’s  family. 
The  result  was,  that  a  gas  of  the  most  noxious 
character  was  evolved,  so  that  in  a  very  few 
minutes,  not  only  Mrs.  Wild,  but  all  the 
children,  were  nearly  suffocated.  They  re¬ 
mained  very  ill  for  some  days,  and  Mrs. 
Wild  became  extremely  so,  as  she  had  not 
long  been  out  of  her  confinement. 

Dr.  Miller,  professor  of  chemistry,  had 
examined  the  matter  which  had  been  used 
by  the  defendant,  and  stated  that  it  was  the 
phosphuret  of  calcium  mixed  with  muriatic 
acid.  The  effect  of  the  latter  was  to  decom¬ 
pose  the  former,  and  thereby  to  evolve  a 
gaseous  substance  termed  phosphuretted 
hydrogen.  This  last-named  gas  was  one  of 
the  most  obnoxious  and  offensive  of  all  the 
gases,  and  if  used  in  any  quantity  was  de¬ 
cidedly  injurious  to  health.  There  could  be 
no  doubt  but  that  the  symptoms  which  the 
family  of  the  prosecutor  had  exhibited  had 
been  caused  by  the  step  the  defendant  had 


THE  CHOLERA  IN  THE  METROPOLIS. 


685 


taken.  It  was  not  chloride  of  calcium,  but 
phosphuret  of  calcium  ;  for  if  it  had  been 
the  former,  it  would  not  have  acted  as  a  de¬ 
composing  agent,  as  it  was  in  truth  an  “  in¬ 
ert  salt.” 

Mr.  O’Brien  made  a  powerful  speech  to 
the  jury  on  behalf  of  the  defendant. 

The  learned  Judge,  in  leaving  the  case  to 
the  jury,  said,  he  must  ask  them  to  say 
whether,  in  their  opinion,  the  defendant  had 
by  himself,  or  another  by  his  order,  placed 
this  mixture  at  the  door  of  the  prosecutor’s 
room  with  the  intention  of  doing  an  injury 
to  their  health,  or  whether  it  had  been 
placed  there  simply  as  an  annoyance,  with 
the  view  of  getting  rid  of  the  family  from 
the  house. 

The  jury  having  consulted  for  a  few  mi¬ 
nutes,  said  that  the  defendant  was  guilty  of 
having  placed  the  mixture  at  the  door,  but 
that  he  had  not,  in  their  opinion,  done  so 
with  any  intention  of  doing  the  parties  harm. 

Mr.  Prendergast  said,  that  virtually  this 
was  a  verdict  of  “  Not  Guilty,”  for  he  could 
not,  upon  such  a  finding,  move  for  judg¬ 
ment. 

A  verdict  of  Not  Guilty  was  therefore 
entered. 


©oiTTsponbcnce. 


REMARKS  ON  THE  CHOLERA. 

Sir, — Let  the  absolute  nature  of  cholera 
be  as  undecided  by  the  profession  now  as  it 
was  in  1832  ;  I  think,  nevertheless,  that  it 
behoves  every  one  to  cast  his  mite  of  know¬ 
ledge  into  the  treasury  of  treatment  so  far 
as  he  can  ;  and,  as  the  disease  seems  to  be 
gradually  advancing  upon  us,  and  amidst  a 
variety  of  opinions  published  as  to  the 
il  best  course  to  be  pursued,”  no  mention 
has  fallen  under  my  notice  of  a  plan  I  saw 
to  be  the  only  one  successful  of  the  many 
that  were  practised  in  1832,  I  beg  to  trou¬ 
ble  you  with  it,  and  recal  it  to  the  minds  of 
some  of  your  readers,  who  no  doubt  treated 
the  disease  in  like  manner,  and,  I  hope, 
with  the  same  amount  of  success  as  I  wit¬ 
nessed  in  nearly  twenty  cases. 

All  the  symptoms ,  as  well  as  the  effects , 
of  cholera,  in  my  humble  opinion,  draw  to 
the  conclusion  that  the  portal  portion  of  the 
circulatory  system  is  the  domicile  of  the 
choleraic  poison,  or  the  part  on  which  it 
seems  to  vent  all  its  rage,  and  from  which 
all  its  destructive  effects  to  the  system  at 
large  emanate  ;  and  I  observed,  with  this 
view  of  its  nature,  that,  if  summoned  to  a 
case  before  collapse  had  set  in,  and  bleeding 
was  immediately  practised,  that,  with  the 
aid  of  mustard  poultices  over  the  regions  of 
the  heart  and  liver  externally,  and  calomel, 


with  opium  given  internally,  the  patients 
generally  recovered  ;  but  if  the  stage  of  col¬ 
lapse  had  been  allowed  to  supervene,  they 
nearly  all  died. 

As  for  the  treatment  recommended  in  the 
daily  papers,  and  supposed  to  come  from 
the  Board  of  Health,  it  no  doubt  is  very 
good  for  ordinary  English  cholera  ;  but  I 
should  not  anticipate  much  benefit  if  pur¬ 
sued  with  cases  of  true,  or,  as  the  French 
would  say,  the  “  veritable ,”  cholera,  which 
we  are  all  so  much  dreading. — I  am,  sir, 
Your  obedient  servant, 

Albert  Owen. 

Aylesbury,  Oct.  16,  1848. 


JMetucal  Intelligence. 


THE  CHOLERA  IN  THE  METROPOLIS. 

There  were  four  cases  of  cholera  reported 
on  Monday  in  the  metropolis.  There  were 
scattered  cases  reported  as  having  occurred 
in  the  eastern  ports  to  seamen  from  the 
Baltic.  Eleven  cases  were  reported  on 
Tuesday  in  the  metropolis,  making  fifteen 
cases  in  addition  to  those  reported  by  the 
Registrar- General  up  to  Saturday.  Active 
exertions  were  making  in  several  districts 
by  the  local  authorities. 

THE  CHOLERA  ON  THE  RIVER. 

The  only  accounts  of  new  cases  of  cholera 
officially  reported  on  Sunday  were  from  the 
Thames  police,  of  two  sailors  just  arrived  in 
the  river.  One  was  from  Sunderland,  who 
was  attacked  at  8  o’clock  on  Friday  evening, 
and  died  at  half-past  2  in  the  morning.  The 
other  arrived  from  North  Shields.  In  this 
case  the  attack  commenced  at  4  o’clock  on 
Friday,  and  terminated  fatally  before  morn¬ 
ing.  Inquests  were  held  in  these  cases,  and 
the  medical  evidence  left  no  doubt  that  the 
deaths  were  caused  by  malignant  cholera. 
The  police  have  hitherto  entirely  escaped. 

THE  CHOLERA  IN  BIRMINGHAM. 

Oct.  16. — A  case  of  decided  Asiatic  cho¬ 
lera  is  said  to  have  occurred  in  this  town 
last  night.  Mr.  John  Cheetham,  a  clerk  in 
the  bank  of  Messrs.  Attwood  and  Spooner, 
was  seized  with  unequivocal  symptoms  on 
Saturday  evening,  and  expired  on  Sunday 
night.  Mr.  Cheetham  was  attended  by  Dr. 
Wright,  Mr.  Chavasse,  and  Mr.  Blake,  and 
no  doubt  is  entertained  of  the  disease  being 
Asiatic  cholera.  The  deceased  was  a  healthy 
person,  of  regular  habits,  and  resided  in 
George  Street,  Edgbaston,  considered  to  be 
a  very  healthy  part  of  the  town. 

THE  CHOLERA  AT  UXBRIDGE. 

It  is  reported  that  four  cases,  confidently 
stated  to  be  of  Asiatic  cholera,  were  notified 


686  CHOLERA  AT  WOOLWICH,  GRAVESEND,  EDINBURGH,  AND  HULL. 


at  Uxbridge  on  the  13th  instant.  In  Lon¬ 
don,  on  the  same  day,  there  were  scattered 
attacks,  and  very  numerous  cases  of  diar¬ 
rhoea,  but  no  fatal  cases. 

THE  CHOLERA  IN  THE  HULKS. 

Woolwich,  Oct.  15. — The  disease  still 
continues  on  board  the  Justitia  convict-ship, 
opposite  the  Royal  arsenal,  the  number  re¬ 
ported  up  to  12  o’clock  on  Saturday  being 
28  attacked  since  the  commencement,  there 
being  3  new  cases  in  the  Saturday’s  report 
and  one  death,  making  in  all  6  deaths. 
There  were  3  new  cases  reported  up  to  12 
o’clock  to-day,  making  a  total  of  31  at¬ 
tacked,  6  deaths,  and  5  recovered.  The 
others  are  not  yet  considered  to  be  out  of 
danger.  Fortunately  there  has  not  been  a 
single  case  recorded  by  any  of  the  medical 
practitioners  in  the  town  and  parish,  and 
not  the  least  symptoms  of  the  cholera  on 
board  the  Warrior  convict-ship,  opposite 
the  dockyard,  although  the  food,  confine¬ 
ment,  and  general  regulations  of  both  the 
convict  ships  are  the  same.  The  peculiarity 
of  the  disease  being  so  exclusively  confined 
to  one  vessel  induced  us  to  ask  if  it  was 
more  severe  in  one  part  of  the  hulk  than  the 
other,  and  the  reply  was,  that  the  whole  of 
the  cases  originated  in  the  lower  deck,  on 
the  starboard  side  and  stern  of  the  Justitia ; 
that  part  being  exactly  opposite  the  mouth 
of  a  sewer,  which  empties  itself  into  the 
Thames.  Surely,  when  that  fact  becomes 
known  to  the  authorities,  they  will  not  lose 
a  moment  in  having  the  vessel  removed  from 
her  perilous  position,  or  if  that  cannot  be 
done  for  a  few  days,  the  unfortunate  con¬ 
victs  should  be  removed  on  shore  to  some 
temporary  and  secluded  barrack,  where  they 
would  run  less  risk  of  being  attacked  by  the 
disease. 

Oct.  16. — There  have  been  4  new  cases 
since  12  o’clock  yesterday,  making  in  all 
35  cases  of  attack.  There  has  been  one 
death  to-day,  and,  the  names  of  those  who 
died  of  cholera  having  been  returned,  it  ap¬ 
pears  that  eight  have  died  of  the  disease. 
The  following  are  their  names  and  the  date 
of  the  days  on  which  they  died  : — October 
3rd,  Owen  Jones;  7th,  John  Rutherford 
and  James  Jones ;  8th,  James  Bigwood ; 
10th,  John  Debank ;  13th,  George  Mitchell ; 
14th,  William  Eastman ;  16th,  Edward 
Devine.  The  number  of  recoveries  return¬ 
ed  are  five,  being  the  same  as  yesterday. 
No  cases  or  the  least  appearance  of  cholera 
have  been  returned  by  the  medical  practi¬ 
tioners  in  the  town  and  parish  of  Woolwich 
up  to  12  o’clock  to-day  ;  so  that  the  disease 
is  still  exclusively  confined  to  the  Justitia 
convict  hulk. 

THE  CHOLERA  AT  GRAVESEND. 

Oct.  15. — Yesterday,  as  the  William  and 
Mathew,  of  Sunderland,  was  proceeding 


down  the  river  from  London  for  Sunder¬ 
land,  and  when  off  this  place,  Mr.  Saunders 
was  summoned  on  board  to  see  the  captain, 
whom  he  found  in  the  last  stage  of  Asiatic 
cholera,  and  who  lived  but  a  few  hours 
after  the  medical  gentleman  had  used  all  the 
appliances  necessary  for  a  patient  in  such  a 
stage  of  this  dreadful  disease.  Immediately 
the  man  died  the  vessel  was  directed  by  the 
Custom-house  authorities  to  proceed  on  her 
voyage,  and  instructions  were,  as  we  learn, 
given  to  the  mate  and  crew  to  commit  the 
corpse  to  the  deep  on  reaching  the  open 
sea. 

THE  CHOLERA  IN  EDINBURGH. 

From  the  information  received  in  town,  it 
still  appears  that  the  progress  of  the  disease 
was  marked  and  decided  in  Edinburgh  and 
its  neighbourhood.  The  following  were  the 
cases  reported  of  Asiatic  cholera  from  the 
4th  to  the  16th  inst.,  and  examined  by  the 
local  authorities  : — 


No.  of 

Died. 

Reco¬ 

Remain¬ 

cases. 

vered. 

ing. 

In  Edinburgh  .  42 

34 

6 

2 

Newhaven  .  21. 

15 

5 

1 

Leith  .  .27 

16 

3 

8 

Total  .  .90 

65 

14 

11 

On  Friday  two  cases  of  this  pestilence  oc¬ 
curred  in  the  Canongate,  and  one  in  the 
Grass-market,  all  of  which  proved  fatal.  On 
Saturday  a  young  woman  in  the  Grass- 
market  was  seized,  but  she  is  recovering. 
On  Sunday  there  were  two  cases  reported  in 
Gladstone's  Close,  Canongate,  one  of  which 
terminated  in  death.  One  or  two  more 
cases  were  announced  yesterday,  but  the 
disease  is  apparently  on  the  decline  in  the 
city.  Unfortunately,  however,  it  has  made 
its  appearance  in  Leith,  where,  during  the 
last  three  days  of  the  week,  seven  or  eight 
!  fatal  cases  occurred.  On  Sunday,  two  were 
added  to  this  list,  one  of  whom  was  a  sca¬ 
venger,  who  was  at  his  work  in  the  morning, 
and  a  corpse  in  the  afternoon.  Yesterday 
there  were  four  cases,  and  it  was  feared  that 
they  would  all  prove  fatal. 

THE  CHOLERA  AT  HULL. 

Since  our  last  report  a  fatal  case  of  cholera 
has  occurred  on  board  a  Danish  vessel, 
named  the  Catharina  Maria,  Hansen,  from 
Odense,  which  arrived  in  this  port  on  the 
28th  ult.  The  deceased  was  one  of  the 
crew,  named  Christian  Bruhn,  and  at  the 
time  of  the  occurrence  the  vessel  was  lying 
in  the  Humber  Dock.  The  unfortunate 
man  was  taken  suddenly  ill  on  Monday 
morning,  and  died  on  Tuesday.  As  the 
vessel  was  about  to  sail  that  day,  Mr.  Burt, 
the  Customs  inspector  of  the  river,  directed 
the  captain  to  keep  the  body  on  board  until 


THE  EDINBURGH  COLLEGE  OF  PHYSICIANS  ON  THE  CHOLERA.  687 


he  got  to  sea,  and  then  throw  it  overboard, 
properly  loaded  to  prevent  its  rising.  These 
directions  were  given  in  pursuance  of  an 
Order  in  Council,  dated  the  5th  of  October 
inst.,  received  by  the  Customs  authorities  at 
this  port.  The  vessel  proceeded  at  once  to 
the  Roads,  and  left  the  following  day. 

THE  CHOLERA  AT  AMSTERDAM. 

Letters  from  Amsterdam  of  the  13th  state 
that  several  cases  of  Asiatic  cholera  have 
been  declared  in  that  city,  some  of  which 
have  terminated  fatally.  At  Konigsberg 
(Prussia)  the  disease  is  raging  fearfully,  and 
up  to  the  10th  inst.  720  persons  had  been 
attacked,  of  whom  286  succumbed,  and  only 
112  were  cured. 

THE  CHOLERA  AT  HAMBURGH. 

The  official  reports  state  that  up  to  the  9th 
instant  the  total  number  of  persons  attacked 
was  2,229,  of  whom  1,043  had  up  to  that 
day  fallen  victims  ;  that  411  remained  under 
treatment,  and  775  had  been  cured.  The 
information  from  Lubeck,  where  the  pesti¬ 
lence  had  broken  out,  was  unfavourable  ;  it 
was  rapidly  increasing. 

MEDICAL  OFFICER  OF  HEALTH  FOE  THE 
CITY  OF  LONDON. 

At  a  meeting  of  the  Commissioners  of 
Sewers  for  the  City  on  Monday  last,  Mr. 
John  Simon  and  Mr.  George  Borlase  Childs 
were  nominated  out  of  a  list  of  nineteen 
candidates,  as  fit  to  fill  the  office  of  medical 
officer  of  the  City,  until  the  City  sanitary  bill 
comes  into  operation.  One  of  these  candi¬ 
dates  will  be  elected  by  the  Court  of  Com¬ 
mon  Council.  Dr.  Gavin  and  Mr.  Simon 
underwent  some  cross-examination  respect¬ 
ing  their  published  opinions  on  the  City 
Health  of  Towns  Bill. 

There  appears  to  have  been  some  misap¬ 
prehension  respecting  the  amount  of  salary 
attached  to  the  new  office.  It  has  been  cur¬ 
rently  reported  that  this  had  been  fixed  at 
the  low  rate  of  ,£J150  per  annum  ;  but  the 
fact  appears  to  be,  that  this  sum  is  merely  a 
grant  of  money  by  the  Court  of  Common 
Council  for  the  performance  of  the  duties  of 
sanitary  officer,  up  to  the  1st  of  January 
next,  when  the  City  sanitary  bill  will  come 
into  complete  operation,  and  new  arrange¬ 
ments  will  be  made. 

QUARANTINE  AND  CHOLERA. 

On  Tuesday  last  it  was  stated,  in  answer  to  in¬ 
quiries  made  at  the  Board  of  Health  by  persons 
connected  with  the  shippingof  thePortofLon- 
don,  that  representations  had  been  made  to 
the  Privy  Council  of  the  evil  and  inutility  of 
quarantine,  especially  after  cases  of  Asiatic 
cholera  had  already  broken  out  in  different 
parts  of  the  country  in  spite  of  the  quaran¬ 
tine.  It  was  announced  in  the  afternoon, 


however,  that  in  consequence  of  the  Board’s 
notification  of  the  fact  of  cases  of  Asiatic 
cholera  being  in  England,  it  had  been  deter¬ 
mined,  and  orders  would  now  be  forthwith 
given,  to  have  the  quarantine  removed. 

THE  COLLEGE  OF  PHYSICIANS  OF  EDIN¬ 
BURGH  ON  THE  PREVENTION  OF  CHOLERA. 

We  understand  that  instructions  to  the  in¬ 
habitants  of  Edinburgh  for  the  prevention  of 
Cholera  have  been  prepared  by  the  Local 
Board  of  Health,  and  will  soon  be  issued. 
These  instructions  having  been  laid  before 
the  Royal  College  of  Physicians  by  the 
President,  at  a  meeting  held  on  the  12th 
instant,  they  were  unanimously  and  cordially 
approved  of  by  the  College.  The  medical 
precautions  contained  in  the  instructions  of 
the  Board,  which  we  have  the  authority  of 
the  Council  of  the  Royal  College  to  publish, 
as  adopted  by  that  body,  and  which  are  called 
for  in  consequence  of  many  persons  having 
misinterpreted  the  directions  contained  in 
the  official  announcement  of  the  London 
Board  of  Health,  are  as  follows  : — 

I.  To  avoid  excess  in  the  use  of  spirits ; 
experience  having  shown  that  it  is  not  un¬ 
common  for  a  fit  of  intoxication  to  pass  into 
an  attack  of  cholera. 

II.  To  observe  more  than  ordinary  care 
in  avoiding  cold  from  light  clothing  or  wet ; 
and  when  the  body  has  been  accidentally 
chilled,  to  restore  warmth  by  artificial  means, 
especially  by  the  warm  foot-bath. 

III.  To  use  as  substantial  a  kind  of  food 
as  possible  ;  avoiding  free  indulgence  in 
liquids  of  all  kinds,  and  the  use  of  uncooked 
vegetables,  unripe,  sour,  or  stone  fruit,  the 
poor  kinds  of  small-beer,  all  tart  sorts  of 
malt  liquor,  ginger-beer,  and  acid  drinks 
generally. 

IV.  To  shun  long  fasts ;  above  all  when 
business  obliges  any  one  to*be  much  in  places 
where  cholera  prevails. 

V.  To  attend  to  the  proper  regulation  of 
the  bowels  ;  and  therefore — 

1.  To  check  a  tendency  to  looseness  of 
the  bowels.  It  has  been  everywhere  found 
that  many  cases  of  cholera  are  preceded  for 
a  short  time  by  a  warning  stage  of  looseness 
of  the  bowels,  in  which  stage  the  disease  may 
be  arrested,  although  it  is  with  difficulty 
cured  when  farther  advanced.  When  any 
one,  therefore,  is  attacked  with  looseness, 
although  unattended  with  pain  or  other  in¬ 
convenience,  he  should,  if  possible,  apply 
for  immediate  medical  advice.  And  if  advice 
cannot  be  obtained  at  once,  he  ought  in  the 
meantime  to  take  a  pill  composed  of  one 
grain  of  opium,  or  fifteen  drops  of  morphia- 
solution  or  laudanum  in  a  little  water  ;  and 
he  should  repeat  the  dose  in  an  hour,  if  not 
relieved.  He  should  also  take  a  teaspoonful 
of  compound  tincture  of  cardamom  undiluted, 
or  compound  tincture  of  cinnamon,  or 


■688  THE  COLLEGE  OF  PHYSICIANS  ON  THE  PREVENTION  OF  CHOLERA. 


tincture  of  ginger,  diluted  with  a  tablespoonful  | 
of  water,  or,  in  the  want  of  these,  a  little 
warm  brandy  and  water,  and  avoid  at  the 
same  time  all  cold  drinks,  or  much  drink  of 
any  kind. 

N.B.  Half  the  above  doses  for  young 
persons  about  fourteen,  and  one-fourth  for 
children  about  five.  Opium,  laudanum,  and 
morphia,  not  to  be  given  to  very  young  chil¬ 
dren  without  medical  advice. 

2.  To  correct  a  liability  to  costiveness. 
For  this  purpose,  saline  purgatives,  such  as 
Epsom  salt,  Glauber’s  salt,  and  effervescing 
powders,  and  strong  purgatives  of  all  kinds, 
or  large  doses  of  any  purgatives,  should  not 
be  used  during  the  prevalence  of  Cholera 
unless  under  medical  advice, — but  only  such 
mild  laxatives  as  castor-oil,  Gregory’s  mix¬ 
ture,  the  lenitive  electuary,  compound  rhu¬ 
barb  pills,  colocynth  and  henbane  pills,  or 
any  other  medicine  known  by  experience  to 
act  mildly.  And  any  undue  effects  acciden¬ 
tally  produced  by  such  medicines  should  be 
counteracted  by  opium,  laudanum,  or 
morphia,  as  above. 

VI.  To  attend  also  promptly  to  attacks 
of  sickness  or  vomiting,  which  sometimes 
precede  the  epidemic,  and  which,  after  the 
stomach  has  been  once  cleared  out,  may  be 
treated  by  the  same  remedies  as  those 
directed  for  looseness  of  the  bowels. 

At  the  same  meeting,  the  following  resolu¬ 
tions  were  adopted  unanimously  : — 

1.  That  it  is  not  advisable  to  remove 
cholera  patients  from  their  own  houses  if  it 
be  possible  to  command  advantageously  the 
means  of  treating  them  there  ;  but  that,  ac¬ 
cording  to  experience  in  the  former  epidemic, 
a  large  proportion  of  cases  must  occur  in 
Edinburgh  among  the  lowest  population,  in¬ 
habiting  apartments  in  which  it  is  impossible 
to  treat  the  sick  for  want  of  proper  beds, 
bedding,  fires,  and  other  means  of  heating 
the  body,  besides  other  necessary  medical 
resources. 

2.  That,  on  the  occasion  of  the  former 
epidemic,  serious  injury  was  in  many  cases 
caused  in  this  city  by  the  directions  of  one 
cf  the  Boards  of  Health  in  London,  to  avoid 
the  use  of  laxatives  during  the  prevalence  of 
the  epidemic,  and  rather  to  encourage  a 
somewhat  constipated  condition  of  the 
bowels — inasmuch  as  many  accustomed  to 
use  laxatives,  and  requiring  their  occasional 
or  regular  use,  gave  them  up,  and  suffered 
from  the  consequences  of  constipation — the 
College,  seeing  no  reason  why  mild  laxatives 
should  not  be  used  for  the  removal  of  con¬ 
stipation  during  cholera,  and  believing  that 
both  cholera  and  other  serious  intestinal 
diseases  may  arise  from  a  neglect  of  them  in 
many  circumstances,  unanimously  approve 
of  the  regulation  V.  2,  as  stated  above. 

The  first  of  these  resolutions  is  called  for 
in  consequence  of  the  condemnation  pf 
hospitals,  contained  in  the  directions  of  the 


London  Board  of  Health,  being  inapplicable 
in  Edinburgh,  where  the  population  chiefly 
liable  to  cholera  is,  in  general,  absolutely 
destitute  of  all  the  appliances  necessary  to 
render  medical  treatment  available.  The 
second  has  been  called  for  in  consequence  of 
many  persons  here  having  fallen  into  the 
very  same  error  which  is  stated  to  have 
occurred  in  1832,  although  the  directions 
of  the  London  Board  of  Health  are  by  no 
means  so  condemnatory  of  the  use  of  all 
laxatives  as  on  that  occasion. 

The  College  of  Physicians  also  passed  a 
unanimous  resolution  strongly  approving  of 
the  establishment,  as  in  1832,  of  Houses  of 
Refuge  for  the  removal  of  the  healthy  from 
localities  threatened  with  a  severe  visitation 
of  the  epidemic.  This  measure  was  carried 
through  energetically  by  the  Edinburgh 
Board  of  Health  during  the  first  epidemic ; 
so  that  at  one  period  upwards  of  700  persons 
from  infected  districts  were  lodged  under 
observation  in  Houses  of  Refuge,  but  al¬ 
lowed  to  go  to  their  usual  places  of  work. 
There  is  no  doubt,  according  to  the  opinion 
of  the  best  judges,  that  the  ravages  of  the 
disease  were  in  that  way  greatly  circum¬ 
scribed  in  various  localities  in  Edinburgh; 
and  that  no  other  measure  contributed  so 
much  to  keep  the  epidemic  within  moderate 
bounds.  The  utility  of  such  Houses  of 
Refuge  must  be  obvious  to  all,  whether  the 
disease  be  viewed  as  originating  in  infection, 
or,  as  seems  now  far  more  probable,  in  a 
peculiar  miasma  prevailing  with  intensity 
only  in  limited  localities. — Edinburgh  Ad¬ 
vertiser. 

MEDICAL  POLITICS  IN  FRANCE. 

From  a  recent  return  it  appears,  that  out  of 
3423  persons  who  have  been  condemned  to 
transportation  on  account  of  their  having 
been  concerned  in  the  insurrection  of  June 
in  Paris,  there  were  only  one  physician* 
three  medical  students,  and  two  chemists. 

MEDICAL  APPOINTMENTS,  LEICESTER 
INFIRMARY. 

Joseph  Noble,  M.B.,  of  Danett’s  Hall, 
and  John  Barclay,  M.D.,  have  been  elected 
Physicians  to  the  Leicester  Infirmary,  in 
consequence  of  a  resolution  of  the  Governors, 
on  the  resignation  of  Dr.  Freer,  to  increase 
the  medical  staff  to  three  physicians  and 
three  surgeons. 

ROYAL  COLLEGE  OF  SURGEONS. 

Gentlemen  admitted  Members,  October 
13th  : — T.  Wheeler — T.  Atkinson — R.  S. 
Stedman  —  F.  Findlater  —  Y.  A.  Brown— r. 
R.  E.  Unthank — J.  Owen. 

OBITUARY. 

On  Wednesday,  the  18th  inst.,  Thomas 
Blanchanj,  Esq.,  surgeon,  79,  'Warwick 
Square.  Jlelgrave  Road,  Pimlico, 


ON  THE  OXIDATION  OF  THE  DIAMOND  IN  THE  LIQUID  WAY.  689 


^election*  from  ^Journals. 


ON  THE  OXIDATION  OF  THE  DIAMOND  IN 
THE  LIQUID  WAY.  BY  PROF.  R.  E.  RO¬ 
GERS  AND  PROF,  W.  B.  ROGERS. 

The  processes  for  oxidizing  the  diamond 
hitherto  described  consist  in  actually  burn¬ 
ing  this  gem,  either  in  the  air  or  in  oxygen 
gas,  or  in  some  substance  rich  in  oxygen,  as 
nitrate  of  potassa.  In  all  of  these  experiments 
a  very  elevated  temperature  is  required.  It 
is  therefore  interesting  to  discover  that  the 
diamond  may  be  converted  into  carbonic 
acid  in  the  liquid  way,  and  at  a  moderate 
heat,  by  the  reaction  of  a  mixture  of  bi¬ 
chromate  of  potassa  and  sulphuric  acid ; 
in  other  words,  by  the  oxidating  power 
of  chromic  acid.  To  succeed  in  this 
experiment,  it  is  necessary  to  reduce  the 
diamond  to  the  most  minute  state  of 
division.  A  single  grain  of  the  gem  will 
suffice  for  many  experiments.  In  repeated 
trials  more  than  half  a  grain  has  never  been 
used, — and  clear  evidence  of  the  oxidation 
has  been  obtained  by  the  evolution  of  car¬ 
bonic  acid.  The  bichromate  of  potash 
when  heated  is  always  found  to  afford  some 
carbonic  acid, — but  error  from  this  source 
is  avoided  by  first  heating  the  acid  alone 
in  the  retort  to  about  350°,  then  adding 
the  bichromate  by  degrees,  and  stirring 
the  mixture  so  as  to  effect  a  complete  sepa¬ 
ration  of  chromic  acid.  A  very  brisk  re¬ 
action  takes  place — much  oxygen  is  dis¬ 
engaged,  and  with  it  any  carbonic  acid  which 
the  materials  themselves  are  capable  of 
evolving.  When  no  more  carbonic  acid 
can  be  detected  by  the  lime-water  test,  the 
powdered  diamond  is  carefully  added.  The 
evolution  of  carbonic  acid  is  soon  evinced  by 
the  growing  milkiness  of  the  lime-water,  and 
this  continues  slowly  to  increase  so  long  as 
there  is  any  free  chromic  acid  left  in  the  re¬ 
tort.  The  chief  point  of  interest  in  the  sub¬ 
ject,  however,  is  the  fact — now  published  for 
the  first  time — that  the  diamond  is  capable 
of  being  oxidated  in  the  liquid  way,  and 
at  a  comparatively  moderate  temperature — 
varying  between  350°  and  450°. — British 
Association ,  Athenceum  report. 

case  of  chronic  tetanus  successfully 

TREATED  BY  ETHER  INHALATION. 

Dr.  Isaac  Parrish  read  to  the  Philadel¬ 
phia  College  of  Physicians,  March  7th 
{Trans.  Coll.  vol.  ii.  No.  4),  an  interesting 
case  of  phlegmonous  erysipelas,  commencing 
in  the  finger  and  extending  up  the  hand  and 
arm.  Rigidity  of  the  jaws  supervened  on 
the  sixth  day,  followed  by  shooting  pains  up 
the  limb  to  the  neck  and  jaws.  The  pre¬ 
parations  of  opium,  assafoetida,  &c.,  having 


failed  to  make  any  impression,  the  inhalation 
of  ether  was  tried  on  the  seventh  day,  and  it 
produced  a  most  favourable  anodyne  effect, 
causing  several  hours’  refreshing  sleep.  The 
inhalation  was  repeated  on  the  eighth  day 
also  with  a  favourable  effect.  Convalescence 
from  this  time  was  confirmed,  and  the  patient 
recovered. — American  Journal  of  Med.  Sci¬ 
ences,  July  1848. 

THE  USE  OF  ERGOT  IN  POST  PARTUM 
HEMORRHAGE. 

We  have  mentioned  the  administration  of 
ergot  of  rye  as  a  preventive  of  post  partum 
haemorrhage  ;  and  in  the  Hospital  we  have 
seen  such  decidedly  favourable  results  from 
its  use,  when  employed  for  this  purpose,  as 
to  have  no  hesitation  in  pronouncing  the 
practice  to  be  both  safe  and  efficient.  With 
this  intention  it  may  be  given  at  one  or  other 
of  three  periods  :  namely,  when  the  head  of 
the  child  is  on  the  perinaeum,  and  about  to 
be  expelled ;  or  immediately  after  the  head 
has  cleared  the  os  externum,  and  before  the 
shoulders  have  passed  ;  or,  thirdly,  so  soon 
as  the  insertion  of  the  cord  into  the  placenta 
can  be  felt.  “By  giving  ergot  before  the 
child  has  been  expelled,  some  time  may  be 
gained  ;  but  should  the  placenta  be  morbidly 
adhering  to  the  uterus,  the  difficulty  of  in¬ 
troducing  the  hand  for  its  removal  will  be 
greatly  increased.  By  adopting  the  third 
plan,  this  source  of  apprehension  is  avoided. 
To  this  method  it  may  be  objected  that  much 
time  will,  perhaps,  elapse,  and  a  considerable 
quantity  of  blood  be  lost,  before  the  ergot  is 
administered;  nevertheless,  the  possibility  of 
the  placenta  being  morbidly  adherent  should 
be  ever  present  in  the  mind  of  the  practi¬ 
tioner,  and  deter  him  from  resorting  to  a 
measure  which  may  so  greatly  augment  the 
danger  of  the  complication.”  Dr.  Johnson, 
who  introduced  the  practice  into  this  Hospi¬ 
tal,  generally  gives  the  ergot  according  to 
the  mode  last  recommended.  In  certain  in¬ 
stances,  however,  where  from  previous  losses 
it  was  a  matter  of  the  utmost  importance  to 
prevent  any  further  haemorrhage  after  deli¬ 
very,  we  have  not  scrupled  to  administer  it 
in  the  second  way  spoken  of  above,  and 
hitherto  without  any  unpleasant  effect. 
Here,  as  on  every  other  occasion,  we  should 
be  careful  to  use  ergot  of  undoubted  genuine 
quality,  for  otherwise  its  exhibition  can  be 
productive  of  no  good,  and  will  only  cause 
disappointment.  Few  medicines  so  readily 
spoil,  or  are  to  be  found  of  such  variable 
quality  ;  and  this  circumstance  goes  far,  we 
think,  to  reconcile  the  conflicting  opinions 
which  have  been  entertained  respecting  its 
properties  and  doses. —  MlCiintock  and 
Hardy’s  Practical  Observations ,  pp.  220 
and  221. 


690  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY,  ETC. 


BIRTHS  &  DEATHS  in  the  Metropolis 


During  the  week  ending  Saturday ,  Oct.  14. 


Births. 
Males....  706 
Females..  597 


Deaths. 
Males....  470 
Females..  521 


Av.  of  5  Sum. 
Males ....  581 
Females. .  573 


Rain,  in  inches,  0’42 :  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological. — The  mean  temperature  of  the 
week  was  3°.2  above  the  mean  of  the  month. 


BOOKS  &  PERIODICALS  RECEIVED 


1303 


991 


1154 


Causes  of  Death. 

All  Causes . . 

Specified  Causes . 

1.  .Zi/?wofic(orEpidemic,Endemic, 

Contagious)  Diseases . . 
Sporadic  Diseases,  viz. — 

2.  Dropsy,  Cancer,  &c.  of  uncer¬ 

tain  seat  . 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  . 

4.  Lungs  and  other  Organs  of 

Respiration . 

5.  Heart  and  Bloodvessels . 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion  . 

7.  Diseases  of  the  Kidneys,  &c.. . 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c . 

9.  Rhematism,  Diseases  of  the 
Bones,  Joints,  &c . 

10.  Skin,  Cellular  Tissue,  &c . 

11.  Old  Age . 

12.  Violence,  Privation,  Cold,  and 

Intemperance . . 


Av.  of 
5  Aut. 

991 

1154 

990 

1149 

448 

270 

36 

52 

84 

127 

90 

222 

32 

38 

40 

67 

8 

12 

9 

14 

1 

8 

1 

2 

32 

64 

22 

32 

The  following  is  a  selection  of  the  numbers  of 
Deaths  from  the  most  important  special  causes: 


Small-pox  .  47 

Measles  .  10 

Scarlatina  . 188 

Hooping-cough..  24 

Diarrhoea  .  37 

Cholera  .  39 

Typhus  . 80 

Dropsy .  13 

Sudden  deaths  ..  10 

Hydrocephalus..  16 
Apoplexy .  22 


Paralysis .  12 

Convulsions  ....  26 

Bronchitis .  25 

Pneumonia .  51 

Phthisis .  96 

Dis.  of  Lungs,  &c.  7 

Teething . . .  2 

Dis.  Stomach,  &c.  3 
Dis.  of  Liver,  &c.  6 

Childbirth .  4 

Dis.  of  Uterus,&c.  3 


Remarks.— The  total  number  of  deaths  was 
no  less  than  163  below  the  weekly  autumnal  ave¬ 
rage.  See  page  680. 


METEOROLOGICAL  SUMMARY. 


Mean  Height  of  Barometer .  29’82 

“  “  Thermometer1  .  52*1 

Self-registering  do.b _ max.  87‘  min.  33-2 

“  in  the  Thames  water  —  61*  —  52’5 


DURING  THE  WEEK. 

The  British  Record  of  Obstetric  Medicine. 
No.  20,  October  1848. 

On  Functional  Diseases  of  the  Liver  associated 
with  Uterine  Derangement,  by  Butler  Lane, 
M.D.  &c. 

Hints  on  the  Malignant  Cholera,  by  Dr.  B.  White, 
M.D.  &c.  1832. 

The  Nature  of  Cholera  investigated,  by  John 
George  French,  Resident  Surgeon  to  the  Infir¬ 
mary  of  St.  James’s.  1835. 

Revelations  on  Cholera,  or  its  Causes  and  Cure, 
by  Samuel  Dickson,  M.D. 

Practical  Observations  on  the  Nature  and  Treat¬ 
ment  of  Cholera,  by  G.  H.  Bell,  F.R.C.S.E. 

(The  remainder  will  be  given  in  our  next  No.) 


NOTICES  to  CORRESPONDENTS. 

We  regret  that  the  pressure  ou  our  columns  is 
at  present  so  great  as  to  render  it  impossible 
for  us  to  find  room  for  the  Report  of  the  Bene¬ 
volent  Fund. 

The  papers  forwarded  by  Dr.  Jameison,  Aber¬ 
deen,  and  Dr.  Gavin  Milroy,  shall  be  inserted 
so  soon  as  our  arrangements  will  permit. 

Mr.  Hicks’s  request  shall  be  attended  to. 

The  space  occupied  by  Lectures  in  this  number 
has  rendered  the  postponement  of  the  follow¬ 
ing  communications,  which  are  in  type,  una¬ 
voidable  ;  namely,  those  of  Mr.  Swan,  Mr. 
Macdonald,  and  Dr.  Parkes. 

Dr.  D.  B.  White’s  pamphlet  on  Cholera,  although 
of  old  date,  shall  receive  our  attention. 

Fatal  Dose  of  Arsenic.  —  A  correspondent  has 
called  our  attention  to  an  error  in  the  report 
of  a  case  of  poisoning  by  arsenic,  at  page  87 
of  the  present  volume.  It  is  there  stated  that 
the  deceased  died  from  a  dose  of  T83  grains. 
As,  however,  half  an  ounce  of  Fowler’s  Mineral 
Solution  was  swallowed  in  divided  doses, 
the  quantity  of  arsenic  taken  must  have  been 
two  grains.  The  fact  is  of  importance,  as  this 
is  the  smallest  quantity  of  arsenic  which  has 
been  known  to  destroy  life. 

Mr.  W.  B.  Kesteven.— We  are  obliged  by  the 
translation,  which  shall  be  inserted. 

M.  E.  II.  Durden. — Your  request  shall  be  com¬ 
plied  with.  We  hope  to  receive  the  reports 
with  regularity. 

Studiosus  Medicinse. — Our  list  is  at  present  filled 
up. 

Dr.  Seaton. — Received  too  late  for  this  week. 


a  From  12  observations  daily.  b  Sun. 


Received.— Dr.  Mayo.— Dr.  C.  H.  Jones. 


THE  GENERAL  INDEX. 

We  have  to  announce  to  our  Subscribers  that  a  General 
Index  to  the  first  40  Volumes  of  the  London  Medical  Gazette 
will,  it  is  calculated,  form  a  large  Yolnme  of  about  700  pages. 
The  cost  of  the  Index  Yolume,  respecting  which  many  inquiries 
have  been  made,  will  be  Twenty-four  Shillings;  and  it  is  proposed 
to  commence  it  so  soon  as  the  Names  of  Five  Hundred  Subscribers 
have  been  obtained. — The  printers,  Messrs.  Wilson  and  Ogilvy, 
57,  Skinner  Street,  will  receive  the  Names  of  Subscribers. 


^Lectures. 


COURSE  OF  SURGERY, 
Delivered  in  the  years  1846  and  1847, 

By  Bransby  B.  Cooper,  F.R.S. 

Surgeon,  and  Lecturer  on  Surgery  at  Guy’s 
Hospital. 


Lecture  XLI. 

DISEASES  OF  THE  RECTUM. 

Functions  of  rectum — defeecation  and  nu¬ 
trition.  Prolapsus  ani — causes — treat¬ 
ment  —  constitutional  and  mechanical. 
Diagnosis  between  stricture  of  the  rec¬ 
tum  and  piles.  General  treatment  of 
piles — bleeding  sometimes  the  only  symp¬ 
tom  of  internal  piles — removal  by  liga¬ 
ture.  Method  of  exposing  internal  pile 
— administration  of  opium — removal  of 
external  pile — excision — use  of  rectum 
bougie. 

Warty  excrescences  and  condylomata 
about  the  anus — syphilitic  excrescences. 
Fissure  of  the  rectum — cause — constipation 
— diagnosis — cureby  operation ,  and  con¬ 
stitutional  remedies. 

The  rectum  must  be  regarded  almost  exclu¬ 
sively  as  an  organ  of  def'secation,  although  it 
must  be  admitted  that  it  may  assist  to  some 
degree  in  the  process  of  nutrition  ;  and  this" 
is  proved  by  the  benefit  derived  from  the  ad¬ 
ministration  of  nutritious  enemata.  At  the 
same  time  we  find  that  in  the  diseases  of 
this  organ  any  disturbance  in  its  functions  as 
an  excretory  apparatus,  calls  much  more 
urgently  for  surgical  interference  than  any 
diminution  of  its  absorbent  powers. 

Prolapsus  ani,  the  protrusion  of  the 
mucous  membrane  of  the  rectum  through 
the  anus,  is  a  very  common  affection,  and 
although  not  in  itself  of  a  dangerous  cha¬ 
racter,  it  is  very  frequently  the  result  of 
general  debility,  and  must  be  considered  as 
evidence  of  some  very  serious  constitutional 
derangement.  Costiveness  is  perhaps  one  of 
the  most  frequent  exciting  causes  of  pro¬ 
lapsus  ani,  which  in  such  cases  arises  in 
great  measure  from  the  constant  straining 
necessary  to  produce  evacuation  of  the 
bowels,  which,  in  case  of  prolapsus,  is  indeed 
generally  attended  by  the  passage  of  a  greater 
or  less  quantity  of  blood.  That  straining  is 
an  exciting  cause,  is,  in  my  opinion,  suffi¬ 
ciently  proved  by  the  circumstance  that  pro¬ 
lapsus  ani  is  so  often  a  concomitant  with 
stone  in  the  bladder  or  stricture  in  the 
urethra;  and,  indeed,  straining  may  na¬ 
turally  be  looked  upon  as  the  cause  of  pro- 

xlii.— 1091.  Oct.  27,  1848. 


lapsus,  for,  by  a  continuation  of  that  action, 
the  power  of  the  abdominal  muscles  and 
levator  ani  is  brought  to  preponderate  so 
much  over  that  of  the  sphincter,  as  to  de¬ 
prive  the  rectum  of  the  support  of  the  latter 
muscle ;  the  necessary  consequences  being 
the  eversion  and  protrusion  of  the  mucous 
membrane.  When  costiveness  is  the  cause 
of  prolapsus,  purgative  remedies  are  chiefly 
indicated  ;  but,  gentlemen,  if  in  aggravated 
cases  you  were  to  rely  upon  these  alone,  I 
do  not  think  that  you  would  easily  suceeed 
in  removing  the  disease,  and  might,  indeed, 
in  many  instances,  greatly  increase  it.  Strict 
attention  to  diet,  change  of  air,  tonic  medi¬ 
cines,  shower  baths,  and  restringent  injec¬ 
tions  into  the  rectum,  are  all  requisite;  such 
aperients  alone  being  employed  as  tend 
gently  to  produce  the  increased  perstaltic 
action  of  the  bowels,  rather  than  to  com¬ 
mand  it  though  the  potency  of  the  medicine. 
It  is  also  highly  important  to  induce  a  habit 
of  evacuating  the  bowels  shortly  before  bed¬ 
time,  as  the  recumbent  position  of  the 
body  relieves  the  rectum  from  the  pressure 
of  the  small  intestines,  and  admits  of  its 
ready  return  into  the  pelvis ;  while,  if  the 
bowels  be  evacuated  immediately  after  break¬ 
fast,  as  is  usually  the  habit,  the  continued 
erect  position  and  muscular  exertion  almost 
inseparable  from  the  avocations  of  the  day, 
prevent  the  rectum  from  receding,  and  tend, 
in  fact,  to  increase  the  protrusion.  In  very 
protracted  cases  of  prolapsus,  palliative 
means  may  not  prove  sufficient,  and  me¬ 
chanical  contrivances  may  be  requisite  to 
return  the  protruded  membrane  within  the 
anus :  bougies,  or  the  finger  may  be  employed 
for  this  purpose ;  but  in  some  instances  the 
tone  of  the  sphincter  may  be  so  completely 
destroyed  that  it  would  be  incapable  of  re¬ 
taining  the  intestine  even  after  it  is  re¬ 
turned  :  a  pessary  should  in  that  case  be 
passed  into  the  rectum,  and  allowed  to  re¬ 
main  there  for  a  few  hours,  so  as  to  main¬ 
tain  the  loose  portion  of  membrane  suffi¬ 
ciently  long  in  situ  to  allow  of  its  recovery 
from  the  congestion  arising  from  its  protru¬ 
sion  and  exposure  to  external  agency.  I 
have  seen  an  instrument  which  is  worn  by 
the  Chinese,  who  are  very  liable  to  prolapsus 
ani,  for  the  purpose  of  retaining  the  bowel 
within  the  anus.  It  consisted  of  a  ball  of 
silver,  perforated  with  holes,  to  permit  of 
the  escape  of  flatus,  and  made  to  unscrew  in 
the  middle,  so  that  it  could  be  easily  cleaned  : 
this  instrument  appeared  to  me  to  be  admi¬ 
rably  suited  to  the  purpose  for  which  it  was 
intended.  When  a  pessary  is  employed,  it 
should  be  passed  into  the  bowel  above  the 
sphincter  muscle,  otherwise  it  would  prove 
a  source  of  increased  irritation  rather  than 
of  relief.  And  at  the  same  time  that  me¬ 
chanical  contrivances  are  made  use  of,  con¬ 
stitutional  means  should  also  be  adopted 


692 


PROLAPSUS  ANI.  HEMORRHOIDS  OR  PILES. 


for  the  purpose  of  improving  the  tone  of  the 
health.  In  spite,  however,  of  all  these  means, 
the  prolapsus  may  remain  unrelieved,  in 
which  case  a  surgical  operation  must  he  un¬ 
dertaken,  in  the  hope  of  effecting  “  a  radical 
cure.”  This  object  may  sometimes  be 
attained  by  pinching  up  with  a  pair  of  forceps 
a  small  portion  of  the  mucous  membrane  of 
the  bowel,  and  secm-ing  it  with  a  ligature, 
taking  care  not  to  include  anything  besides 
the  mucous  membrane.  In  this  manner  two 
or  three  different  portions  may  be  taken  up 
just  above  the  sphincter  at  about  equal  dis¬ 
tances  from  each  other,  and  each  being  tied, 
the  resulting  cicatrization  will  produce  a  very 
uniform  contraction,  so  as  to  prevent  the 
future  protrusion.  I  have  also  in  two  or 
three  obstinate  cases  divided  the  anal  extre¬ 
mity  of  the  sphincter  muscle,  for  the  pur¬ 
pose  of  permanently  diminishing  the  size  of 
the  opening  of  the  anus  ;  the  after  treatment 
consists  in  keeping  the  patient  in  the  recum¬ 
bent  posture,  and  maintaining  for  a  few 
days  a  constipated  state  of  the  bowels,  to 
enable  the  parts  to  recover  from  the  effect 
of  the  operation. 

Prolapsus  ani  may  in  some  cases  prove  in 
itself  dangerous  to  life  ;  the  following  case 
affords  a  good  example  of  the  urgency  of  the 
symptoms  that  may  appear  under  such  cir¬ 
cumstances  : — A  gentleman  sent  for  me  to 
visit  him,  in  the  neighbourhood  of  Croydon  ; 
when  I  arrived  at  his  house,  I  found  him 
labouring  under  all  the  symptoms  of  stran¬ 
gulated  hernia,  and  these  so  strongly  marked 
that  I  proceeded  at  once  to  examine  for  the 
hernia,  which  I  expected  to  be  the  cause  of 
his  disorder.  I  could  not,  however,  detect 
any  external  tumor  to  account  for  the  severe 
symptoms,  although  I  asked  him  repeatedly 
whether  he  was  conscious  of  the  existence  of 
a  protrusion  in  any  part  of  his  body  :  just, 
however,  as  I  had  decided  that  he  was  the 
subject  of  some  internal  obstruction,  he  re¬ 
marked,  “By  the  way,  there  is  something 
queer  about  my  fundament upon  examin¬ 
ing  that  part,  I  was  astonished  to  find  not 
less  than  three  inches  of  rectum  protruded 
from  the  anus ;  the  protruded  part  was 
highly  congested,  and  so  dark  in  colour  that 
I  doubted  whether  sphacelus  had  not  already 
commenced  :  I  endeavoured  to  return  the 
bowel,  but  the  constriction  at  the  anus  was 
too  great  to  admit  of  its  passing  back  ;  I 
then  applied  cold  to  the  part,  but  this  also 
proved  inefficacious  ;  and  as  relief  was  ur¬ 
gently  demanded,  I  proceeded  to  make  nu¬ 
merous  longitudinal  incisions  in  the  mucous 
membrane  to  liberate  the  overcharged  ves¬ 
sels  :  from  the  quantity  of  blood  lost  I  was 
now  enabled  to  return  the  prolapsed  intes¬ 
tine  into  its  proper  situation.  This,  gentle¬ 
men,  was  in  fact  a  true  case  of  strangulated 
hernia,  under  conditions  quite  new  to  my 
experience  of  the  subject. 


Prolapsus  ani  may  be  considered  by  some 
as  too  unimportant  a  disease  to  deserve  the 
detailed  account  I  have  given  of  it ;  but  al¬ 
though  it  is  quite  true  that  this  complaint 
rarely  proves  dangerous,  it  is  nevertheless  a 
source  of  such  excessive  inconvenience,  and 
produces  so  much  excessive  depression, 
that  I  know  of  no  cases  in  which  the  repu¬ 
tation  of  a  medical  practitioner  is  likely  to 
be  more  enhanced  than  in  its  successful 
treatment. 

Hemorrhoids  or  Piles. — These  painful 
tumors  must  be  looked  upon  as  resulting 
from  a  varicose  condition  of  the  veins  of  the 
rectum  ;  a  state  generally  produced  by  some 
obstruction  in  the  portal  system. 

I  may  here  remind  you,  gentlemen,  that 
the  superior  hsemorrhoidal  vein  returns 
its  blood  to  the  vena  portae,  which,  if  it  be¬ 
come  obstructed  from  disease  of  the  liver, 
would  necessarily  tend  to  congestion  of  the 
veins  of  the  rectum ;  and  this  anatomical 
fact  teaches  us  that,  in  piles,  the  remedies 
may  often  be  advantageously  directed  to  the 
relief  of  the  loaded  liver.  High  living,  want 
of  exercise,  or  constipated  bowels,  frequently, 
therefore,  induce  congestion  of  the  veins  of 
the  rectum,  and  their  consequent  varicose 
condition.  If  this  congestion  become  per¬ 
manent,  the  blood  within  the  veins  coagulates, 
and,  acting  as  extraneous  matter,  excites  in 
flammation  in  the  surrounding  submucous 
cellular  tissue :  adhesive  matter  is  then  thrown 
out,  and  unites  the  congeries  of  varicose  veins 
into  a  solid  mass,  which  constitutes  a  pile. 
It  sometimes  happens  that  some  of  the  veins 
included  in  the  adherent  mass  still  contain 
fluid  blood,  and  therefore  slight  haemorr¬ 
hage  occasionally  occurs.  From  these 
bleedings  the  patient  frequently  derives  so 
much  relief  as  to  be  led  to  believe  that  the 
attack  of  piles  has  subsided ;  such  relief  is, 
however,  generally  but  of  short  duration,  as 
the  vessels  soon  fill  again,  and  produce  a  re¬ 
turn  of  all  the  symptoms. 

Haemorrhoids,  moreover,  necessarily  pro¬ 
duce  great  obstruction  to  the  passage  of  the 
egesta,  and  the  piles  are  often  forced  down  by 
the  efforts  of  the  patient  during  evacuation, 
so  that  they  protrude  through  the  anus, 
often  attended  by  considerable  prolapsus ; 
generally,  however,  upon  the  completion  of 
the  act  of  defaecation,  both  the  haemorrhoids 
and  the  prolapsed  bowel  spontaneously 
return  into  the  anus.  Sometimes  the  piles 
become  so  much  elongated  by  frequent  pro¬ 
trusion  as  to  be  rendered  permanently  exter¬ 
nal  ;  when,  from  exposure  to  constant  fric¬ 
tion  and  other  sources  of  irritation,  their 
mucous  membrane  soon  becomes  converted 
into  true  skin.  It  would  be  supposed  that 
in  this  condition  the  haemorrhoids  would 
produce  much  less  irritation,  but  such  is  not 
the  case ;  for  as  they  still  remain  connected 
with  the  interior  of  the  rectum,  they  continue 


TREATMENT  OF  PILES. 


693 


to  excite  considerable  disturbance,  and  some¬ 
times,  becoming  themselves  inflamed,  require 
leeches,  and  strict  dietetic  observance,  for 
their  I’elief,  it  being  also  necessary  that  the 
patient  should  be  kept  in  the  recumbent 
position.  External  piles  do  not,  however, 
always  appear  as  the  mere  result  of  the  pro¬ 
trusion  of  internal  piles,  but  are  sometimes 
entirely  independent  of  them,  and  arise  from 
inflammation  and  thickening  of  the  subcu¬ 
taneous  cellular  tissue  around  the  anus : 
these  piles  are  apparently  unconnected  with 
a  dilated  condition  of  the  veins,  although 
originally  the  congestion  of  the  latter  may 
have  produced  the  inflammation. 

External  piles,  even  when  unattended  by 
internal,  frequently  produce  prolapsus  ani, 
extreme  pain  in  the  course  of  the  sciatic 
nerve,  pain  in  the  perineum,  and  in  some 
instances  even  difficulty  in  passing  the  urine  ; 
nor  are  these  phenomena  inexplicable  to  the 
anatomist  and  pathologist,  when  it  is  remem¬ 
bered  that  these  parts  are  supplied  by  fila¬ 
ments  of  nerves  derived  from  the  same 
source.  The  excision  of  the  piles  forms, 
however,  an  almost  infallible  means  of  re¬ 
moving  all  these  symptoms.  A  short  time 
since  I  was  consulted  by  a  patient  in  the 
Edgware  Road,  who  was  the  subject  both  of 
internal  and  external  piles  :  his  medical  at¬ 
tendant  had  tied  several  of  the  internal  ones 
without  affording  any  permanent  relief ;  but 
when  I  removed  the  external  haemorr¬ 
hoids  the  patient  was  rapidly  cured.  In 
another  case,  I  was  called  to  a  lady,  a 
governess  in  the  family  of  a  nobleman  :  part 
of  her  duties  consisted  in  walking  out  with 
her  pupils,  but  this  exertion  caused  her  so 
much  pain  that  she  was  obliged  to  con¬ 
fide  her  condition  to  the  elder  of  the  ladies, 
and  whenever  they  went  out  to  walk  she  was 
in  the  habit  of  going  to  lie  down  at  the  house 
of  a  friend  close  by  :  this  could  not  go  on 
long,  and  she  was  obliged  to  seek  medical 
aid.  She  told  me  a  pitiable  tale  of  her 
sufferings  :  the  piles  were  external,  and  were 
attended  by  frequent  bleedings,  but  after  I 
excised  them,  she  very  rapidly  recovered. 
I  remember  also  the  case  of  a  gentleman,  who 
was  very  fond  of  hunting,  but  who  was 
afflicted  by  piles  to  such  a  degree  that  his 
saddle  was  often  covered  with  blood  :  at 
length  the  disease  became  so  bad  that  he 
was  obliged  to  give  up  his  favourite  amuse¬ 
ment.  I  then  saw  him,  and  after  having  ex¬ 
cised  the  piles,  treated  him  with  enemata 
and  laxatives  ;  principally,  however,  insist¬ 
ing  upon  the  necessity  for  always  passing 
his  motions  at  night.  He  very  soon  re¬ 
covered,  and  it  is  now  eight  years  since  he 
had  any  symptom  of  a  return  of  his  com¬ 
plaint. 

Whether  the  piles  be  internal  or  external, 
they  necessarily  cause  great  inconvenience 
in  the  act  of  defecation,  and  the  faeces  are 


generally  passed  in  small  portions,  and  are 
often  attended  by  a  flow  of  blood  :  these 
symptoms  are  not,  however,  referrible  to 
piles  alone,  as  they  may  equally  proceed 
from  stricture  of  the  rectum.  It  may,  how¬ 
ever,  easily  be  ascertained  by  an  examina¬ 
tion  per  anum,  whether  the  symptoms  are 
produced  by  piles  or  stx-icture.  The  first 
treatment  of  piles  should  always  bear  refer¬ 
ence  to  the  state  of  the  patient’s  general 
health ;  for,  as  they  usually  depend  upon 
some  disturbance  to  the  function  of  the  liver 
and  bowels,  or  both,  until  the  healthy  action 
of  those  organs  be  re-established  there  can 
be  but  little  hope  of  removing  the  local  dis¬ 
ease.  Small  doses  of  mercury  to  act  on  the 
liver,  and  mild  purgatives  to  excite  a  healthy 
action  of  the  bowels,  constitute  the  means 
to  be  employed  ;  but  the  purgatives  should 
be  of  the  least  drastic  nature,  and  not  likely 
to  act  especially  upon  the  lower  bowels. 
The  nostrum  termed  “  Ward’s  paste,”  or 
the  Confec.  Piper.  Nigr.  of  the  London 
Pharmacopoeia,  will  be  found  useful ;  but  if 
they  should  produce  nausea,  as  they  fre¬ 
quently  do,  I  have  found  the  following  pre¬ 
scriptions  of  very  great  benefit  in  restoring 
the  natural  action  of  the  bowels  : — Aloes 
Decoc.  Co.  5iss.  ;  Sarsae  Ext.  5ss. ;  Sarsae 
Decoc.  Co.  jiss.  M. — Ft.  haustus  ter  quo- 
tidie  sumendus  ;  giving  also  an  alterative 
pill  two  hours  before  dinner  to  induce 
evacuation  of  the  bowels  at  bed-time.  If  the 
irritation  still  remains,  so  as  to  create  an 
uncontrollable  action  of  the  bowels,  con¬ 
siderable  benefit  will  be  derived  from  the 
use  of  the  following  pill : — R  Morph.  Acet. 
gr.  £th;  Hyos.  Ext.,  gr.  iss.  ;  Camphorae, 
gr.  ij.  ;  Colocynth  Ext.  Co.,  gr.  ij.  M. — Ft. 
pil.  bis  terve  quotidie  sumenda. 

For  the  reasons  I  have  already  adduced  in 
speaking  of  the  treatment  of  prolapsus  ani, 
the  patient  should  resist  as  much  as  possible 
the  habitual  desire  to  evacuate  the  bowels  in 
the  morning.  I  believe  there  are  but  few 
cases  of  haemorrhoids  that  would  not  yield 
to  judicious  constitutional  treatment,  if  the 
subject  of  the  disease  did  but  apply  earlier 
for  medical  assistance.  Generally,  however, 
he  defers  calling  in  the  surgeon  until  the 
piles  have  become  permanently  beyond  the 
reach  of  medicine,  and  require,  therefore,  a 
surgical  operation  for  their  removal. 
Bleeding  is  sometimes  a  symptom  of  haemor¬ 
rhoids,  even  when  there  are  no  external 
signs  of  the  disease  ;  and  it  is  not  uncom¬ 
mon  for  patients  to  become  anaemiated  from 
this  cause,  without  their  being  aware  of 
the  nature  of  their  complaint.  When  called 
in  to  such  a  case,  an  examination  per  anum 
should  be  made,  and  if  an  internal  pile  be 
discovered,  it  should  be  at  once  removed; 
for  it  would  be  injudicious  to  wait  for  the 
operation  of  constitutional  remedies,  as  the 
haemorrhage  may  recur  to  such  an  extent  as 


694  REMOVAL  OF  INTERNAL  PILES.  CONDYLOMATOUS  GROWTHS. 


to  endanger  the  safety  of  the  patient.  When 
piles,  either  internal  or  external,  present  an 
organization  which  renders  them  incapable 
of  being  relieved  by  medical  treatment  alone, 
they  must  be  removed  by  surgical  means ; 
but  the  plan  to  be  adopted  varies  very 
essentially  according  to  the  kind  of  pile. 

Internal  piles,  which  are  only  covered  by 
mucous  membrane,  should  always  be  re¬ 
moved  by  ligature,  in  consequence  of  their 
great  tendency  to  bleed  ;  and,  indeed,  I  have 
known  more  than  one  instance  of  death  from 
excision  in  such  cases.  There  is,  however, 
sometimes  a  degree  of  difficulty  in  exposing 
the  pile  sufficiently  to  enable  you  to  apply 
the  ligature ;  but  this  may  generally  be 
effected  by  causing  the  patient  to  sit  over  a 
hand-basin  filled  with  hot-water,  and  placed 
upon  the  floor,  so  that  he  is  obliged  to  stoop 
or  crouch  over  it.  By  some  straining  the 
pile  will  now  generally  protrude,  and  the 
ligature  can  be  passed  around  it :  the  mu¬ 
cous  membrane  and  submucous  cellular 
tissue  must  alone  be  included,  and  then  the 
operation  is  attended  with  but  little  pain. 
If  the  base  or  root  of  the  pile  be  very  broad, 
the  ligature  may  be  applied  by  another 
method.  A  needle,  armed  with  a  double 
silk,  should  be  passed  through  the  centre  of 
the  tumor,  and  the  threads  being  separated 
are  tied  on  opposite  sides,  each  including  one 
half  of  the  pile.  The  latter  should  then  be 
laid  open  by  the  knife,  which  affords  great  re¬ 
lief  to  the  constriction,  and  is  wholly  without 
danger,  as  the  ligatures  preclude  haemorrhage. 
After  the  operation,  the  patient  should  be 
kept  in  the  recumbent  posture,  upon  low 
diet,  and  a  dose  of  opium  be  administered, 
to  keep  up  a  constipated  state  of  the  bowels 
until  the  ligature  has  sloughed  away.  An 
external  pile  is  better  removed  at  once  by 
excision  ;  and,  in  performing  this  operation, 
the  pile  should  be  taken  off  by  one  sweep  of 
the  knife  :  if  there  be  more  than  one  pile  to 
be  excised,  it  is  best  to  remove  them  all  at 
the  same  “  sitting,”  as  in  that  case  the 
patient  suffers  less  constitutional  irritation 
than  when  each  pile  is  made  the  subject 
of  a  separate  operation.  In  thus  removing 
piles,  there  is,  however,  one  point  that 
ought  not  to  be  lost  sight  of  :  the  process  of 
cicatrization  will  necessarily  contract  the 
verge  of  the  anus  ;  and,  unless  some  mecha¬ 
nical  means  be  employed  to  obviate  this, 
there  would  arise  permanent  difficulty  in 
expelling  the  faeces.  Bougies  should  there¬ 
fore  be  daily  passed  during  the  progress  of 
the  healing  process,  to  prevent  such  contrac¬ 
tions. 

Should  you  have  to  perform  this  opera¬ 
tion,  gentlemen,  you  must  not  be  disap¬ 
pointed  if  for  the  first  three  or  four  days 
the  patient  seems  to  have  received  but 
little  relief;  and,  indeed,  a  fresh  growth 
of  piles  sometimes  appears  to  be  formed ; 


these  generally  prove,  however,  to  be 
nothing  more  than  folds  of  mucous  mem¬ 
brane,  which  pass  down  probably  in  con¬ 
sequence  of  some  of  the  fibres  of  the 
sphincter  ani  muscles  having  been  divided. 
Such  protrusions  genex-ally  subside  by  the 
application  of  cold  poultices ;  and  the  re¬ 
union  of  the  sphincter  muscle  prevents  their 
return. 

Prolapsus  ani,  as  I  have  already  said,  is 
a  frequent  result  of  external  piles,  and  the 
removal  of  the  latter  almost  invariably  cures 
that  tendency.  I  am  inclined  to  believe 
that  excision  of  a  portion  of  the  circum¬ 
ference  of  the  anus  would  prove  a  more 
certain  means  of  radical  cure  of  prolapsed 
rectum  than  the  operation  usually  had  re¬ 
course  to,  viz.  removal  of  portions  of  the 
mucous  membrane  of  that  intestine  by  means 
of  ligatures. 

Condylomatous  growths  are  frequently 
formed  about  the  verge  of  the  anus  ;  these 
may  be  mistaken  for  external  piles,  but  are 
generally  produced  by  the  irritation  caused 
by  the  discharge  in  protracted  gonorrhoea  : 
they  rarely  require  excision,  as  the  “  yellow 
wash”  may  almost  be  considered  as  a  specific 
for  the  disease.  Another  description  ofwai’ty 
excrescence  follows  syphilitic  affections, 
but  it  may  be  distinguished  from  that  in 
gonorrhoea,  as  they  resemble  rather  warty 
granulations,  and  are  attended  by  considera¬ 
ble  discharge  and  pain,  and  can  only  be 
cured  by  the  internal  administration  of  mer¬ 
cury:  they  are  generally  attended  by  sore- 
throat,  cutaneous  eruption,  or  some  other 
symptoms  which  mark  their  syphilitic  cha¬ 
racter.  A  question  may  arise  as  to  the 
source  of  these  warty  excrescences :  they 
certainly  must  be  considered  as  primary 
symptoms  of  syphilis,  and  can  therefore 
only  be  generated  by  inoculation,  to  which 
there  must  be  some  considerable  liability, 
from  the  frequent  existence  of  excoriation 
about  the  anus,  and  the  proximity  of  the 
originally  affected  parts. 

Fissure  of  the  rectum. — I  have  rarely 
met  with  this  disease  in  hospital  practice, 
but  have  found  it  not  unfrequently  among 
the  higher  classes  of  society,  particularly  in 
females ;  and  it  may  perhaps  be  considered 
to  depend  upon  luxurious  habits  of  living, 
want  of  sufficient  bodily  exercise,  and  also 
from  inattention  to  the  state  of  the  bowels, 
as  constipation  is  usually  concomitant  with 
the  complaint.  Protracted  constipation 
tends  to  induce  a  state  of  contraction,  and 
consequent  resistance  of  the  sphincter  mus¬ 
cle  ;  so  that,  the  faeces  being  retained  in  the 
rectum,  from  the  altered  condition  of  the 
sphincter,  the  mucous  membrane  of  the 
bowel  becomes  inflamed  ;  there  is  produced 
a  liability  to  ulceration,  and  fissure  is  no 
doubt  the  frequent  consequence.  The  exist¬ 
ence  of  fissure  is  indicated  by  an  excruciat* 


DR.  LAYCOCK  ON  THE  PREVENTION  OF  ASIATIC  CHOLERA. 


(595 


ing  pain  in  the  rectum,  which  is  felt  for  an 
hour  or  two  after  defecation.  The  remarka¬ 
ble  acuteness  of  this  pain  forms  the  prin¬ 
cipal  diagnostic  mark  of  the  disease  ;  for  in 
prolapsus  and  fistula  in  ano  the  character  of 
the  pain  is  rather  aching  than  acute.  The 
pain  of  fissure  is  sharp  and  stinging,  and 
generally  confined  to  one  part  of  the  bowel, 
usually  on  its  posterior  surface  towards  the 
os  coccygis.  The  description  of  this  kind  of 
pain  would  lead  the  surgeon  at  once  to  make 
an  examination  per  anum,  when  the  exces¬ 
sive  pain  experienced  on  passing  the  finger 
through  the  sphincter  would  constitute  an 
additional  diagnostic  sign  of  the  nature  of 
the  complaint.  When  the  finger  is  intro¬ 
duced,  which,  from  the  irritability  of  the 
muscle,  can  only  be  effected  with  some 
difficulty,  a  ragged  depression  will  be  dis¬ 
tinguishable  in  the  mucous  membrane  ;  an 
accurate  appreciation  of  the  length  and 
depth  of  the  fissure  will  thus  be  obtained, 
and,  when  the  finger  is  withdrawn,  a  stain 
of  blood  is  perceivable  on  it,  which  indicates- 
in  some  measure  the  form  and  extent  of  the 
ulcer.  This  disease  may  be  readily  cured 
by  the  following  means  : — A  straight  probe- 
pointed  bistoury  should  be  passed  along  the 
finger  through  the  anus,  so  as  to  divide,  in 
a  longitudinal  direction,  not  only  the  ulce¬ 
rated  mucous  membrane,  but  also  the  sub¬ 
jacent  muscular  fibres  of  the  sphincter, 
which  prevent  the  healing  of  the  ulcer  by 
their  frequent  contractions.  The  knife 
must  not  be  employed  too  freely,  as  there 
would  be  danger  of  cutting  through  the 
bowel ;  but  here,  as  I  have  before  often  re- 
mai'ked,  the  degree  of  force  that  may  be 
safely  employed  can  only  be  learned  by 
practical  experience.  During  the  operation 
the  patient  must  be  placed  in  the  prone 
position,  with  his  feet  resting  on  the  ground 
and  his  body  lying  across  the  bed  :  the  ulcer 
will  then  be  found  on  the  upper  or  coccygeal 
surface  of  the  bowel,  and  conveniently 
placed  for  making  the  incision.  Nitrate  of 
silver,  or  lotions  of  any  kind,  are  unavailing 
in  this  disease;  but  in  almost  every  case 
the  above  operation  affords  a  certain  means  of 
cure.  It  is  true  that  the  operation  removes 
only  the  effect,  the  cause  still  remaining  ; 
but  this  also  may  generally  be  overcome  by 
a  strict  system  of  diet,  and  the  employment 
of  such  constitutional  remedies  as  the  pecu¬ 
liarities  of  the  case  indicate.  A  very  similar 
fissure  often  occurs  in  the  centre  of  the 
lower  lip.  This  sometimes  resists  all  local 
applications,  but  I  have  cured  it  upon  the 
principle  just  described;  that  is  to  say,  by 
dividing  the  fibres  of  the  orbicular  muscle 
immediately  below  the  fissure,  the  conse¬ 
quence  being  that  the  ulcer  which  had  re¬ 
mained  unhealed  for  several  months  was 
completely  cured  in  the  course  of  a  very 
few  days. 


LECTURE 

ON  THE 

PREVENTION  of  ASIATIC  CHOLERA. 

Delivered,  October  9 th,  at  the  York 
Medical  School, 

By  Thomas  Laycock,  M.D. 

Physician  to  the  York  Dispensary,  and  Lecturer 
on  the  Theory  and  Practice  of  Medicine 


Disputes  as  to  contagion — two  general 
facts — definition  of  terms — contagion  al¬ 
ways  conditional — nature  of  conditions 
requisite — quarantine  —  comparison  be¬ 
tween  the  progress  of  imported  plague 
and  cholera — commercial  jealousy  of  the 
doctrines  of  contagion — prevention  of 
transmission  of  poison — the  latter  may  be 
packed  up  and  transmitted  by  public 
conveyance — use  of  dry  hot  air — removal 
of  moisture — ventilation — bad  effect  of 
crowded  assemblies  facilitating  trans¬ 
mission — conditions  exempting  from,  or 
predisposing  to,  contagion  in  the  indi¬ 
vidual — latent  period  —  elimination  of 
the  poison  —  diarrhoea  a  stage  of  the 
disease,  and  infectious — does  the  cholera 
poison  always  induce  cholera  ? — treat¬ 
ment  of  early  stage — predisposition  from 
hepatic  and  renal  disease — from  the  pre¬ 
sence  of  other  poisons  in  the  blood— from 
depressing  agencies — causes  of  the  decline 
of  the  epidemic — cholera  a  contagious 
fever . 

The  occurrence  of  a  few  sporadic  cases  of 
Asiatic  Cholera  on  board  ships  lying  in  one 
or  two  of  our  northern  ports,  reminds  me  of 
a  practice  which  we  have  previously  adopted, 
of  taking  special  note  of  epidemical  diseases. 
On  former  occasions  I  had  to  address  you  on 
epidemic  diarrhoea,  on  epidemic  scurvy, 
typhus  and  influenza  ;  and  it  seems  as  if  we 
had  gone  back  to  the  middle  ages,  not  merely 
in  matters  of  taste  and  vertu,  but  also  in  the 
more  serious  and  substantial  realities  of  wide- 
spreading  and  destructive  epidemics.  I  con¬ 
fess  that  I  cannot  look  upon  this  state  of 
things  without  some  apprehension  as  to  the 
results  to  humanity,  and  even  to  civilization. 
Epidemic  disease,  has  been  combined  m 
Europe  before  this  with  failing  crops,  sink¬ 
ing  commerce,  and  international  and  civil 
wars,  and  civilization  then  took  a  mighty 
step  backwards.  The  existing  generation  ia 
Europe  has  enjoyed  a  long  peace,  and  upon 
the  whole  prosperity  ;  but  things  have  won¬ 
derfully  changed  within  the  last  few  years, 
and  it  may  be  called  upon  to  endure  a  sad. 
contrast. 

Whatever  war  or  famine  may  do  or  re¬ 
quire,  the  medical  profession  comes  into 
close  combat  with  pestilence.  History 


696 


DR.  LAYCOCK  ON  THE  PREVENTION  OF  ASIATIC  CHOLERA. 


teaches  this  one  great  sorrowful  lesson,  that 
when  the  enemy  is  fairly  abroad  in  his  might, 
our  weapons  are  utterly  useless.  Let  the 
monster  attain  but  a  moderate  growth,  and 
our  efforts  to  subdue  him  are  weak  as  “  the 
idle  wind.”  Our  strength  is 'in  the  preven¬ 
tion  of  that  growth. 

To  succeed  in  an  attempt  of  this  kind,  we 
ought  to  know  thoroughly  what  we  have  to 
prevent.  Can  we  say  this  of  Asiatic  cho¬ 
lera  ?  The  newspapers  tell  us  that  at  Da¬ 
mascus  10,000  persons  died  of  the  disease 
between  the  6th  and  26th  of  August  last, 
and  there  are  distinguished  men  who  main¬ 
tain  that  such  a  fact  is  amply  sufficient  to 
prove  it  to  be  communicated  from  man  to 
man  ;  but  there  are  others,  equally  distin¬ 
guished,  who  maintain  just  the  contrary  :  and 
thus,  at  the  very  outset,  there  is  a  great 
stumbling-block  to  the  means  of  prevention; 
for  what  can  we  know  of  the  disease  when 
authorities  are  equally  balanced  on  such  an 
essential  fundamental  point  as  this  ? 

Now  if  I  thought  that  any  discussion  on  the 
point  would  be  of  use  to  you,  I  would  enter 
upon  that  discussion,  but  I  believe  the 
question  has  been  discussed  at  the  utmost 
length  over  many  a  weary  rood  of  printed 
page,  and  not  only  has  the  question  as  to  the 
contagiousness  of  cholera  been  so  discussed, 
but  also  that  of  plague, without  any  substan¬ 
tial  result.  I  have  read  of  physicians  going 
to  Egypt  for  the  purpose  of  proving  the 
non-contagiousness  of  the  plague  by  getting 
inoculated  with  its  virus,  and  there  dying  of 
the  disease, — so  great  was  the  warmth  with 
which  they  maintained  their  doctrine.  Now 
you  will  observe  one  peculiarity  in  all  these 
discussions — namely,  that  the  contending 
parties  get  bewildered  and  vexed  in  a  host  of 
minutiae  as  to  the  mode  of  transmission  of 
the  virus  ;  as  to  the  escape  of  this  person 
from  the  disease,  and  the  attack  of  that 
person  by  it,  &c.  and  so  lose  sight  of  the 
main  point — the  great  practical  questions 
of  the  nature  of  the  poison  and  its  rela¬ 
tions. 

What  are  the  universal  facts  observed 
with  regard  to  cholera  ?  In  the  first  place, 
many  are  attacked,  but  a  greater  number 
escape — and  why  ?  See  what  an  important 
question  this  is  in  prophylaxis  ;  for  if  you  can 
put  a  whole  population  into  the  same  situa¬ 
tion  as  that  portion  is  in,  which  escapes,  the 
disease  is  extinguished.  In  the  next  place, 
as  a  general  rule,  it  begins  with  sporadic 
cases — droppings,  as  it  were,  before  the 
thunder-shower — in  the  locality  about  to  be 
affected ;  and  it  gradually  increases  in  in¬ 
tensity  until  it  attains  a  climax,  and  then 
declines — and  why  ?  Here  is  another  im¬ 
portant  question ;  for  if  we  can  induce 
the  same  circumstances  at  the  outset  which 
occur  at  the  decline  of  the  disease,  it  need 
never  appear  except  sporadically. 


Let  us  first  fix  the  meaning  of  terms  to 
be  used  in  our  inquiry ;  for  I  believe  three- 
fourths  of  the  confusion  which  arises  in  the 
discussion,  as  to  the  spread  of  febrile  dis¬ 
eases,  arises  from  a  misapprehension  of 
terms.  I  have  just  used  the  term  sporadic  : 
it  means  scattered,  dispersed,  disseminated 
(Greece),  cases,  one  dropped  here  and  there, 
like  seeds  :  thus,  variola  or  scarlatina  may  be 
sporadic — there  being  a  few  dropping  cases 
here  and  there.  But  if  circumstances  favour 
their  spread,  and  if  there  be  a  number  of 
persons  predisposed  to  be  acted  on  by  the 
contagious  principle,  then  they  will  become 
epidemic — that  is  to  say,  generally  preva¬ 
lent  amongst  the  people :  for  that  is  the 
meaning  of  the  term.  So,  then,  a  disease  is 
epidemic  when  it  is  generally  prevalent, 
whether  it  be  contagious  or  not.  But  what 
do  I  mean  by  contagion,  you  will  ask  ? 
Why,  this — that  there  is  a  materies,  either 
solid  or  gaseous,  given  off  by  or  from  the 
bodies  of  persons  labouring  under  a  disease 
which  is  received  into  the  blood  of  another 
person,  and  which,  if  (when  received)  it 
produces  a  morbid  change  in  the  blood,  that 
change  is  followed  by  morbid  phenomena, 
like  those  under  which  the  originally  dis¬ 
eased  person  laboured.  Without  these  con¬ 
ditions  there  can  be  no  contagion.  Strictly 
speaking,  the  term  means  the  communica¬ 
tion  of  the  poisonous  materies  by  actual 
contact ;  but  if  the  poison  be  in  the  at¬ 
mosphere  (as  it  is  in  the  majority  of  conta¬ 
gious  fevers),  still  it  comes  to  the  blood  by 
contact — in  fact,  we  may  say,  by  direct  con¬ 
tact  through  the  lungs.  Contagion,  then, 
or  the  production  of  the  disease,  can  only 
be  conditional;  if  it  were  absolute  and 
unconditional,  the  human  race  would  by 
this  time  have  been  exterminated.  For¬ 
tunately,  the  conditions  the  concurrence  of 
which  is  necessary  are  so  numerous,  that  it 
is  only  at  considerable  intervals  that  that 
concurrence  takes  place  and  fever  becomes 
epidemic  at  all,  and  even  then  only  a  frac¬ 
tion  of  the  population  are  subject  to  its  in¬ 
fluence  by  presenting  the  necessary  condi¬ 
tions.  As  the  whole  force  of  prophylaxis 
must,  I  think,  be  directed  to  the  removal  of 
these  conditions,  let  us  consider  what  they 
are.  I  shall  assume  that  cholera  is  a  con¬ 
tagious  disease,  in  the  sense  I  have  just  laid 
down ;  for,  as  I  have  no  doubt  whatever  on 
this  point,  it  is  my  duty  to  assume  the  doc¬ 
trine  in  this  discourse.  Anything  like  a 
discussion  of  the  question  would  be  altoge¬ 
ther  out  of  place.  You  will  do  well  to  re¬ 
member  that  the  principles  of  prevention  I 
shall  state  are  applicable  to  all  other  conta¬ 
gious  fevers. 

There  must  be  a  generation  of  the 
materies  morhi  in  a  diseased  person — 
we  have  no  proof  it  can  be  generated  in  a 
healthy  one ;  consequently,  the  first  rule  of 


DR.  LAYCOCK  ON  THE  PREVENTION  OF  ASIATIC  CHOLERA.  697 


prevention  is  to  prevent  the  diseased  coming 
into  contact  with  the  healthy  :  quarantine  is 
put  in  force.  So  long  as  cholera  ravaged 
distant  countries  no  precaution  was  taken  ; 
the  diseased  population  was  too  remote  for 
us  to  fear  contact  with  them ;  but  now, 
when  it  is  near  to  our  own  coasts,  as  at 
Hamburgh,  the  Government  is  taking  active 
measures  to  enforce  quarantine.  The  period 
of  isolation  is  limited  to  six  days :  it  is 
doubtful  whether  this  be  sufficient  or  not ; 
but  even  if  it  be,  I  entertain  very  slight 
hopes  that  the  importation  of  the  materies 
morbi  can  be  prevented  by  any  measures 
of  the  kind  as  adopted  at  present :  the 
poison  may  be  introduced  at  so  many 
points,  by  means  of  clothing  or  goods, 
or  even  by  persons  who,  at  the  time 
of  landing,  are  in  good  health.  Now, 
it  is  a  strong  argument  in  proof  of  cholera 
being  contagious,  that  it  has  hitherto  shewn 
itself  in  England  only  on  board  of  ships 
from  an  infected  place — namely,  Hamburgh; 
and  in  this  respect  it  presents  a  close  analogy 
in  its  progress  to  plagues  admitted  to  be 
such.  I  will  give  you  an  example.  On  the 
25th  of  May,  1720,  a  trading  vessel  arrived 
at  Marseilles  from  the  coast  of  Levant,  with 
clean  bills  of  health,  the  plague  not  having 
appeared  there  till  after  her  departure.  In 
her  voyage  she  touched  at  Leghorn,  where 
some  of  her  crew  died  of  what  was  supposed 
to  be  a  malignant  fever.  Another  sailor  died 
two  days  after  arriving  at  Marseilles,  and 
then  one  of  the  quarantine  guards  stationed 
on  board.  In  a  week  or  two  dropping  cases 
began  to  occur  in  other  vessels  arriving  from 
the  Levant,  where  the  plague  was  now 
declared ;  but  it  was  not  until  the  8th  of 
July  that  the  plague  bubo  shewed  itself. 
The  physicians  now  raised  the  alarm,  and 
the  means  taken  to  arrest  the  progress  of 
contagion  prevented  the  immediate  spread 
of  the  disorder ;  but  the  common  people 
began  openly  to  insult  the  physicians  and 
surgeons,  whom  they  accused  of  causing 
false  alarms,  injurious  to  the  town.  This 
has  always  been  the  case  in  commercial  com¬ 
munities  ;  and  you  will  find  a  repetition  of 
this  conduct  in  England,  as  soon  as  the 
cholera  spreads.  Even  now  the  newspapers 
are  denouncing  as  “  old  women,”  those 
gentlemen  who  think  some  precautions 
should  be  taken  against  cholera  as  a  con¬ 
tagious  disorder.  The  sporadic  instances  are 
occurring  amongst  shipping  population,  as 
of  the  plague  at  Marseilles.  But  the  people 
of  that  emporium  paid  dearly  for  their  folly 
in  insulting  their  best  friends  :  their  mur¬ 
murs  were  soon  suppressed  by  the  progress 
of  the  disorder  itself,  which  attacked  with 
particular  violence  the  poor  and  crowded 
population  of  the  old  part  of  the  town. 
About  the  middle  of  August,  it  spread  into 
every  quarter,  and  a  thousand  persons  died 


daily  for  several  days.  I  hope  and  trust  the 
parallel  will  not  be  carried  out  in  regard  to 
cholera  in  this  country ;  but  we  need  only 
read  the  reports  of  its  progress  in  other 
countries,  where  predisposing  causes  abound, 
to  show  how  terribly  similar  it  has  been  in 
its  ravages. 

Secondly,  as  it  appears  all  but  certain 
that  quarantine  regulations  will  only  delay 
the  onset  of  the  disease,  the  next  step  in 
pi’evention  is  to  hinder  the  transmission 
of  the  poison  from  the  sick  to  the  healthy. 
Here  chemistry  comes  into  action  :  it  ap¬ 
pears  certain  that  vapour  in  the  atmosphere 
— or,  in  other  words,  a  damp  atmosphere, — 
facilitates  this  transmission,  probably  by 
holding  the  poison  in  solution  :  we  know 
that  this  is  so  with  other  gaseous  products. 
This  being  the  case  with  the  poison  of 
cholera,  not  only  will  there  be  a  more 
ready  transmission  through  a  damp  atmos¬ 
phere,  but  a  larger  quantity  will  enter  the 
system  at  a  given  time,  and  in  proportion  to 
the  quantity  taken  will  be  the  poisonous 
effect.  Cholera  will,  therefore,  spread  more 
rapidly — that  is  to  say,  a  greater  proportion 
of  persons  will  be  attacked  in  a  less  time,  in 
a  low  damp  locality  than  in  a  dry  high 
situation.  The  means  of  prevention  in  this 
case  is  to  dry  the  air  by  every  possible 
means,  or  else  that  the  damp  locality  be 
abandoned  ;  the  latter  would  certainly  be 
the  most  efficacious,  although  seldom  prac¬ 
ticable.  The  bedding  and  clothes  of  the  pa¬ 
tients  and  attendants  should  be  kept  per¬ 
fectly  dry  :  dry  heat  should  he  used  in  every 
possible  way,  and  all  open  vessels  contain¬ 
ing  water  removed  altogether  from  the 
apartment.  Effective  draining  should  be 
carried  out ;  stagnant  pools  filled  up  with 
some  dry  absoi'bent  material,  to  prevent  the 
transmission  of  the  poison  to  a  distant 
locality  (which  I  believe  may  be  done  by 
packing  up  some  damp  clothes  fresh  from 
a  cholera  patient,  in  a  well-fitting  box,  and 
transmitting  them  per  rail  or  otherwise)  ; 
all  articles  of  clothing  should  be  exposed  to 
as  high  a  temperature  as  they  will  bear  in 
a  dry  atmosphere  ;  a  blast  of  hot  dry  air 
upon  clothing  of  this  kind  will,  I  have 
reason  to  think,  effectually  destroy  the 
poison. 

You  may  also  dilute  the  poisonous  atmo¬ 
sphere  by  frequently  changing  it — that  is  to 
say,  you  must  ventilate  well.  If  you  can 
ventilate  with  dry  air,  it  will  be  better,  but 
you  had  better  use  damp  air  freely,  rather 
than  shut  up  the  poisonous  atmosphere. 
You  should  prevent  many  persons  being 
near  a  patient,  or  even  crowding  their  apart¬ 
ments,  for  they  not  only  abstract  oxygen 
from  the  atmosphere,  and  displace  a  certain 
proportion  of  it,  but  they  load  it  with  vapour 
derived  from  their  lungs.  When  crowded 
religious  services  are  held  during  a  time  of 


698 


DR.  LAYCOCK  ON  THE  PREVENTION  OF  ASIATIC  CHOLERA. 


pestilence,  they  are  always  followed  by  an 
increase  in  the  number  of  sufferers,  partly 
from  this  circumstance,  and  partly  from  the 
fact  that  persons  take  the  poison  with  them 
in  their  clothing,  or  in  their  blood.  People 
predisposed  to  the  disease  should,  there¬ 
fore,  avoid  all  public  meetings. 

As  to  the  use  of  disinfectants  I  cannot 
speak  confidently,  but  where  they  can  be 
tised  with  safety,  use  them  ;  they  will  do  no 
Iiarm,  and  may  do  good  by  giving  confidence 
and  courage  to  attendants,  and  by  destroy¬ 
ing  the  poison  in  part,  perhaps.  The  dead 
Ibodies,  at  least,  might  be  disinfected.  After 
you  have  done  your  best  for  preventing  the 
transmission  of  the  poison  from  the  diseased 
to  the  healthy,  you  will  seldom  succeed. 
All  persons  coming  in  contact  with  a  cholera 
patient  must  receive  more  or  less  of  the 
poison,  and  you  must  diligently  endeavour 
to  prevent  another  condition  necessary  to 
contagion — namely,  its  morbid  action  in  the 
Mood  of  the  person  receiving  it.  I  need 
Ibardly  tell  you,  gentlemen,  in  express  terms, 
that  millions  of  persons  receive  one  febrile 
poison  or  other  into  their  blood,  which  never 
envelopes  its  effects.  Every  practitioner 
who  attends  cases  of  small-pox  or  scarlatina, 
or  exanthematous  typhus,  or  rubeola,  or 
pertussis,  must  necessarily  do  this  at  every 
irisit,  and  they  are  almost  as  often  exempt 
from  disease.  And  so  with  cholera.  Sur¬ 
geons  have  lived  night  and  day  in  cholera 
Ihospitals  :  nay,  wearied  and  worn-out,  they 
lhave  fallen  forward  in  deep  sleep  upon  the  bed 
©f  their  patient,  and  on  waking  found  they 
had  a  cholera  corpse  for  their  pillow.  But  is 
this  a  reason  for  declaring  cholera  a  non- 
contagious  disease  ?  If  you  were  to  commit 
the  great  logical  mistake  of  admitting  the 
deduction,  then  every  other  contagious  fever 
must  be  declared  non-contagious  by  you  on 
the  same  grounds.  Thus  the  plague  which 
ravaged  Marseilles  in  1720,  to  which  I  have 
already  referred,  cannot  have  been  conta¬ 
gious  ;  for  not  one  medical  practitioner  was 
attacked,  and  the  bishop  is  described  as  going 
to  the  sick  and  dying  stretched  on  straw  in 
the  open  streets,  or  visiting  the  infected  in 
the  most  miserable  dwellings,  striding  over 
multitudinous  corpses,  and  confessing  the 
sufferers,  not  only  without  fear,  but  with 
perfect  calmness  and  safety.  So,  also,  the 
Archbishop  of  Milan  acted  when  a  petechial 
fever  devastated  that  city ;  yet  neither  pre¬ 
late  ever  contracted  the  disease.  A  person 
who  had  already  had  exanthematous  typhus 
or  variola  might  make  the  corpse  of  a  per¬ 
son  dying  of  either  disease  his  pillow  with 
perfect  impunity  ;  but  would  you  therefore 
say  that  neither  disease  is  contagious  ?  No  ; 
your  answer  would  be,  that  person  had  not 
the  conditions  necessary  to  the  morbid  ac¬ 
tion  of  the  poison. 

After  the  reception  of  a  febrile  poison 


into  the  blood,  a  certain  period  elapses 
before  it  renders  its  presence  manifest  :  this 
is  termed  the  latent  period.  Writers  have 
fixed  the  latent  period  of  cholera  variously 
at  from  eight  to  three  days.  Now  it  is 
obvious  that  something  prevents  the  poison 
from  acting  immediately,  or  else  something 
occurs  to  excite  it  into  action, — the  poison 
itself  lying  dormant  until  that  excitation 
takes  place.  It  is  just  possible  (I  don’t  say 
probable,  but  possible)  that  the  latent  period 
may  be  prolonged  for  weeks  or  months. 
The  real  fact  in  the  majority  of  cases  pro¬ 
bably  is,  that,  if  it  do  not  act  on  the  blood  in 
accordance  with  its  nature  in  eight  or  ten 
days,  it  is  eliminated  quietly  through  some 
of  the  excretory  outlets,  probably  through 
the  mucous  surface  of  the  intestinal  canal, 
and  perhaps  it  just  excites  a  little  diarrhoea, 
and  no  more. 

What  principle  of  prevention  do  we  draw 
from  these  views?  This — that  the  excre¬ 
tion  of  the  poison  must  be  facilitated. 

Now,  unfortunately,  while  there  has  been 
such  discussion  as  to  the  contagiousness  or 
non- contagiousness  of  the  disease,  and  the 
anti-contagionists  generally  have  all  along 
acknowledged  that  the  disease  is  excited  by 
a  poison,  the  principle  of  preventing  the 
disease,  by  eliminating  the  poison,  has  had 
no  attention.  But  here  the  two  parties  are 
on  common  ground,  the  poison  being  in  the 
blood  according  to  both.  How  are  we  to 
get  it  out  ?  or,  if  it  will  stay,  how  prevent 
its  action  ? 

I  apprehend  persons  in  perfectly  good 
health,  and  using  ordinary  care  in  keep¬ 
ing  so,  will  always  excrete  the  poison 
and  never  have  cholera :  Nature  is  quite 
sufficient,  under  these  circumstances,  to 
take  care  of  herself.  I  apprehend,  too,  that 
persons  only  in  moderate  health,  who  attend 
to  the  ordinary  rules  of  hygiene,  will  excrete 
the  poison  with  very  little  constitutional 
disturbance — having,  perhaps,  a  slight  febrile 
attack  ending  in  perspiration,  or  slight 
diarrhoea.  These  have  the  cholera,  and  may 
communicate  it,  too,  totally  unaware  of  the 
fact.  Now,  of  course,  popularly  speaking, 
diarrhoea  is  not  cholera ;  but,  technically 
speaking,  it  is  quite  as  much  an  effect  of 
the  poison  as  the  more  violent  symptoms  ; 
just  as  mercurial  erethism  is  quite  as  much 
a  symptom  of  poisoning  by  mercury  as 
ptyalism  or  diarrhoea.  And  here  let  me 
advise  you  not  hastily  to  conclude  that  the 
ordinary  symptoms  of  cholera  are  the  only 
symptoms  produced  by  the  poison  :  it  may, 
and  I  believe  does,  produce  symptoms 
altogether  different  from  its  commoner 
effects  ;  and  this  is  the  case  with  all  poisons 
whatever.  The  poison  of  erysipelas,  for 
example,  will  excite  puerperal  fever.  You 
may  have  measles  without  catarrh — scarla- 
tina  without  a  rash  ;  and  this  leads  me  to 


DR.  LAYCOCK  ON  THE  PREVENTION  OF  ASIATIC  CHOLERA.  699 


remark  how  necessary  it  is  to  use  the 
greatest  caution  in  your  conclusions  as  to 
the  symptoms  produced  by  febrific  poisons, 
and  always  remember  that  one -half,  at  the 
least,  of  their  natural  history  is  entirely 
unknown. 

If,  then,  when  the  cholera  is  epidemic, 
you  have  a  patient  with  slight  diarrhoea,  but 
especially  with  rice-water  stools,  act  as  if 
the  enemy  were  upon  him.  Now  I  don’t 
think  you  should  instantly  check  the  diar¬ 
rhoea,  for  I  suspect  it  is  an  effort  of  nature 
to  carry  off  the  poison — not  the  diarrhoea, 
hut  that  the  poison  is  passing  out  by  the 
intestinal  canal,  and  irritating  it  as  it  passes. 
Moderate  the  irritation  by  gentle  opiates  ; 
set  up  other  excretions,  as  by  the  skin  and 
kidneys  ;  give  your  patient  plenty  of  demul¬ 
cent  drinks,  and  of  free  pure  air ;  charge 
him,  as  he  values  his  life,  not  to  irritate  the 
gastro-intestinal  mucous  membrane,  and, 
as  an  antidote  to  the  poison  in  the  blood, 
give  a  few  doses  of  quinine,  or  the  vegetable 
acids.  The  best  formula  perhaps  would  be, 
a  grain  or  two  of  amorphous  quinine  with 
two  or  three  grains  of  tartaric  acid  and  a 
few  minims  of  laudanum  every  six  hours. 

But  suppose  your  patient  have  already 
disorder  of  the  excretory  organs,  so  that  the 
blood  is  not  depurated  in  the  ordinary  course 
of  events,  you  have  then  a  dangerous  state 
of  things,  and  one  -which  will  demand  all 
your  skill,  if  the  greatest  can  be  of  any 
avail.  If  your  patient  have  chronic  disease 
of  the  intestinal  mucous  membrane,  or  of 
any  of  the  principal  viscera,  but  especially 
of  the  liver  or  kidneys,  his  exposure  to  the 
poison  will  most  probably  be  followed  by  a 
violent  if  not  fatal  attack.  You  must  there¬ 
fore  warn  him  to  adopt  all  possible  means 
of  avoiding  contagion.  Patients  with  chro¬ 
nic  disease  of  the  liver  and  intestinal  mu¬ 
cous  membrane,  and  especially  with  Bright’s 
disease  of  the  kidneys — drunkards  belong  to 
this  class — will  suffer  far  more  than  any 
other  class  ;  and  I  am  inclined  to  think  few 
such  receiving  the  poison  will  recover. 

The  exemption  of  persons  engaged  in 
chandleries  and  tanneries  from  the  disease, 
points  out  their  atmosphere  as  being  pro¬ 
phylactic, — why,  I  cannot  say.  Persons 
highly  predisposed,  from  the  causes  stated, 
might  avail  themselves  of  this  hint.  I  am 
assured  that  the  emanations  from  tallow  are 
obnoxious  to  insect  life,  and  therefore  they 
have  some  virtue  or  activity  as  yet  unknown 
to  us,  and  are  widely  different  in  their  na¬ 
ture  from  mere  putrid  emanations. 

Now  you  may  have  all  the  functions 
going  on  with  tolerable  regularity,  or  at  least 
without  any  marked  irregularity,  further 
than  the  sort  of  ill  health  which  deficient  diet, 
defective  supply  of  atmospheric  air,  and  the 
presence  of  malarious  poisons,  may  excite, 
and  yet  such  person  be  highly  predisposed 


to  disease.  Any  thing  which  lowers  the 
tone  of  the  system  will  give  the  poison  acti¬ 
vity  :  thus  a  great  number  of  persons  may- 
have  already  received  the  poison  into  the 
blood,  and  it  remains  latent  until  the  depres¬ 
sion  which  precedes  a  heavy  thunder-storm, 
or  a  fatiguing  journey — as  a  march  of  troops, 
or  the  want  of  a  meal,  or  excess  in  a  meal 
after  a  long  fast,  will  at  once  develop  the 
morbid  action  of  the  poison.  Those  exam¬ 
ples  in  which  a  number  of  persons  have  been 
exposed  to  the  poison  at  the  same  time,  and. 
then  to  such  an  exciting  cause  as  the  pre¬ 
ceding  at  the  same  time,  have  presented 
great  difficulties  to  a  sufficient  explanation, 
and  have  been  called  “  nuts  for  conta- 
gionists”  to  crack;  but  you  will,  I  think, 
find  no  difficulty  in  them  whatever,  if  yon 
have  a  clear  comprehension  of  the  whole 
subject. 

The  miasmata  given  off  from  feculent  de¬ 
bris,  as  from  privies  or  accumulations  in 
the  sewers,  act  as  a  poison,  as  I  have  pre¬ 
viously  shewn,  on  the  intestinal  mucous 
membrane ;  and,  consequently,  persons 
breathing  air  impregnated  with  such  emana¬ 
tions  are  peculiarly  liable  to  be  rapidly 
affected  by  the  poison  of  cholera.  The  re¬ 
ception  of  the  latter  is  but  the  application  of 
the  match  to  a  train  already  laid.  I  need 
not,  I  think,  observe,  that  the  removal  of 
feculent  accumulations,  and  of  animal  and 
vegetable  debi'is,  is  an  important  point  in 
prevention. 

All  the  depressing  emotions  enable  the 
poison,  when  received  into  the  blood,  to 
conquer  the  reaction  of  the  organism  against 
it,  and  to  overcome  the  vis  conservatrix. 
You  will  hear  of  people  taking  fright  at  the 
cholera  hearse,  or  something  of  the  kind — - 
hardly  suffering  from  diarrhoea,  perhaps — 
and  go  home,  lie  down,  and  die  in  all  the 
agonies  of  the  disease.  Now  such  persons, 
if  they  had  not  had  their  vital  powers  so  de¬ 
pressed  by  terror,  would  have  resisted  the 
action  of  the  poison  ;  for  rest  assured,  gen¬ 
tlemen,  that  when  a  person  dies  of  Asiatic 
cholera,  he  must  have  received  a  specific 
poison  into  his  blood,  however  difficult  it 
may  be  to  account  for  the  communication  or 
reception  of  it.  You  might  as  reasonably 
say,  that  a  person  with  small-pox  had  never 
received  the  contagion  of  small -pox. 

What  are  the  circumstances  that  lead  to 
the  decline  of  the  epidemic  ?  In  the  first 
place,  all  persons  who  have  had  an  attack; 
do  not  seem  immediately  liable  to  a  second ; 
then  the  highly  predisposed  have  either  died 
or  had  it ;  so  that,  like  a  fire,  it  dies  out  for 
want  of  fuel ;  or,  thirdly,  an  atmospheric 
change  may  conjoin  with  the  preceding,  and 
the  air  becoming  very  cold  and  dry,  puts  a 
stop  to  the  development  of  predisposing 
miasmata,  and  the  more  ready  transmission 
of  the  poison.  It  is  in  this  way  all  epi- 


700  DR.  hughes’  cases  of  pneumonia  variously  treated. 


demies  whatever  come  to  a  close,  whether 
arising  from  miasm  or  contagion. 

The  grand  object,  then,  in  the  prevention 
of  cholera,  is  to  remove  as  many  of  the  pre¬ 
disposing  causes  as  you  can.  Many  of  these 
are  entirely  within  the  power  of  man — in¬ 
deed,  all  the  most  important :  I  mean  those 
emanations  which  arise  from  over-crowding 
or  decaying  debris,  &c.  With  regard  to 
cachectic  and  visceral  disease,  you  can  do 
little. 

And  now  let  me  strongly  advise  you  to 
study  cholera  as  a  fever  belonging  to  the 
contagious  class  ;  seek  out  its  analogies,  and 
scrutinize  it  in  relation  to  them  :  if  you  do 
this,  the  difficulties  which  arise  in  explain¬ 
ing  the  propagation  and  course  of  cholera 
will  be  found  to  be  common  to  other  conta¬ 
gious  fevers,  and  that,  with  a  careful  atten¬ 
tion  to  the  analogies,  many  of  these  difficul¬ 
ties  will  disappear  with  reference  to  the 
whole  group. 


©rigtnal  ©ommuntcattons. 


CASES  of  PNEUMONIA,  VARIOUSLY 
TREATED ; 

WITH  BRIEF  OBSERVATIONS. 

Read  at  the  South  London  Medical  Society , 
Oct.  12  th,  1848. 

By  H.  M.  Hughes,  M.D. 

Assistant  Physician  to  Guy’s  Hospital,  and  late 
President  of  the  Society. 


In  a  paper  published  a  few  years  since 
in  the  Guy’s  Hospital  Reports,  “  On 
Pneumonia,”  I  made  the  following  ob¬ 
servations  on  the  treatment  of  the  com¬ 
plaint: — “  To  assert  that  any  one  mode 
of  treatment  should  be  adopted  in  pneu¬ 
monia,  is,  I  think,  open  to  grave  ob¬ 
jections.  To  say  that  venesection, 
twice  or  thrice  repeated,  or  that  anti¬ 
mony,  or  calomel  and  opium,  should 
always  be  the  remedy  employed,  ap¬ 
pears  to  me  to  be  as  unphilosophicalin 
theory,  as,  if  always  regarded  as  a  rule 
of  action,  it  would  be  dangerous  in 
practice.  If,  indeed,  the  disease  always 
existed  in  persons  of  the  same  natural 
power, — of  the  same  habits,  mode  of 
life,  country,  and  locality, — if  it  was 
always  presented  to  the  notice  of  the 
physician  in  the  same  stage, — if  it  was 
always  uncomplicated,  or  had  the  same 
complication, — if  it  always  occurred  in 
the  same  ‘  epidemic  constitution,’ — if, 


in  fact,  the  ‘  caeteris  paribus  ’  were 
always  truly  applicable  to  the  disorder, 
— then,  indeed,  one  system  of  treatment 
might  be  adopted,  not  only  without 
danger,  but  with  advantage ;  and  tables 
showing  the  amount  of  cures  and  of 
deaths  from  one  or  another  mode  might 
be  safely  trusted  as  guides  to  practice. 
But  as  the  truth  is  exactly  the  reverse 
of  all  this  ;  as  pneumonia  occurs  in 
persons  of  all  ages  and  all  constitutions, 
and  is  seen  for  the  first  time  in  all 
stages,  and  with  great  variety  of  com¬ 
plications,  each  case  should  be  more  or 
less  studied  by  itself,  and  the  effects  of 
remedial  agents,  as  represented  by 
tables,  should,  I  think,  only  be  pub¬ 
lished  with  cautious  limitations  and 
explanations,  and  be  viewed  as  rules 
of  practice  only  after  a  careful  consi¬ 
deration  of  the  attendant  circumstances 
of  each  individual  case.”  To  treat  all 
cases  of  pneumonia  hoinoeopathically, 
or  by  poultices,  or  “decoctumgraminis,” 
appears  to  myself  not  less  wise,  and  to 
a  well-informed  physician,  I  would  say, 
not  less  justifiable,  than  the  determina¬ 
tion  to  adopt  a  more  vigorous  system 
of  bleeding,  because  a  French  experi¬ 
mentalist,  in  an  equal  number  of  per¬ 
sons,  affected  with  slight  pneumonia, 
found  that  those  who  were  bled  at¬ 
tained  to  convalescence  a  few  days 
earlier  than  those  who  were  not  sub¬ 
mitted  to  the  operation  of  venesection. 
Excepting  when  all  the  attendant  cir¬ 
cumstances  are  similar  (a  coincidence 
which  rarely  occurs),  or  in  the  case  of 
specific  remedies,  and, perhaps,  in  some 
epidemic  complaints,  I  believe  that  the 
“  methode  numerique”  is  not  only  not 
fairly  applicable,  but,  if  applied  at  all, 
is  likely,  in  a  majority  of  cases,  to  be 
injuriously  applied  to  the  treatment  of 
disease.  With  all  deference  to  great 
talent  displayed  by  the  philosophic 
school  of  medicine,  and  to  the  theories 
of  “  young  physic,”  1  still  think  that 
experience,  in  the  common  acceptation 
of  the  term,  is  something,  and  is  not  to 
be  discarded  ;  and  that  ordinary  ob¬ 
servation  should  not  be  thrown  aside 
in  the  practice  of  our  profession ;  that 
judgment  as  well  as  reasoning  should 
be  exercised  in  the  treatment  of  disease ; 
that,  as  the  phases  and  attendant  cir¬ 
cumstances  of  the  same  affections  are 
constantly  varying,  so  the  treatment 
should  varv  also ;  and  therefore  that  it  is 
only  as  an  exception  that  the  results  of 
remedies  can  be  fairly  estimated  by  the 


DR.  HUGHES’  CASES  OF  PNEUMONIA  VARIOUSLY  TREATED.  701 


“  methode  numerique,”  or  that  the 
genuine  effects  of  treatment  can  be  pro¬ 
perly  judged  after  the  manner  of  an 
addition  sum.  It  is  with  the  view  of 
illustrating  this  statement  by  exhibiting 
the  successful  treatment  of  the  same 
disease  in  different  forms,  and  occurring 
in  persons  of  different  constitution,  by 
methods  not  only  different  from,  but  in 
some  respeets  opposite  to,  each  other, 
that  I  beg  to  submit  to  the  notice  of 
the  Society  the  following  series  of  cases 
of  pneumonia,  which  has  fallen  under 
my  care  during  the  last  year. 

Case  I. — Simple  pneumonia — treated 

with  calomel ,  antimony,  opium,  and 

cupping . 

J.  W.,  aged  37,  admitted  into  Guy’s 
Hospital  under  my  care,  June  23d, 
1847-  He  was  a  common  daily  la¬ 
bourer,  and  had  been  ill  for  seven 
days,  as  it  was  supposed,  from  fever  ; 
for  which,  in  fact,  he  was  admitted. 
Upon  examining  his  chest,  however,  it 
was  found  that  he  had  great  dulness  of 
the  right  side,  as  high  up  as  the  base 
of  the  scapula,  and  that  the  breathing 
was  tubular,  and  the  voice  bronohopho- 
nic  in  the  same  parts ;  while  in  the 
upper  part  of  the  same  lung  the  respi¬ 
ration  was  mixed  with  crepitating  and 
mucous  rattles.  His  skin  was  hot,  and 
pungent;  his  tongue  loaded,  white, 
and  moist ;  he  complained  of  pain  in 
the  right  side,  but  had  very  little  cough, 
and  but  scanty,  mucous,  white,  and 
tenacious  expectoration.  His  bowels 
were  confined  ;  his  pulse  frequent,  but 
small ;  he  had  taken  no  medicine. 
Ordered — Hydrarg.  c.  Creta,  gr.  iv.  st. 
01.  Ricini,  5vj-5  post.  hor.  vj. ;  C.  C. 
ad.  ^vj.  parti,  dolent.  ;  Hydrarg. 
Chlorid.  gr.j.;  Pulv.  Antim.  gr.  iv. ; 
Pulv.  Ipecac.  co.  gr.  ij. ;  4ta  quaque 
hor.  c.  Julep.  Ammon.  Acetat. 

24th. — Much  the  same.  Tongue 
more  dry.  He  complained  now  of  pain 
in  the  right  side,  over  the  region  of 
the  liver,  and  in  this  part  nearly  pure 
crepitating  rattle  was  now  distinctly 
audible. — Rep.  Cucurb.  cruent.  ad  ^vj. 
parti  dolent. ;  Pil.  Antim.  Opiat.  c. 
Hydrarg.  Chlorid.  gr.  iss.  4ta  quaque 
hor.  c.  J.  Ammon.  Acetat. 

25th. — He  was  much  better;  the 
skin  was  less  hot,  and  was  now  moist ; 
the  tongue  was  moist,  and  the  bowels 
relaxed  ;  the  posterior  part  of  the  lung 
was  becoming  permeable  to  air,  as  the 
respiration  was  more  audible. — Rep. 


Pilul.  6ta  quaque  hor.  Intermittatr. 
Mistur. 

26th. — Bowels  much  relaxed  ;  skin 
soft  and  moist;  the  pulse  less  frequent, 
and  more  expanded.  Crepitation  was 
now  distinct  at  the  lower  part  of  the 
right  side. — Rep.  Pil.  nocte  maneque; 
Mistur.  Cretse,  31SS.  6ta  quaque  hora 
sumend;  Enema  Amyli.  c.  Tr.  Opii, 
ITfxx.  statim  et  vespere  injiciend. 

28th. — Bowels  still  relaxed ;  chest 
affection  almost  gone,  a  little  mucous 
rattle  alone  remaining. — Rep.  Mistur. 
Pulv.  Ipecac.  C.  gr.  v.  quaque  nocte 
sumend. 

From  this  time  he  had  no  complaint. 
The  lung  was  gradually,  but  quickly, 
restored  to  its  normal  condition,  and 
the  patient  was  discharged  “well”  two 
weeks  after  his  admission. 

This  case  presents  no  peculiarity, 
unless  that  it  was  admitted  as  a  case 
of  fever,  and  was  discovered  to  be 
pneumonia  almost  entirely  by  the  phy¬ 
sical  signs,  to  which,  however,  atten¬ 
tion  was  necessarily  directed  by  the 
local  pain. 

Case  II. — Pneumonia  of  the  apex,  simu¬ 
lating  simple  fever  in  its  general 

features,  and  phthisis  as  to  its  physical 

signs. — Treated  with  antimony. 

D.  M‘C.,  aged  12,  an  Irish  lad,  was 
admitted  into  the  hospital,  under  my 
care,  June  23d,  1847.  He  had  been 
ill  for  three  days,  and  had  taken  no 
medicine.  He  was  at  first  supposed  to 
be  labouring  under  fever,  with  bowel 
irritation,  which  was  at  that  time  very 
rife  in  the  hospital,  and  was  ordered 
Mistur.  Cretee,  *iss.  6tis  horis.  Before 
the  visit  of  the  next  day  (thanks  to  the 
assiduity  and  intelligence  of  my  clerk, 
Mr.  Stedman)  it  was  discovered  that 
he  had  great  dulness  of  the  upper  part 
of  the  right  lung,  nearly  as  low  down 
as  the  nipple.  Tubular  breathing 
also,  and  bronchophony,  existed  before 
and  behind,  and,  over  the  upper  part  of 
the  scapula,  and  in  the  acromial  region, 
as  distinct  gurgling,  pectoriloquism, 
and  tubular  breathing,  as  I  almost  ever 
heard.  He  complained  of  no  pain, 
and  had  no  cough  and  no  expectora¬ 
tion.  The  local  signs  were  clearly 
those  which  ordinarily  accompany  ad¬ 
vanced  phthisis ;  but  as  it  was  con¬ 
fidently  asserted  that  he  was  quite 
well  five  days  before  his  admission,  as 
he  had  none  of  the  general  symptoms 
of  phthisis,  and  as  he  had  many  of  the 


702  DR.  hughes’  cases  of  pneumonia  variously  treated. 


constitutional  symptoms  of  pneumonia 
. — viz.  intense  force,  with  a  flushed  face, 
a  pungently  hot  skin,  a  congested  con¬ 
junctiva,  a  loaded  and  dry  tongue,  and 
an  accelerated  and  tense  pulse, — it  was 
presumed  that  he  was  suffering  from  a 
moderately  advanced  stage  of  acute 
pneumonia  of  the  apex  of  the  lung, 
and  he  was  treated  accordingly;  though 
with  some  suspicion  that  the  local 
pneumonia  might  be  at  any  rate  con¬ 
nected  with  tubercles.  Ordered  — 
Hirudines  v.  infra  claviculam  dextr. 
applicand.  Ipc  Antim.  Potassio-tart. 
gr.  ss. ;  Tr.  Opii,  miss. ;  A'q.  Font.  5SS. 
4ta  quaque  hora  sumend. 

25th. — Medicine  excited  nausea,  but 
produced  no  vomiting.  General  symp¬ 
toms  and  physical  signs  little  changed. 
■ — Pergat. 

26th. — He  was  in  every  respect 
better.  He  perspired  freely ;  the 
tongue  was  more  moist ;  he  had  no 
diarrhoea,  and  still  complained  of  no 
cough  ;  the  local  signs  also  were  much 
less  strongly  marked  ;  the  gurgling  and 
pectoriloquism  had  disappeared,  and 
the  tubular  breathing  was  less  decided; 
air,  indeed,  entered,  though  imper¬ 
fectly,  into  the  pulmonary  tissue,  and 
induced  muco  -  crepitating  rattle. — 
Eep.  Mistur.  6tis  horis. 

From  this  time  he  rapidly  improved, 
and  on  the  29th  he  took  only  half  the 
dose  of  antimony  first  prescribed.  The 
progress  of  the  retiring  pneumonia  was 
distinctly  marked  by  the  gradual  dis¬ 
appearance  of  the  local  signs  :  his  con¬ 
stitutional  symptoms  ceased  on  the 
fourth  day  after  his  admission,  and  he 
was  discharged  in  a  fortnight  without 
any  indication  of  disease,  either  local 
or  general.  No  rhonchus,  not  any 
harshness  of  respiration  even,  could  be 
beard  in  any  part  of  the  lung. 

This  case  is,  I  think,  interesting, 
m>t  to  say  important,  in  many  particu¬ 
lars.  In  the  first  instance  the  lad  was 
admitted  for  common  continued  fever; 
and  it  was  only  by  the  physical  signs 
that  the  disease  of  the  lung  was  dis¬ 
covered.  It  was  not  indicated  either 
by  cough,  expectoration,  pain,  or  dysp- 
ncea.  Fever  was  rife  at  the  period, 
and  he  might  have  easily  been  passed 
(as,  indeed,  in  the  first  instance  he 
was  passed)  as  an  example  of  the  dis¬ 
ease  endemic  at  the  time.  The  next 
circumstance  worthy  of  notice  in  the 
case  was  the  exact  similarity — yes, 
after  some  little  experience  in  these 


matters,  I  repeat,  the  exact  similarity 
of  the  physical  signs  which  existed,  to 
those  present  in  advanced  phthisis. 
Tubular  breathing,  gurgling,  and  pec¬ 
toriloquism,  with  local  dullness  on  per¬ 
cussion,  all  at  the  apex  of  the  lung, 
and  there  alone,  were  so  distinct  that 
had  we  trusted,  as  some  experienced 
auscultators  are  sometimes  falsely 
charged  with  trusting,  alone  to  phy¬ 
sical  signs,  a  serious  error  in  diag¬ 
nosis  would  have  been  committed. 
The  history  of  the  ailment,  and  the 
constitutional  symptoms,  were  quite  op¬ 
posed  to  the  probability  of  the  existence 
of  advanced  phthisis.  The  treatment 
was  directed  accordingly  ;  but  it  may 
be  acknowledged  that  it  was  not 
adopted  without  some  slight  misgiv¬ 
ings,  or  continued  without  anxious 
watching;  so  very  characteristic  ap¬ 
peared  the  physical  signs  of  old  and 
advanced  disease.  The  third  circum¬ 
stance  worthy  of  regard  is  the  exceed¬ 
ingly  beneficial  action  of  the  antimony, 
which,  with  the  exception  of  the  appli¬ 
cation  of  five  leeches,  was  in  fact  the 
only  medicine  employed  for  the  cure 
of  the  complaint.  Half  a  grain  of 
tartar  emetic  every  four  hours  excited 
no  vomiting,  but  produced  the  desira¬ 
ble  nausea,  in  a  lad  only  twelve  years 
of  age,  and  obviously  resolved  the 
complaint  in  the  space  of  about  forty- 
eight  hours.  The  case  was  a  most  in¬ 
structive  one  both  to  physician,  and 
pupil. 

Case  III. — Simple  pneumonia,  treated 
with  antimony . 

¥m.  W.,  aged  34,  admitted  into  the 
hospital,  under  my  care,  for  fever,  July 
7th,  1847.  He  had  been  ill  for  five 
days,  and  had  suffered  from  pain  in 
the  side  and  cough,  but  had  taken  little 
or  no  medicine.  His  skin  was  pun¬ 
gently  hot ;  his  tongue  loaded,  white, 
and  moist;  and  his  pulse  frequent  (96 
in  the  minute).  The  cough  was  not 
frequent,  but  the  expectoration,  though 
not  copious,  nor  remarkably  viscid, 
was  of  a  rust  colour.  Marked  dulness 
on  percussion  existed  on  the  left  side, 
posteriorly,  as  high  as  the  scapula, 
together  with  tubular  breathing,  mixed 
with  some  muco-crepitating  rattle  and 
bronchophony.  Ordered — C.  C.  parti 
dolent.  ad  3vj.  Antim.  Potassio-tart. 
gr.  j.  ;  Tr.  Opii,  ITfiij. ;  Aq.  Fontan.  §j. 
4ta  quaque  hora. 


DR.  HUGHES*  CASES  OF  PNEUMONIA  VARIOUSLY  TREATED.  70S 


8th. — No  vomiting,  and  no  obvious  I  dered — Emplastr.  Cantharid.  lateri  si® 
change.  nistro;  Julep.  Ammon.  Acet ;  Inf.  Ser- 

9th. — Medicine  excited  vomiting;  pentariee,  aa.  sjss.,  6ta  quaque  hor. ; 
but  the  skin  was  now  cool  and  moist,  Pulv.  Ipecac,  c.  gr.  iss. ;  Pulv.  Antim. 
and  the  pulse  84. — Rep.  Mistur.  ter  (Jacob.),  gr.  iij.;  Hydrarg.  ChloricL 
die.  gr.  j.  ft.  Pulv.  nocte  sumend.  Beef  tea 

10th. — tie  had  had  no  vomiting  ;  and  arrow  root, 
the  skin  was  quite  cool,  and  the  pulse  9th. — Bowels  not  open.  No  other 
70 ;  his  cough  was  frequent ;  and  change.  Capt.  Olei  Ricini,  5SS.  Rep. 
muco-crepitant  and  mucous  rattles  Mist,  et  Pulv.  When  the  blister 
were  still  obvious  in,  though  the  dul-  allowed  of  the  re-examination  of  the 
ness  on  percussion  had  entirely  disap-  chest,  after  two  or  three  days5  continu- 
peared  from,  the  partaffected. — Allowed  ance  of  the  same  means,  during  which 
beef-tea.  From  this  time  he  had  no  her  general  symptoms  were  little 
remains  of  pneumonic  symptoms,  but  changed,  the  lung  was  found  to  be 
continued  to  cough  a  good  deal.  He  much  more  premeable  by  air.  At  this 
was  consequently  ordereda  mixture  with  time  a  free  perspiration  suffused  the 
extract  of  conium  and  twenty  minims  skin,  and  the  general  symptoms  abated, 
of  ipecacuanha  wine,  thrice  daily  ;  and  But  now  the  cough  became  more  fre¬ 
on  the  15th,  a  blister  for  a  slight  pleu-  quent  and  troublesome,  and  bronchitis 
ritic  pain.  He  was  afterwards  kept  in  (probably  congestive)  appeared  in  the 
the  hospital  only  that  “  he  might  re-  posterior  part  of  the  other  lung,  though 
gain  his  strength,”  which  he  fancied  without  any  increased  fever.  A  blister,, 
was  not  restored  till  August  2d,  a  and  some  conium  mixture,  were  for  this 
month  after  his  admission.  prescribed  with  benefit.  In  a  few  clays 

The  only  circumstance  worthy  of  she  was  up,  and  free  from  complaint, 
remark  in  this  case  was  the  exceed-  and  wishing  to  return  home.  But  re- 
ingly  beneficial  action  of  the  antimony,  collecting  her  neglected  condition  on 

.  ...  her  admission,  and  regarding  her  pre- 

Case  IV.  /  neumonia  complicating  sent  debility,  I  thought  it  right  to 

fever.  (?)  detain  her  till  the  28th,  three  weeks 

J.  C.,  aged  12,  an  Irish  girl,  who  after  her  admission, 
was  reported  to  have  been  ill  for  two  This  case  was  probably,  though  I 
weeks  (though  in  what  mode  could  not  think  by  no  means  certainly,  one  of 
be  satisfactorily  ascertained),  was  ad-  fever  complicated  with  pneumonia; 
mitted  into  the  hospital,  under  my  but  the  child  had  been  so  grossly  ne- 
care,  July  7th,  1847.  She  appeared  to  glected,  that  the  origin  and  progress  of 
have  been  greatly  neglected,  as  she  the  case  could  not  be  ascertained,  and 
was  filthily  dirty,  and  so  overrun  with  the  nature  of  the  case  could  only  be 
vermin,  that,  even  after  her  hair  had  conjectured  from  the  actual  condition, 
been  removed,  she  could  not  be  efifi-  in  which  we  found  her. 
ciently  examined  till  the  next  day, 

after  she  had  been  thoroughly  washed.  Case  V.  Pneumonia  of  the  right  sidev 
As,  however,  the  bowels  were  reported  with  influenza ,  followed  by  extensive 
to  be  relaxed,  the  skin  was  hot  and  anc ^  pleurisy ,  with  effusion  of 

dry,  and  the  tongue  dry  and  coated,  the  left  side,  and  pericarditis. 
she  was  presumed  to  be  suffering  from  At  12  p.m.,  of  Friday,  December 
fever,  with  bowel  complication,  and  3d,  I  was  requested,  by  Mr.  Ray,  of 
was  ordered  simply  the  Mist.  Cretse,  Dulwich,  to  visit,  with  him,  a  lady  in 
Gtis  horis,  vel  pro  re  nata,  till  the  next  the  Camberwell  New  Road.  She  was: 
visit.  The  next  day  she  was  found  about  38  years  of  age,  married,  and  the 
with  a  pungently  hot  skin,  a  dry  and  mother  of  one  girl,  of  about  8  years, 
loaded  tongue,  a  frequent  and  feeble  Though  a  somewhat  delicate  person, 
pulse,  the  expression  of  countenance  she  had  been  tolerably  well  till  three 
languid  and  sunken,  and  the  lower  or  four  days  before,  from  which  time 
and  posterior  part  of  the  left  side  dull  she  had  suffered  from  the  ordinary 
on  percussion  ;  the  breathing  at  this  symptoms  of  influenza,  which  was  then 
part  tubular,  with  shrill  muco-crepitat-  common.  For  twenty-four  hours  she 
ing  rattles,  and  the  voice  broncho-  had  suffered  from  pain  in  the  right 
phonic.  She  had  very  little  cough,  side,  and  Mr.  Ray  had  suspected,  and 
and  scarcely  any  expectoration.  Or-  been  anxiously  looking  for,  the  ordinary 


704  DR.  hughes’  cases  of  pneumonia  variously  treated. 


signs  of  pleuritis,  and  had  discreetly 
treated  her  with  the  application  of  a 
blister  and  the  administration  of  calo¬ 
mel,  antimony  and  opium,  with  salines. 
At  my  visit  she  still  complained  of  pain 
in  the  right  side  :  her  breathing  was 
frequent  and  painful;  her  tongue 
furred  and  moist,  and  her  pulse  fre¬ 
quent,  feeble,  and  unequal.  The  right 
side  of  the  chest,  as  high  as  the  mam¬ 
ma  anteriorly,  and  over  its  entire  ex¬ 
tent  posteriorly,  was  dull  on  percus¬ 
sion;  the  voice  in  the  affected  part  was 
resonant,  and  the  breathing  approach¬ 
ing  to  bronchial,  but,  upon  deep  inspi¬ 
ration  and  coughing,  accompaniedwith 
muco- crepitating  rattle.  The  apex 
anteriorly,  and  the  anterior  margin  of 
the  lung,  afforded  puerile  respiration. 
The  left  lung  and  pleura,  and  the 
heart,  appeared  healthy.  The  bowels 
were  open.  I  recommended  another 
blister,  a  continuation  of  the  calomel 
and  opium,  without  the  antimony,  and 
some  infusion  of  serpentary  to  be 
added  to  her  mixture.  The  next  day 
(Saturday)  she  was  certainly  somewhat 
better,  and  the  air  entered  the  affected 
lung  more  freely.  A  continuance  of 
the  remedies  was  advised,  together 
with  good,  mild,  nutritious  diet.  The 
following  day,  Sunday,  she  was  not 
nearly  so  well :  the  right  lung  was  not 
so  permeable,  and  she  had  more  dysp¬ 
noea.  Mr.  Ray  thought  he  discovered 
some  rubbing  of  the  serous  surfaces  on 
the  anterior  of  the  chest,  over  the  re¬ 
gion  of  the  heart ;  and  there  now  ex¬ 
isted  obvious  dulness,  with  tubular 
breathing,  over  the  base  of  the  left 
side,  posteriorly :  her  powers  were 
more  prostrated,  and  her  general  dis¬ 
tress  greater.  A  blister  to  the  left  side 
was  now  recommended.  The  pills 
were  continued,  and  the  mixture  re¬ 
peated,  with  a  few  grains  of  carbonate 
of  ammonia. 

At  11  o’clock  the  same  evening,  a 
colleague  saw  this  lady,  and  in  conse¬ 
quence  of  the  great  distress  of  breath¬ 
ing,  and  the  severe  pain  in  the  left 
side,  ordered  her  to  be  cupped.  This 
afforded  her  considerable  temporary 
relief ;  but  in  a  fewT  hours  Mr.  Ray 
was  called  to  her  again,  when  her 
suffering  was  as  great  as  before.  She 
was  again  cupped,  though  the  blood 
removed  was  to  a  small  amount,  and 
afforded  no  relief.  At  1 1  o’clock  the 
next  morning,  I  was  again  summoned 
to  her  bed-side,  but  she  wTas  then  evi¬ 


dently  sinking,  and  she  expired  early 
the  same  evening. 

Inspect io  cadaveris,  28  hours  after 
death. — The  chest  only  was  examined. 
The  right  pleura  was  generally  adhe¬ 
rent,  and  the  whole  right  lung,  with 
the  exception  of  the  apex  and  the 
anterior  edge,  was  soft  and  pultaceous, 
of  a  dull  brick-dust  colour,  and  nearly 
airless.  The  left  pleura  contained  a 
small  quantity  of  serum,  and  a  very 
large  amount  of  semi-solid  plastic 
lymph,  resembling  clarified  butter,  by 
which  the  otherwise  unaffected  lung 
was  greatly  compressed,  and  conse¬ 
quently  rendered  firm  and  but  slightly 
crepitant.  The  heart  was  soft,  small, 
and  feeble.  The  pericardium  con¬ 
tained  a  little  viscid  serum,  with  a  few 
flakes  of  lymph,  and  had  a  little  fibrine 
on  the  surface. 

It  would  perhaps  be  unwise  to  specu¬ 
late  upon  the  probable  termination  of 
this  lady’s  original  local  disease,  (the 
pneumonia  of  the  right  lung,)  if  she  had 
not  been  attacked  with  extensive  and 
acute  secondary  pleuritis  and  pericar¬ 
ditis.  My  own  impression,  however, 
is,  that  hy  supporting  her  power,  and 
by  the  administration  of  very  mild  re¬ 
medies,  it  is  highly  probable  that  she 
would  have  recovered. 

[To  be  continued.] 


ON  THE  EXISTENCE  OF  OZONE  IN  THE  AT¬ 
MOSPHERE.  BY  DR.  MOFFAT. 

Prof.  Schonbein  has  stated  the  pecu¬ 
liar  substance  to  which  he  has  given  the 
name  of  Ozone,  is  to  be  detected  in  varying 
proportions  in  the  atmosphere, — in  which  it 
is  to  be  discovered  by  a  mixture  of  iodide  of 
potassium  and  starch.  Slips  of  paper  are 
smeared  with  the  following  composition — 
a  drachm  of  common  starch  is  mixed  with 
an  ounce  of  boiling  water,  and  the  solution 
boiled  until  it  is  of  the  consistency  of  that 
used  in  the  laundry, — then  twelve  grains  of 
iodide  of  potassium  are  to  be  added,  and  the 
whole  well  mixed  together.  The  presence 
of  ozone  is  indicated  by  the  decomposition 
of  the  potassium  salt,  and  the  formation  of 
a  blue  iodide  of  starch.  Dr.  Moffat,  from 
the  results  which  he  has  obtained  (and  a 
great  number  of  specimens,  showing  the 
changes  produced  on  the  iodide  of  potas¬ 
sium,  were  exhibited),  comes  to  the  con¬ 
clusion,  that  the  presence  of  ozone  in  large 
quantities  in  the  atmosphere,  is  invariably 
attended  with  catarrh  and  mucous  diarrhoea. 
— British  Association,  Atlienceum  report. 


MR.  SIBSON  ON  THE  CONFIGURATION  OF  THE  CHEST. 


705 


ON  THE 

CONFIGURATION  of  the  CHEST, 

AND  THE  GENERAL  ASPECT  IN  VESICULAR 
EMPHYSEMA. 

By  Francis  Sibson. 


1.  The  description,  by  Dr.  Stokes,  of  the 
physiognomy  and  general  configuration , 
in  cases  of  vesicular  emphysema,  corres¬ 
ponding  with  the  Daguerreotypes  which 
accompany  the  paper. 

2.  Varieties  in  the  external  configuration 
of  the  chest,  according  to  age — 3.  De¬ 
scription  of  the  aspect  and  external  con¬ 
figuration  in  Rawson  ( see  the  ls£  en¬ 
graving),  a  boy  affected  with  emphysema 
and  bronchitis.  The  face  full  and  of  a 
purplish  red.  The  chest  full,  rounded 
and  prominent  above,  anteriorly,  and 
below,  posteriorly ;  the  chief  prominence 
of  the  sternum  a  little  above  its  lower 
end ;  the  lower  ribs  and  cartilages  un¬ 
usually  fattened  and  hollow — 4.  Descrip¬ 
tion  of  the  external  configuration  in 
Shaw  ( see  the  2nd  engraving),  a  man 
affected  with  emphysema.  The  face  arid 
and  dusky,  the  features  furrowed  and 
corrugated ;  the  chief  prominence  of  the 
sternum  at  the  articulation  of  its  first 
and  second  bones ;  the  lower  two-thirds 
of  the  sternum  depressed ;  the  xyphoid 
cartilages  and  the  abdomen  below  it, 
hollow,  between  the  7th  costal  cartilages, 
those  cartilages  forming  an  obtuse  angle 
below  the  sternum — 5.  In  the  emphysema 
of  advanced  life,  the  sternum  most  pro¬ 
minent  at  the  lower  end ;  the  chest  at 
its  upper  part  barrel-like ;  the  dorsal 
and  cervical  spine  very  much  curved ,  and 
the  head  much  lowered — 6.  The  height 
always  diminished  in  emphysema — 7. 
Partial  emphysema — 8.  Great  diagnostic 
value  of  the  signs  furnished  by  the  con¬ 
figuration  of  the  chest  in  emphysema  and 
other  chest  diseases — 9.  Comparison  of 
the  configuration  of  the  chest  in  emphy¬ 
sema  with  that  in  health  and  in  other 
chest  diseases. 

The  former  paper  on  Vesicular  Emphy¬ 
sema  (Med.  Gaz.,  Sept  8),  shewed 
that,  in  that  disease,  and  in  a  less 
marked  degree  in  bronchitis,  the  lungs 
are  permanently  enlarged,  the  heart  is 
generally  increased  in  size,  its  right 
cavities  being  dilated  and  hypertro¬ 
phied.  The  diaphragm  is  remarkably 
flattened  and  lowered,  and  the  liver  and 
stomach,  and  indeed  all  the  abdominal 
viscera,  are  displaced  downwards.  In 
the  present  paper,  the  aspect  of  the 


patient  and  the  configuration  of  the 
chest  in  vesicular  emphysema,  will  be 
considered. 

The  accompanying  engravings  were 
traced  from  Daguerreotypes,  and  accu¬ 
rately  drawn  by  Mr.  Linton  from  these, 
and  from  a  view’  of  the  patients  them¬ 
selves.  The  engraving  of  Raw7son 
illustrates  the  characteristic  form  of  the 
chest  in  the  boy ;  and  that  of  Shaw  in 
the  adult,  in  well-marked  cases  of  em¬ 
physema  and  bronchitis.  They  cor¬ 
respond  in  many  respects  with  the 
following  admirable  description  by  Dr* 
Stokes,  of  the  physiognomy  and  general 
configuration  in  cases  of  vesicular  em¬ 
physema. 

“  The  physiognomy  of  these  indi¬ 
viduals  is  almost  characteristic.  The 
complexion  is  generally  of  a  dusky  hue* 
and  the  countenance,  though  with  an 
anxious  and  melancholy  expression, 
has  in  several  cases  a  degree  of  fulness 
which  contrasts  remarkably  with  the 
condition  of  the  rest  of  the  body.  It  is 
probable  that  this  results  from  hyper¬ 
trophy  of  the  cellular  membrane  and 
respiratory  muscles  of  the  face ;  the 
first  produced  by  repetitions  of  venous 
obstructions,  and  the  second  by  the 
violent  exertion  of  the  whole  system  of 
respiratory  muscles.  The  nostrils  are 
dilated,  thickened,  and  vascular.  The 
lower  lip  is  enlarged,  and  its  mucous 
membrane  everted  and  livid,  giving  a 
peculiar  expression  of  anxiety,  melan¬ 
choly,  and  disease,  to  the  countenance. 
The  shoulders  are  elevated  and  brought 
forward,  and  the  patient  stoops  ha¬ 
bitually,  a  habit  contracted  in  his 
various  fits  of  orthopnoea,  and  cough, 
and  the  relief  which  is  experienced 
from  inclining  the  body  forwards.  Thus 
even  in  bed  wre  often  find  these  patients 
sitting  up,  with  their  arms  folded,  and 
resting  on  their  knees,  and  the  head 
bent  forwards,  the  objectof  w7hichseems 
to  be  to  relax  the  abdominal  muscles, 
and  to  substitute  the  mechanical  sup¬ 
port  of  the  arms  for  that  of  muscles 
which  would  interfere  with  respiration. 
To  such  a  degree  does  this  habit  of 
stooping  alter  the  conformation  of  the 
chest,  that  I  have  seen  several  cases  in 
which  theacromial,  interscapular,  supra 
and  subspinous  surfaces,  had  become5 
nearly  horizontal.  Under  these  circum¬ 
stances,  the  apices  of  the  scapula  are 
remarkably  projected ;  anteriorly  we 
observe  the  clavicles  arched  and  pro¬ 
minent,  and  the  triangular  spaces  wdiich 


706 


MR.  SIBSON  ON  THE  CONFIGURATION  OF  THE  CHEST, 


answer  to  the  insertion  of  the  sterno- 
roastoid  and  scaleni  muscles,  are  singu¬ 
larly  deep.  The  cellular  membrane 
and  adipose  tissue  of  the  neck  seem  to 
2>e  absorbed ;  but  the  muscles  of  in¬ 
spiration,  and  particularly  the  sterno- 
mastoid  and  scaleni,  are  hypertrophied, 
and  the  thyroid  cartilage  is  generally 
prominent  and  hard,  so  as  to  feel  as  if 
ossified.  When weexaminethe chest, we 
discover  other  and  remarkable  changes; 
the  sternum  has  lost  its  flatness  or  its 
relative  concavity,  but  is  thrown  for¬ 
ward  and  arched  both  in  a  longitudinal 
and  transverse  direction ;  the  intercos¬ 
tal  spaces  are  widened,  but  not  dilated 
as  in  empyema ;  on  the  supero- 
anterior  portion,  indeed,  the  chest  seems 
smooth  and  convex,  but  this  is  owing 
to  the  hypertrophied  state  of  the  pec¬ 
toral  muscles,  a  condition  induced  by 
the  long-continued  difficulty  of  respira¬ 
tion.  When  we  examine  the  side, 
however,  we  find  the  intercostal  spaces 
deeply  marked,  and  presenting  no  indi¬ 
cation  of  protrusion ;  so  that  if  we 
compare  the  diseases  of  dilatation  of 
the  cell  and  empyema,  with  respect  to 
the  external  conformation  of  the  chest, 
we  find  that  in  the  first  the  appearance 
©f  smoothness  and  dilatation  is  most 
evident  superiorly,  while  in  the  latter 
the  reverse  occurs.  The  lateral  portions 
©f  the  chest  are  remarkably  deep,  and 
their  convexity  not  at  all  proportioned 
to  that  of  the  anterior  or  posterior  por¬ 
tions  of  the  thorax.  On  applying  the 
hand  to  the  inferior  sternal  region,  we 
generally  find  that  the  heart  is  pulsating 
with  a  violence  that  we  would  not  ex¬ 
pect  from  the  examination  of  the  pulse 
at  the  wrist,  which  is  often  small  and 
feeble,  while  impulses  of  the  right 
ventricle  are  given  with  great  strength.” 
(Stokes  on  Diseases  of  the  Chest,  pp. 
176-8.) 

.2.  In  all  casesof  vesicular  emphysema 
the  chest  is  enlarged,  but  I  find  that 
the  configuration  of  the  chest  in  such 
cases  differs  at  different  ages. 

3.  In  boyhood,  as  in  Rawson,  owing 
to  the  flexibility  of  the  costal  cartilages, 
and  the  yielding  nature  of  the  sternum, 
the  conformation  of  the  chest  is  not 
modified  by  emphysema  in  the  same 
manner  that  it  is  in  the  adult  : 
William  Rawson,  a  boy  of  13  years 
©f  age,  from  whom  the  first  of  the  ac¬ 
companying  Daguerreotypes  was  taken, 
who  lias  been  long  affected  with 
&Aoncnitis,  and  no  doubt  also  with  em¬ 


physema,  is  a  type  of  the  physiognomy 
and  the  configuration  of  the  chest  in 
such  cases.  While  the  lower  eyelids 
are  somewhat  sunken,  and  of  a  purple 
hue,  the  cheeks  and  lips  are  very  full, 
and  of  a  reddish  purple.  The  nostrils 
are  dilated,  the  lips  just  asunder. 


The  whole  of  the  upper  part  of  the 
chest  above  the  fifth  rib  is  remarkably 
full,  rounded,  and  prominent  —  the 
ribs,  cartilages,  and  sternum,  being 
manifestly  raised  forwards  and  up¬ 
wards.  Although  the  shoulders  are 
raised,  the  clavicles,  instead  of  descend¬ 
ing  obliquely  and  slightly  forwards,  as 
in  health,  project  almost  directly  for¬ 
wards  from  the  scapula  to  the  sternum. 
The  sternum  is  arched ;  it  is  prominent 
at  the  upper  end,  and  becomes  more 
and  more  prominent  from  above  down¬ 
wards,  so  that  about  an  inch  above  the 
xyphoid  cartilage  it  projects  conside¬ 
rably.  It  there,  as  is  well  shewn  in 
the  drawing,  falls  suddenly  backwards, 
so  that  the  xyphoid  cartilage  lies  in  a 
hollow.  The  five  superior  ribs,  which 


AND  THE  GENERAL  ASPECT  IN  VESICULAR  EMPHYSEMA. 


707 


X 


comprise  the  thoracic  set,  project  for¬ 
wards  each  more  and  more  from  above 
downwards.  Immediately  below  the 
projection  of  the  fifth  ribs  and  carti¬ 
lages,  there  is  a  deep  depression,  and 
the  inferior  ribs,  and  their  cartilages 
from  the  sixth  to  the  tenth,  instead  of 
being  prominent  and  rounded,  are 
■usually  flattened  and  hollow,  the  carti¬ 
lages  apparently  yielding  inwards  at 
their  junction  to  the  ribs. 

The  sternum  is  so  much  more  pro¬ 
minent  than  the  three  superior  ribs  and 
the  clavicles,  that  the  chest  is  there 
almost  boat-shaped;  but  the  fourth 
and  fifth  costal  cartilages,  especially 
the  right,  are  somewhat  more  promi¬ 
nent  than  the  sternum :  indeed,  the 
prominence  of  the  chest  seems  to  gather 
into  two  foci  a  little  below  and  within 
the  nipples.  The  abdomen  below  and 
between  the  seventh  costal  cartilages  is 
rounded  and  rather  full ;  the  space 
between  those  cartilages  below  the 
sternum  is  not  increased.  The  xyphoid 
cartilage  and  the  linea  alba  just  below 
it  form  a  hollow.  The  recti  muscles 


being  constantly  somewhat  tense,  de¬ 
pressions  are  formed  between  and  on 
each*  side  of  them.  The  neck  is  un¬ 
usually  short  and  deep:— the  shortening 
and  deepening  of  the  neck  is  due  to 
two  causes.  First,  the  elevation  up¬ 
wards  and  forwards  of  the  scapulae, 
clavicles,  sternum,  and  ribs,  especially 
the  sternum ;  the  muscles  in  the  neck 
effecting  these  movements,  the  sterno- 
mastoid,  scaleni,  and  trapezius,  being 
unusually  well  developed.  Second, 
the  increased  curvature  of  the  arch 
formed  by  the  dorsal  and  cervical  ver¬ 
tebrae.  The  whole  dorsum  is  rounded 
and  full,  but  the  chief  fulness,  instead 
of  being,  as  it  is  in  front,  at  the  upper- 
part,  is  at  the  lower  part  of  the  dor¬ 
sum  :  this  is  in  keeping  with  the  posi¬ 
tion  of  the  bulk  of  the  lungs,  which  in 
front  occupies  the  upper,  and  behind, 
the  lower  part  of  the  chest.  The  arch 
is  shortened,  the  cervical  vertebrae  bend 
forward,  and  the  head  is  consequently 
lowered  and  thrown  forward,  and  the 
neck  shortened.  The  origin  of  the 
sterno-mastoid  and  the  scaleni  are 


708 


MR.  SIBSON  ON  THE  CONFIGURATION  OF  THE  CHEST, 


almost  directly  over  their  insertion,  and 
better  purchase  being  thus  given  for  the 
action  of  those  muscles  in  drawing 
upwards  and  forwards  the  sternum  and 
the  superior  ribs.  The  sterno-mastoid 
and  scaleni,  while  they  raise  the  ster¬ 
num  and  ribs  acting  from  above,  react 
from  below  to  draw  forwards  and 
downwards  the  vertebrae  and  the  head. 
The  portion  of  lung  above  the  clavicle 
is  comparatively  small :  this  is  far  from 
being  due  to  diminution  of  the  apex  of 
the  lung — which  is  of  course  more 
voluminous  from  the  disease — but  is 
owing  to  the  remarkable  elevation  of 
the  sternum  in  front,  and  the  lowering 
of  the  first  dorsal  vertebra  behind. 
The  obliquity  of  the  first  ribs,  and,  in¬ 
deed,  of  all  the  ribs,  is  from  the  same 
cause  materially  diminished.  The  in¬ 
tercostal  spaces  below  the  fifth  ribs 
are  widened,  while  those  above  the 
fourth  are  narrowed.  The  narrowing 
of  the  superior  or  intercostal  spaces  is 
an  additional  reason  to  that  given  by 
Dr.  Stokes — viz.  the  development  of 
the  pectoral  muscles— for  the  smooth¬ 
ness  and  roundness  of  the  upper  part 
of  the  chest. 

4.  W.  Shaw,  aged  30,  the  subject  of 
the  second  Daguerreotype,  is  a  charac¬ 
teristic  example  of  the  alteration  in  the 
form  of  the  chest  which  attends  emphy¬ 
sema  in  the  adult,  in  whom  the  costal 
cartilages  are  firm,  and  the  sternum  is 
consolidated  into  two  bones.  • 

In  many  respects,  Shaw  presents  the 
same  configuration  as  Rawson.  The 
chest  is  voluminous,  being  full  and 
rounded  above  the  fifth  rib.  The  neck 
is  short :  the  shoulders  and  clavicles 
are  square  and  high  ;  the  upper  part 
of  the  sternum  and  the  superior  ribs 
are  elevated  upwards  and  forwards ; 
only  a  small  portion  of  the  apices  of 
the  lungs  is  seated  above  the  clavicles ; 
the  respiratory  muscles  of  the  neck  are 
enlarged  and  prominent ;  the  arch 
made  by  the  dorsal  and  cervical  verte¬ 
bra)  is  much  curved ;  the  head  is 
lowered  and  brought  forward ;  the 
dorsum  is  rounded  and  full,  especially 
over  the  lower  region ;  the  superior  in¬ 
tercostal  spaces  are  narrowed,  while 
the  inferior  are  widened ;  the  obliquity 
of  all  the  ribs  is  lessened ;  and  the 
whole  chest  is  deepened. 

The  physiognomy  in  Shaw  differs 
materially  from  that  in  Rawson  ;  the 
skin  of  the  lower  part  of  the  face,  in¬ 
stead  of  being  full,  pulpy,  and  co¬ 


loured,  is  arid  and  dusky ;  the  cheeks 
are  sunk,  furrowed,  and  drawn  into 
lines;  the  eyelids  are  drawn  and  elon¬ 
gated  ;  the  eyebrows  and  forehead 
corrugated ;  the  nostrils  dilated  to 
the  full;  the  lips  thick,  yet  compressed, 
and  the  mouth  protruding;  the  eyes 
are  expressive  of  a  peculiar,  dull,  un¬ 
satisfied  anxiety.  The  features  seem 
to  clasp  the  bones  of  the  face  by  per¬ 
manent  muscular  efforts. 

There'  is  a  well-marked  difference 
between  Rawson  and  Shaw  in  the 
form  of  the  sternum,  and  in  the  direc¬ 
tion  and  form  of  the  sixth  and  seventh 
costal  cartilages,  where  they  proceed 
downwards  from  the  sternum  on  each 
side  of  the  xyphoid  cartilage.  In 
Rawson  the  sternum  is  yielding  ;  in 
Shaw  it  is  consolidated  into  two  bones, 
articulating  by  cartilage  with  each 
other  at  the  junction  of  the  second 
costal  cartilages.  In  Rawson  the 
sternum  is  arched  throughout,  but  is 
markedly  prominent  an  inch  above  the 
xyphoid  cartilage,  which  is  much  de¬ 
pressed.  In  Shaw,  the  upper  end  of 
the  sternum  is  prominent ;  the  sternum 
projects  considerably  at  the  junction 
of  the  first  and  second  bones,  the 
former  of  which  forms  a  projecting  in¬ 
clined  plane,  while  the  latter  is  per¬ 
fectly  vertical,  or  inclines  somewhat 
backwards  from  its  upper  to  its  lower 
end,  the  xyphoid  cartilage  being  con¬ 
siderably  depressed.  In  Shaw,  as  in 
Rawson,  the  five  superior  ribs  become 
gradually  more  prominent  from  above 
downwards,  the  projection  in  the  latter 
being  much  greater  than  in  the  former. 
The  sternum,  which  at  its  upper  part 
is  markedly  more  prominent  than  the 
first  and  second  ribs,  forms  a  depres¬ 
sion  below,  between  the  marked  pro¬ 
minences  of  the  fourth,  and  especially 
the  fifth  ribs  and  cartilages.  The 
sixth  and  seventh  costal  cartilages, 
which  in  Rawson  are  much  depressed 
at  their  articulation  with  the  sternum, 
are  in  Shaw  but  little  less  prominent 
than  the  fifth  ;  consequently  the  lower 
end  of  the  sternum  and  the  xyphoid 
cartilage  form  a  marked  depression 
between  those  costal  cartilages. 

An  important  sign  in  emphysema  in 
the  adult  is  the  enlarged  space  for  the 
abdomen  between  the  seventh  costal 
cartilages,  the  angle  formed  between 
those  cartilages  below  the  sternum 
being  unusually  large. 

.  In  those  cases  of  emphysema  in  the 


AND  THE  GENERAL  ASPECT  IN  VESICULAR  EMPHYSEMA. 


709 


adult  in  which  the  disease  has  origi¬ 
nated  in  early  youth,  the  form  of  the 
chest  will  retain  those  deviations  from 
the  normal  configuration  which  it  has 
acquired  in  youth. 

5.  The  third  variety  in  the  form  of 
the  chest  in  emphysema  exists  in  per¬ 
sons  who  are  attacked  by  the  disease 
in  advanced  life,  when  the  bones  of  the 
sternum  are  consolidated  into  one 
piece ;  and,  the  cartilages  being  semi- 
ossified,  each  of  them  forms  one  un¬ 
yielding  piece  with  the  rib. 

The  characteristic  differences  in  such 
cases  are  the  gradually-increased  pro¬ 
jection  forwards  of  the  sternum  from 
its  upper  to  its  lower  end,— -the  dif¬ 
fused  barrel-like  roundness  of  the  whole 
chest  above  the  sixth  rib, — the  want  of 
the  prominences  of  the  fourth  and 
fifth  costal  cartilages  to  each  side  of 
the  sternum,  that  bone  being  usually 
on  a  level  with  those  cartilages, — the 
great  space  for  the  abdomen  formed 
between  the  opposite  seventh  costal 
cartilages,  which  form  with  each  other 
an  unusually  obtuse  angle  below  the 
sternum, — the  unusual  lateral  bulging 
of  the  ninth  aud  tenth  ribs, — and  the 
unusual  posterior  curvature  of  the 
dorsal  part  of  the  spine,  and  inclina¬ 
tion  forward  and  lowering  of  the  head 
and  neck. 

In  some  of  these  cases  the  front  of 
the  chest  does  not  at  first  appear  to  be 
prominent,  owing  to  the  great  back¬ 
ward  prominence  of  the  whole  dorsum, 
and  the  forward  position  of  the  head 
and  neck.  In  these  cases  the  abdo¬ 
men  is  usually  full,  but  it  is  commonly 
hollow  just  below  the  prominent 
xyphoid  cartilage. 

I  have  met  with  one  case  of  bronchi¬ 
tis  and  emphysema  in  a  man,  aged  33, 
in  whom  the  sternum  projected  gra¬ 
dually  forward  to  the  lower  end ;  and 
with  two  cases,  between  the  ages  of  50 
and  GO,  in  which  the  sternum  became 
less  prominent  towards  the  lower  end. 

6.  In  all  cases  of  emphysema  and 
bronchitis  the  height  is  diminished,  the 
body  being  shortened  and  the  head  nod 
neck  lowered.  Shaw,  who  stood  5  feet 
and  !■§  inch  in  May  last,  now  (October) 
stands  scarcely  5  feet  and  f-  inch,  so 
that  he  has  lost  more  than  a  quarter  of 
an  inch  within  the  last  five  months. 
His  extreme  breathing  capacity,  which 
was  90  cubic  inches  in  May,  is  now 
about  87. 

In  another  case  recently  re-examined, 


the  man's  height,  which  is  now  5  feet 
8§,  was,  30  years  ago,  5  feet  9§ :  he  is 
now  50  years  of  age.  In  the  case  of 
an  old  man,  now  in  the  hospital,  the 
shortening  is  much  more  considerable, 
being  1  inch. 

7.  If  only  one  lung  is  affected  with 
emphysema,  then  the  walls  of  the  chest 
will  be  morbidly  and  characteristically 
prominent  on  that  side  only  which  is 
diseased.  If  a  portion  only  of  one  or 
of  each  lung  be  diseased,  then  the  tho¬ 
racic  walls  will  be  excessively  developed 
only  over  the  seat  of  disease. 

MM.  Louis  and  Voilliez  have  each 
given  an  elaborate  analysis  of  the  va¬ 
rieties  in  the  form  of  the  chest  which 
they  have  observed  in  different  cases 
of  emphysema. 

8.  It  will  be  found  that  in  vesicular 
emphysema  and  in  bronchitis,  as,  in¬ 
deed,  in  all  other  diseases  of  the  chest, 
much  valuable  diagnostic  information 
will  be  obtained  by  observing  closely 
in  what  particulars  the  symmetry  of 
the  configuration  of  the  chest  is  dis¬ 
turbed.  Such  information  is  not,  of 
course,  in  any  case  sufficient  of  itself 
to  enable  one,  without  farther  inquiry, 
to  pronounce  on  the  nature  of  the  dis¬ 
ease  ;  but  such  information  is  almost 
always  a  guide,  directing  the  attention 
to  the  nature  and  to  the  seat  of  the 
disease,  and  is  always  an  important 
auxiliary  to  the  other  modes,  or  rather 
steps,  employed  in  investigating  dis¬ 
ease,  and  arriving  at  a  correct  physical 
and  rational  diagnosis. 

9.  After  having  considered  the  mo¬ 
dification  in  the  form  characteristic  of 
vesicular  emphysema,  it  will  be  well 
to  give  a  short  comparative  statement 
of  the  more  important  points  in  which 
the  configuration  of  the  chest  in  health, 
and  in  several  of  the  diseases  of  the 
chest,  differs  from  its  configuration  in 
emphysema. 

The  form  of  the  chest  in  health  is 
distinguished  from  that  in  emphysema 
by  this — that  its  symmetry  is  not  al¬ 
tered  by  any  excessive  and  partial  de¬ 
velopment.  The  upper  part  of  the 
chest,  in  form,  is  neither  raised  nor 
brought  prominently  forward :  the 
neck  is  long,  not  short ;  the  shoulders 
are  sloping,  not  elevated  ;  the  clavicles 
are  oblique,  not  square  and  forward, 
and  elevated  at  their  sternal  end;  the 
curve  of  the  dorsal  and  cervical  verte¬ 
brae  is  normal,  not  excessive;  the  dor¬ 
sum  is  gently  convex,  not  rounded  and 


710  MR.  MACDONALD  ON  THE  FUNCTIONAL  AND  ANATOMICAL 


prominent,  especially  over  its  lower 
portion  ;  the  intercostal  spaces  are  wide 
above  and  narrow  below,  not  narrow 
above  and  wide  below;  the  angle 
formed  between  the  seventh  costal 
cartilages,  below  the  sternum,  to  each 
side  of  the  xyphoid  cartilage,  is  a  right 
and  not  an  obtuse  angle. 

The  form  of  the  chest  in  considera¬ 
ble  narrowing  of  the  larynx  or  trachea, 
with  consequent  obstruction  to  respira¬ 
tion,  is  distinguished  from  that  in  em¬ 
physema  by  its  being  narrow,  flattened, 
and  elongated,  instead  of  being  rounded, 
prominent,  and  deepened. 

The  form  in  phthisis  is  distinguished 
by  the  wails  of  the  chest  being  flat¬ 
tened,  instead  of  being  prominent,  over 
the  seat  of  the  disease. 

The  distinction  in  emphysema  is 
fully  and  clearly  stated  above  in  the 
quotation  from  Dr.  Stokes’  work. 

The  form  of  the  chest  in  extensive 
heart  disease  differs  from  that  in  emphy¬ 
sema  in  that  the  cartilages  and  ribs  over 
the  cardiac  region  are  much  more  promi¬ 
nent  than'the  corresponding  cartilages 
and  ribs  on  the  right  side,  instead  of 
being  nearly  equal  to  them,  as  they 
often  are  in  emphysema. 

In  abdominal  distension,  the  general 
configuration  is  exactly  the  reverse  of 
that  in  emphysema :  instead  of  the 
chest  being  full  above  and  somewhat 
depressed  below,  and  the  abdomen 
being  hollow  just  below  the  xyphoid 
cartilage,  the  abdomen  is  tense 
throughout,  the  lower  end  of  the  ster¬ 
num,  and  the  lower  portion  of  the 
chest  are  full  and  prominent,  and  the 
upper  part  of  the  chest  is  flat  and 
narrow. 


USE  OF  CHLOROFORM  IN  THE  TREATMENT 
OF  OPHTHALMIA. 

Chloroform  is  said  to  have  been  employed 
with  great  success  by  M.  Uyteerhoeven,  of 
Brussels,  to  relieve  the  severe  pain  of  trau¬ 
matic  and  strumous  ophthalmia.  He  uses 
it  as  a  local  application,  in  the  proportion  of 
eight  drops  to  an  ounce  of  distilled  water. 
MM.  Busch  and  Cunier  have  likewise  ob¬ 
served  great  advantage  to  ensue  in  such 
cases  from  its  internal  administration.  They 
recommend  a  mucilaginous  mixture  con¬ 
taining  from  8  to  16  drops  of  chloroform, 
to  be  given,  by  teaspoonfuls  at  a  time,  in 
the  course  of  twenty-four  hours.  In  eight 
cases  of  strumous  ophthalmia,  and  in  one 
case  of  neuralgic  pain  of  the  eye,  the  benefit 
derived  from  this  plan  of  treatment  was  very 
remarkable. — L'  Union  Medicale,  1848.  A 


OBSERVATIONS  ON  THE 

FUNCTIONAL  AND  ANATOMICAL 
ANALOGIES  EXISTING 

BETWEEN 

THE  EYE  AND  THE  EAR. 

By  J.  D.  Macdonald,  Esa. 

King’s  College. 

[Continued  from  p.  452.] 


When  the  active  motion  of  a  sonorous 
body  excites  the  passive  vibration  of 
surrounding  substances,  they  are  said 
to  vibrate  sympathetically.  This  sym¬ 
pathetic  vibration  may  be  of  two  kinds : 
the  one  where  the  tremors  of  a  sound¬ 
ing  body  are  communicated  by  the 
atmosphere  or  other  means  to  an  ad¬ 
jacent  substance,  in  the  particles  of 
which  a  corresponding  motion  is  ex¬ 
cited  ;  and  the  other,  where  sonorous 
bodies  give  out  their  own  peculiar 
sound,  when  the  vibrations  of  others 
are  conducted  to  them  in  the  manner 
just  mentioned.  The  motion  of  the 
bellies  of  violins  induced  by  the  tremor 
of  the  strings,  is  an  instance  of  the 
former  class;  and  the  excitement  of 
one  string  on  the  harp  by  the  vibra¬ 
tion  of  another,  would  illustrate  the 
latter.  Here  the  string,  sympatheti¬ 
cally  affected,  sounds  its  own  note,  and 
not  that  of  the  string  which  thus  ex¬ 
cited  it. 

It  is  most  probable  that  the  mem- 
brana  tympani  (while  it  collects  and 
transmits  the  sounds  which  subse¬ 
quently  impinge  on  the  auditory 
nerve)  may  be  sympathetically  affected 
in  both  these  ways :  for  in  its  passive 
state  it  is  susceptible  of  the  vibration 
of  any  note  falling  upon  it  within 
a  certain  sphere,  but  by  its  muscular 
adaptation  it  may  commingle  its  own 
proper  vibration  with  that  of  the  sound 
affecting  it,  and  thus  augment  the 
sonorous  impression. 

The  following  experiments  and  con¬ 
siderations  clearly  illustrate  these  re¬ 
marks,  and  establish  some  essential 
points  in  the  functional  analogy  be¬ 
tween  the  eye  and  the  ear. 

In  the  first  place,  we  shall  compare 
the  sound-board  of  the  piano-forte  with 
the  membrana  tympani ;  and  in  the 
second,  draw  an  analogy  between  the 
latter  membrane  and  the  ordinary 
drum-head. 


ANALOGIES  EXISTING  BETWEEN  THE  EYE  AND  THE  EAR.  711 


The  sound-board  of  a  piano-forte 
vibrates  in  exact  accordance  with  any 
string  sounding.  In  proof  of  this,  if 
a  small  steel  bar  be  placed  upon  it,  and 
a  string  be  struck,  a  stramming  sound 
will  be  produced  in  perfect  unison  with 
that  of  the  string,  and  this  without 
reference  to  the  size  of  the  bar.  Still 
further ;  the  same  particles  of  the 
sound-board  are  susceptible  of  the 
vibrations  of  two  or  more  notes  at  the 
same  time,  for  when  a  chord  is  struck, 
as  C  E  G,  each  individual  note  may  be 
recognised  by  the  percussion  of  the 
bar  upon  the  sound-board.  This  expe¬ 
riment  shows  how  the  membrana  tym- 
pani  may,  at  the  same  degree  of  tension, 
transmit  to  the  internal  ear  many  dif¬ 
ferent  sounds,  either  simultaneously, 
as  in  a  harmonious  chord,  or  in  succes¬ 
sion,  as  in  a  melody.  But,  as  in  the 
case  of  the  sound-board,  the  bar  an¬ 
swers  better  in  some  situations  than  in 
others,  according  to  the  pitch  of  the 
note,  the  inference  is,  that  all  its  parts 
are  not  alike  susceptible  of  the  same 
vibration  (but  this  we  shall  presently 
see  more  fully  illustrated  in  the  drum¬ 
head).  It  also  indicates  that  a  certain 
change  in  the  tension  of  the  membrana 
is  necessary  for  the  more  efficient  re¬ 
ception  of  sounds  when  their  pitch  ex¬ 
tends  beyond  a  certain  range,  so  that 
by  a  very  few  stages  of  tension  it  may 
suit  all  the  sounds  coming  within  the 
scope  of  audition,  without  adapting 
itself  to  each  respective  sound,  as  some 
physiologists  suppose. 

In  the  eye  the  beautiful  arrangement 
of  transparent  media,  varying  in  refract¬ 
ing  power,  does  away,  to  a  great  extent, 
with  the  necessity  for  a  special  adapta¬ 
tion  of  the  organ  to  colours  of  a  dif¬ 
ferent  refrangibility ;  which  property 
holds  the  same  ratio  to  colours  that 
pitch  does  to  sounds. 

There  are  two  special  functions  en¬ 
joyed  by  the  human  ear :  by  the  exer¬ 
cise  of  one  we  are  enabled  to  tell  the  dis¬ 
tance  and  locality  from  whence  sounds 
originate;  and  by  the  other,  we  can 
compare  the  relative  pitches  of  sounds. 
And  so  also  in  the  case  of  the  eye  we 
notice  corresponding  endowments  :  for 
while  we  form  a  judgment  of  the  dis¬ 
tance  and  position  of  objects  by  the 
light  which  they  reflect,  we  can  also 
appreciate  their  colours.  But  indivi¬ 
duals  are  to  be  found  in  whom  one  or 
other  of  these  functions  is  deficient, 
either  as  regards  the  eye  or  the  ear. 


Thus,  a  person  may  have  no  power  of 
judging  the  distance  through  which  a 
sound  may  have  travelled  in  order  to 
reach  his  ear;  or,  what  is  analagous 
with  respect  to  the  organ  of  vision,  he 
may  not  be  able  to  conceive  how  far 
an  object  is  distant  from  him  by  its 
image  depicted  on  his  retina.  Again, 
he  may  have  acute  hearing  in  every 
respect,  but  no  power  of  ascertaining 
the  pitch  of  a  musical  sound,  or  its  re¬ 
lative  position  in  a  scale  of  eight  notes ; 
or,  what  is  similar  with  regard  to  the 
eye,  he  may  not  be  able  to  discriminate 
between  one  colour  and  another,  al¬ 
though  every  object,  as  to  outline, 
light,  and  shade,  is  distinctly  perceived ; 
so  that  the  power  of  distinguishing  the 
pitch  of  sounds  by  the  ear,  and  the 
species  of  colour  by  the  eye,  are  analo¬ 
gous  functions  in  both  these  organs. 
Now,  as  in  those  persons  who  have  had 
no  perception  of  the  pitch  or  agree¬ 
ments  of  musical  sounds,  no  change  of 
the  structure  of  the  ear  is  revealed  by 
dissection,  which  would  explain  the 
cause  of  the  deficiency,  we  have  only 
to  infer  that  it  is  functional,  i.  e.  not 
depending  upon  any  modification  of 
the  organization  of  the  ear  itself,  but 
probably  upon  some  defect  in  the 
centre,  to  which  its  impressions  are 
conveyed.  And  thus  we  may  also  say 
that  the  cause  of  that  want  of  power 
which  some  individuals  manifest  in 
ascertaining  the  different  colours,  is  not 
to  be  discovered  by  dissection ;  and 
the  explanation  given  in  reference  to 
the  ear  is  also  applicable  here  until  a 
better  can  be  afforded  by  future  dis¬ 
covery. 

We  now  proceed  to  examine  the  pro¬ 
perties  of  the  ordinary  drum-head  as 
applied  to  the  physiology  of  the  mem¬ 
brana  tympani. 

There  are  three  notes  on  the  drum¬ 
head,  which  are  just  as  naturally  pro¬ 
duced  as  the  harmonics  of  a  musical 
string.  One  is  limited  to  the  centre, 
a  second  to  the  circumference,  and  a 
third  to  the  intermediate  portion. 

The  central  point  gives  the  tonic  or 
key-note  of  the  instrument,  say  C ; 
that  of  the  circumference  being  a  5th, 
or  five  notes  higher  than  the  central, 
is  equivalent  to  G;  while  the  note  be¬ 
tween  these,  which  is  a  third  above 
the  key-note,  corresponds  to  E :  thus, 
the  constituents  of  the  perfect  chord  or 
triad  of  C  may  be  produced  by  striking 
those  several  parts  successively.  Here 


712  MR.  MACDONALD  ON  THE  FUNCTIONAL  AND  ANATOMICAL 


also,  we  perceive  that  the  laws  of  vi¬ 
brating  chords  are  extended  to  mem¬ 
branous  substances,  and  harmonic 
vibrations  may  be  induced  in  either, 
forming  the  natural  harmonies  of  its 
own  peculiar  note :  thus,  a  string 
sounding  C  may  have  secondary  or 
harmonic  vibrations  excited  in  several 
of  its  parts,  making  up  the  elements  of 
the  perfect  chord,  and  this  is  also  well 
exemplified  in  the  drum-head. 


sounds  are  in  the  direct  ratio  of  their 
depth  and  gravity,  just  as  colours  are 
more  powerful  in  distant  effect  as  they 
approach  the  red,  or  least  refrangible 
degree  of  the  scale.  The  bassoon  may 
be  heard  distinctly  in  a  distant  band, 
while  the  clarionets  and  treble  instru¬ 
ments  generally,  are  inaudible.  And 
again,  the  flute  stop  on  the  organ  is 
very  mild,  producing  no  attractive 
effect  beyond  its  peculiar  sweetness, — 
while  the  lower  notes  of  the  stop  dia¬ 
pason  throw  the  whole  church  into 
sympathetic  vibration :  the  window 
sashes  commonly  take  their  part  in  the 
general  excitement,  giving  out  sounds 
resembling  the  snare  of  a  drum,  but 
which  are  in  perfect  unison  with  the 
notes  of  the  pipes.  Indeed,  without 
multiplying  instances,  it  clearly  ap¬ 
pears  from  these  facts,  that  a  very  con¬ 
siderable  diversity  exists  in  the  power 
and  penetrability,  or  distant  effect  of 
sounds,  which  differ  in  pitch  and 
quality  of  tone. 

The  consideration  of  the  properties 
.of  the  drum-head  (above  referred  to) 
accounts  for  the  extension  of  the  handle 
of  the  malleus  to  the  apex  or  centre  of 
the  membrana  tympani,  (as  indicated 


|  by  the  perpendicular  in  the  diagram), 
in  order  that  it  might  fully  receive,  and 
convey  to  the  seat  of  impression,  the 
vibrations  of  its  separate  segments, 
(whether  harmonically  or  sympatheti¬ 
cally  excited),  according  to  the  relative 
strength  of  their  sounds, — so  that  the 
inequality  naturally  existing  between 
them  may  be  diminished,  and  an 
equable  effect  be  produced  on  the 
nerve.  Thus  we  find  that  the  high 
notes  affecting  the  circumference  of  the 
membrane  take  but  a  short  course 
along  the  handle  of  the  malleus,  agree¬ 
able  to  their  pitch  and  intensity ; 
while  the  vibrations  of  the  centre, 
which  are  of  a  grave  and  penetrating 
character,  take  the  trajet  of  the  entire 
manubrium ;  and  in  this  manner 
the  inequality  is  compensated,  and 
an  important  physiological  end 
answered.  In  short,  the  handle  of  the 
malleus,  in  correcting  the  unequal 
effects  that  would  necessarily  result 
from  the  diversity  of  the  pitch  and 
power  of  musical  intervals,  takes  an 
analogous  office  to  that  fulfilled  by  the 
refracting  media  of  the  eye,  whereby 
the  contending  refrangibilities  of  diffe¬ 
rent  colours  are  reconciled}  and  all  are 
brought  as  nearly  as  possible  to  im¬ 
pinge  upon  the  retina  at  the  same 
time. 

There  is  another  interesting  fact  to 
be  mentioned  in  reference  to  the  change 
of  key  in  music,  i.  e.  that  in  order  to 
establish  any  note  as  anew  key,  a  cor¬ 
rect  conception  of  its  fifth  is  necessary, 
as  any  other  interval  will  not  deter¬ 
mine  it.  And  this  constitutes  the  diffi¬ 
culty  in  following  abrupt  modulations, 
or  sudden  changes  from  one  key  to 
another,  without  notes  of  transition, 
just  as  the  educated  eye  feels  hurt  when 
discordant  colorific  intervals  are  igno¬ 
rantly  associated ;  for  the  impression 
of  one  colour  must  be  artfully  neutra¬ 
lized  by  the  juxta-position  [of  others 
having  a  sympathy  with  it.  Now  the 
three  vibrating  segments  of  the  mem¬ 
brana  tympani,  corresponding  to  a  key¬ 
note,  its  third  and  fifth,  embrace  all  the 
requisites  for  determining  the  key  j 
and  this  natural  or  physical  division 
of  the  membranous  surface,  producing 
the  perfect  chord  above  mentioned,  ex¬ 
plains  the  necessity  for  every  musi¬ 
cal  composition,  both  commencing  and 
ending  with  this  combination  of  sounds, 
and  applying  the  laws  of  musical  har¬ 
mony  to  the  association  of  colours, — 


ANALOGIES  EXISTING  BETWEEN  THE  EYE  AND  THE  EAR.  713 


we  shall  find  a  necessity  for  establish¬ 
ing  some  one  colour  for  a  key-note  in 
pictures,  upon  which  we  may  construct 
a  colorific  chord. 

Again,  on  the  principle  of  harmonic 
vibration,  if  we  suppose  the  note  C 
alone  to  impinge  on  the  membrana 
tympani,  the  notes  E  and  G  will  be 
harmonically  excited  :  and  thus,  the 
physical  change  on  the  surface  of  the 
membrane  being  communicated  to  the 
auditory  nerve,  induces  the  mental 
conception  of  its  natural  agreements  ; 
and  this,  we  may  conclude,  is  the  mode 
of  instruction  which  the  mind  under¬ 
goes  in  the  formation  of  what  is  called 
“  a  musical  ear  ” — a  faculty  enjoyed  by 
some  favoured  individuals,  independent 
of  any  musical  education. 

The  laws  of  the  complementary 
colours  have  a  similar  bearing  on  the 
visual  faculty :  thus  the  impression  of 
red  (equivalent  to  C)  on  the  retina 
induces  the  perception  of  its  comple¬ 
mentary  colour  (green),  or  the  union 
of  yellow  and  blue  (the  third  and 
fifth),  answerable  to  E  and  G  respec¬ 
tively,  to  the  complementary  colours 
of  which  (purple  and  orange)  the  same 
mode  of  analysis  will  apply,  as  they 
form  part  of  this  harmonious  triad. 

In  conclusion,  we  shall  make  a  few 
observations,  founded  on  a  remarkable 
phenomenon  connected  with  the  bar 
and  sound-board,  not  mentioned  in  de¬ 
tailing  the  experiment,  serving  to  elu¬ 
cidate  thenature  of  time,  and  the  mental 
appreciation  of  the  rhythmical  division 
of  the  parts  and  bars  in  musical  com¬ 
positions. 

When  a  tune  was  played  on  the  piano¬ 
forte,  the  steel  rod  was  found  to  mark 
the  time  with  unerring  precision,  by  a 
drumming  action  on  the  sound-board, 
taking  part  in  the  base  and  treble,  and 
delicately  articulating  the  accented 
parts  of  both, — as  when  a  bar  of  four 
crotchets  in  the  base  was  accompanied 
by  sixteen  semiquavers  in  the  treble, 
the  simple  and  compound  percussions 
were  distinctly  audible,  and,  although 
simultaneous,  the  pulsations  of  the 
crotchets  were  perceptible;  while  the 
treble  performed  a  sixteen  stroke  roll, 
far  excelling  the  first  order  of  drum¬ 
ming,  in  closeness  and  neatness  of 
execution.  During  the  performance 
of  many  passages,  every  species  of 
paridicle,  five,  seven,  and  nine  stroke 
rolls,  with  such  instances  as  occur  in 
French,  Austrian,  and  other  rebeilles. 


where  the  utmost  skill  in  drum-beating 
is  called  into  exercise. 

-  These  observations  would  be  of  small 
moment  in  themselves  did  they  not 
bring  to  light  certain  physiological 
facts  in  the  action  of  the  membrana 
tympani  and  ossicula  auditus  hitherto 
undiscovered.  Thus  the  membrana 
tympani,  and  malleus,  accurately  re¬ 
present  the  sound-board  and  steel  rod 
of  the  foregoing  experiments  ;  and  we 
fairly  infer  from  the  reasons  a  priori , 
that,  while  the  membrana  communi¬ 
cates  its  vibrations  to  the  ossicles,  it 
also  causes  the  malleus  to  percuss  the 
face  of  the  incus,  responsively  to  the 
sudden  and  powerful  impressions  made 
upon  it.  As  in  the  accentuations,  piano¬ 
forte,  &c.,  in  a  musical  piece,  so  as  to 
mark  with  extreme  accuracy  the  cha¬ 
racter  of  the  time— whether  it  be  com¬ 
mon,  triple,  or  any  modification  of 
these  ;  and  if  the  parts  of  the  music 
be  deranged  by  a  defect  in  time  or 
metre — an  uneasy  jog  is  produced  onthe 
auditory  apparatus :  and  hence  the 
antipathy  which  the  mind  feels  to  any 
erratic  deviation  in  this  respect.  In 
short,  the  malleus  being  in  itself  an 
oral  metronome,  induces  a  sense  of  de¬ 
rangement  with  the  same  fidelity  as  the 
mechanical  contrivance,  whose  oscilla¬ 
tions  correspond  with  every  change  of 
its  index. 

It  is  very  remarkable,  that  the  mal¬ 
leus  and  incus  (the  hammer  and  anvil) 
should  correspond  not  only  in  figure, 
but  also  in  function,  to  the  objects  from 
which  their  respective  names  are  de¬ 
rived;  for,  as  we  have  already  seen,  the 
uses  of  the  hammer  and  anvil,  as  em¬ 
ployed  in  mechanics,  are  literally  ful¬ 
filled  by  the  malleus  and  incus,  which 
function  answers  very  important  ends 
in  the  faculty  of  audition;  as,  by  the 
action  of  one  upon  the  other,  sounds  are 
not  only  correctly  transmitted  to  the 
auditory  nerve  from  their  original 
sources,  but  an  accurate  register  of  time 
is  effected  in  the  manner  above  ex¬ 
plained;  and  thus  the  mind  is  impressed 
with  a  faithful  transcript  of  the  har¬ 
mony,  style,  and  general  effect  of  musi¬ 
cal  pieces. 

With  respect  to  rhythm,  it  is  in 
music  what  symmetry  is  in  the  arts; 
for,  as  the  lateral  parts  of  symmetrical 
bodies  or  their  pictorial  representations 
must  be  similar,  in  order  to  maintaiti 
the  special  character,  so  the  parts  of  a 
melody,  although  consisting  of  a  series 


714 


DR.  MILROY  ON  THE  USE  OF  EMETICS  IN  CHOLERA 


of  intervals,  impinging  successively  on 
the  ear,  must  be  equal  in  duration,  as, 
though  symmetrically  disposed,  on  the 
one  hand  preceding,  and  on  the  other 
following  a  centre  of  time — for  equal 
breadth  in  visual  impressions  is  analo¬ 
gous  to  equal  continuance  in  those  of 
audition,  space  having  the  same  rela¬ 
tion  to  the  organ  of  vision  that  time 
has  to  the  organ  of  hearing.  In  this 
point  of  light  the  difficulty  of  philoso- 
phersin  explaining  the  nature  of  rhythm 
appears  in  some  measure  cleared  away ; 
for  it  is  no  more  wonderful  to  sup¬ 
pose  that  we  should  appreciate  in 
the  mind  equal  portions  of  time  as 
presented  to  the  ear  in  the  several 
parts  of  a  melody,  than  that  we  should 
conceive  of  similar  portions  of  space, 
either  as  occupied  by  natural  objects  or 
their  outlines  in  pictures.  But  this 
power  of  calculating  mentally  the  half 
or  any  fractional  division  of  a  given 
substance,  is  without  doubt  acquired  by 
practice  and  experience.  Now  the 
very  same  thing  may  be  said  of  time  or 
rhythm  in  music  ;  for  it  is  well  under¬ 
stood  that  the  most  difficult  thing  to  be 
attained  in  the  study  of  that  science  is 
a  correct  appreciation  of  the  value  of 
notes  composing  the  several  bars  of 
musical  pieces,  as  regulated  by  a  de¬ 
terminate  time.  And  it  is  not  unrea¬ 
sonable  to  presume,  that  the  physical 
impulses  of  the  malleus,  whereby  it 
percusses  the  incus  in  accordance  with 
the  measure  of  the  music,  are  the  very 
means  employed  by  nature  in  thus  in¬ 
structing  the  mind  to  appreciate  musi¬ 
cal  symmetry  or  rhythm. 


ON  THE 

USE  of  EMETICS  in  CHOLERA. 

By  Gavin  Miluoy,  M.D. 

Member  of  the  Royal  College  of  Physicians,  &c. 


No.  1. 

Although  the  following  remarks  have 
no  claim  to  novelty,  yet,  if  they  should 
have  the  effect  of  fixing  the  attention 
and  guiding  the  practice  of  some  whose 
experience  has  been  limited,  and  wffio 
may  not  have  had  an  opportunity  of  ■ 
witnessing  a  case  of  malignant  cholera,  J 
their  object  will,  I  trust,  be  not  alto-  ; 
gether  unprofitable.  In  the  treatment 
of  every  disease,  it  is,  of  course,  of 
first-rate  consequence  that  we  should 


have  some  rational  principles  to  direct 
the  administration  of  our  remedies — 
principles  derived  not  so  much  from 
speculations  as  to  the  proximate  cause 
of  the  malady,  as  from  a  diligent  ob¬ 
servation  of  the  juvantia  and  Icedeniia , 
and  of  the  method  wffiich  Nature  her¬ 
self  seems  to  follow  in  striving  to 
overcome  or  get  rid  of  the  evil  that  is 
distressing  her.  What  a  simple  and 
striking  example  of  this  have  we  in  a 
mild  case  of  common  or  English  cho¬ 
lera!  From  some  cause  or  another — 
it  matters  little  whether  this  has  been 
an  indiscretion  in  diet,  great  heat  of 
the  weather,  or  a  malarious  condition 
of  the  atmosphere, — an  excessive  quan¬ 
tity  of  bile,  and  this,  too,  generally 
more  or  less  vitiated,  is  thrown  out 
upon  the  bowels  ;  and  the  effect  of  this 
inordinate  secretion  is  to  bring  on 
violent  expulsive  actions  of  the  sto¬ 
mach  and  bowels,  giving  rise  to  the 
bilious  vomiting  and  purging  that  are 
characteristic  of  the  disease.  Such 
cases  very  often  require  no  aid  from 
art :  when  once  the  offending  matters 
are  expelled  from  the  body,  all  the 
symptoms  immediately  subside,  and 
the  patient  is  straightway  as  well,  and 
frequently7  better,  than  he  w7as  before. 
If  professional  assistance  be  sought  for, 
there  can  be  no  doubt  that  every  sensi¬ 
ble  practitioner  wrould  in  the  first  place 
promote  the  medicative  efforts  of  Na¬ 
ture  by  the  liberal  use  of  mild  diluents, 
with  the  view  of  encouraging  the 
prompt  and  effectual  discharge  of  the 
acrid  bile.  The  irritability  of  the  sto¬ 
mach  and  intestines  will  very  generally 
cease,  as  soon  as  this  is  effected.  Should 
it,  howrever,  persist,  the  simplest  as 
w  ell  as  the  most  efficacious  remedy  is 
a  sinapism,  or  such  like  irritant,  ap¬ 
plied  over  the  epigastric  region.  When¬ 
ever  this  begins  to  act,  the  inverted 
and  exaggerated  peristaltic  movements 
will,  in  ninety-nine  cases  out  of  the 
hundred,  simultaneously  subside.  There 
may  be  no  objection  to  give  a  spoonful 
of  brandy,  or  of  any  mild  aromatic 
cordial,  at  the  same  time  :  although 
not  necessary,  it  wall  do  no  harm,  and, 
moreover,  will  not  be  unacceptable  to 
the  patient.  A  day  or  tw?o  after  such 
an  attack,  it  will  generally  be  expe¬ 
dient  to  give  an  aperient  (castor  oil  is 
the  best,  if  the  patient  can  take  it),  as 
a  tendency7  to  constipation  very  often 
ensues,  and  some  portion  of  the  de¬ 
praved  secretions  have  lodged  behind. 


DR.  MILROY  ON  THE  USE  OF  EMETICS  IN  CHOLERA. 


715 


Small  doses,  too,  of  magnesia,  taken 
two  or  three  times  in  the  twenty- four 
hours,  will  be  useful,  by  correcting  the 
acid  condition  of  the  primes  vice  which 
is  usually  present  under  such  circum¬ 
stances. 

So  much  for  a  mild  case  of  the  com¬ 
mon  cholera  of  this  country.  Let  us 
now  see  whether  similar  principles  of 
treatment  are  applicable  to  the  more 
severe  and  aggravated  forms  of  the 
disease.  And  here  l  would  remark, 
that  under  this  term  I  include  all 
cases,  however  alarming,  whether  from 
the  prostration  of  the  patient,  or  from 
the  intense  sufferings  he  endures,  in 
which  the  rejected  matters  from  the 
stomach  and  bowels  are  more  or  less 
bilious,  and  do  not  consist  of  the  rice- 
water-like  fluid  (believed  to  be  the 
serum  of  the  blood  itself,  drained  off 
from  the  mesenteric  vessels),  which  is 
so  characteristic  of  the  Asiatic  pesti¬ 
lence.  In  making  this  distinction,  I 
do  not,  however,  wish  it  to  be  sup¬ 
posed  that  such  a  line  of  well-marked 
demarcation  can  be  always  drawn 
between  different  cases ;  for,  on  the 
one  hand,  in  a  good  many  instances, 
the  true  serous  evacuations  have  un¬ 
questionably  been  observed  in  cases  of 
genuine  English  cholera,  during  sea¬ 
sons  when  the  Indian  epidemic  was 
wholly  absent  from  Europe;  and  on 
the  other,  very  many  cases  of  the 
Asiatic  disease  commence  with  vomit¬ 
ing  and  purging  of  bilious  matters.  It 
is,  therefore,  far  from  being  easy  to 
establish  a  strongly-marked  or  palpa¬ 
ble  distinction  between  certain  cases 
of  the  two  diseases,  however  wide  may 
be  the  distance  between  a  mild  one  of 
the  common  cholera  of  this  country, 
and  a  concentrated  one  of  the  Asiatic 
pestilence ; — not  greater,  however,  than 
between  a  Lincolnshire  ague,  and  the 
worst  forms  of  fever  in  Java  or  on  the 
coast  of  Africa  :  and  yet  the  essence, 
so  to  speak,  of  the  malady  is  the  same 
in  both,  as  might  be  easily  shown  by  a 
variety  of  considerations.  It  is,  there¬ 
fore  more  for  the  convenience  of  the¬ 
rapeutic  than  of  nosological  inquiry, 
that  I  make  the  presence  or  absence  of 
bile  in  the  matters  rejected  from  the 
stomach  and  bowels  the  distinctive 
feature  between  English  and  Asiatic 
cholera;  and,  moreover,  it  has  the  ad¬ 
vantage  of  constituting  a  test  of  the 
gravity  and  danger  of  the  attack  in 
each  individual  case.  Whenever  there 


is  a  tendency,  in  a  case  of  English 
cholera,  to  the  egesta  becoming  watery 
and  devoid  of  colour,  our  prognosis  is 
at  once  more  unfavourable  :  and  I  need 
scarcely  say  that  one  of  the  most  satis¬ 
factory  signs,  in  a  case  of  the  true 
Asiatic  disease,  is  the  first  re-appear¬ 
ance  of  bilious  matter  in  the  evacua¬ 
tions.  As  I  shall  afterwards  have  oc¬ 
casion  to  allude  to  this  point,  I  shall 
not  say  more  at  present,  but  pass  on 
to  consider  the  treatment  in  an  aggra¬ 
vated  case  of  the  English  disease. 
Probably  the  best  way  of  illustrating 
my  views  upon  the  subject  will  be 
briefly  to  narrate  two  cases  that  have 
occurred  under  my  inspection  within 
the  last  few  days. 

J.  W.,  aet.  33,  a  piano-forte  maker, 
residing  at  Camden  Town,  in  a  house 
where  the  drains  were  in  an  offen¬ 
sive  state,  had  been  affected  alter¬ 
nately  with  diarrhoea  and  constipa¬ 
tion  during  the  last  twTo  or  three 
weeks.  On  the  morning  of  Saturday, 
the  7th  instant  (the  weather  for  some 
days  before  was  unseasonably  warm 
and  close),  his  bowels  acted  imme¬ 
diately  before  and  after  breakfast.  He 
then  went  to  his  work ;  and,  while 
there,  was  suddenly  seized  with  profuse 
vomiting  and  purging  of  what  he  de¬ 
scribed  to  be  bilious  matter,  accom¬ 
panied  with  excessive  prostration  of 
strength.  He  was  immediately  con¬ 
veyed  home,  and  Mr.  Jakins,  of 
Osnaburg  Street,  sent  for.  Before 
Mr.  J.  saw  him,  the  vomiting  and 
purging  had  been  almost  incessant, 
and  still  continued  :  what  came  from 
the  stomach  was  tinged  with  bile, 
but  the  dejections  were  watery,  and 
scarcely  coloured.  The  patient,  a  thin 
delicate  man,  was  at  this  time  (2  p.m.) 
in  a  state  of  great  exhaustion;  the 
surface  cold  and  damp ;  the  face  of  a 
bluish  hue,  lips  purple;  the  pulse 
thread-like ;  and  the  lower  extremites 
affected  with  violent  cramps.  Two 
grains  of  emetic  tartar  were  immediately 
given,  and  the  patient  made  to  drink 
freely  of  hot  water.  The  retching  and 
straining  that  ensued  were  most  severe, 
but,  after  continuing  for  a  short  time, 
they  subsided ;  and  from  that  moment 
the  vomiting  entirely  ceased,  and  the 
purging  was  much  quieted;  at  the  same 
time  the  surface  of  the  body  became 
warmer,  and  the  patient  confessed  him¬ 
self  to  be  altogether  more  comfortable. 
At  four  o’clock  Mr.  Jakins  again  visited 


716 


DR.  MILROY  ON  THE  USE 


him,  and  found  that  he  had  not  been 
sick,  but  that  the  bowels  had  acted 
several  times.  He  administered  an 
ounce  of  castor  oil,  with  as  much 
brandy,  and  ordered  an  ammonia  mix¬ 
ture  to  be  given  in  small  and  frequent 
repeated  doses.  At  eight  p.m.  I  saw 
the  patient  with  Mr.  Jakins  :  he  was 
altogether  in  a  most  satisfactory  state. 
There  had  been  no  return  of  the  vo¬ 
miting,  and  the  bowrels  had  acted  only 
once  since  the  castor  oil  was  taken  : 
the  motion  had  more  of  a  fecal  charac¬ 
ter.  I  suggested  a  sinapism  over  the 
epigastric  and  right  hypochondriac  re¬ 
gions,  and  small  doses  of  the  Hyd.  c. 
Creta,  with  Ginger  and  Carb.  Sod.,  to 
be  given  every  three  or  four  hours.  In 
the  course  of  two  or  three  days  the 
patient  was  quite  well. 

The  following  case  is  equally  satis¬ 
factory  as  to  the  effects  of  artificial 
vomiting:  I  saw  it  along  with  my 
friend  Mr.  Chatto. 

A  woman,  about  thirty  years  of  age, 
and  recently  (a month  before)  delivered, 
was  suddenly  seized  on  Friday  last,  the 
6th  instant,  with  excessive  vomiting 
and  purging,  which  had  continued  ever 
since  with  but  little  abatement  (not¬ 
withstanding  the  use  of  a  variety  of 
remedies,  such  as  chalk,  with  opium, 
acetate  of  lead,  creosote,  &c.),  when  we 
visited  her  on  Tuesday  morning.  There 
had  been  no  great  prostration  until 
within  the  twelve  hours  preceding  our 
visit,  during  which  period  the  purging 
and  vomiting  had  recurred  between 
twenty  and  thirty  times ;  there  was 
distinct  bilious  matter  in  both  sorts  of 
evacuations.  We  at  once  administered 
an  ipecacuan  emetic,  and  had  her  to 
drink  off,  as  quickly  as  she  could,  three 
or  four  large  tumblerfuls  of  hot  water. 
For  five  or  ten  minutes  there  was  no 
disposition  to  be  sick  ;  at  length,  the 
greater  part  of  the  water  drunk  was 
rejected,  with  but  inconsiderable  traces 
of  bile.  As  the  vomiting  did  not  return 
within  the  next  quarter  of  an  hour,  we 
left  her  about  noon,  having  previously 
ordered  a  strong  sinapism  to  be  applied 
to  the  epigastric  region,  and  a  dose  of 
castor  oil  and  brandy  to  be  given  two 
hours  subsequently.  On  revisiting  her 
at  five  p.m.,  we  found  that  there'"  had 
not  been  any  vomiting  or  purging,  and 
that  she  was  in  all  respects  much  better. 
Next  day  the  report  was  that  no  vo¬ 
miting  whatever  had  occurred,  and 
that  the  bowels  had  acted  four  times. 


OF  EMETICS  IN  CHOLERA. 


She  had  also  slept  a  good  deal  during 
the  night,  a  luxury  she  had  not  enjoyed 
since  she  was  taken  ill.  As  there  was 
much  flatulence  in  the  bowels,  small 
doses  of  magnesia,  in  peppermint  water, 
were  ordered,  and  beef  tea  and  arrow 
root,  with  brandy,  allowed  for  food.  In 
the  course  of  another  day  she  was  quite 
convalescent. 

It  would  be  easy  to  multiply  such 
examples  of  the  prompt  and  decided 
arrest  of  vomiting  and  purging,  by  the 
use  of  an  emetic :  but  these  two  will 
suffice  for  the  present.  The  relief  in 
both  was  permanent  as  well  as  imme¬ 
diate.  It  appears  to  me  that  the  prac¬ 
tice  in  question  is  not  less  sanctioned 
by  the  results  of  experience,  than  it  is 
strictly  accordant  with  sound  physiolo¬ 
gical  reasoning.  For  if  the  excited 
movements  of  the  stomach  and  intes¬ 
tines  be  induced  by  the  presence  of 
any  acrid  matter  in  the  primes  vice ,  the 
sooner  it  is  dislodged  the  better  ;  and, 
again,  if  they  persist  after  this  has  been 
done,  and  in  consequence  (as  it  would 
often  seem)  of  frequent  but  ineffectual 
efforts  of  the  parts  affected,  is  it  not 
reasonable  to  expect  that  a  constrained 
and  very  forcible  contraction  of  their 
walls,  as  well  as  of  other  co-operating 
muscles,  will  cause  the  feebler  actions 
to  cease  ? 

That  the  purging  should  so  generally 
abate,  and  often  entirely  subside  with  the 
vomiting,  seems  to  be  owing,  in  a  great 
measure,  to  the  inverted  peristaltic 
movements  of  the  stomach  and  duode¬ 
num  superseding,  as  it  were,  and  sus¬ 
pending  the  natural  detrusive  action  of 
the  bowels.  Cullen  recognizes  this 
explanation,  when  he  says,  “  it  is  pos¬ 
sible  that  vomiting  may  give  some  in¬ 
version  of  the  peristaltic  motion  which 
is  determined  too  much  downwards  in 
diarrhoea,  so  that,  upon  the  whole,  it  is 
a  remedy  which  may  be  very  generally 
useful  in  this  disease.”  In  dysentery, 
more  especially,  the  advantages  of 
beginning  the  treatment  with  an  emetic 
dose  of  ipecacuan  have  been  strongly 
enforced  by  some  of  the  best  writers  on 
this  malady;  and  here  I  would  remark, 
en  passant ,  that  the  amount  of  relief  so 
obtained  is  by  no  means  proportionate, 
in  all  cases,  to  the  quantity  or  quality 
of  the  matters  expelled  from  the  sto¬ 
mach.  What  Sydenham  says  of  the 
operation  of  a  vomit  at  the  onset  of  a 
fever,  is  quite  as  applicable  to  dy¬ 
sentery,  and  to  cholera  also.  “  I  have 


DR.  MILROY  ON  THE  USE  OF  EMETICS  IN  CHOLERA. 


often,”  says  this  admirable  writer, 
“  while  looking  at  the  matters  rejected 
by  vomiting — and  these  were,  perhaps, 
not  remarkable  either  for  quantity  or 
for  their  unhealthy  appearance — won¬ 
dered  how  it  came  to  pass  that  the  pa¬ 
tient  should  immediately  experience  so 
much  relief ;  for  no  sooner  has  the 
vomiting  been  over  than  the  severe 
symptoms — viz.  the  nausea,  anxiety, 
restlessness,  deep  sighing,  blackness  of 
the  tongue,  &c. — which  both  distressed 
him  and  alarmed  the  attendants,  have 
been  usually  mitigated  or  altogether 
removed,  and  the  remainder  of  the  dis¬ 
ease  has  been  very  easily  endured.” 
(Observ.  Med.  i.  4,  §  13). 

It  is  well  known  that,  on  more 
occasions  than  one,  Sydenham  empha¬ 
tically  condemns  the  practice  of  trying 
to  stop  the  upward  and  downward 
evacuations  in  cholera,  by  the  use  of 
opiates  and  astringents,  and  that  he 
expressly  recommends  that,  at  first,  the 
vomiting  should  be  encouraged  by  the 
copious  use  of  any  mild  diluents.  In 
this  respect,  he  has  been  followed  by 
almost  all  the  best  practical  writers 
since  his  day.  But  it  is  mainly,  if  not 
solely,  to  the  expulsion  of  offending 
matters,  that  regard  has  generally  been 
had  in  adopting  this  wise  plan :  the 
manifold  and  various  effects  of  full 
vomiting  have,  perhaps,  been  scarcely 
considered  with  sufficient  attention.  I 
must  reserve  my  remarks  upon  this 
subject  till  my  next  paper,  when  I  pro¬ 
pose  to  consider  the  use  of  emetics  in 
Asiatic  cholera.  At  present,  I  shall 
merely  remark,  that  obstinate  and  pro¬ 
tracted  vomiting  will  not  unfrequently 
yield  to  a  full  dose  of  ipecacuan,  after 
opium,  creosote,  effervescing  draughts, 
&c.,  have  been  ineffectually  tried.  In 
other  cases,  I  have  found  it  to  be  best 
relieved  by  the  administration  of  a 
purgative  enema ;  the  forced  action 
of  the  bowels  downwards  suspending 
the  inverted  action  of  the  stomach  and 
duodenum,  and  thus  affording  us  the 
counterpart  to  the  arrest  of  a  diarrhoea 
by  the  operation  of  an  emetic.  In  both 
cases,  the  simultaneous  use  of  an  irri¬ 
tating  epithem  to  the  abdomen  will 
prove  a  powerful  adjuvant. 

In  conclusion,  I  would  remark,  that 
the  medical  practitioner  will  find  it 
most  useful,  in  every  severe  case  of 
cholera,  to  superintend  the  action  of 
the  emetic  himself;  and,  in  a  season 
like  the  present,  it  will  save  much  time 


717 


for  him  to  carry  some  tartrate  of  anti¬ 
mony,  or,  what  is  better,  ipecacuan 
powder,  in  his  pocket ;  a  small  phial 
of  sal  volatile  also  will  be  found  very 
serviceable.  Of  course,  the  patient 
should  always  be  in  bed  at  the  time  : 
indeed,  this  remark  is  of  universal  ap¬ 
plication,  as  respects  the  use  of  eme¬ 
tics  ;  otherwise,  some  of  the  most  salu¬ 
tary  after-effects  of  the  vomiting  will 
be  altogether  lost. 

30,  Fitzroy  Square,  October  1848. 

[To  be  continued.] 


EXCRETION  OF  SULPHUR  BY  THE 
KIDNEYS. 

Sulphur  was  classed  by  Wohler  among  the 
substances  excreted  from  the  system  through 
the  urine,  in  the  form  of  sulphuric  or  hydro- 
sulphuric  acid.  The  presence  of  this  ele¬ 
ment  in  the  urine  has,  however,  been  since 
denied  by  some  chemists ;  but  M.  Griffist, 
of  Strasburg,  as  well  as  other  recent  expe¬ 
rimenters,  have  clearly  demonstrated  the 
truth  of  Wohler’s  observation.  M.  Griffist 
shews,  that  while  in  the  urine  of  man,  in 
its  healthy  condition,  the  quantity  of  sul¬ 
phuric  acid  amounts  to  0’134  per  cent.,  or 
34’3  grains  in  twenty-four  hours,  and  the 
quantity  of  sulphur  to  0- 024  per  cent.,  or 
5T  grains  in  twenty-four  hours,  the  inges¬ 
tion  of  sulphur  with  the  food  will  sometimes 
raise  the  quantity  of  acid  to  85  or  89  grains 
in  twenty-four  hours,  and  of  sulphur  itself 
to  near  8  grains.  This  affords  satisfactory 
proof  that  sulphur  is  absorbed  in  apprecia¬ 
ble  quantity  into  the  system,  and,  in  the 
course  of  its  circulation,  becomes  oxidized. 
— V  Union  Medicate,  1848. 

***  The  presence  in  the  urine  of  a  small 
quantity  of  sulphur  uncombined  with  oxy¬ 
gen  has  lately  been  noticed,  among  others, 
by  Mr.  Ronalds,*  who  believes  that  from 
three  to  five  grains  of  this  element  are  thus 
daily  excreted.  A 

TREATMENT  OF  LEAD  COLIC. 

M.  Martin- Solon  speaks  of  having  de¬ 
rived  great  advantage  from  the  employment 
of  large  quantities  of  emollient  or  acidulated 
drinks  in  the  treatment  of  this  form  of  colic. 
He  adopted  this  plan,  combined  with  the 
use  of  emollient  injections,  twice  a  day,  in 
twenty-two  cases,  in  all  of  which  the  patients 
were  cured  in  from  six  to  fourteen  days.— 
Ibid.  A 


*  Philosophical  Magazine,  1846. 


718 


THE  ORDER  FOR  THE  ABOLITION  OF  QUARANTINE. 


MEDICAL  GAZETTE. 


FRIDAY,  OCTOBER  27,  1848. 

The  fact  that  we  are  unable  by  any 
consistent  theory  to  account  for  the 
erratic  course  of  the  cholera,  is  no  rea¬ 
son  why  we  should  not  employ  every 
available  means  to  prevent  its  propaga¬ 
tion  throughout  the  country.  We  can¬ 
not  enter  into  that  commercial  view  of 
the  subject  which  leads  its  advocates  to 
allow  of  the  free  and  unrestricted  im¬ 
portation  of  cholera  patients  into  our 
seaport  towns.  Admitting  that  the  dis¬ 
ease  is  already  in  this  country,  it  is 
desirable  to  avoid,  as  much  as  possible, 
the  importation  of  further  supplies.  It 
is  bad  enough  to  have  small-pox  in  one 
quarter  of  the  metropolis  ;  but  because 
it  exists  in  one  or  two  districts,  we 
cannot  see  why  we  should  relax  our 
efforts  to  prevent  the  disease  from 
spreading  to  other  quarters.  The 
quasi-medical  writers  of  the  daily  jour¬ 
nals  argue  in  a  different  way :  they 
say,  if  we  have  the  cholera  at  Hull  or 
Sunderland,  it  is  of  no  use  attempting 
to  keep  it  out  from  any  port  where  it 
has  not  hitherto  shown  itself.  The 
best  that  can  be  said  for  such  reasoners 
is,  that  they  are  desirous  of  having 
no  interference  with  free-trade.  They 
would  argue  in  the  same  way,  if  the 
Plague  were  at  Calais,  or  the  Yellow 
Fever  at  Boulogne. 

It  is  only  recently  we  announced  the 
imposition  of  quarantine,  by  an  order 
In  Council,  on  all  vessels  coming  from 
Hamburgh  and  the  Baltic  ports,  where 
cholera  was  known  to  be  prevalent. 
This  was  a  wise  and  judicious  measure, 
but  it  gave  great  offence  to  the  com¬ 
mercial  party,  on  whom,  of  course, 
trouble,  expense,  and  actual  loss,  were 
thereby  thrown. 

The  Privy  Council,  too,  by  reason  of 


this  order,  had  acted  in  opposition  to 
the  views  of  the  non-medical  Board  of 
Health,  the  members  of  which  had  de¬ 
clared  that  cholera  was  not  communi¬ 
cable  from  one  person  to  another,  “  in 
any  manner  whatsoever.’ ’  We  were, 
therefore,  quite  prepared  to  find  that 
the  order  would  be  speedily  rescinded, 
and  that,  on  the  current  principles  of 
trade,  the  importation  of  cholera  into 
this  country  wmuld  be  freely  per¬ 
mitted  ;  in  short,  that,  however  healthy 
a  seaport  town  might  be,  it  should  not 
have  the  remotest  chance  of  escaping 
a  visitation  of  the  disease.  If  the  in¬ 
habitants  of  Hull  and  Sunderland  were 
suffering  from  the  disease,  why  should 
those  of  Southampton  and  Bristol  es¬ 
cape  ?  The  following  order  for  the 
entire  abolition  of  quarantine  was 
issued  only  twelve  days  after  it  had 
been  imposed  : — 

“  Abolition  of  quarantine. — Order 
in  Council.  —  A  communication  has 
been  received  by  the  Commissioners  of 
the  Customs  Department,  from  Mr. 
Bathurst,  one  of  the  clerks  to  the 
Lords  of  Her  Majesty’s  Privy  Council, 
stating  that  he  has  been  directed  by 
the  Lords  of  the  Council  to  inform 
them  that  an  official  communication 
having  been  received  on  the  17th  inst. 
by  their  Lordships,  from  the  General 
Board  of  Health,  stating  the  actual  ex¬ 
istence  of  Asiatic  cholera  in  Great 
Britain,  although  not  in  an  epidemic 
form,  and  that  such  being  the  case 
their  Lordships  are  of  opinion  that 
quarantine  precautions  against  that 
disease  are  no  longer  necessary ;  and 
that  he  (Mr.  Bathurst)  was  further 
directed  to  state  that  in  future  it  will 
not  be  necessary  to  report  on  or  detain 
vessels  arriving  in  Great  Britain  with 
cases  of  cholera  on  board ;  and  further, 
that  all  vessels  at  present  under  re¬ 
straint  of  quarantine  might  be  imme¬ 
diately  released.  In  pursuance  of  this 
communication  from  Mr.  Bathurst,  a 
copy  of  their  Lordships’  order  has  been 
furnished  to  the  principal  officers  of 
the  Customs  Department  at  the  several 
ports  and  places  throughout  the  king¬ 
dom,  as  well  as  to  the  port  of  London, 
with  directions  to  take  care  that  the 
same  be  duly  obeyed.” 


THE  ORDER  FOR  THE  ABOLITION  OF  QUARANTINE. 


719 


We  do  not  entertain  any  doubt  that 
the  cholera  in  Hull  is  to  be  ascribed  to 
its  importation  from  Hamburgh.  At 
first  a  few  cases  occurred  on  board  of 
ships  from  ports  where  the  disease  was 
known  to  exist.  In  our  last  number 
we  had  occasion  to  record  seven  deaths 
from  the  disease,  five  of  which  had 
taken  place  in  the  town  ;  and  we  have 
been  informed,  on  good  authority,  that 
most  of  the  cases  which  have  as  yet 
occurred  in  the  port  of  London,  have 
been  among  the  crews  of  vessels  from 
the  ports  on  our  northern  coast  which 
are  in  direct  communication  with 
Hamburgh.  Putting  these  facts  to¬ 
gether,  we  can  draw  no  other  inference 
than  that,  as  in  1831-2,  the  cholera  has 
reached  our  shores  by  direct  importa¬ 
tion.  When  it  has  once  reached  a 
country,  the  disease  may  diffuse  itself 
under  circumstances  in  which  it  will 
not  be  by  any  means  easy  to  trace  out 
the  mode  of  its  propagation.  It  is  not 
endemic ,  or  confined  to  a  particular 
spot,  although  in  the  case  of  the  Jus- 
titia  convict  ship,  according  to  the 
Times ,  the  cholera  was  endemic  “on 
the  starboard  side  and  stern  thereof 
particularly  and  exclusively, — that  part 
being  exactly  opposite  the  mouth  of  a 
sewer,  which  empties  itself  into  the 
Thames.”  This,  however,  is  a  solitary 
instance,  and  one  so  remarkable,  that 
we  doubt  whether  we  can  find  anything 
like  it  in  the  previous  history  of  the 
cholera.  The  poison  of  the  marshes 
of  Jessore,  on  the  banks  of  the  Ganges, 
is  thus  found  in  the  contents  of  what, 
according  to  our  information,  is  a  com¬ 
paratively  innocent  country  sewer ! 
The  origin  and  localization  of  the 
cholera  in  the  stern  of  the  Justitia 
baffles  all  theory  :  it  is  something  sui 
generis ,  and  cannot,  we  suppose,  be  the 
disease  which  is  described  as  having 
made  a  steady  progress  from  west  to 
east,  appearing  in  the  western  ports  of 
the  continent  before  it  showed  itself  in 


the  eastern  ports  of  our  own  country, 
and  following  throughout  the  great 
lines  of  commercial  and  maritime  inter¬ 
course  ! 

Another  fact  worthy  of  remark  is, 
that  the  cholera  of  the  Justitia  has  not 
manifested  any  epidemic  tendency.  It 
has  been  confined  to  this  convict  ship 
alone.  The  latest  reports  inform  us 
that  the  disease  has  not  shown  itself 
among  convicts  in  other  ships,  or 
among  the  inhabitants  of  the  town  ; 
and  we  are  now  quite  at  a  loss  to  un¬ 
derstand  how  the  cholera  poison  from 
this  Kentish  sewer  has  been  specially 
conveyed  to  the  stern  of  the  Justitia. 
If  there  has  really  been  a  local  origin 
of  this  poison  on  the  banks  of  the 
Thames,  it  remains  to  be  explained 
how  it  is  that  the  cases  which  have  yet 
occurred  in  the  river  have  been  among 
the  crews  of  vessels  from  ports  on  our 
northern  coast.  Besides,  before  ad¬ 
mitting  the  sewerage  theory,  it  would 
be  desirable  to  know  why  cholera  has 
not  shown  itself  among  individuals 
living  near  the  mouths  of  other  sewers 
which  drain  much  more  extensive 
districts. 

The  only  ground  upon  which  this 
sudden  abolition  of  quarantine  can  be 
justified,  is,  that  intercourse  between 
an  infected  and  uninfected  port  cannot 
be  prevented  with  that  degree  of  strict¬ 
ness  which  is  indispensably  necessary 
to  prevent  the  importation  of  a  disease. 
We  are  not  yet  quite  certain  as  to  the 
period  of  incubation  of  cholera.  One 
of  the  recent  fatal  cases  at  Hull  was 
that  of  a  female  who  arrived  in  the 
port  from  Hamburgh  on  Saturday 
night  apparently  in  good  health.  There 
was  no  case  of  cholera  on  board.  A 
few  hours  after  her  arrival  she  was 
seized,  and  died  the  following  day. 
The  fact  that  there  has  been  no  case 
of  cholera  on  board,  and  that  all  are 
apparently  in  good  health,  is  therefore 
not  necessarily  a  criterion  of  safety. 


720 


STATE  OF  HEALTH  OF  THE  METROPOLIS. 


It  appears  to  us  that  the  Lords  of 
the  Privy  Council  have  been  some¬ 
what  premature  in  ordering  the  entire 
abolition  of  quarantine  only  twelve 
days  after  they  had  commanded  its 
imposition.  Such  a  sudden  change  in 
their  views  reflects  but  little  credit 
upon  their  judgment ;  and  the  reason 
which  they  have  assigned  in  their 
order  does  not  justify  their  proceed¬ 
ings.  They  do  not  appear  to  have 
consulted  our  Colleges,  or  to  have 
taken  any  medical  opinions  ;  but  they 
have  allowed  themselves  to  be  guided 
partly  by  the  views  of  a  Board  of 
Health  not  constituted  of  medical  men, 
and  partly  by  the  representations  of 
those  who  are  pecuniarily  interested  in 
the  entire  abolition  of  quarantine.  Ad¬ 
mitting  that  we  have  the  disease  among 
us,  its  attacks  have  been  hitherto  li¬ 
mited  to  a  few  persons,  and  confined 
to  a  few  localities.  The  Lords  of  the 
Council  have  resolved  by  this  order 
that  no  British  sea-port,  however 
healthy,  shall  have  any  sanitary  pro¬ 
tection  thrown  around  it.  The  proper 
course  to  have  pursued  would  have 
been,  in  our  view,  to  have  maintained 
a  limited  quarantine  with  respect  to  all 
vessels  from  infected  continental  ports, 
making  it  more  stringent  when 
deaths  from  cholera  had  occurred 
during  the  voyage,  or  when  the  disease 
had  not  already  shewn  itself  in  the 
British  port  at  which  the  vessel  might 
arrive.  It  is  possible  that,  even  with 
these  precautions,  not  one  of  our  sea¬ 
port  towns  would  escape  the  disease ; 
but  the  recent  order  in  Council  goes 
the  length  of  licensing  its  immediate 
importation  into  healthy  places ;  and 
each  port  may  thus  become  a  channel 
for  the  sure  diffusion  of  the  disease 
over  the  whole  countrv. 

We  must  reserve  for  another  time 
some  remarks  which  we  had  intended 
to  make  on  the  diffusion  of  the  disease 
by  articles  of  clothing.  Quarantine 


appears  to  be  tried  by  an  unfair  test  in 
restricting  the  proofs  of  its  efficiency  to 
the  power  of  preventing  the  propaga¬ 
tion  of  disease  from  person  to  person. 
We  believe  that  due  inquiries  are  rarely 
made  respecting  the  clothing  of  those 
who  have  died  from  cholera;  and  to 
this  secret  and  unsuspected  source  of 
propagation  may  be  probably  attri¬ 
buted  many  cases  in  which  there  is  a 
failure  of  proof  of  personal  intercourse. 


We  have  again  to  report  favourably  of 
the  state  of  health  of  the  metropolis. 
The  cholera  makes  but  little  progress, 
and  still  shows  itself  only  in  a  few  iso¬ 
lated  cases,  so  that  it  cannotbe  truly  said 
to  have  assumed  as  yet  an  epidemic 
character.  We  have  elsewhere*  re¬ 
corded  the  facts  which  have  reached 
us  respecting  the  disease.  As  yet, 
Edinburgh  appears  to  have  suffered 
more  than  any  other  town ;  and  the 
fact  that  out  of  175  cases,  no  less  than 
102  have  proved  fatal,  is  calculated  to 
excite  alarm.  The  deaths  from  cholera 
in  the  metropolis  during  the  past  week, 
have  exceeded  those  of  the  preceding 
week;  and  it  is  still  to  be  observed, 
that  the  greater  number  of  fatal  cases 
have  occurred  at  the  adult  period  of 
life.  On  the  whole,  however,  it  is 
satisfactory  to  know  that  the  weekly 
deaths  are  no  less  than  171  below  the 
average,  and  that  scarlet  fever,  typhus, 
and  other  zymotic  diseases,  have  been 
less  fatal. 


The  only  fatal  cases  of  cholera  re¬ 
ported  this  day  (Thursday)  are  two 
which  occurred  at  the  Millbank  Peni¬ 
tentiary,  and  one  which  occurred  at 
Chatham,  on  all  of  which  inquests 
were  held.  In  the  last-mentioned  case, 
death  wras  ascribed  to  English  cholera. 


*  Page  731. 


On  the  Employment  of  Chloroform  in 
Dental  Surgery  :  its  Mode  of  Exhibi¬ 
tion ,  Sfc.  By  F.  B.  Imlach,  Dentist, 
Licentiate  of  the  Royal  College  of 
Surgeons  of  Edinburgh,  &c.  Pam¬ 
phlet,  8vo.  pp.  9.  Sutherland  and 
Knox,  Edinburgh.  1848. 

We  have  but  recently  discussed  the 
subject  of  this  essay  in  a  notice  of  Mr. 
Tomes’s  Lectures  on  Dental  Surgery.* 
Mr.  Imlach  is  an  advocate  of  the  use 
of  chloroform  vapour  in  dental  opera¬ 
tions;  and,  on  the  old  principle  of 
audi  alteram  partem ,  we  shall  give  him 
the  benefit  of  stating  his  mode  of  em¬ 
ploying  it,  and.  the  conclusions  at 
which  he  has  arrived  respecting  its 
use.  He  says — 

16  Firstly.  I  settle  the  patient  in  an  easy 
and  comfortable  position,  with  the  head  sup¬ 
ported  by  some  firm  object.  I  am  also  in 
the  habit  of  requesting  him  to  close  his  eyes, 
in  order  to  avoid  the  irritation  of  the  chloro¬ 
form  vapour,  and  to  prevent  any  accidental 
mental  or  physical  excitement,  as  from  the 
sight  of  an  amusing  object,  or  the  glare  of 
too  bright  light.  Of  course,  all  noise  of 
every  kind  is  strictly  prohibited  during  the 
inhalation,  and  I  think  it  advisable  to  warn 
him  against  being  alarmed  by  extraordinary 
noises,  as  ringing  in  the  head,  or  by  flashes 
of  light  before  the  eyes,  or  a  feeling  of  giddi¬ 
ness,  or  vertigo. 

“  Secondly.  As  to  the  dose.  I  am  always 
in  the  habit  of  pouring  a  large  quantity  upon 
the  handkerchief,  and  diffusing  it  over  a 
surface  larger  than  will  cover  the  nose  and 
mouth.  The  quantity  I  never  measure,  as  I 
judge  by  the  effects  and  not  the  dose  ;  but  I 
believe  I  seldom  begin  with  pouring,  at  first, 
less  than  three  or  four  drachms  upon  the 
handkerchief.  In  fact,  I  pour  upon  it  a 
quantity  sufficient  to  moisten  completely  the 
required  surface.  Many  of  the  supposed 
bad  effects,  doubtlessly,  result  from  giving  a 
small,  imperfect,  and  consequently  mere  ex¬ 
citing,  dose. 

“  Thirdly.  The  mode  of  administration. 
The  chloroform  is  poured  upon  a  thin  white 
cotton  handkerchief.  An  old  one  answers 
the  purpose  remarkably  well.  This  I  hold 
at  first  at  the  distance  of  two  or  three  inches 
from  the  patient’s  mouth,  and  allow  him 
thus  to  take  two  or  three  deep  inhalations. 
I  then  approximate  it  more  closely  to  the 


face,  but  never  bring  it  into  close  contact. 

In  this  position  the  handkerchief  is  continued 
till  the  anaesthesia  supervenes.  In  judging 
of  this  point,  I  depend  upon  no  single  cir¬ 
cumstance,  and  the  indications  are  of  such  a 
varying  nature  as  cannot  be  described,  but 
are  easily  perceived  after  some  experience  in 
the  practice. 

“  Fourthly.  The  moment  the  handker¬ 
chief  is  removed,  I  apply  the  instrument 
(kept  ready  in  my  hand),  and  at  once  pro¬ 
ceed  to  extract  the  tooth.  If  several  teeth 
are  to  be  extracted  or  punched,  or  if  I  re¬ 
quire  to  change  the  instrument  in  use,  it 
may  be  necessary  to  recommence  the  inhala¬ 
tion  for  a  short  time.  This  readiness  at  the 
proper  time,  and  the  rapid  and  immediate 
extraction,  I  consider  the  chief  secret  of 
success. 

“  Fifthly.  The  great  mass  of  patients,  on 
becoming  insensible,  have  their  jaws  so 
clenched,  that  there  is  no  possibility  of  opening 
the  mouth,  and  the  operator  keeps  working 
away,  tugging  at  the  under  jaw,  or  pressing 
upon  the  angle  of  the  jaw  externally  with  his 
knuckles,  trying  to  force  open  the  mouth. 
This,  again,  is  easily  remedied,  by  the  very 
simple  methodof  never  allowing  the  patient  to 
close  his  jaws  at  all,  by  placing  a  small  gag  of 
ivory  or  gutta  percha  between  the  teeth, 
before  administering  the  chloroform.  No 
patient  objects  to  it,  and  it  causes  him  no 
inconvenience  whatever.” 

Mr.  Imlach  draws  the  following 
conclusions  respecting  the  use  of  chlo¬ 
roform  : — 

“  1.  That  out  of  above  300  cases  of  dental 
surgery,  in  which  I  have  employed  chloro¬ 
form,  I  have  never  seen  the  least  deleterious 
effect  result  from  its  use,  but  the  reverse. 

“  2.  I  have  seen  or  traced  no  after  bad  con¬ 
sequences  of  any  kind  whatever. 

”3. 1  have  seen  no  case  in  which  I  have  been 
afraid  to  give,  and  where  I  have  not  given 
it  quite  successfully. 

“  4.  It  saves  the  patient’s  present  physical 
suffering  and  previous  struggles  of  feeling. 

“5.  It  enables  the  dentist  to  perform  his 
work  with  more  satisfaction,  certainty,  and 
success. 

“6.  Patients  who  have  once  had  a  tooth 
drawn  under  the  influence  of  chloroform,  in¬ 
variably  demand  the  repetition  of  the  chlo¬ 
roform  on  requiring  again  the  same  opera¬ 
tion.” 

It  is  obvious,  from  this  statement, 
that  the  author  has  been  very  success¬ 
ful  in  his  practice.  He  has  fortunately 
not  met  with  a  case  like  that  of  Mr. 
Badger,  which  occurred  in  this  metro¬ 
polis  last  spring.  We  believe  that  the 
result  of  this  case  has  been  a  heavy 


*  Page  545. 


722  DE.  WEST  ON  THE  DISEASES  OF  INFANCY  AND  CHILDHOOD. 


blow  and  great  discouragement  to  the 
use  of  chloroform  in  dental  opera¬ 
tions. 

Of  what  conflicting  elements  medical 
experience  is  made  up,  will  be  suffi¬ 
ciently  apparent  from  a  case  reported 
by  the  author  in  his  essay.  Some  facts 
related  by  Mr.  Tomes  tend  to  shew, 
that  the  inhalation  of  chloroform  va¬ 
pour  has  had  the  effect  of  disturbing 
the  mental  functions,  and  of  producing 
a  state  similar  to  insanity.  Mr.  Im- 
lach’s  experience  goes  the  other  way  ; 
for  he  found  that  the  vapour  had  a 
tendency  to  restore  temporarily  an  in¬ 
tellectual  expression  to  an  imbecile. 

“  One  very  curious  effect  that  I  witnessed 
whilst  administering  chloroform  to  a  patient 
whose  intellect  was  very  much  impaired  from 
some  affection  of  the  head,  so  as  to  leave  her 
imbecile,  was,  that  whilst  under  the  influence 
of  it,  her  eyes  being  open,  her  countenance 
lost  the  vacant  expression  habitual  to  it ;  and 
she  looked  round  in  my  face  with  an  intel¬ 
lectual  expression  so  calm  and  so  rational 
that  I  was  perfectly  startled.  Whilst  gazing 
at  her,  however,  the  effects  of  the  chloroform 
passed  off,  and  she  awoke  with  the  same  un¬ 
meaning  laugh  and  vacant  gaze  that  she  had 
before.  I  mentioned  this  circumstance  to 
my  friend  Dr.  Simpson  the  day  that  it  oc¬ 
curred,  and  I  thought  of  trying  what  effect 
the  habitual  use  of  the  chloroform  might  have 
upon  the  patient  by  stimulating  the  brain  so 
as  to  assist  the  cure  ;  for  this  patient,  I  was 
informed  by  the  parents,  is  gradually,  though 
slowly,  recovering  the  use  of  her  faculties ; 
and  we  do  not  know  but  that,  by  stimulating 
the  brain,  it  might  materially  assist  in  the 
recovery ;  but  I  must  leave  this  for  others 
better  acquainted  with  affections  of  that  sort 
than  I  am,  and  recur  to  my  own  depart¬ 
ment.  ” 

These  conflicting  results  appear  to 
us  inexplicable,  except  upon  homoeo¬ 
pathic  principles  ! 

Mr.  Imlach’s  conclusions  respecting 
the  use  of  this  agent  in  dentistry  are 
fully  warranted  by  the  results  of  his 
own  observations.  Others,  however, 
of  great  experience  as  dental  surgeons, 
have  been  less  fortunate  than  the 
author  ;  and  we  believe  that,  so  far  as 
operations  on  the  teeth  are  concerned, 
the  general  opinion  now  is,  in  the 
words  of  Mr.  Tomes,  that  the  remedy 
is  strangely  out  of  proportion  to  the 
evil  to  be  avoided. 


Lectures  on  the  Diseases  of  In  fancy  and 
Childhood.  By  Charles  West,  M.D., 
Fellow  of  the  Royal  College  of  Phy¬ 
sicians,  and  Lecturer  on  Midwifery 
at  St.  Bartholomew’s  Hospital.  8vo. 
pp.  448.  London  :  Longman  and  Co. 
1848. 

The  fact  that  Dr.  West’s  Lectures  have 
so  recently  appeared  in  the  pages  of  this 
journal,  renders  it  unnecessary  for  us 
to  do  more  than  advert  to  their  separate 
publication.  While  we  consider  that 
these  Lectures  have  formed  a  most 
valuable  contribution  to  our  pages,  we 
cannot  hesitate  to  recommend  this  vo¬ 
lume  as  a  most  useful  addition  to  the 
library  of  every  practitioner.  The  dis¬ 
eases  of  infancy  are  but  too  little 
studied  :  hence  their  treatment  is  often 
of  an  empirical  kind,  and  success  is  the 
result  of  accident,  excepting  in  those 
cases  in  which  long  experience  may 
have  supplied  the  practitioner  with 
that  knowledge  which  should  have 
formed  a  part  of  his  medical  education. 
Several  works  on  the  same  subject 
have  appeared  of  late  years,  but  we 
know  of  none  which  contains  a  more 
complete  account  of  infantile  diseases 
and  their  treatment,  than  that  which 
is  now  before  us.  The  author  is  not 
one  of  those  who  sit  down  contented 
with  their  own  experience :  on  the 
contrary,  the  researches  of  foreign 
writers  on  the  subject  are  duly  noticed, 
and  their  conclusions  fairly  considered. 
The  volume,  which  is  well  printed, 
and  contains  much  in  a  small  com¬ 
pass,  may  be  regarded  as  a  very  cre¬ 
ditable  contribution  to  English  medical 
literature. 


Elements  of  Chemistry ,  including  the 
applications  of  the  Science  inthe  Arts. 
By  Thomas  Graham,  F.R.S.  Pro¬ 
fessor  of  Chemistry  in  University 
College,  London.  Part  3.  2nd  edi¬ 
tion,  from  p.  353  to  544.  London  : 
Bailliere.  1848. 

The  subscribers  to  this  excellent  work 
will  be  glad  to  learn  that  another  Part 
has  just  issued  from  the  press.  Al¬ 
though  the  parts  appear  at  intervals 
somewhat  long  for  those  who  are 
desirous  of  having  a  complete  work  of 
reference,  it  is  evident  that  the  author 
is  sparing  no  pains  to  improve  each 
section  of  his  work,  and  to  bring  it  up 
to  the  high  position  in  science,  which 
modern  chemistry  has  attained. 


ON  SOLUTIONS  OF  GUN-COTTON 


This  part  comprises  Ammonia,  Car¬ 
bon  and  its  compounds  with  oxygen, 
hydrogen,  and  nitrogen,  Boron,  Silicon, 
Sulphur,  Phosphorus,  Chlorine,  Bro¬ 
mine,  Iodine,  and  Fluorine,  with  which 
the  history  of  the  Non-Metallic  Ele¬ 
ments  is  closed.  The  Metallic  Elements 
are  commenced  in  the  sixth  chapter,  and 
besides  the  general  properties  of  the 
metals,  we  have  in  this  part  the  Che¬ 
mical  history  of  Potassium  and  its 
compounds.  The  type  and  paper  are 
better  than  those  used  in  the  first  edi¬ 
tion  of  the  work,  and  many  new  illus¬ 
trations,  which  are  well  executed  and 
clearly  printed,  have  been  added.  So 
far  as  we  have  examined  the  new  edi¬ 
tion,  the  author  appears  to  have  omitted 
nothing  which  might  render  it  a  perfect 
treatise  oil  chemistry. 


^voccetitngs  of  jfcoctetteg. 

EDINBURGH  MEDICO-CHIRURGI- 
CAL  SOCIETY. 

Dr.  Hamilton,  President  in  the  Chair. 

On  Solutions  of  Gun-cotton,  Gutta  percha, 
and  Caoutchouc,  as  dressings  for  wounds, 
fyc.  By  Professor  Simpson. 

[It  is  only  due  to  Professor  Simpson  to  state 
that,  a  subject  which  has  recently  attracted 
great  attention — namely,  the  employment  of 
new  adhesive  preparations  in  surgery,  was 
made  known  by  him  to  the  Edinburgh 
Medico-Chirurgical  Society  in  May  last. 
We  reprint  from  a  recent  number  of  the 
Edinburgh  Monthly  Journal,  the  following 
account  of  his  observations  and  experiments, 
including  those  of  Mr.  Maynard  and  Dr. 
Bigelow,  in  the  United  States.] 

At  different  periods  in  the  histoi’y  of  sur¬ 
gery,  very  different  practices  have  prevailed 
in  regard  to  the  treatment  of  wounds.  At 
one  time,  in  injuries  or  incisions  of  any  great 
extent,  the 'whole  sides  of  the  divided  or  cut 
surfaces  were  dressed  as  separate  and  distinct 
wounds  ;  and  all  chance  of  immediate  union 
prevented.  Slow  reunion  by  suppuration 
and  granulation,  or,  as  the  old  surgeons 
termed  it,  by  “  digesting,  mundyfying,  and 
incarning”  wounds,  was  alone  attempted. 
Afterwards,  however,  and  yet  not  without 
much  doubt  and  opposition,*  the  practice 

*  “  I  would  ask  (gravely  writes  O’Halloran  in 
1765),  I  would  ask  the  most  ignorant  in  our  pro¬ 
fession,  whether  he  ever  saw  or  heard  even  of  a 
wound,  though  no  more  than  one  inch  long, 
united  in  so  short  a  time  (as  three  days).  These 
tales  are  told  with  more  confidence  than  veracity  ; 
healing  by  inosculation,  by  the  first  intention,  by 


AS  DRESSINGS  FOR  WOUNDS.  723 


was  introduced  of  placing  from  the  first  the 
sides  and  lips  of  the  wound  in  contact,  and 
thus  allowing  nature  to  produce  the  sponta¬ 
neous  adhesion  of  the  whole  wound,  or  as 
much  of  its  surfaces  as  will  thus  adhere.  In 
other  words,  reunion  by  the  first  intention 
came  to  be  more  and  more  attempted  after 
the  discovery  of  the  doctrine  of  adhesion  (as 
it  was  termed)  was  duly  made  and  fully  acted 
on. 

But  no  small  difference  of  opinion  and 
practice  has  prevailed  as  to  the  best  mode  of 
bringing  and  retaining  in  contact  the  sides  of 
such  wounds  as  are  capable  of  healing  by  the 
first  intention.  A  great  variety  of  bandages, 
plasters,  needles,  and  stitches,  have  been  in¬ 
vented  for  this  purpose.  And,  the  propriety 
or  non- propriety  of  using  sutures  in  prefer¬ 
ence  to  plasters  (the  sutura  cruenta,  as  it 
was  termed,  in  preference  to  the  sutura 
sicca),  was  at  one  time  a  special  subject  of 
dispute.  Louis,  Pibrac,  and  Young,  main¬ 
tained  that  in  all,  or  in  almost  all,  cases,  the 
employment  of  the  suture  should  be  aban¬ 
doned  as  irritating  and  hurtful.  At  the 
present  day,  both  modes  of  artificial  reunion 
— the  sutura  cruenta  and  sicca — are  followed 
by  the  generality  of  surgeons ;  and  often 
both  modes  are  used  simultaneously. 

It  seems  not  at  all  improbable,  that  ano¬ 
ther  step  in  advance  will  betimes  be  effected, 
and  that  surgeons  will  be  enabled  to  apply 
to  the  wound,  after  its  edges  are  brought  in 
contact,  some  material  or  other  which,  like 
an  artificial  plasma,  or  lute  of  coagulable 
lymph,  will  at  one  and  the  same  time  serve 
the  following  purposes  : — 

1.  It  will  be  sufficiently  strong  and  ad¬ 
hesive  to  retain  the  edges  of  the  wound  to¬ 
gether,  without  the  irritation  sometimes 
following  the  use  and  removal  of  sutures  or 
pins ; 

2.  It  will  serve  as  a  perfect  dressing  to 
the  wound. 

3.  It  will,  however,  not  be  soluble  in 
water,  or  be  easily  removed  :  and  hence  will 
enable  the  surgeon  to  apply  cold,  &c.,  to  re¬ 
strain  and  modify  the  action  in  the  wound, 
if  required. 

4.  Though  insoluble  in  water,  the  mate¬ 
rial  used  must  be  soluble  in  some  menstruum 
that  is  easily  and  readily  vaporized. 

5.  It  will  be  applied  in  a  fluid  or  semi¬ 
fluid  form,  and  be  thus  capable  of  adapting 
itself  to  any  irregularity  in  the  edges  of  the 
wound  or  in  the  neighbouring  cutaneous 
surface  ;  the  fluid  part  evaporating  speedily 
on  exposure,  and  a  solid  tissue  or  substance, 
possessing  sufficient  tenacity,  adhesiveness, 
and  insolubility  in  water  for  the  above  pur¬ 
poses,  being  left  like  a  plaster  on  the  edges 
of  the  united  wound. 

immediate  coalescence  without  suppuration,  is 
merely  chimerical,  and  opposite  to  the  rules  of 
nature.” 


724  PROF.  SIMPSON  ON  SOLUTIONS  OF  GUN-COTTON,  GUTTA  PERCHA, 


The  intention  of  the  present  imperfect 
communication  is  to  bring  before  the  Society- 
some  of  the  attempts  lately  made  in  order  to 
attain  the  above  objects. 

Two  or  three  weeks  ago,  it  was  announced 
in  our  weekly  medical  journals,  that  a  solu¬ 
tion  of  gun-cotton  in  ether  had  been  used  in 
America  as  a  dressing  for  wounds  ;  and, 
within  the  last  two  or  three  days,  the  Ame¬ 
rican  journals  which  have  arrived  in  Edin¬ 
burgh  show  that  the  suggestion  of  this  prac¬ 
tice  is  claimed  by  two  different  persons,  viz. 
by  Mr.  Maynard,  a  medical  student  of  Bos¬ 
ton,  and  by  Dr.  Bigelow,  of  the  same  city. 

Soon  after  the  discovery.of  gun-cotton  or 
pyroxyline,  Schoenbein  and  Boettger  showed 
that  acetic  ether  was  one  of  its  best  solvents. 
— ( Chemical  Gazette  for  April  1,  1847.) 
Richner  had  ascertained  that  it  was  entirely 
soluble  in  the  acetic  ethers  both  of  alcohol 
and  wood  spirit. — ( lb .  for  February  1.) 
When  xyloidine,  or  the  analogous  compound 
made  by  the  action  of  nitric  acid  on  starch, 
is  dissolved  in  ether,  or  ether  and  alcohol, 
Schoenbein  found  that  it  was  reduced  to  a 
colourless  gelatinous  mass,  and  that,  if 
spread  upon  a  smooth  surface,  “it  left  a 
dull  white  opaque  membrane .” — ( Ih .  for 
April  1.)  I  am  not  aware  whether  he  has 
recorded  any  similar  observation  regarding 
the  ethereal  solution  of  pyroxline,  but  it  is 
this  quality  of  it  that  has  been  turned  in 
America  to  practical  purposes  as  an  applica¬ 
tion  and  dressing  for  wounds. 

When  gun-cotton  is  fully  dissolved  in 
strong  sulphuric  ether,  it  forms  a  semi¬ 
transparent  gelatinous  pulp.  When  a  layer 
of  this  is  laid  on  any  surface,  the  ether 
speedily  evaporates,  and  leaves  an  adherent 
whitish,  cotton-like  web,  which  contracts 
strongly  as  it  dries,  and  possesses  still  all 
the  usual  inflammable  and  explosive  proper¬ 
ties  of  gun-cotton.  In  a  great  variety  of  trials 
which  I  have  had  made  as  to  the  best  mode 
of  forming  the  solution,  I  have  met  with 
very  various  results.  Many  of  these  varia¬ 
tions  were  probably  owing  to  imperfections 
and  differences,  either  in  the  quality  of  the 
gun-cotton  or  of  the  ether.  But  occasionally, 
with  the  same  ingredients,  the  quality  of  the 
solution  seemed  liable  to  differ.  Sometimes 
after  the  gun-cotton  had  been  immersed  in 
the  ether  for  ten  or  twelve  hours  without 
much  effect,  the  addition  of  a  little  strong 
spirit  immediately  effected  a  perfect  solution. 
The  gun-cotton  often  possesses  strong  ad¬ 
hesive  properties  when  used  before  it  is  all 
completely  dissolved.  In  using  as  a  solvent, 
aldehyde,  which  had  been  kept  for  a  consi¬ 
derable  time,  I  found  a  perfect  pulpy  solu¬ 
tion  formed  in  a  few  minutes.  If  it  could 
be  used  as  a  menstruum,  it  would  possess  the 
advantage  of  being  even  more  vaporizable 
than  ether.  But  in  trying  to  repeat  the  ex¬ 
periment  with  some  aldehyde  newly  formed 


for  the  purpose,  the  same  results  were  not 
obtained. 

Usually  an  ounce  of  strong  sulphuric 
ether  will  dissolve  thirty  grains  or  more  of 
gun-cotton  in  the  course  of  a  few  hours. 
But  to  form  a  complete  pulp  it  will  in  general 
require  to  stand  for  a  day.  The  advantages 
which  the  ethereal  solution  of  gun-cotton 
seems  to  possess  as  a  dressing  for  wounds, 
and  particularly  for  those  which  it  is  desired 
to  unite  by  the  first  intention,  are  stated  in 
the  following  terms  by  Dr.  Bigelow : — 

“  1st,  By  its  powerful  contraction  upon 
evaporation  it  places  the  edges  of  an  incised 
wound  in  much  more  intimate  contact  than 
is  obtained  by  sutures  and  adhesive  cloth — 
unites  them  by  equal  pressure  throughout 
the  whole  extent  of  the  wound,  and  main¬ 
tains  them  immoveably  fixed.  2d.  It  pre¬ 
serves  the  wound  perfectly  from  contact  with 
air,  being  impermeable  to  the  atmosphere, 
while  its  adhesion  to  the  skin  is  so  intimate 
as  to  preclude  the  possibility  of  air  entering 
beneath  the  edges.  3d.  The  substance  re¬ 
maining  in  contact  with  the  skin  and  wound 
after  the  evaporation  of  the  ether,  seems  to 
be  entirely  inert,  so  far  as  any  irritating 
property  is  concerned,  and  this  can  scarcely 
be  said  of  any  resinous  adhesive  cloth  or  pre¬ 
paration.  4th.  It  does  away  with  the  neces¬ 
sity  for  sutures  in  incised  wounds  of  almost 
any  extent.  5th.  It  is  sure  to  remain  in  in¬ 
timate  contact  with  the  skin  till  union  is 
complete,  and  being  quite  impervious  to 
water,  and  presenting  a  polished  surface,  it 
allows  the  surrounding  parts  to  be  washed 
without  regard  to  the  wound  or  dressing. 
6th.  It  is  colourless  and  transpai’ent,  thus 
permitting  the  surgeon  to  witness  all  that 
goes  on  beneath  without  involving  the  neces¬ 
sity  for  its  removal.  7th.  No  heat  is  neces¬ 
sary  for  its  application,  and  the  presence  of 
any  moderate  degree  of  cold  is  only  objec¬ 
tionable  in  retarding  the  evaporation  of  the 
ether.  8th.  It  may  be  made  at  a  trifling 
cost;  an  ounce  phial,  intrinsically  worth 
little,  being  sufficient  for  a  great  number  of 
dressings.” 

The  adhesive  power  of  this  solution  of 
gun-cotton  is,  when  properly  made  and  ap¬ 
plied,  certainly  very  great.  In  evidence  of 
its  strong  adhesive  powers,  Mr.  Maynard 
states  the  following  experiments: — “He 
glued  a  strap  of  sheepskin  to  the  hand  by  a 
thin  layer  of  the  solution,  nine  lines  long  and 
one  and  a  half  wide,  and  it  sustained  a 
weight  of  two  pounds.  A  second  strap  at¬ 
tached  to  the  hand  by  a  layer  of  the  sub¬ 
stance,  nine  lines  in  length  and  three  in 
width,  sustained  a  weight  of  three.  A  third 
strap  fixed  to  the  hand  by  a  layer  of  the  li¬ 
quid,  twelve  lines  square,  resisted  the  force 
of  ten  pounds  without  giving  way;  and  a, 
fourth  strap  of  the  leather  glued  to  the  hand 
by  a  stratum  of  the  solution,  measuring  one 


AND  CAOUTCHOUC,  AS  DRESSINGS  FOR  WOUNDS,  ETC. 


725 


and  three- fourths  of  an  inch  in  length  and 
one  in  width,  was  not  separated  from  its  at¬ 
tachment  by  the  gravity  of  twenty  pounds  !” 
These  statements,  says  Mr.  Maynard,  may 
appear  incredible,  but  they  are  founded  on 
exact  and  carefully-performed  experiments. 

As  to  the  mode  of  applying  the  ethereal 
solution  of  gun-cotton,  Mr.  Maynard  states, 
that  “  In  slight  cuts  a  moderately  thick 
coating  of  the  solution,  laid  over  the  in¬ 
cised  parts,  was,  on  becoming  dry,  suffi¬ 
cient  to  keep  the  lips  of  the  wound  in  posi¬ 
tion  till  union  took  place ;  but  in  most 
instances  it  was  employed  in  conjunction 
with  straps  of  cotton  and  sheepskin,  and 
with  raw  cotton,  forming  with  them  strong, 
unyielding,  adhesive  straps,  bandages,  and 
encasements  :  and,  after  many  experiments, 
I  am  convinced  that  this  is  the  best  and 
most  effectual  way  in  which  it  can  be  em¬ 
ployed  as  an  adhesive  agent  in  surgery. 
The  solution  dries  rapidly,  and  in  a  few 
seconds  ;  by  the  evaporation  of  the  ether  it 
contains,  it  becomes  solid  and  impermeable 
to  water ;  and  a  strap  moistened  with  it, 
and  glued  to  any  part  of  the  cutaneous  sur¬ 
face,  adheres  to  it  vrith  a  tenacity  that  is 
truly  surprising.”  Mr.  Maynard  mentions 
one  case  in  which,  after  the  removal  of  a 
tumor  from  the  scalp,  the  hair  in  the 
neighbourhood  was  shaved,  and  two  pieces 
of  sheepskin  were  firmly  sealed,  by  the 
solution  of  gun-cotton,  to  each  side  of  the 
wound  at  a  distance  from  the  edges,  and 
then  these  edges  were  approximated  and 
retained  in  contact  by  passing  stitches 
through  the  dead  sheepskin  instead  of 
passing  sutures  through  the  living  tissues  of 
the  walls  of  the  wound. 

Dr.  Bigelow’s  directions  for  applying  the 
gun-cotton  solution  are  as  follows  : — “  For 
straight  incisions,  of  whatever  length ,  pro¬ 
vided  the  edges  can  be  brought  together 
without  great  difficulty,  it  is  better  to  apply 
the  solution  in  immediate  contact  with  the 
skin,  as  follows  : — The  bleeding  should  be 
arrested,  and  the  skin  thoroughly  dried.  If 
the  lips  of  the  wound  are  themselves  in  con¬ 
tact,  the  surgeon  has  only  to  apply  a  coating 
of  the  solution  lengthwise  over  the  approxi¬ 
mated  edges  by  means  of  a  camel’s  hair 
pencil,  leaving  it  untouched  after  the  brush 
has  once  passed  over  it  till  it  is  dry,  during 
perhaps  ten  or  twenty  seconds.  This  first 
film  will  of  itself  have  confined  the  edges 
together  ;  but,  in  order  to  increase  the  firm¬ 
ness  of  the  support,  more  must  then  be 
applied  in  the  same  manner,  allowing  it  to 
extend  on  either  side  of  the  incision  half 
an  inch  or  more.  If,  however,  the  wound 
gapes,  an  assistant  is  required  to  bring  the 
edges  in  contact,  and  retain  them  so  whilst 
the  application  is  made.  If  the  incision  is 
so  long  that  the  assistant  cannot  place  the 
edges  in  apposition  throughout  the  whole 


extent,  begin  by  covering  a  small  portion  at 
the  upper  end,  and  apply  the  solution  to  the 
lower  parts  as  fast  as  it  becomes  dry  above. 
In  this  case  something  more  than  the  film 
which  is  left  adherent  to  the  skin  will  be 
necessary  for  a  safe  and  proper  support  to 
the  wound,  which  may  have  a  tendency  to 
separate.  The  transparency  of  the  dressing 
may  be  still  maintained  by  adapting  a  piece 
of  goldbeater’s  skin  or  oiled  silk  to  the 
wound.  This  should  be  covered  with  the 
solution,  and  the  membrane  applied  after 
the  coating  is  on  and  ah’eady  contracted. 
A  dossil  of  lint,  or  a  strip  of  cloth,  or  even 
a  piece  of  tissue  paper,  which  is  thus  ren¬ 
dered  tough  and  waterproof,  will  answer 
the  same  purpose,  though  not  transparent. 
Where  there  is  much  separation,  it  is  better 
to  fortify  the  wound  in  this  way  at  once, 
and  as  fast  as  the  first  coating  is  applied  and 
dx'y.  ‘  If,  however,  adhesion  by  first  inten¬ 
tion  be  not  desired,  the  gum  may  be  painted 
on  in  transverse  strips,  like  adhesive  cloth, 
letting  the  first  strip  dry,  and  giving  it  the 
goldbeater’s  skin  support  before  the  second 
is  applied.  Thus  room  is  left  for  the  escape 
of  pus,  and  the  exposed  portion  may  be 
watched  without  removing  the  strips.’  ” 

It  has  been  proposed  to  use  the  ethereal 
solution  of  gun-cotton  for  other  purposes 
than  the  dressing  and  union  of  wounds — as, 
for  example,  as  a  substitute  for  the  starch 
bandage  in  fractures  ;  as  an  application  and 
dressing  to  ulcers,  & c.  In  abrasions,  and 
slight  injuries  of  the  skin  about  the  fingers, 
it  forms  an  excellent  and  most  adhesive  dress¬ 
ing.  There  is  one  extremely  painful  and  un¬ 
manageable  form  of  ulcer  in  which  I  applied 
it  eight  or  ten  days  ago,  at  the  Maternity 
Hospital,  with  perfect  success.  I  allude  to 
fissures  at  the  base  of  the  nipple.  Most 
practitioners  know  well  the  agony  that  some 
mothers  undergo,  in  consequence  of  this 
apparently  slight  disease  ;  the  ulcer  or  fis¬ 
sure  being  renewed  and  torn  open  with  each 
application  of  the  child.  In  two  such  cases 
I  united  the  edges  of  the  fissures,  and 
covered  them  over  with  the  solution  of  gun¬ 
cotton,  making  the  layer  pretty  strong.  It 
acted  successfully,  by  maintaining  the  edges 
so  firmly  together  that  they  were  not  again 
re-opened  by  the  infant :  the  gun-cotton 
dressing  was  not,  like  other  dressings, 
affected  by  the  moisture  of  the  child’s 
mouth  ;  and  as  a  dressing,  and  at  the  same 
by  securing  rest  to  the  part,  it  allowed  com¬ 
plete  adhesion  and  cicatrization  speedily  to 
take  place.  I  have  applied  it  also  repeatedly 
to  ulcers  of  the  cervix  uteri  and  over  various 
cutaneous  eruptions.  Its  application  relieves 
at  once  the  smarting  of  slight  burns. 

In  a  case  in  which  Professor  Miller  lately 
removed  a  large  portion  of  necrosed  bone 
from  the  lower  jaw,  I  dressed  the  lips  of  the 
incision  with  the  gun-cotton  solution,  and 


726 


DR.  HUGHES  ON  PNEUMONIA. 


it  held  them  for  some  days  subsequently 
accurately  in  contact  till  adhesion  took 
place.  In  two  minor  amputations  (one  of 
the  finger  and  the  other  of  the  toe),  by  the 
same  gentleman,  it  was  applied,  but  required 
to  be  removed  in  a  day  or  two,  in  conse¬ 
quence  of  its  retaining  the  discharges.  I  have 
made  a  nqmber  of  experiments,  with  solu¬ 
tions  in  different  menstrua,  of  various  other 
substances  besides  gun-cotton,  especially 
viscine,  dextrine,  caoutchouc,  and  gutta¬ 
percha. 

Gutta-percha  readily,  I  find,  dissolves  in 
chloroform.  When  a  thin  layer  of  this 
solution  is  spread  upon  the  skin  or  any 
other  surface,  the  chloroform  rapidly  evapo¬ 
rates,  and  leaves  a  film  or  web  of  gutta¬ 
percha,  possessing  all  the  tenacity  and  other 
properties  of  that  substance.  A  layer  of  it, 
of  the  thickness  of  good  writing-paper,  has 
perhaps  as  much  strength  and  tenacity  as  to 
hold  the  edges  of  a  wound  together,  with  all 
the  required  firmness  and  strength  of  sutures. 
When  a  film  of  it  is  placed  upon  the  skin,  and 
is  allowed  to  dry  thoroughly  for  a  few  minutes, 
the  subsequent  attempt  to  separate  it  is  like 
peeling  and  tearing  off  the  epidermis  after 
erysipelas,  &c.  It  then  forms,  as  it  were, 
at  once  a  kind  of  artificial  tissue,  epidermis, 
or  skin,  which  adheres  strongly  for  a  time. 
There  is  one  disadvantage  pertaining  to  it. 
In  the  course  of  a  day  or  two  it  generally 
dries  and  crisps  up,  like  court  plaster,  at  its 
edges.  If  we  could  either  increase  its  ad¬ 
hesiveness,  or  destroy  its  tendency  to  dry 
and  crisp,  we  should  render  it  more  useful. 

I  have  seen  the  addition  of  a  little  caout¬ 
chouc  apparently  correct  it  in  these  respects. 

The  deposit  or  “  plaster”  left  by  the  solu¬ 
tion  of  gutta-percha  is  far  more  equable, 
smooth,  and  skin-like,  than  that  left  by  the 
solution  of  gun-cotton. 

A  solution  of  caoutchouc  in  bisulphuret 
of  carbon,  ether,  or  chloroform,  leaves  a 
very  thin,  but  perhaps  less  regular  web,  and 
one  which  stretches  too  readily  for  most 
practical  purposes. 

One  great  deficit  in  this  class  of  dressings 
is  the  want  of  a  menstruum  sufficiently 
powerful,  and,  at  the  same  time,  not  stimu¬ 
lating  like  ether  or  chloroform.  This  ob¬ 
jection  may,  perhaps,  in  practice  be  got 
over,  by  applying  an  unstimulating  solution 
of  isinglass  or  the  like  to  the  raw  surface, 
before  applying  the  stimulating  solution  of 
the  gun-cotton  or  gutta-percha.  Or  the  first 
layer  of  gun-cotton  or  gutta-percha  may  be 
made  very  thin,  so  as  to  evaporate  almost 
instantaneously,  and  then  afterwards  a 
series  of  superincumbent  layers  may  be 
added  till  the  web  is  of  the  required  strength. 
Other  better  substances  for  solution  may, 
perhaps,  be  found.  But  no  material  has 
a  chance  of  succeeding,  unless  it  be  insolu¬ 
ble  in  water  after  it  is  consolidated,  and 


un/ess  it  be  sufficiently  strong  in  its  texture, 
and  possesses  powerfully  adhesive  properties. 

[Dr.  Simpson  has  forwarded  to  us  the 
following  addition  to  the  report.] 

P.S.  Since  the  preceding  observations 
were  published  in  the  Monthly  Journal  of 
Medical  Science  for  July  last,  various  at-, 
tempts  have  been  made  by  Messrs.  Duncan, 
Flockhart,  &c.,  to  improve  the  manufacture 
of  collodion  or  gun-cotton  solution.  For 
some  time  past  they  have  thrown  aside 
other  formulae,  and  use  now  only  that  of  M. 
Mialhe  (described  in  the  present  volume  of 
the  Medical  Gazette,  p.  517).  They 
find  this  formula  by  far  the  most  simple  and 
certain  that  they  have  tried.  The  sulphuric 
acid  employed  should  be  the  commercial 
kind ;  as,  when  it  is  too  strong  and  concen¬ 
trated,  it  chars  and  blackens  some  of  the 
cotton,  making  a  dark  instead  of  a  transpa¬ 
rent  solution. 

Edinburgh,  Oct.  1st,  1848. 


SOUTH  LONDON  MEDICAL 
SOCIETY. 

John  Hilton,  Esa.,  President. 

At  an  ordinary  meeting,  held  October  12th, 
Dr.  Hughes  read  a  paper  on 

Pneumonia. 

Dr.  Barlow  commenced,  by  inquiring  of 
the  author  what  indications  pointed  out 
when  calomel,  or  bleeding,  or  antimony, 
were  the  most  suitable  remedies,  and  under 
what  circumstances  were  they  most  bene¬ 
ficial. 

Dr.  Hughes  considered  that  each  indivi¬ 
dual  case  ought  to  be  judged  of  by  itself,  and 
the  cases  just  related  were  treated  according 
to  this  rule.  When  the  patient  was  young, 
stout,  florid,  and  of  full  habit  of  body,  there 
being  no  epidemic  influence  or  hereditary 
disease,  as  tubercle,  as  in  the  case  of  the  girl, 
bleeding  was  indicated  and  adopted,  and  the 
pneumonia  entirely  overcome  on  the  follow¬ 
ing  day.  Antimony  was  indicated  where 
bleeding  was  dreaded,  and  when  there  was 
that  peculiar  pungent  dryness  of  skin 
alluded  to  by  Dr.  Addison.  It  was  contra¬ 
indicated  when  the  skin  was  moist,  and 
when  the  patient  was  suffering  from  ague,  or 
any  miasmatic  influence.  Mercury  was  as 
equally  a  delicate  remedy,  but  did  not  re¬ 
quire  for  its  employment  so  much  discrimi¬ 
nation,  as  it  could  almost  always  be  con¬ 
trolled,  wdiich  was  not  the  case  with  anti¬ 
mony.  It  was  indicated  in  pneumonia  with 
effusion,  where  there  was  no  tubercle,  but  it 
should  be  cautiously  watched. 

Dr.  Barlow  agreed  with  Dr.  Hughes  in 
considering  it  impossible  to  lay  down  a  de- 


DR.  HUGHES  ON  PNEUMONIA.  THE  CHOLERA. 


727 


cidecl  rule.  He  considered  that  mercury  | 
was  useful  in  the  stage  off  consolidation 
bordering  upon  red  hepatizatvm,  where  there 
■was  increase  of  density  withov  heat  of  skin 
or  pallor  of  the  lip,  and  where  in  the  neigh¬ 
bourhood  of  the  dulness,  tVe;’e  was  some 
crepitation,  and  that  antimony  was  useful  in 
the  earlier  stage  of  the  disease.  The  abuse  of 
mercury  was  irretrievable  ;  it  was  an  error 
often  fallen  into,  and  generally  attended  with 
fatal  results. 

Mr.  Robinson  suggested  that  with  re¬ 
gard  to  treatment,  three  special  points 
should  be  attended  to — 1st,  the  constitution 
of  the  patient ;  2nd,  the  cause  of  the 
disease ;  3rd,  its  character.  He  con¬ 
sidered  the  disease  to  be  one  of  two  con¬ 
ditions  as  regards  the  constitution  of  the 
patient — viz.  the  tonic  and  atonic  forms  :  in 
the  one,  depletion  was  beneficial,  and  in 
the  other  it  could  scarcely  be  borne.  The 
cases  related  by  Dr.  Hughes  seemed  to  be 
of  the  atonic  form,  where  bleeding  could 
hardly  be  employed  in  the  early  stage,  and 
where  there  was  a  great  facility  of  checking 
the  disease  by  antimony  and  blisters  :  as 
regards  antimony,  there  was  scarcely  any 
case  where  it  might  not  be  used  with  im¬ 
punity  ;  it  will  even  supersede  the  lancet. 
Mercury  was  also  beneficial,  and  it  was  . 
extensively  used  by  him  in  the  form  of 
Hydr.  c.  Creta :  it  was  objectionable  in 
the  scrofulous  constitutions.  There  was 
another  important  remedy  highly  bene¬ 
ficial  in  the  atonic  forms  of  the  disease, 
and  when  there  was  a  miasmatic  complica¬ 
tion  ;  this  remedy  was  quinine,  which  acted 
not  only  by  combating  the  cause,  but  also 
by  giving  tone  to  the  vessels.  Of  the  effi¬ 
ciency  of  this  treatment  he  narrated  a  case 
in  confirmation.  In  enumerating  the  phy¬ 
sical  signs  in  one  of  the  cases,  Dr.  Hughes 
had  adverted  to  the  presence  of  pectoriloquy. 
He  had  always  considered  it  to  be  indicative 
of  a  phthisical  cavity,  as  taught  by  Dr. 
Davis,  and  he  wished  to  learn  from  Dr. 
Hughes  its  explanation. 

Dr.  Hughes  considered  pectoriloquy  to 
be  one  of  the  most  fallacious  and  valueless 
signs  of  a  cavity  ;  it  generally  occurred  in 
parts  where  there  was  consolidation  around 
and  more  especially  when  the  neighbouring 
tubes  are  large,  and  the  walls  of  the  chest 
thin.  He  believed  that  some  persons  had  a 
natural  pectoriloquy. 

Dr.  Addison  stated  that  all  the  physical 
signs  of  phthisis  may  be  produced  in  the 
apex  of  a  lung  affected  with  pneumonia,  as 
he  had  already  asserted  in  the  Reports  of 
Guy’s  Hospital;  viz.  “when  pneumonia 
occurs  at  the  apex  of  a  lung,  it  gives  rise  to 
signs  not  distinguishable  from  a  cavity  in  the 
lung.”  He  coincided  in  Dr.  Hughes's  opi¬ 
nion,  that  pectoriloquy  occurs  where  the 
lung  is  consolidated,  but  had  never  met  with 


complete  pectoriloquy  in  perfectly  sound 
lungs.  Pneumonia,  he  thought,  might  be 
confounded  with  simple  continued  fever,  and 
so  difficult  of  detection  is  it,  that  the  most 
careful  auscultators  have  been  foiled  and  de¬ 
ceived.  This  point  cannot  be  too  much 
attended  to,  for  Dr.  Addison  had  met  with 
many  cases  of  pneumonia  mistaken  for  fever. 

The  most  important  point  of  the  author’s 
paper  was  the  treatment.  He  entirely  agreed 
with  him  in  considering  the  numerical  sys¬ 
tem,  or  statistics,  as  a  great  and  mischievous 
mistake,  and  so  erroneous  and  beset  with 
difficulties,  that  it  ought  to  be  discarded. 
Nothing  was  more  apt  than  the  remarks  on 
the  treatment  put  forth  by  Mr.  Robinson  : 
when  pneumonia,  occurring  sporadically, 
assumes  a  well-defined  character,  it  may  in 
general  be  treated  by  the  common  principles, 
according  to  the  age  and  constitution  of  the 
patient ;  but  where  occurring  with  peculiar 
epidemic  influence,  as  influenza,  and  followed 
by  a  variety  and  diversity  of  symptoms,  with 
a  form  of  atonic  fever,  then  the  common 
remedies  wall  not  answer,  and  we  must  meet 
the  difficulty,  and  regulate  our  practice  ac¬ 
cordingly. 

Previous  to  the  adjournment  of  the  meet¬ 
ing,  the  President  alluded  to  the  subject  of 
Cholera,  which  he  said  was  of  interest  not 
only  to  the  profession,  but  to  the  public  at 
large ;  and  particularly  wished,  should  any 
cases  occur  on  the  Surrey  side  of  the  water, 
the  medical  practitioners  would  make  the 
South  London  Medical  Society  the  means  by 
which  they  might  be  published  to  the  pro¬ 
fession.  He  hoped  that  the  same  plan  might 
be  adopted  with  the  other  societies  in  the 
metropolis,  as,  by  such  means,  a  better 
knowledge  might  be  obtained  as  to  the  num¬ 
ber  of  cases  that  have  occurred,  and  of  the 
different  modes  of  treatment  which  ha'd  been 
had  recourse  to.  • 

At  the  next  meeting,  Oct.  26th,  Mr.  H. 
K.  Owen  will  read  a  case  of  “  Laceration  of 
the  Liver.” 

MEDICAL  SOCIETY  OF  LONDON. 

Monday,  October  16,  1848. 

Mr.  Hancock,  President. 

Bony  Tumor  of  the  Upper  Jaw  :  Ampu¬ 
tation  of  the  Bone. 

The  President  placed  on  the  table  the 
right  upper  jaw  and  malar  bone  of  a  young 
man,  which  he  had  lately  removed.  He 
had  also  been  seen  by  Mr.  Styles  of  Pinch¬ 
beck,  and  Mr.  Mansell  of  Donnington,  who, 
as  well  as  Mr.  Young,  considered  that  the 
tumor  was  removable,  and  that  its  removal 
was  the  only  resource.  The  particulars  are 
as  follows  : — T.  C.,aged  twenty-two,  the 
son  of  a  respectable  farmer,  residing  at 


728 


MR.  HANCOCK  ON  BONY  TUMOR  OF  THE  UPPER  JAW. 


Bicker,  in  Lincolnshire,  was  admitted 
under  the  care  of  Dr.  Chowne  and  myself, 
into  the  Charing  Cross  Hospital,  on  Mon¬ 
day,  October  1st,  having  been  sent  up  by 
Mr.  Young,  of  Gosberton,  whose  patient  he 
was,  suffering  from  a  bony  tumor  connected 
with  the  maxilla.  His  friends  state,  that 
when  about  a  year  and  a  half  old,  he  was 
found  on  the  floor,  supposed  to  be  in  a  fit ; 
when  taken  up,  he  appeared  to  be  stunned, 
and  the  right  side  was  slightly  affected.  No 
notice  was,  however,  taken  of  it,  and  he 
quickly  recovered  from  the  immediate  symp¬ 
toms,  but  always  afterwards  complained  of 
pain  in  the  right  side  of  the  face,  as  far  back 
as  the  ear.  About  two  years  after  the  acci¬ 
dent,  that  side  of  the  face  was  first  noticed 
to  protrude  more  than  the  other,  and  since 
then  it  has  gradually  enlarged,  but  more 
rapidly  within  the  last  three  years.  He  has 
always  complained  of  pain  in  the  tumor, 
more  particularly  after  it  had  been  touched 
or  examined.  His  general  health  has  been 
pretty  good,  but  he  has  not  followed  any 
employment  on  account  of  his  appearance. 
He  is  rather  deaf,  but  his  friends  do  not 
think  the  deafness  has  increased  with  the  en¬ 
largement  of  the  bone,  for  which  he  has  not 
been  subjected  to  any  treatment.  He  is 
much  disfigured  by  the  disease  ;  a  large  tu¬ 
mor  projects  more  than  two  inches  forwards, 
and  to  the  left  side  invading  the  nose,  which 
it  has  flattened  and  spread,  and  turned  com¬ 
pletely  to  the  left,  so  that  the  openings  of 
the  nostril,  instead  of  being  directed  down¬ 
wards,  and  in  the  medial  line,  are  turned  to 
the  left  side  of  the  face,  and  directed  for¬ 
wards  :  the  right  nostril  is  completely  filled 
by  the  tumor,  except  at  its  upper  part, 
where,  with  a  little  difficulty,  a  curved  probe 
may  be  carried  over  it ;  but  the  septum  naris 
is  touched,  and  pushed  into  the  left  nostril 
so  completely,  that  a  probe  cannot  be 
introduced  between  the  septum  and  tu¬ 
mor  along  the  floor  of  the  nostril.  The 
hard  palate  of  the  right  side  is  thickened, 
and  projects  into  the  mouth,  as  it  also  does 
on  the  left  side.  The  tumor  not  only  ex¬ 
tends  forwards,  but  also  towards  the  right 
side,  generally  implicating  the  malar  bone, 
which  is  much  thickened  and  enlarged, 
as  is  also  the  frontal  bone  at  its  external 
angle  ;  the  zymotic  process  remains  natural ; 
the  right  eye  appears  raised  ;  the  disease 
does  not  extend  backwards  towards  the 
fauces,  neither  are  the  motions  of  the  lower 
jaw  at  all  impeded.  The  right  side  of  his 
head  is  larger  than  the  left,  and  the  surface 
of  the  frontal  bone  presents  prominences, 
thickening  having  taken  place  in  those  situa¬ 
tions  :  his  general  health  is  good  ;  he  sleeps 
and  eats  well ;  his  pulse  is  regular  and 
quiet.  A  consultation  having  been  held 
upon  the  case,  and  it  having  been  considered 
non-malignant,  and  a  proper  one  for  opera¬ 


tion,  I,  on  '‘'hursday  last,  assisted  by 
Messrs.  Avery,  Canton,  and  Echlin,  re¬ 
moved  the  par1-  ywhich  are  now  before  the 
Society.  The  patient  being  secured  in  a 
firm  chair,  souhat  he  could  not  slide  away, 
Mr.  Steggall,  ibe  house-surgeon,  extracted 
the  first  incisbr  tooth  of  the  left  side,  and  I 
commenced  the  first  incision  below  the 
tendon  of  the  orbicularis  palpebrarum  mus¬ 
cle,  and  carried  it.  downwards  by  the  ala  of 
the  nose,  directly  through  the  upper  lip, 
taking  care  to  keep  the  point  of  the  knife 
steadily  against  the  bone,  so  that  the  soft 
parts  were  completely  divided  by  the  one 
cut.  A  second  incision  was  then  made  in¬ 
wards  from  the  lobe. of  the  ear  to  the  ala  of 
the  nose ;  and  a  third  from  about  an  inch 
above  the  middle  of  the  zygoma,  directly 
downwards  to  the  second  incision.  The  flaps 
thus  made  was  then  reflected,  the  one  down¬ 
wards  and  the  other  upwards  ;  the  dissec¬ 
tion  of  the  latter  being  continued  so  as  to 
expose  the  external  angle  of  the  frontal 
bone,  which  were  found  to  be  much  en¬ 
larged  and  thickened,  and  the  floor  of  the 
orbit,  the  attachment  of  the  inferior  oblique 
muscle  of  the  eye  being  divided.  The  parts 
being  thus  fairly  exposed,  a  cut  was  made 
with  a  saw  obliquely  downwards  and  back¬ 
wards,  from  about  a  quarter  of  an  inch  above 
the  root  of  the  zygoma  into  the  spheno¬ 
maxillary  fissure  ;  the  ala  of  the  nose  was  next 
reflected,  and  the  ascending  or  nasal  process 
of  the  superior  maxillary  bone  cut  through  by 
strong  bone  forceps,  as  was  the  floor  of  the 
orbit :  with  a  strong  knife  the  masseter 
muscle  was  next  detached  from  the  zygoma, 
which  was  cut  through  by  the  forceps,  and 
the  patient  was  allowed  a  short  time  to  re¬ 
cover  from  the  chloroform,  under  the  in¬ 
fluence  of  which  he  had  been  placed  for  these 
more  superficial  steps  of  the  operation  :  a 
very  short  interval  sufficed.  One  blade  of 
the  bone  forceps  was  then  carried  firmly 
backwards  into  the  right  nostril,  the  other 
blade  being  placed  on  the  hard  palate  of  the 
left  side,  and  the  palate  was  thus  divided 
obliquely  downwards  and  to  the  left,  as  I 
was  desirous,  if  possible,  to  preserve  the 
septum  naris  attached,  and,  at  the  same 
time,  to  remove  the  whole  of  the  thickened 
palate.  It  required  some  little  power  to  do 
this,  but  the  forceps  went  through  without 
much  difficulty,  although  the  parts  were 
considerably  thickened.  As  the  bone  still 
remained  firm,  and  I  could  not  detach  it 
with  my  finger  and  thumb,  I  concluded  that 
the  malar  bone  had  not  been  completely 
divided  by  the  saw,  and  accordingly  used  the 
bone  forceps  in  that  situation,  after  which 
I  could  with  ease  depress  the  bone,  and 
complete  the  operation  by  cutting  through 
the  soft  palate  with  a  blunt-pointed  bistoury. 
The  parts  removed  were  the  malar,  the 
superior  maxillary,  and  the  palate  bones. 


RE SOLUTIONS  RESPECTING  CHOLERA. 


729 


The  arteries  were  secured  as  quickly  as  pos¬ 
sible,  but  some  difficulty  was  experienced  in 
securing  the  infra-orbital,  which  had  shrunk 
back  into  its  bony  canal,  and  could  not  be 
tied ;  the  bleeding,  however,  was  arrested 
by  plugging  up  the  ^  nal  with  lint,  but  the 
patient  lost  a  large  “"quantity  of  blood,  and 
became  very  faint  whilst  the  sutures  were 
being  applied  ;  tke  flaps  were  very  care¬ 
fully  brought  together,  and  the  patient 
placed  in  bed.  The  chloroform  was  admi¬ 
nistered  to  diminish  the  pain  of  the  more 
superficial  cuts :  it  was  not  only  discon¬ 
tinued,  but  the  patient  allowed  to  become 
perfectly  conscious  before  the  palates,  either 
hard  or  soft,  were  meddled  with,  lest  any 
blood  should  enter  the  glottis  and  do  mis¬ 
chief  :  he  bore  the  whole  operation  with  the 
greatest  steadiness  and  fortitude.  In  the 
course  of  the  evening  he  vomited  twice,  and 
brought  up  a  large  quantity  of  blood,  which 
he  had  swallowed  during  the  operation  ;  he 
passed  a  restless  night,  notwithstanding  he 
had  an  opiate  draught ;  towards  morning 
he  became  more  quiet,  and  went  to  sleep 
for  two  or  three  hours.  He  has  gone  on 
since  extremely  well  up  to  this  time  ;  the 
wounds  in  the  face  have  almost  entirely 
healed  by  the  first  intention.  I  have  sawed 
through  the  jaw  and  tumor,  t«  expose  the 
structure  of  the  latter.  It  appears  to  me  to 
have  originated  from  the  antrum,  and  to 
have  caused  absorption  of  the  body  of  the 
superior  maxillary  bone,  excepting  the  hard 
palate  and  alveolar  processes,  and  its  malar 
process,  which,  with  the  malar  bone,  are 
much  thickened,  enlarged,  and  very  hard, 
whilst  the  tumor  itself  is  of  a  softer  texture, 
very  like  the  cancellated  structure  of  bone. 
The  parts  removed  weighed  seven  ounces 
and  one  drachm. 

Dr.  Waller  related  the  case  of  a  herma¬ 
phrodite  at  present  under  his  observation  in 
St.  Thomas’s  Hospital :  this  gave  rise  to  a 
discussion  on  the  formation  of  monstrosities, 
but  nothing  offered  itself  for  a  report. 


REMOVAL  OF  STAINS  OF  NITRATE  OF 
SILVER. 

Mr.  Parsons,  of  Bristol,  has  recently  re¬ 
commended,  for  the  purpose  of  removing 
stains  produced  by  nitrate  of  silver,  a  solu¬ 
tion  of  corrosive  sublimate  in  muriate  of 
ammonia.  Where  the  bleaching  properties 
of  chloride  of  lime  do  not  interfere,  the 
stain  may  be  washed  with  a  solution  of  this 
compound,  and  the  chloride  of  silver  thus 
formed  removed  by  a  strong  solution  of 
mur’ate  of  ammonia. — Lancet.  A  solution 
^ '  of  cyanide  of  potassium  will  also  remove 
stains  3f  nitrate  of  silver  very  readily  ;  but 
r.nen  this  or  corrosive  sublimate  is  employed, 
/ the  skin  or  stained  article  should  be  speedily 
/  washed  in  water. 


(CociTSponticnce. 


WESTERN  MEDICAL  AND  SURGICAL  SOCIETY. 

RESOLUTIONS  RESPECTING  CHOLERA. 

The  following  resolutions  were  unanimously 
agreed  to  at  a  special  meeting  of  the  Western 
Medical  and  Surgical  Society  on  the  13th 
instant : — 

Resolved, — “  That  with  the  view  of  eluci¬ 
dating  the  history,  and  arriving  at  the  true 
pathology  and  treatment  of  epidemic  cholera, 
it  is  desirable  that,  in  every  case  which  may 
occur,  the  antecedent  and  attending  circum¬ 
stances,  the  symptoms  of  the  disorder,  and 
the  appearances  after  death,  should  be  accu¬ 
rately  observed  and  carefully  recorded  ;  and 
that  the  adoption  of  a  plan  in  which  attention 
is  called  to  the  points  chiefly  to  be  noted, 
will  both  facilitate  the  labour  to  each  ob¬ 
server,  and  will  enable  the  reports  of  various 
observers  to  be  the  more  easily  analysed  and 
compared.” 

Resolved, —  “That  in  order  to  carry  out 
the  foregoing  resolution  within  the  sphere  of 
operations  of  the  Western  Medical  and  Sur¬ 
gical  Society,  a  plan  be  accordingly  drawn 
up,  of  which  copies  shall  be  furnished  to 
each  member  of  the  society  and  of  the  pro¬ 
fession  in  the  neighbourhood  ;  and  that  it  be 
an  earnest  recommendation  to  every  indi¬ 
vidual  to  allow  no  single  case  to  be  unre¬ 
corded,  but  to  forward  the  record  of  each 
case,  as  it  may  be  completed,  to  the  secretary 
of  the  society.” 

Resolved, — “  That  a  committee  be  now 
appointed  to  draw  up  this  plan,  to  collate 
the  reports  sent  into  the  society,  and  to 
communicate  the  results  in  such  manner  as 
they  shall  deem  expedient ;  that  this  com¬ 
mittee  have  the  power  at  any  time  to  sum¬ 
mon  a  general  meeting  of  the  society  ;  and 
that  it  consist  of  the  following  members  (of 
whom  three  shall  be  a  quorum),  Dr.  Mantell, 
Mr.  Lane,  Mr.  Woolley,  Dr.  Kinnier,  Dr. 
Cormack,  Mr.  Haden,  Mr.  Synnot,  Dr. 
Traquair,  Dr.  Barclay,  Mr.  Pollard,  and 
Mr.  Seaton.” 

The  object  which  this  society  has  in  view 
is  so  fully  set  forth  in  the  foregoing  resolu¬ 
tions,  that  it  does  not  appear  necessary  to 
enter  into  a  very  lengthened  explanation.  It 
is  quite  obvious,  that  if  we  can  only  obtain  a 
faithful  record  of  every  case  of  cholera  which 
may  occur,  the  careful  analysis  and  com¬ 
parison  of  such  records  will  not  only  yield 
us  a  complete  history  of  the  epidemic — per¬ 
haps  Me  most  complete  history  ever  afforded 
of  any  epidemic, — but  will,  in  all  probability, 
lead  to  certain  and  positive  results,  throwing 
light  on  the  pathology,  and  thereby  on  the 
rational  treatment,  of  this  fearful  and  hitherto 
obscure  malady.  The  greater  part  of  our 


730 


THE  CHOLERA  IN  THE  METROPOLIS. 


profession  is,  however,  so  unceasingly  occu¬ 
pied,  and  on  that  account  so  little  in  the 
habit  of  recording  cases,  that  it  would  be 
scarcely  possible  to  obtain  from  them  the 
reports  desired,  unless  their  labours  be 
facilitated  by  a  plan  in  which  attention  is 
called  to  the  various  points  to  be  noted.  But 
with  such  a  plan  to  help  them,  and  with  the 
good  spirit  which  I  know  to  prevail  in  the 
profession,  the  object  in  view  does  not  appear 
to  be  difficult  of  attainment.  The  Committee 
of  the  Society  is  at  thismoment  engaged  with 
great  care  and  anxiety  in  the  preparation  of 
this  plan — on  the  fitness  of  which  for  its 
purpose,  much  depends ;  for  it  must  be 
sufficiently  simple  to  be  easily  understood 
and  filled  up — sufficiently  comprehensive  to 
comprise  every  thing  necessary  to  be  ob¬ 
served.  As  soon  as  it  is  matured  it  will  be 
submitted,  through  you,  to  the  profession — 
for  imitation  or  for  correction. 

It  it  is  to  be  remarked  that  epidemic  cho¬ 
lera  is  a  disease  peculiarly  favourable  to  in¬ 
vestigation  of  the  kind  proposed.  Fright¬ 
fully  fatal  as  it  is  to  those  whom  it  attacks, 
it  does  not,  like  influenza,  invade  the  ma¬ 
jority,  or  even  a  large  proportion,  of  the 
population.  Each  practitioner  is  not  over¬ 
whelmed,  therefore,  with  a  multiplicity  of 
cases  ;  and  the  phenomena  in  each  case  are 
of  a  striking  and  obvious  kind. 

The  investigation  which  the  Western  Me¬ 
dical  and  Surgical  Society  is  about  to  at¬ 
tempt  within  its  own  district  (Chelsea,  Pim¬ 
lico,  Knightsbridge,  Brompton,  Kensington, 
Putney,  and  Fulham)  can  only  be  carried 
out  to  its  full  extent  by  the  zealous  co-ope¬ 
ration  of  the  profession  throughout  the 
United  Kingdom.  Such  co-operation  can 
be  easily  brought  to  bear.  The  various 
Metropolitan  Medical  Societies — as  the  Lon¬ 
don  Medical,  the  Wesminster  Medical,  the 
South  London,  &c.  &c. — can,  if  they  will, 
obtain  returns,  each  within  its  own  district, 
and  tabulate  and  analyse  them  by  commit¬ 
tees  of  their  own.  In  most  large  towns 
there  are  already  societies  capable  of  under¬ 
taking  the  same  work  :  where  such  societies 
do  not  exist,  let  voluntary  associations  be 
made  for  the  purpose.  Even  in  villages  and 
outlying  places,  let  the  record  of  every  case, 
if  cases  occur,  be  kept,  and  let  it  be  sent  to 
the  society  or  association  of  some  neighbour¬ 
ing  town,  or  to  our  own  Society,  if  it  be 
preferred,  for  tabulation  and  analysis.  For 
it  is  one  of  the  merits  of  this  scheme,  that  by 
it  a  single  isolated  case — useful,  otherwise, 
only  as  a  means  of  experience  to  the  indivi¬ 
dual  observer — will  have  its  scientific  value. 

In  the  discussion  in  our  Society  on  these 
resolutions,  a  most  useful  suggestion  was 
thrown  out — that  it  would  be  desirable,  if 
possible,  in  every  district  to  have  the  post¬ 
mortem  inspections  conducted  by  the  same 
person,  one  well  familiar  with  morbid  ap¬ 


pearances.  This,  of  course,  cannot  always 
be  done  ;  but  in  Londonland  in  large  towns 
there  must  be  many  men  well  competent  to 
the  task,  having  sufficient  leisure  to  under¬ 
take  it,  and  sufficient  zeal  to  make  them 
glad  of  an  opportun  vt  of  acquiring  expe¬ 
rience  in  a  disease  oaring  so  wide  a  field 
for  investigation  and  dis'eovery. 

I  am  induced  to  send  these  Resolutions 
and  this  letter  to  you  without  waiting  till  our 
plan  of  case-reporting  is  matured,  because 
it  is  necessary  that  the  attention  of  the  pro¬ 
fession  should  be  stirred  up  betimes,  unless 
they  are  willing  to  let  this  epidemic  slip  by, 
like  the  last,  without  drawing  from  it  the 
scientific  results  it  is  capable  of  yielding. 
If  a  similar  plan  to  this  had  been  adopted  in 
1831-2,  how  much  more  positive  and  pre¬ 
cise  would  our  knowledge  have  been.  At 
present  no  great  deal  of  time  has  been  lost. 
The  cases  which  have  hitherto  occurred,  un¬ 
doubted  cases  as  they  are,  can  hardly  be 
considered  more  than  sporadic  ones — the 
precursors — the  merciful  warnings  of  that 
outbreak  which  sooner  or  later  will  surely 
come. — I  have  the  honour  to  be,  sir, 

Your  very  faithful  servant, 
Edward  Cator  Seaton,  M.D. 

Hon.  Sec.  to  the  Western  Med. 
and  Sur.  Society. 

77,  Sloane  Street, 

October  17th,  1848. 


iMctstcal  3mtdltacnce. 


THE  CHOLERA  IN  THE  METROPOLIS. 

No  case  of  cholera  was  reported  on  Thurs¬ 
day  in  or  around  the  metropolis. 

There  were,  on  Friday,  three  cases  of 
cholera  notified  from  Clapham,  one  from  a 
vessel  off  Billingsgate,  and  one  in  the  Mill- 
bank  Penitentiary.  It  was  also  notified  that 
one  decided  case  of  cholera  had  occurred  at 
York,  one  case  at  Plymouth,  one  case  at 
Ware,  in  Hertfordshire,  and  one  case  in  the 
Isle  of  Portland. 

Two  cases  of  cholera  were  reported  on 
Monday  in  the  metropolis.  Much  sickness 
was  reported  to  prevail  amongst  seamen  who 
had  been  in  the  ports  of  the  Baltic.  One 
case  was  reported  from  Swansea  and  one  at 
Rickmansworth. 

On  Tuesday,  besides  numerous  cases  of 
diarrhoea  in  the  metropolis,  2  cases  of  Asiatic 
cholera  were  reported  from  the  New  Kent 
Road,  1  from  Rosemary  Lane,  1  from 
Sydenham,  1  case  was  reported  from  Sun¬ 
derland,  unconnected  with  the  shipping  ;  and 
two  cases  in  the  Bedford  Union. 

THE  CHOLERA  AT  EDINBURGH. 

The  notification  of  cases  at  Edinburgh,  vn 
to  the  evening  of  the  23d  of  October,  \  \ 
as  follows  : — 


THE  CHOLERA  AT  EDINBURGH  AND  WOOLWICH. 


731 


“  Cases  of  Spasmodic  Cholera  authentically  ascertained  by  the  Surgeon  of  the  Police 

since  the  Ath  inst. 


Places. 

Cases. 

Deaths. 

Recoveries. 

Re¬ 

main¬ 

ing. 

Since 

last 

report. 

Since 

com¬ 

mence¬ 

ment. 

Since 

last 

report. 

Since 

com¬ 

mence¬ 

ment. 

Since 

last 

report. 

Since 

com¬ 

mence¬ 

ment. 

Edinburgh  .  . 

10 

80 

5 

55 

— 

7 

18 

Newhaven  .  . 

1 

30 

0 

19 

— 

5 

6 

Leith 

4 

65 

3 

28 

— 

12 

25 

Total .  .  . 

15 

175 

8 

102 

— 

24 

49 

“  George  Glover,  Surgeon  of  Police. 

“Edinburgh  Police  Chambers,  Oct.  23,  8  i\m.” 


THE  CHOLERA  IN  THE  HULKS. 

Woolwich ,  Oct.  20. — A  board  of  medical 
officers  assembled  yesterday  at  the  J ustitia 
convict-ship,  which  caused  a  delay  of  yester¬ 
day’s  return  to  a  rather  later  hour.  The 
number  of  cases  returned  up  to  12  o’clock 
on  Wednesday  was  36  attacked,  10  deaths, 
and  5  recoveries.  On  Thursday  there  were 
1  new  case,  1  death,  and  5  recoveries ; 
making  37  attacked,  11  deaths,  and  10 
recoveries.  From  12  o’clock  yesterday  to 
12  o’clock  to-day  there  have  been  no  new 
cases,  and  consequently  there  are  37  cases 
of  attack,  and  12  deaths,  1  having  died  this 
morning,  and  10  recoveries.  The  result  of 
the  meeting  of  the  medical  board,  and  an 
investigation  of  the  cases  on  board  the  Jus- 
titia,  is  an  order  that  the  convicts  are  to  be 
removed  out  of  that  vessel,  and  for  the  pre¬ 
sent  will  be  hulked  on  board  the  Hebe  and 
^Sulphur,  receiving  vessels,  opposite  Wool¬ 
wich  Dockyard.  The  Justitia  is  also  or¬ 
dered  to  be  removed  from  her  present  posi¬ 
tion,  and  will  be  stationed  lower  down  the 
river,  where  she  was  formerly  placed,  or 
very  nearly  in  the  same  spot,  where  the 
convicts  were  generally  healthy.  These  ex¬ 
cellent  arrangements  will  no  doubt  soon  re¬ 
lieve  the  convicts  from  any  further  fear  of 
the  cholera :  the  inhabitants  of  the  town, 
and  the  convicts  at  the  dockyard,  having 
hitherto  escaped  the  slightest  symptoms  of 
the  disease. 

ELECTION  OF  A  MEDICAL  OFFICER  OF 
HEALTH  FOR  THE  CITY. 

At  a  meeting  of  the  Court  of  Common 
Council,  on  the  19th  inst.,  a  letter  was  read 
from  Mr.  Childs,  one  of  the  medical  gentle¬ 
men  returned  by  the  Commissioners  of 
Sewers  to  the  Court  as  a  fit  and  proper 
person  to  serve  as  medical  officer,  withdraw¬ 
ing  himself  as  a  candidate. 

Mr.  Simon  was  then  elected  by  a  show  of 
hands. 


The  Lord  Mayor  then  congratulated 
Mr.  Simon  upon  his  election. 

Mr.  Simon,  in  returning  thanks  for  his 
election,  said  he  felt  overwhelmed  by  the 
honour  conferred  upon  him,  and  the  onerous 
duties  it  involved  on  the  medical  officer  of 
health  for  the  great  city  of  London.  In  so 
difficult  a  position  it  would  ill  become  him 
to  do  more  than  promise  his  endeavours, 
but  those  endeavours  to  the  very  utmost  he 
did  promise  to  exert  in  performing  the  very 
important  duties  of  the  office. 

apothecaries’  hall. 

Names  of  gentlemen  who  passed  their  exa¬ 
mination  in  the  science  and  practice  of  medi¬ 
cine,  and  received  certificates  to  practise,  on 
Thursday,  19th  October,  1848  : — John 
M’Millan,  Hull — Robert  Webster  Gillespie, 
Newcastle-on-Tyne — Robert  William  Ellis, 
Bristol. 


jedetttons  from  journals. 


MIDWIFERY. 

ACCIDENTAL  EXPULSION  OF  A  CHILD, 
WITHOUT  ITS  EXPERIENCING  ANY  IN¬ 
JURY  FROM  THE  FALL. 

A  woman  of  short  stature,  34  years  of  age, 
strongly  built,  gave  birth  to  a  child  in  an 
ordinary  labour  one  year  after  marriage. 
On  the  10th  July,  being  near  the  end  of  her 
second  pregnancy,  the  period  of  gestation 
was  accidentally  terminated.  She  was  en¬ 
gaged  in  a  violent  dispute  with  her  hus¬ 
band,  which  was  nearly  coming  to  blows  : 
she  abruptly  rushed  into  an  adjoining  room, 
and  was  in  the  act  of  sitting  on  the  bed, 
when  suddenly  strong  labour  came  on. 
Before  she  could  reach  the  door  and  call  for 
help,  the  pains  became  so  severe  that  she 
was  obliged  to  lean  for  support  against  a 


732 


OBSERVATIONS  ON  TWO  NEW  FEBRIFUGES. 


chair ;  at  the  same  moment  the  child  fell 
suddenly  to  the  ground,  without  being  in  the 
least  injured.  On  his  visit,  Dr.  Piekford  found 
not  even  a  bruise  on  the  vertex,  on  which  the 
child  had  fallen.  The  placenta  was  expelled 
as  he  entered,  and  it  showed  that  the  cord 
had  been  ruptured  at  about  the  distance  of 
two  inches  from  the  umbilicus.  The  child 
was  strong,  and  fully  developed.  —  Dr. 
Piekford,  in  Henle’s  Zeitschrift  fur  ra- 
tionelle  Medizin,  vol.  vii.  part  i.  p.  25. 

X 


THERAPEUTICS. 

OBSERVATIONS  ON  TWO  NEW  FEBRIFUGES. 

The  forests  which  yield  the  cinchonas  are 
gradually  becoming  exhausted  :  hence  the 
price  of  these  and  of  their  salts  is  daily  ris¬ 
ing.  These  circumstances  have  directed  the 
attention  of  practitioners  to  the  discovery  of 
substitutes  for  these  expensive  remedies. 
Thus,  besides  arsenious  acid  and  salicine,  the 
antiperiodic  properties  of  which  are  well 
known,  there  are  others  whose  operation  has 
been  less  accurately  studied  :  among  these, 
two  more  particularly  have  been  made  the 
objects  of  investigation  :  they  are  the  bark 
of  the  Baobab  or  Adansonia  Dentata,  and 
the  sulphate  of  Phvllerine. 

The  Baobab  or  Adansonia,  is  a  gigantic 
tree,  indigenous  to  Senegal,  but  it  is 
readily  acclimated  in  colder  countries,  so 
that  should  its  febrifuge  properties  become 
established,  the  bark  will  be  procurable  in 
abundance. 

The  bark,  which  is  the  most  active  part, 
has  a  tolerably  smooth  surface  of  a  blackish- 
grey  colour,  and  is  studded  all  over  with 
lichens  :  its  inner  surface  is  of  a  pure  white, 
quickly  reddening  on  exposure  to  the  air  : 
it  contains  a  large  quantity  of  mucilage,  and 
has  scarcely  any  taste  or  smell.  Its  aqueous 
decoction  has  somewhat  the  odour  of  the 
cinchonas  :  it  is  of  a  clear  reddish  colour,  in¬ 
sipid,  holding  a  large  quantity  of  mucilage, 
the  decomposition  of  which  may  be  pre¬ 
vented  by  the  addition  of  a  small  quantity 
of  sulphuric  acid  or  alcohol.  Without  this 
precaution  the  decoction  becomes  decom¬ 
posed  in  a  few  hours ;  but,  strange  to  say, 
this  does  not  destroy  its  medicinal  qualities. 
When  cold  and  sweetened,  this  decoction  is 
not  unpalatable. 

M.  Duchassaing  has  found  this  bark 
highly  serviceable  in  agues,  even  where 
quinine  had  failed  ;  and  he  states  that  the 
planters  of  Guadaloupe  cui’e  their  negroes  by 
it  alone,  though,  d  priori,  one  would  not  ex¬ 
pect  that  a  mucilaginous  bark,  free  from 
bitterness,  should  possess  anti-periodic  pro¬ 
perties  ;  while  we  see  also  from  the  effects 
of  arsenious  acid,  that  bitterness  is  not 
necessary  to  this  medicinal  action.  Galberry 
and  Frank  have  before  stated  that  the  fruit, 


and  Adanson  that  the  leaves,  possess  anti¬ 
periodic  properties  ;  but  Duchassaing  is  the 
first  who  has  pointed  out  that  the  bark  is 
the  most  active  part  of  the  plant. 

Sulphate  of  Phyllerine. — M.  Jachelli,  of 
Ferrara,  has  lately  added  this  alkaloid  to  the 
list  of  febrifuges  :  it  is  obtained  from  the 
well  -  known  evergreen  shrub,  Phyllerea 
latifolia.  It  was  known,  before  the  researches 
of  Dr.  Jachelli,  as  a  cooling  astringent,  but 
it  is  now  found  to  possess  the  same  active 
anti-periodic  properties  as  others  of  its  class, 
the  ash,  the  olive,  &c. 

An  extensive  series  of  experiments  have 
been  made  since  the  year  1825,  on  the  ac¬ 
tion  of  this  alkaloid  in  agues,  by  Dr. 
Jachelli.  He  has  compared  its  operation 
with  that  of — 1st,  a  powder  of  the  young 
leaves  and  twdgs,  in  doses  of  30  grains  dur¬ 
ing  the  intermission  ;  2ndly,  a  simple  decoc¬ 
tion  of  the  plant,  made  by  boiling  one  part 
of  the  plant  to  60  of  water,  down  to  one- 
third,  and  given  in  large  doses  also  during 
the  intervals ;  3rd,  with  a  compound  decoc¬ 
tion  formed  by  adding  30  minims  of  dilute 
sulphuric  acid  to  the  preceding.  The  sul¬ 
phate,  in  doses  of  from  12  to  15  grains  dur¬ 
ing  the  apyrexia,  has  evinced  its  superior 
activity  over  other  preparations  of  the 
phyllyrea :  thus  of  20  patients  treated  with 
|  the  sulphate,  20  were  cured  ;  of  13  to  whom 
the  powder  was  administered,  11  were  cured  ; 
of  18  to  whom  the  compound  decoction  was 
given,  14  were  cured ;  of  16  who  took  the 
simple  decoction,  7  were  cured. — Bulletin 
General  de  Therapeutique,  July  18,  1848. 

X 


ON  THE  INSPIRATORY  VOICE.  BY  M. 

SEGOND. 

At  the  conclusion  of  a  memoir  on  this  sub¬ 
ject,  M.  Segond  remarks,  that  —  1.  The 
production  of  the  voice  is  not  essentially  de¬ 
pendent  upon  expiration,  for  man  can  speak 
and  sing  during  inspiration.  2.  In  persons 
whose  larynx  is  in  good  exercise,  the  inspi¬ 
ratory  voice  usually  corresponds  to  the  ex¬ 
piratory  voice,  consisting  like  it  of  twro  re¬ 
gisters.  In  the  inspiratory  voice,  however, 
the  range  of  chest  notes  usually  extends  to  a 
greater  depth,  and  that  of  the  falsetto  notes 
to  a  higher  pitch,  than  in  the  expiratory 
voice.  3.  Pronunciation  effected  during 
inspiration  is  distinguished  by  a  certain  soft¬ 
ness  in  the  movements  of  articulation : 
many  letters  are  altered,  and  the  letter  r,  in 
particular,  it  is  impossible  to  produce.  4. 
Ventriioquism  is  effected  by  speaking  during 
inspiration.  (In  this  opinion  M.  Segond 
differs  from  Muller  and  Colombat,  both  of 
whom  consider  that  the  peculiar  modifica¬ 
tion  of  the  voice  in  ventriloquism  is  pro¬ 
duced  by  speaking  with  the  mouth  almost 
closed  and  motionless,  while  air  is  slowly 


DR.  BELLINGHAM  ON  ANEURISM  OF  THE  ARCH  OF  THE  AORTA.  733 


expired  through  a  very  narrow  glottis.)  5. 
Many  of  the  domestic  animals  use  the  inspi¬ 
ratory  voice.  6.  In  birds,  the  production 
of  the  voice  during  both  inspiration  and  ex¬ 
piration  explains  the  great  variety  and  con¬ 
tinuity  of  sounds  observed,  particularly  in 
the  singing  birds.  7.  The  voice  of  some 
batrachians  is  exclusively  inspiratory. — 
Comptes  Rendus,  1848.  A 


DR.  BELLINGHAM  ON  ANEURISM  OF  THE 
ARCH  OF  THE  AORTA. 

In  reference  to  aneurism  of  the  arch  of  the 
aorta,  Dr.  Bellingham  remarks  : — Out  of 
twelve  cases,  the  ascending  portion  of  the 
arch  was,  or  appeared  to  be,  the  seat  of  the 
disease  in  six  instances  ;  in  three,  the  trans¬ 
verse  portion  of  the  arch  was  its  seat ;  in 
two,  the  descending  portion  of  the  arch ; 
and  in  one,  the  descending  thoracic  aorta. 
In  ten  of  these  cases  the  aneurism  eventually 
formed  a  tumor,  so  as  to  be  felt  by  the 
hand  ;  in  the  other  two  it  never  approached 
the  surface,  but  both  these  patients  died 
suddenly. 

Of  these  twelve  cases,  seven  died,  three 
left  the  hospital,  and  I  have  heard  nothing 
of  them  since ;  two  are  still  alive,  and  I  see 
them  occasionally.  Of  the  seven  who  died, 
five  were  examined  by  me  ;  in  four  of  these 
the  tumor  burst ;  in  one,  externally  under 
the  pectoral  muscle  ;  in  two,  into  the  left 
pleura ;  in  one,  into  the  substance  of  the 
left  lung  :  one  died  without  any  rupture  of 
the  sac. 

In  all  the  cases  a  double  sound  was 
audible  on  auscultation  over  the  site  of  the 
aneurism.;  in  two,  a  bruit  de  soufilet  accom¬ 
panied  or  replaced  the  first  aneurismal 
sound  ;  in  one,  the  bruit  replaced  the  second 
sound  ;  and  in  one,  both  sounds  were 
morbid.  In  the  eight  remaining  cases,  a 
double  sound,  exactly  similar  to  that  of  the 
heart,  was  alone  audible.  A  double  impulse 
was  only  perceived  in  the  cases  in  which 
the  aneurism  formed  an  external  tumor,  and 
not  in  all  these  cases. 

Sex. — One  patient  was  a  female  ;  all  the 
rest  were  males :  confirming  the  received 
opinion  of  the  much  greater  frequency  of 
the  disease  in  the  male  than  the  female. 

Aye. — All  the  patients  were  adults;  the 
youngest  was  aged  2G,  the  oldest  60  ;  five 
were  between  30  and  40,  two  between  40 
and  50,  and  three  between  50  and  60. 

Occupation.  —  Of  these  patients,  four 
were  labourers ;  two  domestic  servants  (in¬ 
cluding  the  female)  ;  two  were  tailors  ;  one 
was  an  attorney’s  clerk  ;  one  a  carpenter  ; 
one  a  wine-porter  ;  and  one  a  painter. 

Previous  habits. — Four  of  these  patients 
had  led  intemperate  lives;  the  others  could 
not  exactly  be  said  to  have  been  intem¬ 
perate. 


Causes. — In  three  of  these  cases  the  dis¬ 
ease  was  clearly  traceable  to  an  injury  of 
the  chest ;  in  this  category  are  included  the 
youngest  and  the  oldest  subjects,  both  of 
whom  had  been  intemperate.  In  two,  a 
sudden  strain  seemed  to  have  been  the  ex¬ 
citing  cause.  In  one,  the  aneurismal  dia¬ 
thesis  was  strongly  marked,  indicated  by 
the  patient  having  been  twice  previously  the 
subject  of  spontaneous  aneurism.  In  this 
case,  as  in  one  of  the  others,  the  heart,  on 
examination,  was  found  to  be  infiltrated 
with  fat,  which  penetrated  deeply  into  its 
tissue :  this  I  have  in  several  instances 
found  to  be  an  accompaniment  of  the  aneu¬ 
rismal  diathesis.  In  the  six  remaining  cases 
there  was  no  apparent  cause  to  which  the 
disease  could  be  referred. 

Pulse  at  the  wrist. — In  one  case,  the  pulse 
at  the  left  wrist  was  completely  absent ;  the 
aneurism  sprang  from  the  transverse  por¬ 
tion  of  the  arch  of  the  aorta,  and  the  sub¬ 
clavian  artery  on  that  side  was  found,  on 
examination,  to  have  been  completely  obli¬ 
terated  by  the  pressure  of  the  tumor.  In 
another  case,  where  the  aneurism  pointed 
upon  the  right  side  of  the  sternum,  the  left 
radial  pulse  was  much  smaller  than  the 
right.  In  another,  where  it  compressed  the 
trachea,  the  left  radial  pulse  wras  stronger 
than  the  right.  In  the  remaining  cases  no 
difference  was  perceived  in  the  pulse  at 
either  wrist. 

Pain. — Pain  was  the  most  frequent  and 
the  most  constant  of  the  local  signs.  In 
three  cases  it  was  the  symptom  which  led 
principally  to  the  diagnosis  of  the  disease  ; 
in  these  cases  likewise  it  was  far  more  in¬ 
tense  than  in  any  of  the  others.  In  all, 
the  pain  was  sensibly  aggravated  at  night, 
and  diminished  or  subsided  more  or  less 
during  the  day.  This  I  look  upon  as  one 
of  the  characteristic  marks  of  the  pain  in 
aortal  aneurism. 

Dysphagia. — Difficulty  of  swallowing  was 
not  a  prominent  symptom  in  any  case  :  it 
was  only  observed  when  the  aneurismal  sac 
sprang  from  the  transverse  portion  of  the 
arch  of  the  aorta. 

Dyspnoea  and  cough. — Neither  cough  or 
dyspnoea  were  present  in  the  cases  in  which 
the  aneurism  sprang  from  the  descending 
portion  of  the  arch,  or  from  the  descending 
thoracic  aorta ;  while,  for  obvious  reasons, 
they  were  the  most  prominent  and  the  most 
distressing  symptoms  in  the  two  cases  in 
which  the  trachea  was  compressed,  and 
where  the  sac  arose  from  the  transverse 
portion  of  the  arch.  In  the  cases  in  which 
the  aneurism  sprang  from  the  ascending 
portion  of  the  arch  of  the  aorta,  cough  was 
more  generally  complained  of  than  dyspnoea. 
— Dub.  Med.  Press,  1848. 


734  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY,  ETC. 


BIRTHS  &  DEATHS  in  the  Metropolis 


During  the  week  ending  Saturday ,  Ocl.  21. 


Births. 
Males....  592 
Females. .  574 


Deaths. 
Males....  503 
Females. .  480 


Av.  of  5  Sum. 
Males....  581 
Females..  573 


1166 


983 


1154 


Causes  of  Death. 

All  Causes . 

Specified  Causes . 

1 .  i7«/?/20<ic(orEpidemic,Endemic, 

Contagious)  Diseases . . 
Sporadic  Diseases,  viz. — 

2.  Dropsy,  Cancer,  &c.  of  uncer¬ 

tain  seat  . 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  . 

4.  Lungs  and  other  Organs  of 

Respiration . 

5.  Heart  and  Bloodvessels . 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion  . 

7.  Diseases  of  the  Kidneys,  &c... 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c . 

9.  Khematism,  Diseases  of  the 
Bones,  Joints,  &c . 

10.  Shin,  Cellular  Tissue,  &c . 

11.  Old  Age . 

12.  Violence,  Privation,  Cold,  and 

Intemperance . 


Av.  of 
5  Aut. 

983 

1154 

981 

1149 

333 

270 

47 

52 

87 

127 

102 

222 

29 

38 

52 

67 

10 

12 

4 

14 

5 

8 

3 

2 

32 

64 

17 

32 

The  following  is  a  selection  of  the  numbers  of 
Deaths  from  the  most  important  special  causes  • 


Small-pox  .  26 

Measles  .  15 

Scarlatina  . 147 

Hooping-cough..  30 
Diarrhoea  ......  23 

Cholera  . -45 

Typhus  .  65 

Dropsy .  15 

Sudden  deaths  . .  4 

Hydrocephalus..  23 
Apoplexy .  18 


Paralysis .  i 

Convulsions  ....  33 
Bronchitis  .......  39 

Pneumonia .  4-] 

Phthisis . 103 

Dis.  of  Lungs,  &c.  3 

Teething .  7 

Dis.  Stomach,  &c.  7 
Dis.  of  Liver,  &c.  3 

Childbirth .  1 

•Dis.ofUterus,&c.  1 


Remarks. — The  total  number  of  deaths  was 
l7i  below  the  weekly  autumnal  average.  See 
page  720. 


METEOROLOGICAL  SUMMARY. 

Mean  Height  of  Barometer .  29’63 

“  “  Thermometer1  .  44-7 

Self-registering  do.b _ max.  64-4  min.  3D 

“  in  the  Thames  water  —  55’  —  46- 

a  From  12  observations  daily.  b  Sun. 


Rain,  in  inches,  0‘42:  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological. — Thejjnean  temperature  of  the 
week  was  about  1°  below  the  mean  of  the  month. 


BOOKS  &  PERIODICALS  RECEIVED 

DURING  THE  WEEK. 

The  Homoeopathic  Treatment  and  Prevention 
of  the  Asiatic  Cholera,  by  R.  E.  Dudgeon,  M.D. 

Chemistry  no  Mystery.  Edited  by  Dr.Scoffern. 
2nd  edition.* 

Chart  of  the  Public  Health  Act,  1848,  11  &  12 
Victoria,  Chapter  63.  By  C.  E.  Bernard,  C.E. 

Plain  Rules  for  preventing  and  treating  the 
Cholera.  By  R.  Druitt,  F.R.C.S.L. 

Journal  de  Chimie  Mbdicale,  Octobre  1848. 
Casper’s  Wochenschrift  fur  die  ges.  Heil- 
kunde.  No.  39  and  40,  23  and  30  Sept.  1848. 

Microscopic  Anatomy  of  the  Human  Body. 
By  A.  H.  H assail.  Part  XIV. 

Elements  of  Chemistry.  By  Thomas  Graham, 
F.R.S.  Part  3. 

Clinical  Lectures  on  the  Practice  of  Medicine. 
By  R.  Graves,  M.D.  2d  edition.  Edited  by 
J.  M.  Neligan,  M.D.  M.R.I.A. 

Register  of  Cases  of  Cholera  professionally 
attended. 

Plow  to  avoid  the  Cholera.  By  John  Challice. 
Clinical  Midwifery.  By  Dr.  Robert  Lee. 

The  Idea  of  Life.  By  S.  T.  Coleridge.  Edited 
by  S.  B.  Watson,  M.D. 

Five  Minutes’  Common  Sense  about  the  Asiatic 
Cholera  :  intended  for  the  unprofessional  reader. 
By  a  Fellow  of  the  Royal  College  of  Surgeons, &c. 

Proofs  of  the  Authenticity  of  the  Portrait  of 
Prince  Charles,  by  Velasquez. 

The  British  American  Journal  of  Medical  and 
Physical  Science.  October  1848. 

Oesterreichische  Medicinische  Wochenschrift 
und  Medicinische  Jahrbucher.  July  1848. 

On  the  Treatment  of  Ulcers  on  the  Leg,  &c. 
By  H.  T.  Chapman,  F.R.C.S.  &c. 

On  the  Influenza  or  Epidemic  Catarrhal  Fever. 
By  T.  B.  Peacock,  M.D. 

Die  medicinische  Reform.  No.  1  to  10. 
Journal  de  Pharmacie  et  de  Chimie.  Oct.  1848. 


NOTICES  to  CORRESPONDENTS. 

“  A  General  Practitioner.” — The  plan  pointed 
out  is  a  common  trick  of  quacks.  It  is  an  ad¬ 
vertisement  without  the  advertisement  duty. 

The  letters  respecting  theUpton-on-Severn  Union 
have  been  received. 

Inquiry  shall  be  made  respecting  the  omission 
of  the  Hall  lists  for  the  28th  ult.  and  5th  inst. 

Mr.  J.  Smith’s  (Coventry)  remarkable  case  of 
early  gestation  shall  be  inserted. 

The  Memorial  of  the  Poor  Law  Medical  Officers 
was  received  too  late  for  the  present  number. 

Received. — Dr.  Sloan,  Mr.  Henry  Smith. 


THE  GEMS1AL  INDEX. 

We  have  to  announce  to  our  Subscribers  that  a  General 
Index  to  the  first  40  Volumes  of  the  London  Medical  Gazette 
will,  it  is  calculated,  form  a  large  Yolume  of  about  700  pages. 
The  cost  of  the  Index  Yolume,  respecting  which  many  inquiries 
have  been  made,  will  be  Twenty-four  Shillings ;  and  it  is  proposed 
to  commence  it  so  soon  as  the  Names  of  Five  Hundred  Subscribers 
have  been  obtained. — The  printers,  Messrs.  Wilson  and  Ogilvy, 
57,  Skinner  Street,  will  receive  the  Names  of  Subscribers. 


fl-ontum  fHetucal  ©alette. 


Hectares. 

L  E  C  T  U  R]E  S 

M 

ON 

PRETERNATURAL  AND  COMPLEX 
PARTURITION. 

By  Edward  W.  Murphy,  A.M.  M.D. 

Professor  of  Midwifery,  University  College, 
London. 


Lecture  III. 

PRETERNATURAL  LABOURS :  SHOULDER 
AND  ARM  PRESENTATIONS. 

The  mechanism  of  shoulder  presentations 
— anterior  dorsal  positions  —  diagnosis 
and  signs  of  shoulder  positions — treat¬ 
ment.  IsL  Cases  that  present  no  diffi¬ 
culty  in  turning — mode  of  operating. 
2nd.  Cases  attended  with  difficulties  from 
rigidity  of  the  os  uteri — the  shoulder 
fixed  in  the  brim  of  the  pelvis,  and  the 
uterus  strongly  contracted  about  the  body 
of  the  child — mismanagement — deformity 
of  the  pelvis.  3rd.  Cases  where  turning 
is  either  impracticable  or  dangerous — 
tight  stricture  of  cervix  uteri — inflam¬ 
mation  of  uterus — evisceration. 
Spontaneous  evolution — Denman’s  explana¬ 
tion — Douglas's — decapitation. 

The  next  division  of  preternatural  labours  are 
those  in  which  the  shoulder  and  arm  of  the 
child  occupy  the  pelvis.  When  this  devia¬ 
tion  unfortunately  occurs,  delivery,  unless  in 
some  rare  exceptions,  can  no  longer  be  ac¬ 
complished  by  the  natural  efforts  of  the 
uterus,  and  therefore  the  aid  of  the  accou¬ 
cheur  is  rendered  imperative,  in  order  to 


735 


conclude  the  labour.  The  study  of  these 
positions  demands  the  closest  attention,  be¬ 
cause,  whenever  they  are  met  with,  you  are 
obliged  to  turn  and  deliver  the  child,  and  to 
do  so  with  promptitude,  in  order  to  preserve 
its  life. 

The  mechanism  of  arm  presentations ,  and 
their  relation  to  the  pelvis,  should  be 
thoroughly  understood.  A  shoulder  posi¬ 
tion  may  present  itself  at  any  time  most 
unexpectedly,  and  if  you  are  not  previously 
prepared  with  an  accurate  knowledge  of  its 
nature,  and  the  mode  of  delivery,  no  time  is 
allowed  to  study  it ;  you  must  proceed  with 
the  operation  at  once,  or  give  it  up  alto¬ 
gether.  If  you  are  are  sufficiently  impru¬ 
dent  to  persevere,  and  attempt  to  do  that 
which  you  do  not  understand  how  to  do, 
you  become  responsible  to  a  most  serious 
extent :  such  attempts  have  been  followed 
by  the  most  disastrous  results,  and  have  de¬ 
stroyed  equally  the  life  of  the  patient,  and 
the  character  of  the  accoucheur. 

The  shoulder  and  arm  may  present  in 
four  different  ways.  Either  arm  may 
occupy  the  brim  of  the  pelvis.  The  back  of 
the  child  may  lie  either  backwards  or  for¬ 
wards.  These  four  positions  may  (like 
breech  presentations)  be  included  in  two 
divisions.  1st.  The  anterior -dorsal  posi¬ 
tion  of  the  shoulder,  having  (1st)  the  right 
arm  or  (2nd)  the  left  presenting.  2nd. 
The  posterior-dorsal  position,  subdivided  in 
a  similar  manner,  according  as  the  right  or 
left  arm  lies  in  the  pelvic  cavity. 

Anterior-dorsal  positions  are  the  most 
frequent,  and  the  right  arm,  I  think,  pre¬ 
sents  oftener  than  the  left.  We  shall  con¬ 
sider  this  as  the  first  position,  and  proceed 
to  examine  its  relations. 


Fig.  10. 


First  anterior  dorsal  position. 

xlii.—1092.  Nov.  3,  1848. 


Fig.  11. 


Second  anterior  dorsal  position 


736  PRETERNATURAL  LABOURS - SHOULDER  AND  ARM  PRESENTATIONS. 


In  the  first  anterior -dorsal  position  the 
right  arm  and  shoulder  occupy  the  brim  of 
the  pelvis  :  the  head  of  the  child  having  the 
occiput  forwards,  rests  in  the  left  iliac  fossa  ; 
the  back  lies  obliquely  across  the  lower  seg¬ 
ment  of  the  uterus ;  the  breech  is  upward 
and  to  the  right  side  ;  the  legs  and  remain¬ 
ing  arm  are  collected  together  at  the  back  of 
the  uterus. 

The  second  anterior -dorsal  position  is 
similar  to  the  first,  only  that  its  relations  to 

Fig.  12. 


The  second  posterior- dorsal  position  has 
the  right  shoulder  and  arm  in  the  pelvis,  the 
head  in  the  right  iliac  fossa,  and  the  breech 
to  the  left  of  the  uterus,  but,  in  every  other 
respect,  it  resembles  the  first  posterior-dor¬ 
sal  position. 

Any  of  the  positions  may  be  met  with, 
but  the  same  manner  of  turning  the  child 
cannot  be  adopted  with  each  indifferently. 
In  fact,  the  ill  success  of  this  operation,  and 
many  of  the  accidents  that  have  occurred  in 
attempting  to  turn  the  child,  might  be  fairly 
attributed  to  ignorance  of  its  exact  position. 
A  kind  of  hap-hazard  attempt  is  made  to 
reach  the  foot :  if  it  succeed,  it  is  drawn 
forcibly  out  of  its  proper  direction,  and  the 
difficulty  of  delivery  is  greatly  increased. 
Thus  in  this  protracted  attempt  the  child  is 
generally  sacrificed,  and  sometimes  even  the 
uterus  has  been  ruptured. 

The  diagnosis  of  any  of  these  posi¬ 
tions  is  easy,  provided  that  the  arm  is  suffi¬ 
ciently  within  reach  to  make  a  perfect  ex¬ 
amination  of  it.  For  this  purpose  it  is 
necessary,  as  soon  as  the  waters  escape,  to 
pass  the  fingers  along  the  arm,  as  it  lies  in 
the  vagina,  as  high  as  possible  towards  the 
shoulder,  and  then,  as  the  fingers  are  being 
withdrawn,  to  supinate  the  arm  as  much  as 


the  pelvis  are  reversed ;  the  left  shoulder  is 
in  the  brim  of  the  pelvis ;  the  head  in  the 
right  iliac  fossa  ;  the  breech  to  the  left  side  ; 
and  the  limbs  at  the  back  of  the  uterus. 

In  the  first  posterior-dorsal  position  the 
left  shoulder  and  arm  present  at  the  brim  of 
the  pelvis  :  the  head,  having  the  face  for¬ 
wards,  rests  in  the  left  iliac  fossa.  The 
abdomen  and  limbs  lie  obliquely  across  the 
anterior  walls  of  the  uterus  ;  and  the  breech 
is  to  its  right  side. 

Fig.  13. 


possible,  and  bring  the  hand  of  the  child  so 
placed  outside  the  vulva.  The  examination 
of  the  hand  will  determine  the  position  of 
the  child  in  the  uterus.  The  direction  of 
the  palm,  whether  it  looks  forwards  or 
backwards,  corresponds  to  that  of  the  abdo¬ 
men  and  limbs  of  the  child,  and  the  position 
of  the  thumb,  whether  it  is  to  the  left  or 
the  right  side  of  the  pelvis,  will  be  the  same 
as  the  position  of  the  head.  For  instance, 
in  the  first  position  (anterior- dorsal)  the 
back  of  the  hand  looks  forwards  toward  the 
pubic  side  of  the  pelvis,  and  the  thumb  is 
on  the  left  side  ;  the  back  of  the  child  is, 
therefore,  anterior,  corresponding  to  the 
abdomen  of  the  mother,  and  the  head  rests 
in  the  left  iliac  fossa  ;  the  abdomen  and 
limbs  lie  towards  the  back  of  the  uterus. 
In  this  manner  any  of  these  positions  may 
be  ascertained  with  facility,  provided  that 
the  membranes  are  ruptured,  and  the  waters 
are  discharged,  when  the  operation  of  turn¬ 
ing  can  be  undertaken  with  the  greatest  ad¬ 
vantage. 

The  signs  that  indicate  arm  presentations 
are  sometimes  observable  even  before  labour 
commences.  The  shape  of  the  uterus  is 
altered  :  it  no  longer  presents  its  oval  form, 
but  is  irregular  in  its  outline,  as  if  divided 


PRETERNATURAL  LABOURS - SHOULDER  AND  ARM  PRESENTATIONS.  787 


into  two  tumors,  a  larger  and  smaller  one.  ’ 
The  stethoscope,  also,  proves  a  difference 
in  the  position  of  the  foetal  heart :  it  is 
heard  more  cowards  the  centre  of  the  abdo¬ 
men  in  the  neighbourhood  of  the  umbilicus, 
rather  than  in  the  iliac  regions.  As  soon  as 
labour  commences,  the  pains  go  on  for  some 
time  with  tolerable  regularity  and  strength, 
but  no  advance  of  the  child  is  made  :  “  they 
are  doing  no  good,”  as  the  midwives  say, 
although  sufficiently  powerful  for  that  pur¬ 
pose.  If  a  vaginal  examination  be  made, 
the  membranes  are  generally  found  to  pro¬ 
trude  through  the  os  uteri  containing  the 
liquor  amnii  alone  :  sometimes  the  phalanges 
or  a  limb  may  be  felt,  but,  unless  the  hand  is 
quite  within  reach,  it  is  difficult  to  deter¬ 
mine  the  presentation.  I  have  met  with 
cases  where  the  membranes  occupied  the 
mouth  of  the  womb,  where  even  a  hand  was 
touched,  and  after  all,  the  head  came  down, 
and  the  woman  was  delivered  in  the  usual 
manner.  Lest  such  might  happen  to  you, 
it  is  very  necessary  not  to  be  too  precipitate 
in  sounding  an  alarm,  and  preparing  for  an 
operation  that  may  not  be  called  for.  As 
labour  proceeds,  and  the  dilatation  of  the 
uterus  advances,  the  presenting  part  de¬ 
scends  more  and  more  into  the  pelvis,  and 
then  it  will  be  in  your  power  to  detect  the 
arm,  even  through  the  membranes.  An  arm 
presentation  being  ascertained,  no  further 
vaginal  examination  should  be  made,  unless 
the  membranes  are  broken,  and  the  waters 
are  discharged,  in  which  case  it  will  be 
necessary  at  once  to  turn  and  deliver  the 
child.  The  capacity  of  the  pelvis,  however, 
should  be  carefully  examined,  in  order  to 
determine  the  risk  to  which  the  child  may 
be  exposed  in  delivery. 

The  treatment  of  shoulder-presentations 
is  fixed  in  all  cases  where  the  operation  of 
turning  may  be  performed  with  safety  to  the 
patient.  Any  question  respecting  it  is  only 
one  of  time — vjhen  the  delivery  should  be 
undertaken. 

Certain  cases,  however,  fall  under  the 
notice  of  the  practitioner,  in  which  the  safety 
of  the  patient  is  doubtful,  and  where  it  be¬ 
comes  a  question  whether  such  an  operation 
can  be  ventured  upon  with  propriety.  Be¬ 
tween  these  extremes  there  are  many  varie¬ 
ties  of  cases  that  present  conditions  which 
modify  the  treatment :  we  shall,  therefore, 
consider  separately  the  treatment  of — 1st, 
cases  that  present  no  difficulty  in  delivery  by 
turning  ;  2nd,  cases  that  ar,a  attended  with 
difficulties  to  a  greater  or  less  extent ;  and 
3rd,  those  cases  where  the  .operation  of  turn¬ 
ing  becomes  too  dangerous  to  be  under¬ 
taken. 

1st.  Cases  that  present  no  difficulty  in 
the  delivery ,  must  be  understood  to  embrace 
those  that  the  practitioner  has  had  the  op¬ 
portunity  ,of  observing  from  Jthe  .commence¬ 


ment  of  labour,  where  there  is  no  rigidity  of 
the  os  uteri,  nor  contraction  of  the  pelvis,  to 
interfere  with  a  successful  issue,  and  in  the 
management  of  which,  the  only  question  he 
has  to  consider,  are  the  time  and  the  mode 
in  which  the  operation  should  be  performed . 
If  there  be  any  difficulty  in  the  delivery,  it 
must  be  one  of  his  own  making. 

The  time  best  adapted  for  turning  is 
when  the  os  uteri  is  fully  dilated,  or  nearly 
so  ;  if  the  dilatation  be  incomplete,  there  is 
always  a  risk  in  the  extraction  of  the  head  : 
the  limbs  and  body  may  be  brought  through 
the  os  uteri,  but  there  may  be  great  difficulty 
in  overcoming  its  resistance  so  as  to  allow 
the  shoulders  and  head  to  pass,  during  which 
interval  the  funis  is  compressed,  and  the 
delay  causes  the  death  of  the  child  ;  besides, 
the  cervix  uteri  may  be  torn  in  the  attempt, 
and  the  life  of  the  mother  hazarded.  It 
would  not,  therefore,  be  advisable  to  inter¬ 
fere  before  the  mouth  of  the  womb  was 
sufficiently  open  to  prevent  any  risk  of  this 
kind.  For  this  reason,  also,  it  is  better  not 
to  rupture  the  membranes  prematurely  for 
the  purpose  of  turning,  because  so  long  as 
they  are  preserved  the  liquor  amnii  dilates 
the  os  uteri  more  efficiently  than  the  pre¬ 
senting  part  could,  and  this  advantage  is 
more  effectually  secured  :  but  whenever  the 
membranes  give  way,  and  the  waters  are 
discharged,  the  hand  must  be  passed  into 
the  uterus  in  order  1o  deliver,  lest  its  fibres 
should  contract  strongly  on  the  body  of  the 
child,  and  increase  the  difficulty  of  the  ope¬ 
ration. 

The  time,  then,  to  interfere  should  be 
whenever  the  os  uteri  is  quite  dilated,  whe¬ 
ther  the  membranes  are  broken  or  otherwise, 
or  when  the  waters  are  discharged,  although 
the  os  uteri  may  not  be  quite  dilated.  In 
the  latter  case  the  danger  to  the  child  is 
obviously  increased. 

The  mode  of  delivery  requires  your 
attention,  in  order  to  avoid  the  errors 
that  are  frequently  committed  in  this  ope¬ 
ration.  The  first  step  is  to  determine 
the  exact  position  of  the  child  :  the  moment, 
therefore,  that  the  waters  escape,  the  hand 
of  the  child  should  be  brought  down  and 
examined.  When  the  position  is  ascertained, 
the  practitioner  can  judge  which  hand  is  the 
most  convenient  to  introduce  for  the  pur¬ 
pose  of  turning.  In  general  it  will  be  found 
more  easy  to  turn  with  the  same  hand  as 
that  presenting  in  the  vagina.  If  the  right 
arm  of  the  child  descend,  the  right  hand 
should  be  used  in  delivery  ;  and  so  with 
respect  to  the  left.  You  can  readily  deter¬ 
mine  this  point  by  grasping  the  hand  of  the 
child,  applying  palm  to  palm,  and  if  the 
thumb  of  each  hand  lie  on  the  same  side  the 
hands  are  the  same.  Let,  then,  the  pre¬ 
senting  hand  be  held  with  one  hand,  while 
the  other  is  passed  along  the  arw  9f 


738  PRETERNATURAL  LABOURS - SHOULDER  AND  ARM  PRESENTATIONS. 


child  to  the  the  axilla,  and  then  directed  over 
the  thorax  to  the  abdomen.  The  feet  and 
remaining  hand  are  generally  found  here  so 
intermingled,  that  it  is  by  no  means  easy  (at 
least  to  the  inexperienced)  to  distinguish 
the  foot ;  the  advantage,  therefore,  of  pre¬ 
viously  acquired  tact  is  here  particularly 
obvious  :  but  when  there  is  a  doubt  whether 
the  hand  or  foot  is  seized,  it  may  be  removed 
by  grasping  the  phalanges  :  if  they  can  be 
closed,  it  is  the  hand,  if  not,  being  the  foot, 
it  should  be  held  firmly,  but  no  attempt  as 
yet  made  to  turn.  If  you  should  proceed 
at  once  to  draw  down  the  foot  there  is  a 
great  chance  that  it  may  slip  from  the  fin¬ 
gers,  and  not  be  so  easily  found  again  :  it  is 
preferable  to  get  not  only  the  foot  but  as 
much  of  the  limb  as  possible  within  the 
grasp  of  the  hand  before  it  is  drawn  down  ; 
by  this  means,  also,  more  power  is  gained. 
I  entirely  agree  with  Dr.  Radford,  that  it 
is  quite  unnecessary  to  find  the  second  foot 
before  turning,  because  one  limb  is  sufficient 
for  the  purpose,  and  in  searching  for  the 
second  there  is  some  risk  that  you  may  lose 
the  first ;  it  is  even  possible  that  you  might 
seize  the  foot  of  a  second  child  :  an  advan¬ 
tage  is  also  gained  by  leaving  one  foot  in 
the  uterus — the  child,  when  turned,  presents 
in  a  semi-breech  position,  which  is  more 
favourable  for  the  purpose  of  delivery  than 
if  both  feet  were  brought  down  into  the 
vagina.  When  the  limb  is  seized  firmly, 
and  traction  is  made  in  the  intervals  of 
pains,  the  child  revolves  quite  easily  in  the 
uterus :  the  leg  is  brought  into  the  vagina, 
and  the  remainder  of  the  delivery  is  com¬ 
pleted  as  in  a  breech  or  footling  case ;  but 
you  should  recollect  that  there  is  nothing 
left  to  Nature  here, — it  rests  entirely  on  your 
skill  whether  the  child  descend  through  the 
pelvis  correctly  or  otherwise :  observe, 
therefore,  the  direction  of  the  foot, — that  the 
toes  are  directed  backwards ;  you  should 
watch  the  funis,  and  bring  it  down  when  it 
comes  within  reach,  and  take  care  that  the 
fundus  uteri  is  compressed  while  the  child  is 
being  withdrawn.  In  this  manner,  if  the 
operation  be  undertaken  with  sufficient 
promptitude,  and  time  is  not  unnecessarily 
lost  in  going  through  it,  the  child  is  gene¬ 
rally  saved. 

When  the  hand  is  passed  into  the  uterus, 
immediately  after  the  membranes  are  broken, 
its  fibres  yield  very  readily ;  nevertheless, 
it  is  necessary  to  avoid  irritation  as  much  as 
possible,  and  hence,  while  passing  the  hand 
upwards,  if  a  pain  return,  it  is  better  to  rest 
until  the  uterus  again  relaxes ;  thus,  as  it 
were,  stealing  the  hand  into  the  uterus  in 
the  intervals  of  the  pains.  If  an  opposite 
course  be  pursued,  the  introduction  of  the 
hand  might  excite  strong  uterine  contrac¬ 
tions,  and  thus  the  resistance  to  any  attempt 
to  force  the  hand  upwards  would  be  greatly 


increased :  the  fingers  become  benumbed, 
sensation,  which  is  so  necessary,  is  lost,  and 
there  is  even  a  hazard  that  the  uterus  might 
give  way.  Ruptures  of  the  uterus  are  said 
to  have  been  caused  by  the  projecting  limits 
of  the  child,  when  its  parietes  (we  presume) 
had  been  previously  weakened  by  some 
morbid  alteration  of  structure.  How  much 
more  likely  is  such  an  accident  to.  occur 
when  the  knuckles  are  pressed  against  the 
sides  of  the  uterus,  strongly  contracted  upon 
them  !  Make  it  a  rule,  therefore,  never  to 
force  the  hand  into  the  cavity  of  the  uterus, 
but  to  advance  cautiously,  pressing  forward 
when  the  uterus  yields,  and  ceasing  to  do  so 
the  moment  its  contractions  return.  When 
the  child  is  turned,  the  more  rapidly  it  is 
extracted  the  better  chance  there  is  of  sav¬ 
ing  it. 

2d.  Cases  attended  with  difficulty  in 
turning  are  generally  those  in  which  the 
membranes  have  been  some  time  ruptured 
before  the  operation  is  proceeded  with. 
This  might  happen  when  the  os  uteri  is 
rigid ,  the  waters  having  escaped  early  in 
labour,  before  the  mouth  of  the  womb  is 
sufficiently  dilated  to  admit  the  hand.  Or, 
in  consequence  of  inattention  on  the  part  of 
the  attendant,  or  other  cause  of  neglect,  the 
shoulder  may  be  allowed  to  remain  in  the 
brim  of  the  pelvis  for  hours  unobserved,  the 
attendant  not  being  aware  of  the  nature  of 
the  labour.  Had  he  known  it  in  time  there 
might  have  been  no  difficulty  in  turning, 
but  now  it  is  too  late,  the  waters  have  been 
a  long  time  discharged  ;  the  shoulder  is  fixed 
in  the  brim,  and  the  uterus  is  strongly  con¬ 
tracted  about  the  body  of  the  child.  In 
either  case,  in  consequence  of  the  body  of 
the  child  causing  much  more  irritation  than 
the  fluid  which  had  surrounded  it,  the  action 
of  the  uterus  is  increased,  stronger  pains 
return  again  and  again,  but  are  inefficient 
for  the  purpose  :  the  result  is,  that  spasmo¬ 
dic  contractions  of  the  uterus  may  be  ex¬ 
cited,  and  its  fibres  surround  the  uterus  so 
closely  as  to  render  the  introduction  of  the 
hand  a  matter  of  great  difficulty.  Some¬ 
times  inflammation  of  the  uterus  has  taken 
place,  an  effect  still  more  dangerous  to  the 
patient. 

The  treatment  of  such  cases  is  by  no 
means  so  simple  as  that  of  the  former  class. 
If  you  were  to  proceed  at  once  to  turn, 
difficulties  would  oppose  themselves  in  every 
step  of  the  operation.  The  resistance  of  the 
uterus  to  the  introduction  of  the  hand — the 
danger  of  using  too  much  force — the  effect 
of  compression  on  the  fingers  rendering 
them  insensible  and  almost  powerless — the 
extreme  exertion  required,  and  consequent 
exhaustion  of  the  operator ;  all  these  impe¬ 
diments  meet  you,  and  would  perhaps  render 
the  attempt  abortive.  La  Motte  relates 
that  an  operation  of  this  kind  nearly  cost 


PRETERNATURAL  LABOURS — SHOULDER  AND  ARM  PRESENTATIONS.  739 


him  his  life.  “  Je  crus  tres  certainement  J 
que  je  mourrois  apres  cet  accouchement,  ou 
j’epuisai  et  ma  science  et  mes  forces  et  apres 
lequel  je  restai  sans  respiration;  en  sorte 
qu'it  me  fallut  mettre  sur  un  matelas  (le¬ 
vant  un  grand  feu  et  me  frotter  avec  des 
lignes  chauds  pendant  plus  cVune  heure 
Smellie,  also,  after  such  an  operation,  says, 

“  I  never  was  more  fatigued;  I  was  not 
able  to  raise  my  arms  to  my  head  for  a  day 
or  two  after  this  delivery,  and  one  of  the 
gentlemen  who  was  present  was  so  much 
frightened  that  he  resolved  never  to  venture 
on  the  practice  of  midwifery.”'}'  You  would 
not  desire  such  scenes  as  these,  and  therefore 
it  would  be  advisable  to  reduce  as  much  as 
possible  the  causes  of  difficulty  :  some  pre¬ 
liminary  treatment  is  therefore  required. 
The  first  object  is  to  determine  the  existence 
of  inflammation  :  if  the  passages  are  hot  and 
tender — the  os  uteri  swollen  and  painful — 
the  uterus  very  hard,  intolerant  of  the  least 
pressure,  and  irregular  on  its  surface  ;  if 
the  pulse  be  increased  in  frequency,  with 
dry  tongue  and  great  thirst ;  you  cannot  in¬ 
terfere  until  all  these  symptoms  are  subdued, 
and  even  then  the  manner  in  which  the 
patient  is  delivered  becomes  a  question  of 
serious  consideration.  Inflammation  may 
not  be  present,  but  the  uterus  is  strongly 
contracted  about  the  body  of  the  child ; 
spasmodic  pains  frequently  return  with  great 
agony  to  the  patient,  who  is  irritable  and 
anxious :  the  pulse  is  quick,  and  a  cer¬ 
tain  amount  of  nervous  irritation  is  excited. 
All  such  symptoms  must  be  relieved,  and 
the  best  means  of  doing  so  is  by  a  free  de¬ 
pletion  from  the  arm,  followed  by  nauseating 
doses  of  tartar  emetic  in  combination  with 
opium.  If  any  inflammation  be  present, 
the  proportion  of  tartar  emetic  may  be  in¬ 
creased.  If  spasm,  with  nervous  irritation, 
opium  may  be  given  largely.  By  such 
means  the  os  uteri  will  be  rendered  more 
dilatable,  the  pains  more  regular,  and  at¬ 
tended  with  much  less  suffering. 

The  operation  may  now  be  undertaken. 
The  arm  being  stripped  and  greased  along 
the  back,  the  fingers  in  a  conical  form  may 
be  introduced  into  the  vagina,  and  within 
the  os  uteri :  there  may  be  still  some  diffi¬ 
culty  in  pressing  the  shoulder  back,  but  by 
caution  in  acting  only  during  the  intervals 
of  the  pains,  and  with  some  patience,  you 
will  succeed  in  getting  the  hand  into  the 
cavity  of  the  womb  ;  great  care  is  now  ne¬ 
cessary  while  pressing  it  forward  to  avoid 
irritation  :  the  moment  a  pain  comes  on  the 
hand  should  be  kept  flat  on  the  body  of  the 
child,  and  advanced  only  when  the  uterus 
relaxes  ;  take  as  your  motto,  “  arte  non  vi,” 
and  trust  to  time,  rather  than  force,  for 


*  La  Motte,  Observ.  262,  p.  467. 
t  Smellie,  vol.  iii.  p.  243,  Case  III. 


effecting  your  object.  When  the  foot  is 
reached  the  remainder  of  the  operation  is 
generally,  although  not  always,  easy.  Some¬ 
times,  however,  it  is  both  difficult  and 
fatiguing — difficult  to  gain  and  to  distinguish 
the  foot,  and  often  requiring  great  exertion 
to  overcome  the  resistance  of  the  uterus. 
The  long-continued  pressure,  also,  on  the 
body  of  the  child  and  the  funis  places  its 
life  in  great  hazard,  and  therefore  it  is  ex¬ 
tremely  doubtful  whether  the  child  can  be 
saved. 

Our  chief  attention  should  be  directed  to 
preserve  the  mother  from  injury ;  conse¬ 
quently,  when  the  os  uteri  is  rigid,  and  slow 
in  dilating,  no  attempt  should  be  made  to 
turn  until  the  dilitation  is  somewhut  ad¬ 
vanced  :  no  effort  should  be  made  to  force 
open  the  os  uteri  in  order  to  save  the  child, 
because  it  is  very  probable  that  you  would 
not  only  fail  in  your  object,  but  also  do  such 
injury  to  the  uterus  as  would  endanger  the 
life  of  the  mother  also.  These  are  cases  in 
which  I  think  that  the  new  anaesthetic  agent, 
chloroform,  is  so  valuable.  I  have  used  it 
under  circumstances  nearly  similar,  and  have 
found  it  of  infinite  use  in  relieving  me  from 
tbeembarrassmentof  the  patient’s  irritability, 
and' herself  from  much  suffering. 

Mismanagement  may  cause  great  difficulty 
in  turning.  I  have  been  called  to  cases 
where  an  unsuccessful  attempt  was  made  to 
deliver  the  child,  and  the  second  arm  by 
mistake  brought  into  the  pelvis :  the  pre¬ 
senting  shoulder  still  occupied  the  brim, 
where  it  was  so  firmly  maintained  by  the 
uterus  that  it  was  impossible  to  push  it 
back.  In  such  instances  a  full  opiate  was 
given,  to  allay  nervous  irritation,  and  while 
the  patient  was  under  its  influence  the  hand 
was  cautiously  introduced  into  the  vagina  to 
the  shoulder.  Here  there  was  some  diffi¬ 
culty  in  advancing,  not  only  because  of  the 
shoulder,  but  the  arm  that  was  brought 
down.  The  arm,  however,  was  pressed  back, 
and  thus  room  was  given  for  the  hand  to 
enter  the  cavity  of  the  uterus.  By  advancing 
cautiously  in  the  intervals  of  the  pains,  the 
foot  at  length  was  reached.  The  greatest 
difficulty,  however,  still  remained.  Easy  as 
turning  the  child  generally  is,  it  is  particu¬ 
larly  difficult  in  such  a  case  as  this.  There 
is  very  little  room,  and  consequently  very 
little  power  to  act,  when  the  shoulder  so 
occupied  the  pelvis  :  the  limb  that  is  seized 
cannot  be  drawn  down  completely,  and  it  is 
equally  impossible  to  pass  the  second  hand 
into  the  vagina,  for  the  purpose  of  pushing 
up  the  shoulder.  The  only  resource,  there¬ 
fore,  is  to  fasten  a  noose  of  tape  on  the  ankle 
of  the  child,  so  as  to  secure  it,  and  draw  it 
down,  while  an  effort  is  made  by  the  intro¬ 
duced  hand  to  press  up  the  shoulder.  If  the 
foot  can  be  brought  into  the  vagina,  the  noose 
may  be  formed  on  the  wrist  of  the  arm  that 


740  PRETERNATURAL  LABOURS - SHOULDER  AND  ARM  PRESENTATIONS. 


holds  the  foot,  and  slipped  along  the  hand 
and  over  the  foot  by  two  fingers  of  the 
second  hand.  But  if  the  foot  is  still  in  the 
uterus,  where  the  fingers  cannot  reach  it,  I 
think  a  convenient  means  of  effecting  this 
object  might  be  adopted  by  taking  advantage 
of  Mr.  Steeven’s  catheter  for  replacing  the 
funis.  Let  a  loop  be  formed  on  the  arm  in 
the  same  manner,  and  having  the  ends  suffi¬ 
ciently  long  to  be  held  by  an  assistant.  The 
loop  can  then  be  attached  to  the  catheter, 
and  pushed  along  the  arm  into  the  cavity  of 
the  uterus.  When  the  noose  is  fixed,  the 
assistant  can  draw  the  ends  tightly,  so  as  to 
secure  the  foot.  The  hand  may  now  be 
brought  down  with  the  foot  as  far  as  it  will 
go,  and  then,  holding  the  tape  firmly,  one 
hand  may  be  withdrawn  from  the  uterus, 
while  the  opposite  passes  into  the  vagina,  for 
the  purpose  of  pushing  up  the  shoulder,  and 
thus  turning  the  child.  Some  adroitness  is 
required  in  this  manipulation,  but  if  done 
carefully,  and  without  violence,  you  will 
generally  succeed  safely.  Be  cautious  also 
that  the  tape  may  not  slip  from  the  foot,  be¬ 
cause  if  so,  you  would  have  to  go  over  the 
whole  process  again.  Knowing  the  value  of 
chloroform  in  allaying  the  irritability  of  the 
patient,  and  rendering  the  passages  dilatable, 

I  think  it  would  be  also  of  great  use  in  such 
a  case  as  this. 

Deformity  of  the  pelvis  sometimes  causes 
difficulty  in  delivering  the  child.  It  is  not 
easy  to  pass  the  hand  through  the  pelvis  ;  it 
is  equally  difficult  to  seize  the  foot  when  the 
hand  and  arm  are  confined  in  so  limited  a 
space  ;  and  if  you  succeed  in  turning  the 
child,  there  yet  remains  the  greatest  difficulty 
— the  extraction  from  the  pelvis.  Great 
force  is  often  used  for  this  purpose :  the 
body  and  shoulders  are  generally  safely  de¬ 
livered,  but  the  head  becomes  impacted.  To 
remedy  this,  the  fingers  are  placed,  if  possi¬ 
ble,  in  the  mouth  of  the  child,  if  not,  round 
the  neck  in  front,  while  the  back  of  it  is 
seized  by  the  opposite  hand,  the  body  per¬ 
haps  held  by  an  assistant,  and  a  combined 
and  powerful  tug  made  to  extricate  it.  The 
shock  generally  destroys  the  child  ;  some¬ 
times  the  odontoid  process  of  the  vertebra 
dentata  is  broken  off.  There  is  no  object  in 
using  all  this  violence,  because  it  cannot 
accomplish  the  only  purpose  that  could  jus¬ 
tify  it — the  safety  of  the  child  ;  a  more 
patient  method  will  answer  the  purpose  much 
better.  When  the  head  is  thus  arrested,  and 
the  funis  pulsates,  the  first  object  is  to  secure 
it  from  pressure,  and  in  a  pelvis  of  this  kind 
(the  ovate  pelvis)  it  may  easily  be  placed  at 
either  side  of  the  projecting  promontory  of 
the  sacrum,  which  will,  to  a  certain  extent, 
protect  it,  and  thus  give  time  for  the  extrac¬ 
tion  of  the  head,  which  may  often  be  effected 
by  the  hands  alone.  One  hand  may  be 
passed  up  over  the  face  to  the  forehead,  so 


as  to  press  the  head  down  well  on  the  chest, 
and  the  other  applied  to  the  neck  ;  if  a  steady 
extracting  force  is  then  used,  renewed  at  in¬ 
tervals,  but  without  jerking  or  violence,  it 
will  succeed.  The  vectis  may  be  applied 
over  the  forehead  in  place  of  the  hand,  but  I 
do  not  think  it  answers  so  well.  If  your 
first  efforts  fail,  do  not  despair  so  long  as 
there  is  circulation  in  the  funis ;  let  the 
patient  rest  before  a  second  trial  is  made  to 
extract,  and  provided  the  funis  is  safe,  no 
injury  can  arise  to  the  child  from  leaving  the 
head  fixed  in  the  brim  for  a  short  time  :  how 
often  does  it  remain  thus  for  hours  in  a  diffi¬ 
cult  labour  ?  During  this  interval  the  patient 
may  be  given  an  opiate,  or,  what  I  think  is 
better,  some  chloroform.  When  she  is  re¬ 
freshed  by  rest,  and  the  passages  relieved 
from  the  irritation  of  your  first  efforts,  you 
may  again  attempt  to  extract  as  before.  If 
this  fail,  we  have  no  other  resource  than  to 
perforate  behind  the  ear  or  through  the 
mouth,  as  soon  as  the  pulsation  in  the  funis 
ceases;  but  if  the  means  we  have  recom¬ 
mended  be  managed  with  judgment,  you 
will  not,  unless  in  extreme  cases,  have  to 
perforate. 

3.  Turning  may  he  impracticable  or 
dangerous. — For  instance,  the  uterus  may 
be  so  spasmodically  contracted  about  the 
body  of  the  child,  that  the  hand  cannot  be 
introduced;  a  stricture  is  formed  at  the  junc¬ 
tion  of  the  cervix  and  body  of  the  uterus, 
which  no  reasonable  effort  can  overcome,  nor 
any  general  treatment  relax :  some  other 
mode  of  delivery  must  therefore  be  adopted. 
The  only  practical  means  of  delivery  is 
evisceration ;  that  is,  to  perforate  the  thorax 
at  the  axilla,  and  with  the  crotchet  to  re¬ 
move  the  contents  of  both  the  thorax  and 
abdomen  :  the  body  being  thus  reduced,  the 
crotchet  can  be  hooked  on  the  vertebral 
column  close  to  the  pelvis,  and  the  breech  and 
limbs  brought  down  through  the  stricture. 
It  may  be  necessary  to  perforate  the  head 
also  behind  the  ear,  in  order  to  extract  it. 
There  is  no  operation  in  midwifery  more 
troublesome  to  perform,  or  more  disagreeable 
to  look  at,  than  evisceration  :  we  have  na¬ 
turally  an  instinctive  repugnance  to  tear 
away  the  infant  piece-meal  in  this  manner; 
still,  in  the  case  supposed,  it  must  be  done, 
there  is  no  alternative,  and  unpleasant  as  it 
is,  this  operation  is  much  safer,  and  better 
calculated  to  preserve  the  uterus  from  in¬ 
jury,  than  making  violent  efforts  to  force 
the  hand  into  it  for  the  purpose  of  turning 
the  child.  After  one  or  more  such  unsuc¬ 
cessful  attempts,  you  are  compelled  to  desist, 
greatly  fatigued  by  the  exertion,  and  the 
uterus  being  so  much  exposed  to  irritation 
from  this  violence,  may  become  the  seat  of 
serious  inflammation  afterwards. 

Inflammation  of  the  uterus,  if  severe, 
would  render  turning  impracticable,  because 


PRETERNATURAL  LABOURS — SHOULDER  AND  ARM  PRESENTATIONS.  741 


one  of  its  effects  is  softening  of  the  fibrous 
structure  of  the  uterus,  which  may  give  way 
when  the  hand  is  strongly  pressed  against 
it,  in  the  effort  to  reach  the  feet  of  the  child  : 
thus  the  uterus  may  be  ruptured.  This  has 
happened  more  than  once  without  the  true 
cause  being  assigned  for  it ;  the  practitioner 
may  have  been  blamed  for  undue  violence, 
but  it  is  far  more  likely  that  he  was  to  blame 
for  want  of  caution  in  undertaking  the  ope¬ 
ration  at  all  under  such  unfavourable  cir¬ 
cumstances.  You  should  therefore  be  on 
your  guard  against  a  mistake  of  this  kind. 
If  such  inflammation  exist,  it  should  be  sub¬ 
dued  by  general  antiphlogistic  treatment,  and 
the  child  removed  by  evisceration. 

Inflammation  of  the  uterus  seldom  occurs 
in  arm  presentations  unless  in  very  neglected 
cases,  when  the  waters  have  been  long  dis¬ 
charged,  and  the  uterus,  irritated  by  its  own 
fruitless  efforts,  is  strongly  contracted  upon 
the  body  of  the  child.  The  presenting  arm 
is  greatly  swollen,  perhaps  putrid,  as  the 
child  is  usually  dead  for  some  time  previous; 
the  passages  are  hot  and  tender,  the  uterus 
very  irregular  in  its  shape,  and  painful  to 
the  touch,  and  the  patient  in  a  high  state  of 
irritative  fever.  Even  if  you  succeeded  in 
turning  the  child  under  such  circumstances, 
no  useful  object  could  be  gained  by  it ;  but 
when  you  reflect  on  the  difficulties  before 
you,  that  success  is  more  than  doubtful, 
serious  injury  to  the  uterus  almost  certain, 
and  its  laceration  a  very  probable  result, 
you  would  not  venture  upon  so  imprudent  an 
operation.  The  child  can  only  be  removed 
by  evisceration,  and  as  it  is  frequently 
putrid,  and  the  bones  very  loose,  great  care 
is  necessary  in  extracting  the  head,  lest  it 
separate  from  the  spine,  and  remain  behind 
in  the  uterus. 

Spontaneous  evolution ,  or  the  natural 
turning  of  the  child,  sometimes  takes  place. 
It  is  difficult  to  conceive  it  possible  that  a 
full-grown  child  could  be  forced  crosswise 
through  the  pelvis  ;  nevertheless,  such  has 
happened, — even  children  have  been  born 
living  in  this  manner.  The  natural  delivery 
of  a  cross-birth  was  first  noticed  by  Den¬ 
man,*  who  called  it  “  spontaneous  evolu¬ 
tion'1  “  As  to  the  manner,”  (he  observes) 
“  in  which  this  evolution  takes  place,  I  pre¬ 
sume  that,  after  the  long-continued  action 
of  the  uterus,  the  body  of  the  child  is 
brought  into  such  a  compact  state  as  to  re¬ 
ceive  the  full  force  of  every  returning  action. 
The  body,  in  its  doubled  state,  being  too 
large  to  pass  through  the  pelvis,  and  the 
uterus  pressing  upon  its  inferior  extremi¬ 
ties,  which  are  the  only  parts  capable  of 
being  moved,  they  are  forced  gradually 
lower,  making  room  as  they  are  pressed 


down  for  some  other  part  into  the  cavity  of 
the  uterus  which  they  have  evacuated , 
until ,  the  body  turning ,  as  it  were ,  upon 
its  own  axis,  the  breech  of  the  child  is  ex¬ 
pelled  as  in  an  original  presentation  of  that 
part."*  Some  time  after  this  explanation 
had  been  given,  and  generally  received  by 
the  profession,  Dr.  J.  C.  Douglas,  of 
Dublin,  met  with  seven  instances  in  which 
the  natural  delivery  took  place,  and  in  none 
of  them  did  he  find  anything  like  a  sponta¬ 
neous  evolution  of  the  child.  Comparing 
his  own  observations  with  Denman’s  cases, 
he  found  them  agree  in  the  facts  stated  by 
Denman  as  to  the  mode  in  which  the  body 
is  forced  into  the  pelvis — “  that  the  shoulder 
of  the  child  is  forced  very  low  in  the  pelvis, 
and  that  the  thorax  occupied  so  much  of  its 
cavity  as  to  preclude  the  practicability  of 
the  hand  of  the  accoucheur  being  passed 
into  the  uterus  for  the  purpose  of  turning. ”f 
But  Dr.  Douglas  differs  completely  as  to 
the  manner  in  which  the  child  is  expelled, 
and  prefers  the  term  spontaneous  expul¬ 
sion,  as  being  more  expressive  of  the  facts. 
He  says — “  The  fact,  however,  is,  that  the 
shoulder  and  thorax  thus  low  and  impacted, 
instead  of  receding  into  the  uterus,  are  at 
each  successive  pain  forced  still  lower,  until 
the  ribs  of  that  side  corresponding  with  the 
protruded  arm  press  on  the  perinaeum,  and 
cause  it  to  assume  the  same  form  as  it 
would  by  the  pressure  of  the  forehead  in 
natural  labour.  At  this  period,  not  only 
the  entire  of  the  arm,  but  the  shoulder,  can 
be  perceived  externally  with  the  clavicle 
lying  under  the  arch  of  the  pubis.  By 
further  uterine  contractions,  the  ribs  are 
forced  more  forward,  appearing  at  the  os 
externum  as  the  vertex  would  in  natural 
labour,  the  clavicle  having  been  by  degrees 
forced  round  on  the  anterior  part  of  the 
pelvis,  with  the  acromion  looking  towards 
the  mons  veneris.  But,  in  order  to  render 
as  clear  as  possible  the  successive  move¬ 
ments  in  this  astonishing  effort  of  Nature, 
I  will  endeavour  to  describe  still  more  pre¬ 
cisely  the  situation  of  the  foetus  immediately 
prior  to  its  expulsion.  The  entire  of  it 
somewhat  resembles  the  larger  segment  of  a 
circle  :  the  head  rests  on  the  pubis  inter¬ 
nally  ;  the  clavicle  presses  against  the  pubis 
externally,  with  the  acromion  stretching 
towards  the  mons  veneris ;  the  arm  and 
shoulder  are  entirely  protruded,  with  one 
side  of  the  thorax  not  only  appearing  at  the 
os  externum,  but  partly  without  it;  the 
lower  part  of  the  same  side  of  the  trunk 
presses  on  the  perinEeum,  with  the  breech 
either  in  the  hollow  of  the  sacrum  or  at  the 
brim  of  the  pelvis,  ready  to  descend  into  it, 


Denman,  328  (Ed.  8vo.  Lond.  1824). 


*  Denman,  p.  327- 

f  An  Explanation,  &c.  &c.  of  Spontaneous 
Evolution,  p.  25,  3d  Ed.  Dublin,  1844. 


742  PRETERNATURAL  LABOURS - SHOULDER  AND  ARM  PRESENTATIONS. 


and,  by  a  few  further  uterine  efforts,  the  re¬ 
mainder  of  the  trunk,  with  the  lower  extre¬ 
mities,  is  expelled. 

“  And,  to  be  still  more  minutely  expla¬ 
natory  in  this  ultimate  stage  of  the  process, 
I  have  to  state  that  the  breech  is  not  ex¬ 
pelled  exactly  sideways,  as  the  upper  part  of 
the  trunk  had  previously  been  ;  for,  during 
the  presence  of  that  pain  by  which  the  evo¬ 
lution  is  completed,  there  is  a  twist  made 
about  the  centre  of  the  curve  at  the  lumbar 
vertebrae,  when  both  buttocks,  instead  of 
the  side  of  one  of  them,  are  thrown  against 
the  perinseum,  distending  it  very  much  ; 
and  immediately  after,  the  breech,  with  the 
lower  extremities,  issues  forth,  the  upner 
and  back  part  of  it  appearing  first,  as  if  the 
back  of  the  child  had  originally  formed  the 
convex,  and  its  front  the  concave,  side  of 
the  curve.”* 

This  explanation  of  the  natural  delivery 
of  shoulder  presentations  has  been  con¬ 
firmed  by  Gooch,  Ramsbotham,  and  other 
practical  writers  :  it  coincides  also  wfith  the 
facts  that  have  fallen  under  my  own  notice ; 
nevertheless,  I  am  inclined  to  think  that 
spontaneous  evolution,  in  the  strict  sense  of 
the  term,  sometimes  occurs.  I  have  met 
with  cases  where  the  arm  presented  and 
occupied  the  os  uteri  completely,  but  after¬ 
wards  it  retreated,  and  the  breech  descended 
in  its  place.  The  united  testimony  of  the 
profession  confirms  the  description  of 
Douglas,  which,  therefore,  may  be  consi¬ 
dered  as  the  manner  in  which  this  sponta¬ 
neous  expulsion  of  the  child  takes  place. 
But,  knowing  the  confidence  that  may  be 
placed  in  Denman’s  fidelity  as  an  author,  I 
am  satisfied  that  spontaneous  evolution  also 
sometimes  happens.  I  think  that  it  is  very 
likely,  when  the  child  is  full  grown  and 
living,  that  the  shoulder,  in  the  intervals  of 
the  pains,  might  gradually  leave  the  pelvis 
if  the  body  was  forced  down  into  it  by  the 
action  of  the  uterus.  These  cases  are  very 
rarely  met  with  ;  but,  when  they  do  occur, 
how  are  we  to  manage  them  ?  Is  it  better 
to  interfere,  or  to  leave  it  all  to  Nature  ?  If 
the  action  of  the  uterus  were  powerful,  and 
that  the  body  were  advancing,  I  should 
adopt  the  latter  course,  my  only  interference 
being  to  support  the  perinaeum  against  the 
strong  pressure  acting  against  it.  But  if 
the  process  was  retarded  or  difficult,  a  blunt 
hook  might  be  passed  over  the  body  of  the 
child  above  the  pelvis,  to  assist  its  advance. 
If  this  fail,  the  child  should  be  removed  by 
evisceration,  because  when  the  body  is  thus 
forced  into  the  pelvis,  and  the  uterus  is 
strongly  contracted  on  it,  an  attempt  to 
force  the  hand  into  it  for  the  purpose  of 
turning  would  be  very  dangerous.  It  is 
most  probable  that  you  could  not  do  so,  and 


there  would  be  great  risk  of  laceration  if 
much  force  were  used. 

Decapitation  of  the  child  is  still  practised 
in  some  cases  where  turning  is  impracticable. 
This  operation  has  been  performed  since  the 
time  of  Celsus,  and  now  remains  as  a  kind 
of  relic  of  those  mutilations  of  the  child 
which  were  had  recourse  to  in  order  to  de¬ 
liver  a  cross-birth,  before  the  operation  of 
Ambrose  Pare.  I  confess  that  I  have  never 
met  with  a  case  of  arm  presentation  in 
which  decapitation  was  indispensable ;  and, 
therefore,  I  may  not  properly  appreciate  the 
difficulties  that  it  is  intended  to  overcome. 
Under  any  circumstances  that  I  have  met 
with,  it  was  far  easier  to  perforate  the 
thorax  than  to  decapitate  the  child  ;  but, 
even  if  it  were  equally  easy,  it  seems  to  me 
liable  to  some  objections  from  which  the 
former  is  free.  When  the  head  is  separated, 
the  body,  it  is  true,  may  be  easily  removed  ; 
but  how  is  the  head  to  be  delivered  ?  If 
the  operation  be  performed  because  the 
pelvis  is  contracted,  the  extraction  of  a  loose 
unmanageable  mass  through  it  would  appear 
to  me  a  matter  of  no  ordinary  difficulty. 
We  would  not  think  of  it  if  the  head  were 
retained  in  the  womb  by  a  stricture  of  the 
cervix,  because  then  the  head  would  have  to 
be  removed  like  the  placenta  in  an  hour¬ 
glass  contraction  of  the  uterus,  and  you  can 
easily  imagine  what  kind  of  operation  that 
wrould  be.  I  cannot  readily  picture  to 
myself  a  case  requiring  decapitation  ;  but, 
as  it  has  been  performed  by  men  of  exten¬ 
sive  practical  experience  with  success,  it 
wmuld  be  improper  to  allow  these  objections 
to  outweigh  facts.  The  late  Dr.  Davis  and 
Dr.  Ramsbotham  have  both  decapitated  the 
child.  The  late  Dr.  Ramsbotham  invented 
an  instrument  for  this  purpose — a  hook, 
having  an  internal  cutting  edge  and  a  long 
shaft,  which  was  fixed  in  a  wooden  handle 
of  the  usual  length.  The  manner  of  using 
it  is  thus  described  by  Dr.  Ramsbotham  :  — 
“  The  finger  having  been  passed  around  the 
neck,  a  large-sized  blunt  hook  must  be  in¬ 
troduced  upon  it,  and  the  presenting  part 
must  be  brought  as  low  into  the  pubis  as  is 
consistent  with  the  woman’s  safety.  An 
assistant  must  then  steady  the  blunt  hook  : 
the  decapitator  must  be  directed  over  the 
neck  by  its  side;  and,  the  first  adapted  in¬ 
strument  having  been  withdrawn,  a  sawing 
motion  must  be  given  to  the  cutting-hook 
by  the  right  hand,  while  the  first  finger  of 
the  left  is  kept  steadily  in  contact  with  its 
blunt  point.  It  will  soon  be  found  that  the 
structures  give  way,  and  that  the  separation 
is  effected.  The  child’s  body  must  then  be 
drawn  out  by  whichever  arm  may  protrude, 
and  the  head  extracted  by  a  crotchet  or  blunt 
hook  introduced  into  the  foramen  magnum 
or  mouth  ;  nor  will  its  removal  generally 
offer  much  difficulty,  unless  the  pelvis  be 


*  Douglas,  op.  cit.  p.  25-27. 


DR.  HUGHES’  CASES  OF  PNEUMONIA  VARIOUSLY  TREATED.  743 


contracted  in  its  dimensions Such  is 
the  operation,  which  we  may  presume  pre¬ 
sents  some  little  difficulty  when  the  pelvis  is 
contracted  ;  and  if  it  be  not  contracted,  and 
such  mutilation  is  necessary,  I  think  evisce¬ 
ration  much  easier  and  safer  to  perform. 
Both  operations  are  equally  to  be  avoided  ; 
but  if  we  are  compelled  to  undertake  either, 
I  should  prefer  that  which  is  attended  with 
the  least  risk. 


©rigtnaf  (Communications. 


CASES  of  PNEUMONIA,  VARIOUSLY 
TREATED ; 

WITH  BRIEF  OBSERVATIONS. 

Read  at  the  South  London  Medical  Society , 
Oct.  12  th,  1848. 

By  H.  M.  Hughes,  M.D. 

Assistant  Physician  to  Guy’s  Hospital,  and  late 
President  of  the  Society. 

[Continued  from  p.  704.] 


Case  VI. —  Pleuro-pneumonia,  exten¬ 
sive  awl  severe ,  with  delirium ,  fyc. — 
Influence  of  antimony.  (From  the 
admirable  Report  of  Mr.  Hodson.) 

E.  E.,  aged  22,  admitted  into  Spare 
ward,  under  my  care,  Dec.  8th,  1847. 
He  was  a  bricklayer’s  labourer,  and 
had  been  in  Samaritan  ward  for 
five  weeks  for  syphilis,  of  which  he 
had  been  quite  cured.  He  had  pre¬ 
viously  enjoyed  good  health.  Five 
days  ago  he  was  seized,  two  or 
three  hours  after  dinner,  and  when 
feeling  quite  well,  with  violent  vo¬ 
miting,  succeeded  by  chilliness  and 
nausea,  which  were  followed  during  the 
night  by  rigors,  heat  of  the  surface, 
and  pain  of  the  head.  On  the  follow¬ 
ing  morning  he  complained  of  a  slight 
stitch  below  the  right  nipple.  He  was 
cupped,  and  took  some  saline  medicine 
by  order  of  Mr.  Stocker,  the  resident 
medical  officer,  but  without  any  relief. 
On  the  next  day  the  pain  became  ex¬ 
ceedingly  acute,  and  prevented  deep 
inspiration,  but  was  unattended  with 
cough.  A  blister  was  applied,  and  | 
rose  well.  The  next  day  he  had  a 
harsh,  dry,  short  cough,  with  some 
hurry  of  the.  respiration,  which  added 
to  his  general  suffering — Ordered  :  Pil. 


Antim.  Opiat.  fort,  (containing  Opii, 
gr.  j.)  c.  Hydrarg.  Chlorid.  gr.  ij. — 
The  day  before  he  was  submitted  to 
my  care  the  pain  and  distress  had 
greatly  increased  in  severity,  and  he 
was  bled  to  the  amount  of  ^viij.,  hut 
without  relief.  When  first  seen  by  me 
his  condition  appeared  to  be  very  un¬ 
promising.  The  distress  of  breathing 
was  great  ;  the  eyes  were  staring  and 
wildly  rolling,  and  the  countenance 
flushed,  but  at  the  same  time  pinched 
and  anxious;  he  wandered  when  left 
to  himself,  but  correctly  answered  the 
questions  addressed  to  him.  The  skin 
was  dry,  hot,  and  pungent ;  the  tongue 
dry,  and  covered  with  a  thick  brown 
coat;  the  lips  dry,  parched,  and 
cracked;  the  respirations  32  in  the 
minute,  short,  gasping,  hurried,  and 
mainly  abdominal ;  the  pulse  112,  tense 
and  small.  He  complained  of  pain  in 
the  head,  and  of  acute  laminating  pain 
in  the  right  side,  increased  on  cough¬ 
ing,  deep  inspiration,  and  decubitus  on 
the  affected  part.  He  had  very  little 
cough,  find  no  expectoration.  His  very 
little  sleep  was  disturbed  by  dreams. 
Upon  inspection  of  the  chest,  the  ribs 
were  found  to  be  very  slightly  raised 
upon  inspiration,  and  the  breathing  to 
be  almost  entirely  abdominal.  Per¬ 
cussion  elicited  a  dull  sound  from  the 
nipple  downwards  anteriorly,  and  from 
the  centre  of  the  scapula  downwards 
posteriorly.  Upon  auscultation  below 
the  nipple,  no  respiratory  murmur  wras 
audible,  but  a  loud  and  harsh  pleuritic 
rubbing;  while  above  that  point 
a  slight  mnco  crepitating  rattle  existed. 
Posteriorly,  at  the  upper  part,  existed 
marked  tubular  breathing,  and  at  the 
lower  part,  no  respiration  of  any  kind 
could  be  heard;  while  oegophony  and 
bronchophony,  or  a  combination  of  the 
two,  were  to  be  heard  throughout 
nearly  the  whole  of  the  back  part  of 
the  side.  On  the  left  side  the  breath¬ 
ing  was  pure,  but  puerile  — Ordered  : 
Emplast.  Cantharid.magn.lateridextro; 
Hydrarg.  Chlorid.  gr.  j.;  Antim. 
Potassio-tart.  gr.  £  3tia  quaque  hora  c. 
Mist.  Salina;  Pil.  Antim.  Opiat.  fort, 
c.  Hydrarg.  Chlorid.,  gr.  ij.  hord 
somni. 

9th. — Had  been  very  violent,  raving 
and  blaspheming  during  the  night,  and 
got  out  of  bed,  so  that  it  was  necessary 
to  confine  him.  The  face  was  flushed  ; 
the  eyes  staring  and  wandering;  the 
skin  and  tongue  as  before  ;  pulse  140, 


*  Ramsbotham,  p.  453. 


744  DR.  hughes’  cases  of  pneumonia  variously  treated. 


small  and  contracted.  Physical  signs 
unchanged.  An  additional  grain  of 
opium  had  been  administered,  by  order 
of  Mr.  Stocker,  late  in  the  evening, 
but  without  any  good  effect. — Rep. 
Pulv.  c.  Antim.  Potassio-tart.  gr.  ss. ; 
Cont.  Mistura;  Rep.  Pii.  flora  somni. 

10th. — Was  delirious  during  the 
whole  night,  but,  though  heavy  and 
dull,  was  quiet  this  morning,  and 
answered  correctly  the  questions  ad¬ 
dressed  to  him.  The  countenance  was 
less  wild  and  anxious  ;  the  tongue  still 
thickly  coated  with  brown  fur,  but 
slightly  moist ;  the  skin  warm  and  per¬ 
spiring;  the  pulse  100,  more  expanded 
and  compressible;  the  cough  was  still 
very  trifling,  and  he  had  no  expectora¬ 
tion.  He  had  passed  his  water  and  mo¬ 
tions  in  bed,  and  the  latter,  four  or  five 
in  number,  contained  some  blood  and 
mucus.  The  anterior  pleuritic  rale  was 
less  distinct,  and  heard  only  occa¬ 
sionally.  Over  the  lower  two-thirds  of 
the  chest  posteriorly  was  now  audible 
small  crepitating  rattle  ;  tubular  breath¬ 
ing  existed  above  the  spine  of  the  sca¬ 
pula,  and  distinct  oegophony  below  it. 
The  dulness  on  percussion,  both  before 
and  behind,  remained  as  before. — Rep. 
Pulv.  4ta  quaque  hora,  et  cum  sin¬ 
gulis  pulvenb.  capt.  Mistur.  Cretae, 

3iss- 

11th. — Passed  a  quiet  night,  but  ap¬ 
peared  stupid  and  deaf  in  the  morning. 
No  pleuritic  rubbing,  but  in  its  place 
slight  crepitation  was  now  heard  ante¬ 
riorly  as  well  as  posteriorly.  Pulse  96, 
feeble;  bowels  still  relaxed.— Rep. 
Empl.  Cantharid.  ;  Cont.  Pulv.  et  Mis¬ 
tura  6ta  quaque  hora. 

13th. — Had  passed  a  good  night,  and 
had  had  only  rwo  healthy  alvine  eva¬ 
cuations  since  the  day  before.  Pulse 
72,  soft  and  compressible ;  tongue 
moist,  and  covered  with  a  thick 
yellowish  mucus,  with  some  aphthee 
about  the  tip  and  freenum.  The  dul¬ 
ness  on  percussion  had  decreased.  The 
respiration  was  now  puerile  in  the 
right  infra-clavicular  region ;  the 
tubular  breathing  and  oegophony  had 
entirely  disappeared  posteriorly,  and  mu¬ 
cous  and  muco-crepitating  rattles  were 
general  in  all  the  parts  affected.  To 
have  an  egg  and  beef-tea. — Omitt. 
Pulv.  Capt.  Mistur.  Cretee  c.  Yin.  Ipe- 
cacuanh.  lipxx.  ter  die.  Gargarism. 
Acid.  Nitric,  pro  ore. 

14th. — The  aphthee  had  a  sloughing 
aspect,  and  were  ordered  to  be  brushed 


with  nitrate  of  silver  :  he  enjoyed  his 
food  notwithstanding. — Pergat. 

16th. — Countenance  cheerful,  and 
breathing  quite  easy  ;  the  mucous  were 
gradually  taking  the  place  of  the  more 
crepitating  rattles.  He  now  had  a 
slight  cough,  with  greenish  mucous 
expectoration  ;  the  dulness  on  percus¬ 
sion  had  almost  entirely  disappeared. 
Ordered  —  Decoct.  Cinchonee ;  Tr. 
Aurantii,  5j-5  Ammon.  Sesquicarb. 
gr.  iss.  6tis  horis.  Allowed  2  eggs. 

The  future  reports,  being  merely  in¬ 
dications  of  progressive  improvement, 
need  not  be  here  noticed. 

On  January  9th,  a  month  after  he  came 
under  my  care,  and  five  weeks  after  the 
commencement  of  the  attack,  the  re¬ 
port  is,  “  he  had  grown  quite  fat ;  the 
respiration  was  natural  on  both  sides, 
and  the  dulness  on  percussion  of  the 
right  side  was  barely  perceptible/’ — 
Presented. 

This  was  certainly  one  of  the  most 
severe  cases  of  pneumonia  which  I  ever 
saw  recover.  The  efficient  remedy  ap¬ 
peared  to  be  the  tartar  emetic.  No 
improvement  had  occurred  :  indeed,  he 
had  gone  on  from  bad  to  worse,  until 
this  medicine  was  increased  from  one- 
sixth  to  half  a  grain  every  three  hours. 
The  very  next  day  there  was  a  decided 
amelioration  of  some  of  the  symptoms, 
and  notwithstanding  the  dysenteric 
stools,  and  the  aphthee,  (probably  the 
result  of  the  medicine),  he  continued 
progressively  to  improve  till  he  got 
quite  well.  At  the  same  time,  it  may 
be  well  to  recollect,  that  had  not  the 
patient  been  young,  and  in  the  main 
healthy,  he  could  not  have  borne  the 
remedies  administered,  and  that  if  he 
had  not  died  of  the  disease,  he  would 
with  the  use  of  such  means  not  impro¬ 
bably  have  died  of  the  doctor. 

Case  YIT. — Pneumonia  —  treated  in¬ 
effectually  by  cup  piny,  calomel , 

antimony,  and  opium ,  afterwards  suc¬ 
cessfully  by  venesection.  (Reported 
by  Mr.  Devenish). 

E.  P.,  aged  29,  admitted  under  my 
care  into  Guy’s  Hospital,  Feb.  10th, 
1S48.  She  was  a  cook-maid,  living 
at  Brixton,  with  light  eyes,  full  face, 
and  brown  hair,  was  unmarried,  and 
had  previously  enjoyed  good  health. 
Four  days  ago,  after  exposure  to  cold 
while  washing,  she  felt  very  chilly, 
and  had  pains  in  all  her  limbs,  followed 
by  perspiration  and  pains  across  her 


DR.  HUGHES’  CASES  OF  PNEUMONIA  VARIOUSLY  TREATED.  745 


chest,  preventing  full  inspiration.  Upon 
admission,  she  was  very  sick,  from  the 
administration  of  medicine  containing 
antimony,  and  she  had  a  severe  cough, 
with  copious,  tenacious,  and  deep-red 
expectoration.  She  had  a  catching 
pain  in  the  left  side.  Her  respiration 
was  hurried  and  difficult  ;  her  tongue 
very  much  coated,  but  moist  ;  her 
bowels  actively  purged  from  medicines 
previously  administered  ;  her  skin  hot, 
dry,  and  pungent ;  her  pulse  quick  and 
full,  96-100,  and  her  appetite  defective. 
Adsunt  catamenia.  At  the  lower  part 
of  the  left  side  of  the  chest  there  ex¬ 
isted  great  dulness  on  percussion,  and, 
with  the  exception  of  the  infra-clavi- 
cular  region,  dulness,  though  to  a  less 
degree,  was  present  over  the  entire  an¬ 
terior  surface  of  the  left  side.  Over  the 
dull  parts  were  heard  marked  tubular 
breathing  and  bronchophony,  and  the 
former  of  these  gradually  merged  supe¬ 
riorly  into  characteristic  pneumonic 
crepitation.  The  right  side  appeared 
healthy. — Appl.  Cue.  Cruent.  ad  5 v i i j . ; 
Capt.  Pil.  Antim.  Opiat.  c.  Hydrarg 
Chlorid.  gr.  iss.  Ota  quaque  hord. 

1 1th. — The  face  was  flushed,  and  the 
skin  still  hot  and  pungent.  No  im¬ 
provement  existed  in  any  respect. — 
Rep.  C.  C.  lateri  sinistro  ad  3 v i i j . ;  et 
postea  Cataplasm  Lini. ;  Cont.  Pil.  4ta 
quaque  hold. 

12th.— Complained  of  great  pain  and 
great  distress  of  breathing.  The  dul¬ 
ness  on  percussion  and  crepitation 
were  each  more  extensive,  and  were 
obviously  but  progressively  creeping 
upwards,  and  involving  the  upper  part 
of  the  lung.  The  disease  was  still 
unchecked ;  on  the  contrary,  it  was 
obviously  on  the  advance,  though  the 
gums  were  slightly  affected  with  the 
mercury.  The  cough  was  very  dis¬ 
tressing, and  the  expectoration  mucous, 
reddish,  and  tenacious.  The  bowrels 
were  confined. — V.  S.  ad  prima  signa 
deliquii;  Capt.  Olei  Ricini,  statim. 
Rep.  Pilul. 

13th.— Relieved  by  bleeding  ;  about 
ten  ounces  of  blood  were  removed : 
coagulum  was  cupped  and  slightly 
buffed;  bowels  loose. —  Rep.  Pil.  6ta 
quaque  bora,  et,  si  opus  fuerit,  Mist. 
Cretan 

15th. — Felt  much  better:  the  skin 
was  now  moist;  the  pulse  87,  soft; 
the  gums  and  mouth  were  very  sore. 
The  crepitation  formerly  existing  in 
the  upper  part  of  the  lung  had  disap¬ 


peared,  and  had  supplied  the  place  of 
the  tubular  breathing  previously  pre¬ 
sent  in  the  low^er  part  of  the  lung. — 
Rep.  Pil.  sine  Hydrarg.  Chlorid.; 
Capt.  Vin.  Antim.  Potassio-tart.  npxx. ; 
Potass.  Nitrat.  gr.  v. ;  Syr.  Papaver. 
5j.  ex  Aqua  6tis  horis.  Applicet. 
Emplastr.  Cantharid.  lateri  sinistro. 

17th. — Felt  better.  The  resonance 
on  percussion  of  the  two  upper  thirds 
of  the  left  side  wras  nearly  normal ;  and 
the  respiratory  murmur  was  more  dis¬ 
tinct,  more  free  from  crepitation,  and 
extended  further  down.  The  bowels 
wrere  still  relaxed,  and  the  blister  verv 
sore. — Capt.  Mistur.  Cretee,  c.  Syr. 
Papaver.  5b;  et  "Vin.  Ipecacuanh. 
Iiqxxv.,  6ta  quaque  hord  ;  Rept.  Pil. 

19th. — Was  making  favourable  pro¬ 
gress  in  every  respect.  Crepitating 
rattle  w?as  now  heard  to  the  very  base 
of  the  chest,  at  the  end  of  the  inspira¬ 
tion,  and  the  commencement  of  the 
expiration,  though  bronchophony  and 
tubular  breathing  still  existed  there; 
cough  and  soreness  of  mouth  still 
troublesome ;  expectoration  mucous 
and  white,  mixed  with  a  few  streaks 
of  blood. — Pergat  Gargarism.  Acid. 
Nitric. 

24th. — The  resonance  of  the  left 
side  was  now  equal  to  that  of  the  right 
side;  the  vesicular  murmur  was  now 
general,  but  was  obscured  by  mucous 
rattles;  she  complained  principally  of 
want  of  sleep. — Capt.  hora  somni  Opii, 
gr.  j.  ;  Quinse  Di&ulphat.  gr.  j. ;  Acid. 
Sulph.  dil.  rt|iss. ;  Tr.  Aurantii,  3ss.; 
Syr.  Aurantii,  5i*  ex  Aq.  ter  die. 

26th. — Had,  on  some  parts  of  her 
body,  a  crop  of  eczema,  to  W'hich  she 
had  been  previously  subject. 

28th. — Eczema  general.  Evidences 
of  pneumonia  had  entirely  disappeared. 

March  2d. — Eczema  haddisappeared. 
Convalescent. 

18th. — Presented  quite  well. 

Never  was,  I  think,  presented  to  my 
notice  a  more  marked  instance  of  pneu¬ 
monia,  and  rarely  has  venesection  been 
more  obviously  beneficial  than  in  this 
case.  Until  bleeding  w7as  employed 
the  disease  was  on  the  advance, 
notwithstanding  that  the  gums  were 
already  highly  affected  by  the  mercury. 
Immediately  that  the  bleeding  was 
practised,  and  partial  syncope  was  in¬ 
duced,  the  disease  appeared  checked, 
and  from  that  time  the  recovery  of, 
the  patient  was  steadily  progressive. 


746  DR.  hughes’  cases  of  pneumonia  variously  treated. 


Possibly  large  doses  of  antimony  might 
have  been  equally  effective.  Was  the 
eczema  the  effect  of  the  mercury  on  a 
person  previously  liable  to  this  affec¬ 
tion  of  the  skin  ?  From  its  sudden 
appearance,  and  equally  sudden  disap¬ 
pearance,  I  presume  that  it  was  the 
exciting  cause  of  the  complaint.  Had 
the  eruption  any  effect  in  the  removal 
of  the  more  severe  complaint  ?  I  be¬ 
lieve  that  it  had  none,  as  it  only  ap¬ 
peared  when  the  cure  was  already 
almost  complete. 

Case  VIII. — Pleuro-pneumonia  ;  ordi¬ 
nary  constitutional  symptoms  absent. 

Treatment — calomel,  antimony ,  and 

opium,  with  cupping. 

R.  B.,  aged  38,  admitted  into  Talbot 
Ward,  under  my  care,  April  14th, 
1848.  A  tall,  sallow  man,  of  regular 
habits,  by  occupation  a  mason,  was 
in  the  hospital  four  years  ago,  in  con¬ 
sequence  of  a  mason’s  chisel  being 
accidentally  thrust,  up  to  the  very 
head,  into  his  side,  just  below  the  left 
scapula.  He  then  suffered  very  little; 
had  no  haemoptysis  or  pneumonia,  or 
even  pleurisy,  in  consequence,  and  was 
discharged,  free  from  complaint  in  a 
month.  From  that  time  he  had  always 
enjoyed  good  health  up  to  ten  days 
ago,  when  he  was  attacked  with  shiver¬ 
ing,  faintness,  and  headache,  together 
with  a  sharp  pain  under  the  sixth  and 
seventh  ribs,  on  the  right  side,  which 
was  increased  upon  coughing  and  deep 
inspiration.  He  had  some  slight  cough 
and  expectoration.  He  now  suffered 
from  general  malaise,  and  complained 
of  pain  in  the  right  side,  increased  on 
deep  inspiration  ;  he  had  a  little  herpes 
round  the  lips,  but  very  little  cough, 
and  no  expectoration.  The  skin  was 
cool,  and  rather  moist,  and  he  had 
occasionally  rather  free  perspirations. 
The  urine  was  rather  abundant,  high 
coloured,  and  bilious.  The  right  side, 
below  the  nipple  before,  and  the  centre 
of  the  scapula  behind,  was  very  dull 
on  percussion.  Posteriorly,  tubular 
breathing  and  cegophonic  broncho¬ 
phony  ;  and  anteriorly,  pleuritic  rub¬ 
bing,  together  with  characteristic  cre¬ 
pitating  rattle,  were  sodistinctly  audible 
as  to  be  recognised  by  several  pupils. 
Ordered— C.  C.  parti  dolent.  ad  3X. ; 
Pil.  Antim.  Opiat.c.  Hydrarg.  Chlorid. 
gr.  iss.  6tis  horis,  c.  Julep.  Ammon. 
Acetatis. 

15th. — Pain  relieved;  slept  well; 


pulse  70,  compressible :  in  other  re¬ 
spects  as  before.— Pergat. 

16th.— Complained  again  of  pain  in 
the  right  side,  but  had  no  cough  and 
noexpectoration.  Pleuritic  rubbing  and 
crepitating  rattle  anteriorly,  and  tubu¬ 
lar  breathing,  with  bronchophony, 
posteriorly,  still  distinc  ly  audible,  and 
dulness  on  percussion  observable  in  all 
the  parts  affected. — Empl.  Cantharid. 
magn.  lateri  dexlro.  Pergat. 

17th. — The  tubular  breathing  was 
less  marked  posteriorly.  Air  began 
now  to  enter  into  the  finer  divisions  of 
the  bronchial  tubes,  and  some  mucous 
and  some  mueo-crepitating  rattles  be¬ 
came  audible  behind.  The  pleuritic 
rubbing  was  still,  but  no  crepitation 
was  now,  audible  anteriorly.  The 
pulse  was  regular,  the  tongue  clear, 
and  the  bowels  open. — Pergat. 

18th. — The  gums  w7ere  rather  tender ; 
the  mucous  crepitation  was  gradually 
becoming  more  general  behind ;  the 
dulness  on  percussion  was  less  exten¬ 
sive,  and  less  marked  ;  and  the  tubular 
breathing  had  considerably  decreased. 
The  tongue  was  moist,  and  rather 
furred.  Pulse  62. — Pergat. 

22d. — “Rale  crepitant  redux”  had 
since  the  last  report  been  very  general 
posteriorly,  but  had  now  diminished, 
as,  indeed,  had  all  the  physical  signs, 
though  considerable  dulness  on  per¬ 
cussion  still  existed. — Rep.  Pil.  ter  die. 

27th. — The  pleuritic  rubbing  was 
quite  gone,  and  the  dulness  had  di¬ 
minished  :  pure  respiratory  murmur 
was  now  audible  in  the  parts  in  which 
tubular  breathing  and  bronchophony, 
the  mucous,  muco-crepitant,  and  cre¬ 
pitant  rattles,  had  been  successively 
distinctly  heard.  The  administration 
of  the  pill  had  been  gradually  reduced 
in  frequency:  the  pulse  was  regular; 
the  bowels  open,  and  the  appetite 
good. — Rep.  Pil.  alternis  noctib. 

May  8th. — He  had  continued  to  im¬ 
prove  in  strength,  though  some  dul¬ 
ness,  the  only  remnant  of  the  disease, 
continued  posteriorly.— Rep.  Empl. 
Cantharid. ;  Inf.  Gentian,  c.  c.  Liq. 
Potass,  nix.  ter  die. 

16th. — He  felt  pretty  well  and  strong. 
Presented. 

Independently  of  the  fact  of  the 
mason’s  chisel  being  forced  into  the 
left  side  of  the  chest  four  years  be¬ 
fore,  and  no  indication  of  internal 
injury,  and  scarcely  any  mark  of 
external  violence  being  left  behind, 


DR.  MAYO’S  OUTLINES  OF  MEDICAL  PROOF. 


747 


the  peculiarity  of  this  case,  if  any, 
existed  in  the  extremely  well-marked 
characters  of  the  physical  signs,  and 
the  facility  with  which  the  complaint 
was  marked  thereby,  together  with, 
considering  the  extent  and  nature 
of  the  disease,  the  exceedingly  slight 
constitutional  symptoms  which  ac¬ 
companied  them.  It  may  not,  per¬ 
haps,  be  too  much  to  say  that  the 
nature,  the  gravity,  and  extent  of  the 
affection,  without  the  aid  of  percussion 
and  auscultation,  could  not  have  been 
discovered,  and  would  scarcely  have 
been  suspected. 

Case  IX. — Simple  pneumonia  during 

the  progress  of  fever.  (From  the 

Report  of  Mr.  Tassel.) 

M.  F=,  aged  19,  admitted  May  3d, 
1848,  under  my  care,  into  the  hospital 
in  a  considerably  advanced  stage  of 
fever,  with  a  dry  brown  tongue;  ma¬ 
cula  upon  the  surface  of  the  trunk, 
diarrhoea  and  retention  of  urine,  for 
which  ammonia  and  serpentary  wine, 
opiate  and  starch  enemata,  and  the  ca¬ 
theter,  were  employed  with  advantage, 
was,  upon  the  eighth  day  of  her  ad¬ 
mission,  and  the  eighteenth  day  of  the 
complaint,  while  making  favourable 
progress,  attacked  with  pain  of  the 
side,  below  the  mamma,  accompanied 
with  heat  of  skin,  and  great  vascular 
excitement,  cough,  dulness  on  percus¬ 
sion,  and  muco-crepitating  rattle  in 
the  part  affected,  together  with  white, 
frothy,  and  tenacious  expectoration. 
Ordered — Empl.  Cantharid.  lateri  si- 
nistro  ;  Pulv.  Ipecac,  c.  gr.  v.  ;  Hy- 
drarg.  c.  Creta,  gr.  ij.  quaque  nocte ; 
Ammon.  Sesquicarb.  gr.  iij. ;  Julep. 
Ammon.  Aceiatis,  Infus.  Serpentarise 
c.  aa.  5vj.;  Yin.  Ipecac,  nqxx.  6ta  qua¬ 
que  hora.  Omitte  Yinum. 

May  11th.  — The  next  day  the  cre¬ 
pitation  was  less;  the  cough  equally 
frequent  and  severe,  but  she  appeared 
very  low. — Pergat,  sed.  capt.  Yini,  3iv. 

13th. — Great  excitement  was  pre¬ 
sent;  the  tongue  was  rather  dry,  and 
the  skin  was  hot,  dry,  and  pungent, 
though  the  dulness  on  percussion  was 
less,  and  the  crepitation  had  now 
merged  into  a  simple  mucous  rattle. — 
Omitte  Yinum  ;  Cont.  Mistur.  et 
Pulv.  From  this  time  she  progressed 
favourably  and  rapidly;  though  she 
was  again  considerably  excited,  and 
complained  of  headache,  when,  during 
her  convalescence,  she  was  again  or¬ 


dered  a  little  wine.  It  was  conse¬ 
quently  withdrawn  altogether  ;  she 
rapidly  gained  strength  without  it,  and 
was  enabled  to  leave  the  hospital  quite 
well  by  the  end  of  the  month. 

I  do  not  think  that  this  case  requires 
any  especial  remark,  though  I  do  not 
consider  it  on  that  account  the  less 
importantly  illustrative  of  the  ques¬ 
tions  referred  to  in  the  opening  para¬ 
graph  of  this  communication. 

[To  be  continued.] 


OUTLINES  of  MEDICAL  PROOF. 

By  Thomas  Mayo,  M.D.  F.R.S. 

Physician  to  the  Infirmary  of  St.  Marylebone. 

[Continued  from  p.  4S7.] 

In  my  last  paper  I  made  an  admission 
of  very  obvious  truth,  that  the  causes 
which  we  assign  in  pathology  and 
therapeutics  do  not  fulfil  the  strictly 
philosophical  idea  of  the  word  cause  : 
that  they  rarely  pretend  to  contain  the 
whole  antecedents  to  the  effect.  Still, 
in  order  that  the  name  may  be  assigned 
in  a  sense  distinguishing  it  from  mere 
condition  or  property,  the  cause  must 
offer  some  explanation  of  the  effect. 
Thus,  to  take  an  example  from  general 
physics,  let  us  suppose  an  inquirer  into 
the  phenomena  of  dew  to  have  arrived 
at  the  fact  that  bodies  which  radiate 
heat  most  are  so  far  most  readily  be¬ 
dewed  on  their  surfaces.  Now,  ob¬ 
serving  that  the  radiation  of  heat  is 
productive  of  relative  cold  to  the  ra¬ 
diating  body,  he  will  be  justified  in 
considering  radiation  of  heat  in  bodies 
a  cause  of  dew  by  chilling  them,  and 
thus  producing  on  them  a  deposit  of 
moisture  from  the  surrounding  air. 
Let  him  pursue  his  inquiry  further, 
and  he  will  find  radiation  of  heat  only 
a  modifying  circumstance  in  reference 
to  the  general  laws  of  condensation  of 
insensible  vapour  by  cold,  as  the  true 
cause  of  dew.  But  the  extent  to  which 
his  first  conception  on  the  subject  has 
proved  explanatory  of  the  phenomena 
will  have  entitled  him,  according  to 
the  usages  of  language,  to  assign  to  it 
a  causative  agency.  Neither  does  this 
supposition  on  my  part  imply  any  re¬ 
turn  to  the  justly  exploded  doctrine  of 
efficient  causes.  It  is,  indeed,  most 
true,  that  of  the  essence  of  causation, 
we  have  no  knowledge  beyond  the  re- 


748 


DR.  MAYO’S  OUTLINES  OF  MEDICAL  PROOF. 


cognition  of  a  sequence  of  phenomena: 
yet,  in  assenting,  in  these  respects,  to 
the  limitation  of  T)r.  Brown,*  I  may 
allege  that  the  recognition  of  this 
sequence  of  phenomena  does  in  some 
cases  involve  a  discovery  of  the  man¬ 
ner  in  which,  or  the  laws  under  which, 
the  effect  takes  place.  Such  is,  I  be¬ 
lieve,  the  sense  in  which  we  are  justly 
said  to  comprehend  the  relation  of  an 
effect  to  its  cause,  in  the  fullest  degree. 
And  such  is,  I  believe,  the  sense  in 
which  every  language  possesses  a  term 
corresponding  to  cause,  and  distin¬ 
guishing  a  causal  condition  from  all 
other  conditions  or  properties ;  whe¬ 
ther  the  idea  be  that  under  which  all 
the  antecedents  to  the  effects  are  com¬ 
prehended,  or  that  more  limited  one  in 
which,  as  I  have  observed,  we  are 
often  contented  to  apply  the  term  in 
medicine. 

Now  it  must  be  admitted  that  the 
causes  assigned  on  a  gratuitous  hypo¬ 
thesis  will  partake  in  the  nature  of 
that  hypothesis ;  and  that  the  expla¬ 
nation  which  such  causes  suggest  will 
be  fanciful.  Their  propounder,  in¬ 
deed,  if  he  rightly  understand  their 
use,  will  view  them,  comformably  to 
the  expression  of  Sydenham,  only  as 
subservient  to  a  more  vivid  illustration 
of  his  ideas. 

I  have  observed,  in  the  Outlines  of 
Medical  Proof,  that  in  this  latter  point 
of  view  a  gratuitous  hypothesis  may 
be  useful,  or  even  essential,  as  an  ex¬ 
ponent  of  certain  researches.  “No 
definite  idea,”  I  remark,!  “  could  be 
conveyed  by  description  of  the  cogitata 
et  visa  of  microscopical  physiologists, 
either  to  themselves  or  others,  unless 
in  expressing  them  they  had  assumed 
a  theory  of  uses  and  purposes.”  But, 
while  I  contend  for  the  value  of  gra¬ 
tuitous  hypotheses  in  such  respects,  I 
must  express  a  suspicion  that  these 
philosophers  are  not  always  sufficiently 
cautious  as  to  the  extent  of  proof  w  hich 
they  consider  it  to  afford.  Nor  am  I 
satisfied  on  this  point  by  their  occa¬ 
sional  admissions  of  the  speculative 
character  of  their  researches.  “  It  is 
by  the  special  vital  activity  of  indivi¬ 
dual  cells,”  says  Dr.  Addison,  “  and  of 
all  the  visible  particles  composing 
their  structures,  that  the  secretions 
are  produced.”!  Surely  some  modify¬ 


*  On  Cause  and  Effect, 
t  Page  19-20. 

!  This  passage  is  taken  by  me  out  of  a  long 


ing  terms  are  wanted  here  expressive 
of  the  total  absence  of  all  the  really 
explanatory  ingredients  of  causation, 
under  wThich  this  assignment  of  a 
cause  to  the  secretions  labours.  Com¬ 
pare  this  passage  w*ith  the  important 
experiment,*  No.  XIII.,  by  the  same 
author,  through  which  he  enables  us 
to  conjecture  analogically  how  a  for¬ 
mative  powder  may  be  generated  in  pus 
corpuscles,  by  observing  them  in  con¬ 
tact  wdth  liquor  potassa,  and  witness¬ 
ing  the  tissue  formed  by  this  combina¬ 
tion.  In  the  first  of  the  cases  adverted 
to,  the  existence  of  a  cell-power  is 
begged  by  the  use  of  terms  w'hich  pre¬ 
suppose  it;  in  the  second  case,  we  are 
taught  by  a  well-devised  experiment 
howr  such  a  pow-er  may  be  possibly 
contributed  ah  extra;  and  an  analogy  is 
thus  supplied  wrhich  may  at  some  time 
suggest  the  organic  cause  of  such  tis¬ 
sues.  Such  is  the  difference  between 
the  gratuitous  hypothesis  first  stated, 
and  the  experiment  last  alluded  to  ; 
yet  both  are  given  by  the  ingenious 
author  with  the  same  apparent  con¬ 
fidence  as  to  their  value. 

But  wherein,  T  may  be  asked,  con¬ 
sists  the  harm  of  the  gratuitous  hypo¬ 
thesis  thus  quoted,  serviceable  as  it  is 
in  giving  a  bond  of  union  to  vital  pro¬ 
cesses  ?  Merely  in  this— that  its  au¬ 
thor  assigns  it  a  positive,  and  not  a 
conditional,  truth.  So  anxious,  indeed, 
is  he  to  maintain  cell-structure  in  the 
possession  of  a  causative  power,  that, 
in  the  experiment  just  quoted,  summing 
up  its  results,  he  damages,  if  I  mistake 
not,  its  real  value  as  an  analogical 
illustration  of  the  manner  in  which,  by 
a  superinduced  agency,  cells  may  form 
a  tissue  or  membrane,  by  using  it  as  a 
direct  evidence  of  the  truth  of  a  gra¬ 
tuitous  hypothesis  that  cells  do  form 
such  membranes  proprio  motu.  His 
expressions  are — “It  is  evident  the 
plasticity  of  the  resulting  membrane 
results  from  the  rupture  of  the  cells.”! 
Herein  he  takes  no  account  of  the  con¬ 
ceivable  agency  of  the  liquor  potassse, 
not  only  in  making  them  discharge 
their  contents,  but  in  modifying  the 
product. 

paragraph.  My  reader  will  readily  ascertain,  by 
referring-  to  the  original  work,  whether  I  have 
done  it  injustice  in  calling  it  a  gratuitous  hypo¬ 
thesis,  in  spite  of  the  ingenious  matter  which 
accompanies  it,  in  that  and  the  preceding  para¬ 
graph.— See  Experimental  Researches  on  Secre¬ 
tion,  by  W.  Addison,  F.  L.  S.  page  22. 

*  See  actual  process  of  nutrition,  page  18. 

!  See  Experiment  XIII. 


DR.  MAYO’S  OUTLINES  OF  MEDICAL  PROOF. 


749 


Thus  it  happens  that  a  description  is 
confounded  with  an  inductive  process. 
The  plastic  or  formative  power  which 
is  assigned  to  cells  are  not  conditions 
involved  in  the  relations  in  which 
those  cells  and  molecules  are  witnessed 
through  the  microscope,  whether  com¬ 
bined  or  in  successive  development. 
The  relation  expressed  by  Dr.  Addison 
in  those  terms  is  gratuitous  at  present, 
and  awaits  the  discovery  of  a  real 
power,  as  it  would  be  called,  according 
to  the  doctrine  of  efficient  causes ;  or 
of  an  inductive  explanation,  as  we 
should  venture  to  term  the  deficient 
element. 

The  plastic  or  formative  power  of 
cells  forms  the  basis,  in  Schwann’s  ad¬ 
mirable  work,  ol  much  reasoning,  se¬ 
ductive,  as  it  appears  to  me,  from  the 
real  mode  of  obtaining  truths  on  the 
construction  of  tissues,  and  the  causa¬ 
tion  of  secretions.  Beginning  with  an 
admission  of  his  hypothetical  mode  of 
proceeding,  “  the  unknown  cause  pre¬ 
sumed  to  be  capable  of  explaining  these 
processes  in  the  cells  may  be  called  the 
plastic  power  of  the  cells,”  his  rea¬ 
soning  proceeds  absolutely  and  autho¬ 
ritatively  as  if  a  true  cause  had  been 
eliminated.  In  the  first  place,  there  is 
a  power  of  attraction  exerted  at  the 
commencement  of  cell  life,  in  the 
molecules,  which  occasions  the  addi¬ 
tion  of  fresh  molecules  to  those  first 
observed.  Now  let  us  consider  what 
explanatory  force  this  word  attraction 
may  possess. 

Physical  attraction  is  said  to  act  at 
sensible  or  insensible  distances  :  in  the 
former  sense,  it  is  in  relation  to  our 
globe,  gravitation  disposing  all  bodies 
to  descend  to  the  earth.  In  the  other 
sense,  it  preserves  the  forms  of  bodies, 
modifies  texture,  gives  spherical  form 
to  fluids,  causes  adhesion  ol  surfaces, 
and  influences  their  mechanical  cha¬ 
racter  ;  operating  upon  dissimilar  par¬ 
ticles,  it  produces  their  union.  But  in 
all  these  cases  it  operates  agreeably  to 
laws.  It  is  for  the  microscopist  to 
point  out  under  what  laws  his  attraction 
acts  in  the  cases  referred  to.  This  he 
has  not  done. 

We  next  find  a  metabolic  power,  or 
a  power  of  originating  changes,  attri¬ 
buted  to  cells ;  and  vinous  lermenta- 
tion  is  adduced  by  Schwann  as  an 
instance  of  this.  “  A  decoction  of  malt,” 
he  observes,  “  will  remain  for  a  long 
time  unchanged,  but  as  soon  as  some 


yeast  is  added  to  it,  which  consists 
partly  of  entire  fungi,  partly  of  single 
cells,  the  chemical  change  immediately 
ensues.  Herethedecoctionof  malt  is  the 
cytoblastema;  the  cells  already  exhibit 
activity,  the  cytoblastema,  in  this  in¬ 
stance,  even  aboiled  fluid, beingperfectly 
passive  during  the  change.”*  Now, 
is  not  this  a  game  of  words  ?  Would 
it  not  be  as  easy  to  say,  that  the  activity 
of  the  cells  is  itself  occasioned  by  the 
cytoblastema,  the  decoction  of  malt,  or 
that  the  actions  are  reciprocal  P  Each, 
in  fact,  undergo  changes,  though  “  the 
contents  of  the  cell  undergo  more  fre¬ 
quent  changes  than  the  external  cyto¬ 
blastema.  The  movement  of  the  cell 
is  no  proof  that  they  originate  motion, 
neither  is  the  apparent  quietness  of  the 
decoction  of  malt  a  ground  for  asserting 
that  it  is  not  influencing  the  cells.  If 
the  fact,  that  this  fluid  is  boiled,  be 
adverted  to  by  Schwann,  as  involving 
inactivity  of  the  cytoblastema,  why 
does  it  not  also  involve  inadequacy  in 
its  materials  to  form  parts  of  active 
cells  ?  How  unlike,  in  the  important 
particular  of  referring  phenomena  to 
general  laws,  is  Schwann’s  cell  theory 
of  fermentation,  to  Liebig’s  reference 
of  that  process  to  the  contagious  in¬ 
fluence  of  chemical  action,  a  law  so 
widely  instanced  in  the  decomposition 
of  substances  held  together  by  weak 
chemical  forces  !  By  this  law,  truly  a 
chemical  one,  we  are  enabled  to  accept 
the  primary  influence  of  the  cells,  as 
being  in  a  state  of  chemical  action,  and 
the  contagious  decomposition  of  the 
cytoblastema. 

In  the  above  remarks,  I  have  ven¬ 
tured  to  criticise  important  inquiries  in 
a  field  out  of  which  pathological  and 
therapeutical  hypothesis  of  a  valuable 
kind  may  eventually  be  raised.  It  is 
my  consciousness  of  the  importance  of 
the  subject,  on  these  grounds,  that  has 
made  me  select  it  for  these  strictures. 
But  I  am  far  more  confident  in  the  im¬ 
portance  of  my  subject  than  in  my 
success  in  handling  it.  However  this 
may  be,  I  will  suggest  a  few  of  the 
principal  grounds  for  caution,  against 
those  errors  in  reference  to  presumed 
causation,  which  I  have  endeavoured 
to  elucidate. 

The  simplest  descriptions  involve,  in 
a  degree,  hypothetical  language,  and  I 


*  Page  198.  Microscopical  Researches,  pub¬ 
lished  by  the  Sydenham  Society. 


750  ON  THE  BLOOD-VESSELS  OF  THE  NERVES  OF  THE  HEART. 


have  pointed  out  its  peculiar  demand 
in  microscopical  inquiries.  But  the 
objects  of  perception  ascertained,  and 
the  order  in  which  they  are  presented, 
being  the  truly  important  points  at  the 
present  stage  of  the  above  inquiries, 
may  be  obscured  and  overlaid,  as  it 
were,  by  too  ambitious  hypothesis. 

The  progress  of  inquiries  towards 
the  ascertainment  of  inductive  causes 
will  be  thus  retarded,  the  discovery  of 
such  causes  being  assumed  to  have  al¬ 
ready  taken  place,  while  causes  founded 
on  gratuitous  hypothesis,  and  explain¬ 
ing  nothing,  are  adduced  as  inductive 
causes. 

Finally,  risk  is  incurred  of  some 
sterile  hypothesis  being  drawn  from 
these  views,  and  engrafted  on  medical 
investigation. 

The"  last  of  these  considerations 
touches  a  subject  deeply  connected  with 
our  philosophical  interests.  The  con¬ 
current  energy  with  which  medical 
science  is  at  present  cultivated  through 
Europe  and  America,  places  us  on  the 
threshold  of  great  discoveries  ;  and 
these  may  probably  be  expected  via 
the  prosecution  of  microscopy  and  che¬ 
mistry,  as  giving  us  the  completest 
information  respecting  structure  and 
composition.  I  have  suggested,  on  a 
former  occasion,  that  chemistry  has 
sometimes  been  over-daring  in  its  ap¬ 
plication  to  medicine  of  causes  founded 
on  induction.  From  microscopy  we 
are  in  some  peril  of  receiving  causes, 
having  no  foundation  but  words. 

[To  be  continued.] 


OX  THE 

BLOODVESSELS  OF  THE  NERVES 
OF  THE  HEART. 

By  Joseph  Swan,  F.R.C.S. 

[Continued  from  page  366.] 


Part  II. 

Besides  the  superficial  plexus  for  the 
supply  of  the  fat,  the  pericardium  and 
nerves,  the  coronary  arteries  in  descend¬ 
ing  send  numerous  small  branches  to 
the  surface  of  the  muscle,  and  large 
branches,  almost  transversely,  through 
the  parietes,  which  freely  distribute 
smaller  branches  to  the  muscular  fibres, 
and  send  some  to  form  a  plexus  on  the 


attached  surface  of  the  lining  mem¬ 
brane.  Athough  the  coronary  arteries 
communicate  at  the  ring  at  the  base 
of  the  heart,  and  at  the  apex,  the  com¬ 
munication  is  not  very  free,  but  each 
can  do  very  little  more  than  supply  its 
respective  region  ;  so  that  if  one  is  in¬ 
jected  with  red  and  the  other  with 
black,  the  parietes  each  supplies  will 
assume  the  colour  of  the  injection; 
and  when  the  left  coronary  artery  was 
wounded  at  the  ring  three  quarters 
of  an  inch  beyond  the  trunk,  and  each 
end  of  the  wound  was  secured  by  a 
ligature,  the  part  it  supplied  was  not 
injected,  but  required  another  pipe  to 
be  fixed  in  the  wounded  part  for  this 
purpose.  When  the  veins  have  been 
filled  w7ith  quicksilver,  the  apex,  on 
being  pressed,  instantly  rebounded  like 
an  elastic  ball ;  and  it  may,  therefore, 
appear  probable  that  besides  the  taper¬ 
ing  form,  the  large  bloodvessels  in  this 
part  tend  to  prevent  the  reception  and 
communication  of  too  great  an  impulse. 
The  superficial  plexus  has  been  ad¬ 
verted  to  by  Portal*  in  his  description 
of  the  coronary  arteries,  inasmuch  as 
Ruysch  had  injected  these  arteries  so 
minutely  that  the  head  of  a  pin  could 
not  be  put  in  any  vacant  place  on  the 
surface.  In  one  heart,  l  lately  injected 
not  onlv  the  bloodvessels  but  the  ab- 
sorbents,  at  id  there  was  a  great  ap¬ 
proach  to  this  description;  indeed, 
from  apparently  nothing  to  see,  in  a 
few  minutes  not  only  the  whole  surface 
covered  with  vessels,  but  their  order 
and  distinctness,  excited  a  greater  de¬ 
gree  of  admiration  than  I  have  ever 
before  experienced  from  any  anatomi¬ 
cal  display. 

In  the  last  three  hearts  I  injected,  I 
filled  not  only  blood-vessels,  but  ab¬ 
sorbents.  In  the  first,  some  of  the 
injection  had  reached  the  veins,  and 
an  absorbent  of  the  size  of  one  or  two 
bristles  was  filled  with  the  varnish, 
but  not  with  any  of  the  vermilion,  on 
every  nerve  I  examined.  The  second 
I  have  already  alluded  to,  and  the  ab¬ 
sorbents  on  the  largest  nerves  were 
filled  to  the  size  of  a  crow’s-quill  ;  on 
the  smaller  nerves  they  were  smaller. 
In  the  third,  none  of  the  injection 
appeared  to  enter  the  veins,  but  the 
exhalants  allowed  the  clear  varnish  to 
exude  so  freely  as  to  keep  the  pericar¬ 
dium  bathed  as  the  skin  would  be  in  a 


*  Anatomie  Medicate,  tome  iii.  p.  148. 


REMARKABLE  CASE  OF  EARLY  MENSTRUATION  AND  PREGNANCY.  751 


profuse  sweat. ;  the  largest  absorbents 
were  of  the  size  of  a  crow’s-quill. 

Anatomists  have  for  more  than  half 
a  century  believed  that  mistakes  have 
frequently  arisen  from  adopting  absor¬ 
bents  for  nerves.  When  the  absorbents 
are  empty,  they  appear  as  parts  of  the 
nerves,  and  when  they  are  moderately 
filled,  they  appear  in  close  connection 
with  the  nerves  ;  but  when  they  are 
fully  distended,  they  completely  over¬ 
shadow  them. 

I  have  thus  shown  that  the  white 
lines  on  the  surface  of  the  heart  are  not 
pure  nerves,  but  contain  a  large  pro¬ 
portion  of  extraneous  matters,  and  if 
they  are  carefully  examined,  they  will, 
I  think,  appear  to  possess  only  the 
small  quantity  of  nervous  matter  they 
derive  from  their  respective  trunks. 

Although  from  the  quotation  I  have 
made  it  is  clear  it  has  been  longknown 
that  there  existed  a  general  superficial 
plexus  of  blood-vessels,  and  although 
the  absorbents  of  the  heart  are  de¬ 
scribed  by  almost  every  author  on  ana¬ 
tomy,  no  mention  has  been  made  either 
of  the  one  or  the  other  as  having  a 
peculiar  arrangement  with  respect  to 
the  nerves. 


REMARKABLE  CASE 

OF 

EARLY  MENSTRUATION  AND 
PREGNANCY. 

By  John  Smith,  M.R.C.S.  L.A.C. 

The  circumstances  connected  with  the 
subsequent  case,  on  account  of  the  ex¬ 
treme  youth  of  the  party,  have  excited 
considerable  interest  in  this  city  and 
neighbourhood ;  and  as  communica¬ 
tions  have  been  made  to  me  from  dis¬ 
tant  parts  of  the  country  for  purposes  of 
inquiry,  it  is  a  point  of  duty  to  give 
publicity  to  the  facts  in  a  different  form 
from  that  in  which  they  have  already 
appeared.  It  is  due,  however,  to  myself, 
to  premise  that,  inasmuch  as  no  un¬ 
toward  symptoms  occurred  during  the 
progress  of  parturition,  it  did  not  seem 
necessary,  nor  was  it  my  intention,  to 
have  made  any  further  record  of  the 
occurrences  themselves,  than  by  giving 
them  a  place  among  my  notes  of  cases, 
— so  that,  in  this  simple  desire  to  satisfy 
the  public  mind,  I  trust  I  may  escape 
the  imputation  of  obtrusiveness. 

It  may  not  have  been  forgotten  by  some 


of  your  readers,  that,  at  the  Coventry 
Assizes  of  August  last,  a  young  girl, 
named  Julia  Amelia  Sprayson,  pre¬ 
ferred  a  charge  of  rape  against  her 
uncle,  James  Chattaway,  who  was  con¬ 
victed  of  the  assault,  and  sentenced  to 
two  years’  imprisonment  and  hard 
labour  in  the  House  of  Correction.  The 
girl  was  far  advanced  in  a  state  of 
pregnancy  ;  and  as  it  is  of  rare  occur¬ 
rence  for  conception  to  take  place  at  so 
early  an  age  as  between  eleven  and 
twelve  years,  many  surmises  were  ex¬ 
pressed  by  the  gossips,  as  to  what 
would  be  the  probable  issue. 

She  continued  in  good  health  up  to 
the  day  of  delivery,  which  took  place 
on  the  16th  of  September  last.  In  the 
early  part  of  the  morning  she  became 
restless  and  uneasy,  and  from  the  hour 
of  11  a.m.,  slight  pains  occurred  at 
irregular  intervals,  until  about  5  p.m., 
when  it  was  evident  that  labour  was 
rapidly  advancing.  On  being  sent  for 
soon  after,  in  consequence  of  the  ab¬ 
sence  from  town  of  Dr.  Dewes,  who 
had  been  engaged  to  attend  her,  I  pro¬ 
ceeded  to  make  an  examination,  when 
I  found  the  pelvis  of  average  dimen¬ 
sions,  and  the  os  uteri  about  the  size  of 
a  shilling  piece ;  but,  as  the  parturient 
throes  were  active,  and  returned  every 
eight  or  ten  minutes,  it  appeared  pru¬ 
dent  to  remain  until  the  case  had  ter¬ 
minated.  Nothing  remarkable  super¬ 
vened  during  the  progress  of  the 
labour, except  that  it  was  of  unusually 
short  duration.  From  first  to  last,  she 
was  not  more  than  ten  hours  ailing, 
while  the  period  of  actual  labour  was 
not  extended  beyond  four  hours,  and 
this  would  have  been  further  shortened, 
but  for  the  smallness  of  the  external 
outlet.  The  subsequent  symptoms 
were  just  as  favourable  as  the  labour 
had  been  short.  The  lochia  ceased 
after  the  lapse  of  a  few  days,  the 
mammm  became  duly  developed,  and 
the  secretion  of  milk  was  so  copious,  as 
presently  to  suggest  to  her  mother  the 
idea  of  seeking  for  her  a  situation  as  wet 
nurse. 

The  infant,  at  birth,  was  long, 
slender,  and  emaciated,  but  rather 
below  the  average  size,  and,  in  many 
respects,  may  be  said  to  have  borne  a 
striking  resemblance  to  the  offspring 
of  mothers  who  had  been  imperfectly 
nourished  during  Pregnancy.  It  did 
not  occur  to  me  at  the  time,  either  to 
place  it  in  the  scales,  or  to  take  its  ad¬ 
measurement  ;  but  at  the  time  of  pub- 


752  REMARKABLE  CASE  OF  EARLY  MENSTRUATION  AND  PREGNANCY. 


lishing  this  report,  it  is  8J  pounds  in 
weight.  The  present  weight  of  the 
mother  is  104f  pounds. 

When  she  had  so  far  recovered  as  to 
take  a  share  in  domestic  avocations, 
it  seemed  advisable  to  pay  her  an  early 
visit,  to  elicit,  if  possible,  some  further 
information  than  what  had  transpired 
in  Court,  with  a  view  of  establishing 
some  data  as  to  the  period  of  utero- 
gestation ;  and,  although  foiled  and 
disappointed  with  the  result  of  this 
part  of  the  investigation,  some  parti¬ 
culars  of  interest  were  readily  obtained. 
She  was  rather  of  prepossessing  ap¬ 
pearance,  of  fair  complexion,  with 
brown  hair  and  dark  grey  eyes — more 
womanly  by  far  than  is  usually  wit¬ 
nessed  at  her  age,  her  figure  being 
tolerably  plump,  well-set  and  propor¬ 
tioned,  and  her  height  being  rather 
more  than  five  feet;  and,  notwith¬ 
standing  her  casually  childish  manner, 
there  was  that  forwardness  of  expres¬ 
sion  which  betokened  a  more  than 
ordinary  development  of  character. 
On  inquiry,  her  mother  assured  me 
that  she  began  to  menstruate  when 
ten  years  and  six  weeks  old ;  and  it 
was  distinctly  ascertained  that  there 
had  been  a  regular  return  of  the  cata¬ 
menial  discharge,  in  somewhat  profuse 
quantity,  up  to  the  period  at  which 
conception  took  place.  The  girl  had 
lost  her  father  about  two  years  ago, 
and,  that  she  might  not  be  a  burthen 
to  her  widowed  mother,  had  been  in 
residence  with  her  uncle,  who  was  a 
weaver,  at  Foleshill.  This  unhappy 
man,  who  proved  her  seducer,  was  set. 
47,  living  with  his  wife,  to  whom  he 
had  been  married  25  years,  and  by 
whom  he  had  had  a  family  of  two  or 
three  children.  The  niece  was  taught 
to  weave  at  a  hand- loom  which  stood 
in  the  same  apartment  as  the  one  at 
which  her  uncle  pursued  his  daily  em¬ 
ployment  ;  and  here  it  would  seem  that 
familiarities  arose  which  issued  at 
length  in  criminal  intercourse.  This 
latter  took  place  for  the  first  time  about 
the  middle  of  November,  1847,  and 
was  allowed  to  be  repeated  on  four 
occasions,  at  weekly  intervals  ;  but,  as 
the  catamenia  had  appeared  during  the 
last  week  of  that  month,  and  did  not 
recur  in  the  Christmas  week,  she  dated 
conception  from  the  latter  period.  No 
communication  wps  made  to  her  rela¬ 
tions  of  what  had  transpired  until  six 
months  had  elapsed,  when  her  situa¬ 


tion  became  too  prominent  to  elude 
further  observation ;  and  then  it  was 
that  arrangements  were  made  for  bring¬ 
ing  her  under  the  maternal  roof,  and 
means  were  taken  for  delivering  her 
seducer  into  the  hands  of  justice.  The 
most  rigid  inquiry  failed  in  deducing 
any  further  particulars  that  could  be 
at  all  relied  on  as  authentic  informa¬ 
tion. 

Several  examples  are  on  record 
wherein  pregnancy  has  occurred  in 
very  early  life;  but  no  well-accredited 
case  has  come  to  my  knowledge  in  this 
country  of  a  child  at  twelve  years  and 
a  half  old  giving  birth  to  a  living,  and 
for  the  most  part  healthy,  infant.  Such, 
however,  was  the  fact  in  the  foregoing 
instance;  and,  that  there  might  be  mo 
misapprehension  on  this  subject,  I 
have  been  at  the  pains  of  consulting 
the  registers  both  of  her  birth  and  bap¬ 
tism.  The  former  bears  the  date  of 
February  13th,  1836;  and  the  latter, 
March  7th  of  the  same  year. 

King1  Street,  Coventry, 

Oct.  23,  1848. 


OBSERVATIONS  and  SUGGESTIONS 

IN  REGARD  TO 

CHOLERA  ASPHYXIA, 

ADDRESSED  TO  THE  CENTRAL  BOARD  OF 
HEALTH,  LONDON. 

By  Charles  Bell,  M.D.  F.R.C.P.E. 

One  of  the  Physicians  to  the  Cholera  Hospital, 
Dumfries,  in  1832. 


Having  had  extensive  opportunities  of 
observing  the  nature  and  progress  of 
Cholera  Asphyxia  in  1832,  during  the 
whole  of  its  continuance  in  Dumfries, 
where  it  appeared,  I  believe,  in  a  more 
virulent  form  than  in  any  other  part 
of  Europe,  I  hope  I  shall  not  be  con¬ 
sidered  presumptuous  in  offering  a  few 
remarks  on  this  most  inscrutable  dis¬ 
ease,  now  that  it  has  again  come 
amongst  us,  when  we  are  so  little  pre¬ 
pared  for  its  reception.  It  is  true  that 
no  human  means  could  have  prevented 
the  approach  of  cholera;  but  there  is 
every  reason  to  believe  that,  by  timely 
and  judicious  arrangements,  the  suf¬ 
ferings  of  the  sick  might  have  been 
greatly  alleviated;  and,  by  the  blessing 
of  Providence,  much  might  have  been 
done  to  limit  the  extent  and  mortality 
of  the  disease. 


DR.  BELL’S  SUGGESTIONS  IN  REGARD  TO  CHOLERA  ASPHYXIA.  753 


The  experience  I  have  had  in  the 
management  of  cholera  induces  me  to 
'  speak  with  confidence  on  the  subject. 
I  had  the  joint  charge,  along  with  my 
friend  Dr.  Grieve,  of  the  Cholera  Hos¬ 
pital  in  Dumfries,  and,  at  the  same 
time,  had  frequent  opportunities  of 
seeing  the  disease  in  private  prac¬ 
tice,  arising  from  the  melancholy 
circumstance,  that  many  of  the  better 
classes  of  society  were  affected  ; 
to  which  was  added,  the  attend¬ 
ance  in  the  districts  when  the  medical 
officers  appointed  to  that  duty  were 
nnable  to  perform  it,  from  over-fatigue 
or  illness.  I  thus  had  a  wide  field  for 
observation,  of  which  I  did  my  utmost 
to  take  advantage  ;  and  I  trust  the  re¬ 
sult  of  my  experience  may  prove  useful 
in  allaying,  on  the  present  occasion, 
much  needless  alarm  in  regard  to  the 
eontagion  of  cholera.  I  hoped  that 
this  subject  had  been  set  at  rest ;  but 
I  understand  it  is  likely  to  be  again  re¬ 
vived  in  this  town.  Nothing  can  be  more 
erroneous  or  injurious  than  giving  en¬ 
couragement  to  such  an  impression, 
and  it  is  of  the  utmost  importance  that 
every  means  should  be  adopted  to  pre¬ 
vent  its  gaining  ground  among  the 
people. 

When  cholera  appeared  in  Dumfries, 
I  resolved  to  lay  aside  all  preconceived 
notions  on  the  subject,  and  to  form  my 
opinion  of  the  nature  of  the  disease 
entirely  on  what  came  under  my  per¬ 
sonal  observation.  With  this  view  I 
visited  every  case  within  my  reach, 
and  endeavoured  to  ascertain  its  cause. 

I  spent  from  six  to  seven  hours  every 
day  in  the  hospital,  prescribing  for  the 
sick,  and  dissecting  the  dead.  Having 
observed  the  dread  that  was  generally 
entertained  with  regard  to  cholera  pa¬ 
tients  being  buried  alive — a  fear  that 
was  greatly  increased  by  the  regulation 
which  rendered  it  necessary  that  the 
bodies  should  be  buried  within  twelve 
hours  after  death, — I  opposed  such  a 
gross  infringement  on  the  customs 
and  prejudices  of  the  people,  and 
had  the  bodies  kept  four  and  five 
days.  Frequently  after  that*  period 
I  spent  several  hours  inspecting  them 
while  I  was  surrounded  by  the  dead. 
On  one  occasion  1  was  so  unfortunate 
as  to  wound  myself  severely  when  exa¬ 
mining  a  body  which  had  been  kept 
five  days ;  yet  no  bad  effects  resulted. 
Nor  was  the  health  of  the  inmates  of 
the  hospital  in  any  way  injured  by  the 


bodies  being  so  long  detained  within, 
its  precincts,  although  the  apartment 
in  which  the  nurses  spent  much  of 
their  time  when  not  on  dutv  in  the 
wards  was  on  the  same  floor,  and  close 
to  the  dead-house. 

The  result  of  the  practice  in  the  hos¬ 
pital  was  certainly  satisfactory,  when 
we  consider  the  virulent  character  of  the 
disease  in  the  town,  and  the  very  ad¬ 
vanced  stage  at  which  the  patients  were 
generally  brought  to  it ;  and  it  proved  at 
the  same  time,  in  a  striking  manner, 
the  non-contagious  nature  of  cholera. 
By  the  cases  which  w7ere  reported  to 
the  Board  of  Health,  it  appeared  that 
rather  more  than  one-tenth  of  the  in¬ 
habitants  of  the  town  were  affected, 
and  that  above  one-half  of  those  died. 
From  the  hospital,  more  than  one- 
third  was  dismissed  cured.  There 
were  in  the  establishment  four  house- 
surgeons  and  fourteen  nurses,  and  the 
only  individual  who  was  affected  with 
cholera  was  a  male  nurse,  who  was 
taken  from  an  infected  locality,  after 
several  of  his  family  had  fallen  victims 
to  the  disease;  and  he  was  employed 
principally  in  the  districts,  burying  the 
dead. 

I  saw  no  case  which  could  be  traced 
as  the  result  of  contagion.  The  disease 
progressed  along  the  ground  floors ; 
and  there  was  no  example  of  its  spread¬ 
ing  in  upper  stories  of  houses  with 
common  stairs,  although  there  was  no 
interruption  to  the  intercourse  between 
the  apartments  of  the  sick  and  the 
healthy  in  such  situations.  I  may 
here  mention  a  case  which  illustrates 
the  non-contagious  nature  of  the  dis 
ease  very  forcibly. 

A  highly  respectable  and  wealthy 
farmer,  sixty  years  of  age,  of  broken 
constitution,  who  lived  several  miles 
from  town,  attended  Dumfries  market 
some  time  after  cholera  had  apparently 
disappeared,  and  was  induced  to  visit 
a  brewery  situated  in  the  quarter 
where  the  disease  lingered  longest  in 
its  most  virulent  form.  He  spent  some 
time  tasting  the  different  liquors  made 
at  the  brewery,  and  finished  off  with  a 
liberal  allowance  of  whiskey.  Within 
two  days  after  this  visit  he  was  seized 
with  a  severe  attack  of  cholera,  which 
was  followed  by  the  consecutive  fever. 
During  the  whole  of  this  gentleman’s 
illness  he  was  attended  by  two  sisters 
and  a  niece,  all  of  whom  were  in  a  state 
of  health  most  unfavourable  for  such  a 


754  dr.  bell’s  suggestions  in  regard  to  cholera  asphyxia. 


duty ;  and  although  I  have  observed 
these  individuals  partaking  of  the  food 
which  the  patient  left,  yet  none  of  them 
was  affected  with  the  disease ;  nor  was 
it  communicated  to  any  of  his  friends, 
who  visited  him  without  reserve. 

From  these  facts,  I  feel  convinced 
that  cholera  was  not  communicated  by 
contagion  from  one  individual  to  ano¬ 
ther;  but  that  it  arose  from  some 
poison  generated  near  the  surface  of 
the  earth,  just  as  we  observe  carbonic 
acid  gas  emitted  in  certain  localities. 
The  nature  of  this  poison  is  wholly  un¬ 
known  ;  but  it  is  very  certain  that  it 
occurs  with  greater  virulence  in  close, 
damp,  and  filthy  situations  ;  and  that 
in  such  places  its  influence  on  the 
human  system  will  be  more  difficult  to 
overcome  ;  and  should  the  physician 
be  so  fortunate  as  to  be  the  means  of 
arresting  the  progress  of  the  disease  in 
an  individual  in  such  a  locality,  a  re¬ 
lapse  is  very  likely  to  occur,  and  will 
inevitably  cut  off  the  patient. 

Under  these  circumstances,  there¬ 
fore,  I  deeply  regret  that  it  should 
have  been  resolved  upon  by  the  au¬ 
thorities  to  treat  the  poor  in  their 
own  houses :  such  an  attempt  will 
prove  an  utter  failure,  and  be  a  cer¬ 
tain  source  of  disappointment ;  while 
it  will  expose  the  friends  and  atten¬ 
dants  of  the  sick  to  an  attack  of  the 
disease,  which  they  might  otherwise 
avoid,  thereby  tending  materially  to 
encourage  the  impression  that  it  is 
contagious.  The  result  of  this  will 
be  to  deprive  the  sick,  in  many  in¬ 
stances,  of  the  comfort  of  having 
their  friends  around  them,  which  is 
always  an  accessory  to  their  cure.  It 
appears  to  me  it  would  be  as  reasona¬ 
ble  to  expect  to  reanimate  a  person  in 
a  state  of  anaesthesia,  while  surrounded 
by  a  dense  atmosphere  of  ether  or 
chloroform,  as  to  cure  a  patient  in  such 
circumstances ;  and  it  would  not  be 
more  surprising  to  find  his  attendants 
thrown  into  the  same  state  as  himself. 

I  trust  that  no  encouragement  will 
be  given  to  this  “  penny  wise  and  pound 
foolish’’  system  of  economy;  otherwise 
it  will  lead  to  great  distress  and  ulti¬ 
mate  expense.  No  time,  therefore, 
ought  to  be  lost  in  providing  suitable 
comforts  and  accommodation,  with 
proper  attendants,  for  the  poor  during 
the  continuance  of  the  present  epide¬ 
mic.  Let  hospitals  be  appointed  for 
the  sick  who  live  in  low  and  damp 


situations,  from  which  they  ought  to  be 
removed  immediately  on  being  affected 
with  the  disease  ;  and  at  the  same  time 
let  a  sufficient  supply  of  nurses  be  col¬ 
lected  for  the  attendance  of  those  who 
live  in  the  upper  stories  where  the  sick 
may  be  treated  with  advantage  to 
themselves,  and  safety  to  their  attend¬ 
ants.  The  propriety  of  these  sugges¬ 
tions  being  acted  upon  without  delay, 
appears  to  me  to  be  fully  substantiated 
by  the  results  in  Leith,  where,  I  under¬ 
stand,  every  case  has  proved  fatal.  1 
have  only  further  to  recommend,  that 
no  outrage  be  committed  against  the 
feelings  of  the  people,  by  the  hasty 
burial  of  the  dead,  which  only  produces 
unnecessary  alarm. 

By  such  arrangements  as  these  we 
may  hope,  under  the  blessing  of  Pro¬ 
vidence,  to  relieve  the  miseries  of  the 
poor,  if  not  to  circumscribe  the  ravages 
of  cholera. 

Edinburgh,  October  12,  1848. 


DR.  BUEL  OX  THE  STATISTICS  OF  AMPUTA¬ 
TIONS  AT  THE  NEW  YORK  HOSPITAL. 

The  whole  number  of  amputations  presented 
in  the  tables  amounts  to  ninety-one,  of 
which  twenty-six  were  fatal,  making  the 
mortality  28'57  per  cent. 

Of  amputations  of  the  hip-joint  there  was 
one,  and  that  fatal. 

Of  amputations  of  the  thigh  the  whole 
number  was  thirty -four,  of  which  ten  were 
fatal,  making  the  mortality  26*47  per  cent. 

At  the  knee-joint  there  was  one  amputa¬ 
tion,  and  that  fatal. 

Of  amputations  of  the  leg  the  whole  num¬ 
ber  was  twenty-four,  of  which  seven  were 
fatal,  making  the  mortality  29T6  per  cent. 

Of  amputations  at  the  shoulder-joint  the 
whole  number  was  nine,  of  which  four  were 
fatal,  making  the  mortality  44*44  per  cent. 

Of  amputations  of  the  arm  the  whole 
number  wras  eleven,  of  which  none  were 
fatal. 

Of  amputations  of  the  forearm  the  whole 
number  was  thirteen,  of  which  three  were 
fatal,  making  the  mortality  23*07  per  cent. 

So  that  we  have  sixty  amputations  of  the 
lower  extremity,  of  which  nineteen  were 
fatal,  making  the  mortality  31*66  per  cent. 

While  of  thirty-three  amputations  of  the 
upper  extremity,  seven  were  fatal,  making 
the  mortality  21*21  per  cent. — American 
Journal  of  Med.  Sciences,  July  1848. 


THE  UNJUST  TREATMENT  OF  MEDICAL  OFFICERS  OF  THE  NAVY.  755 


MEDICAL  GAZETTE. 


FRIDAY,  NOVEMBER  3,  1848. 


We  have  at  various  times  given  inser¬ 
tion  to  letters  of  complaint  respecting 
the  treatment  of  medical  officers  of  the 
navy;  and  if  we  have  not  hitherto 
called  public  attention  to  the  ill-treat¬ 
ment  which  they  have  for  some  years 
sustained  at  the  hands  of  those  in 
authority,  it  has  not  arisen  from  any 
want  of  sympathy  with  their  cause. 

It  appears  that  in  the  year  1805,  an 
order  in  Council  was  issued,  placing 
these  officers  on  the  same  footing  as  to 
“  rank,  pay,  and  designation,”  with  the 
medical  officers  of  the  land  forces. 
The  object  of  the  order  was  plain — 
namely,  to  induce  able  and  well  edu¬ 
cated  men  to  serve  at  sea  ;  but  its  execu¬ 
tion  was  unfortunately  entrusted  to  the 
Lords  of  the  Admiralty,  who  allowed  it 
to  remain  a  dead  letter.  It  was  not 
until  after  the  lapse  of  nearly  thirty 
years,  during  which  continual  com¬ 
plaints  had  been  made  bv  the  medical 
officers,  that  their  case  was  brought 
before  the  last  Parliamentary  Commis¬ 
sion,  and  the  Admiralty  was  compelled 
to  do  in  1832,  what  the  King  had 
ordered  in  1805.  The  “  pay  and  desig¬ 
nation”  were  granted,  and  the  “  rank” 
could  not  be  denied,  but  all  its  real  and 
practical  advantages  are  still  refused,  in 
open  defiance  of  the  Royal  authority 
and  order  in  Council.  If  “  rank”  mean 
anything  at  all,  it  surely  implies  that 
the  possessor  should  enjoy  equal  privi¬ 
leges  with  others  of  the  same  rank. 
Yet,  so  far  is  this  from  being  the  case 
in  the  navy,  that  the  medical  officers 
in  active  service  are  not  only  refused 
accommodations,  which  their  equals 
enjoy,  but  accommodations  which  are 
actually  enjoyed  by  their  inferiors. 
The  first  lieutenants  of  marines  are 


equal  in  rank  with  assistant-surgeons  ; 
the  second  lieutenants  are  inferior,  yet 
both  mess  with  the  grown-up  officers, 
and  are  allowed  cabins,  while  the  as¬ 
sistant  surgeon  has  no  cabin,  and  is 
obliged  to  mess  with  the  midshipmen. 
The  chaplains  and  naval  instructors 
have  no  rank  whatever,  yet  cabins  are 
provided  for  them,  and  they  mess  with 
men.  We  do  not  hesitate  to  sav,  that 
a  more  shameful  act  of  injustice  has 
never  been  perpetrated  by  a  set  of  men. 
ordered  by  their  King  to  carry  out  his 
wishes,  and  paid  by  the  country  to  see 
that  every  branch  of  the  service  is  in 
an  efficient  state. 

So  much  for  the  justice  of  the  Lords 
of  the  Admiralty  ;  let  us  now  consider 
for  a  moment  their  policy.  They  must 
surely  know  how  very  much  their  own 
health  and  comfort,  as  well  as  of  the 
officers  and  men  under  their  command 
— in  a  word,  how  much  the  efficiency 
of  every  ship — must  depend  upon  the 
ability  of  the  medical  officer  ?  Even  in 
war  time,  the  number  of  men  disabled 
by  sickness  far  exceeds  those  who 
suffer  from  direct  violence  :  in  either 
case  their  fate  depends  in  a  great  de¬ 
gree  on  the  skill  and  experience  of  the 
surgeon.  Yet  so  far  from  these  ob¬ 
vious  considerations  inducing  those  in 
authority  to  encourage  able  men  to 
enter  and  remain  in  the  service,  they 
have  been  not  only  overlooked,  but 
measures  have  been  actually  adopted 
to  render  the  medical  branch  of  the  ser¬ 
vice  as  unpopular  as  possible — to  reduce 
the  number  of  candidates  to  nil,  and  to 
make  every  one  who  has  entered  the 
service,  seize  the  very  first  oppor¬ 
tunity  of  leaving.  If  this  class  of  men 
were  fairly  dealt  with,  we  do  not  hesi¬ 
tate  to  say  that  it  would  be  by  far  the 
most  popular  medical  branch  in  the 
public  service :  able  men  would  enter 
and  remain  in  it, — they  would  have 
convenience  for  study  ;  and  we  should 
not  then  have  to  regret  the  small  con- 


756 


THE  UPTON-ON-SEVERN  MEDICAL  APPOINTMENTS. 


tributions  which  those  who  have  re¬ 
mained  long  in  the  navy,  have  made  to 
the  science  or  literature  of  their  profes¬ 
sion. 

The  medical  officers  ask  no  favour 
of  the  Lords  of  the  Admiralty ;  they 
merely  demand  the  rights  granted  by 
their  Sovereign;  but  these  have  now 
been  so  long  and  so  obstinately  with¬ 
held,  that  it  is  plain  there  will  be  no 
redress  until  their  case  is  brought 
before  Parliament  by  some  member 
whose  position  and  character  will  en¬ 
title  him  to  the  attention  of  the  House. 
We  trust  that  another  session  will  not 
be  allowed  to  pass  without  some  strin¬ 
gent  rule  being  adopted,  which  may 
place  professional  men  in  the  navy 
beyond  the  reach  of  the  caprice  or  ill- 
temper  of  those  who  are  unable  to  ap¬ 
preciate  the  importance  of  this  class  of 
officers  to  the  public  service. 


The  Upton-on-Severn  case,  in  refer¬ 
ence  to  which  some  documents  are 
elsewhere*  inserted,  has  terminated 
much  as  we  had  expected.  It  appears 
that  medical  men  have  come  forward 
to  take  the  offices  rendered  vacant,  on 
the  part  of  the  late  medical  officers,  by 
an  adherence  to  principles  of  which 
we  cannot  but  approve.  It  is  there¬ 
fore  quite  clear  that  the  profession  is 
itself  the  cause  of  the  unjust  treatment 
of  which  so  many  hard-working 
country  practitioners  complain.  Boards 
of  Guardians  must  not  be  blamed  for 
making  the  best  terms  which  they  can. 
If  they  can  obtain  medical  services  at 
a  low  rate,  it  would  be  contrary  to  all 
experience  to  expect  them  to  come 
forward  in  a  chivalrous  way  and  offer 
to  pay  a  higher  sum  than  that  which 
some  members  of  the  profession  are 
ready  and  willing  to  take.  If  we  con¬ 
trast  the  conduct  of  the  assistant- 
surgeons  in  the  Navy  with  that  of  the 


general  practitioners  who  are  so  eager 
to  rush  into  Poor-law  offices  involving 
much  work  and  a  nominal  salary,  we 
can  only  infer  that  some  sections  of 
the  profession  are  guided  by  very 
different  codes  of  medical  ethics.  The 
naval  medical  officers  feel  themselves 
unjustly  treated,  and  the  Admiralty 
experiences  the  greatest  difficulty  in 
supplying  their  places  :  in  fact,  there 
are  no  candidates  for  offices,  the  accept¬ 
ance  of  which  involves  professional 
degradation.  In  Poor-law’  districts, 
however,  no  difficulty  is  found  in  fill¬ 
ing  offices  that  become  vacant  under 
circumstances  which  are  as  honourable 
to  the  feelings  of  those  who  lately 
occupied  them,  as  they  are  discreditable 
to  the  Boards  of  Guardians  who  have 
rendered  resignation  the  only  course 
to  be  pursued.  Such  is  the  lesson 
practically  taught  by  the  recent  me¬ 
dical  appointments  to  the  Upton-on- 
Severn  Union.  To  make  appeals  to 
the  generosity  of  Parliament  or  of  the 
Poor-Law  Board,  is,  of  course,  a  vain 
and  profitless  labour,  wrhen  these  are 
the  results  of  an  unwholesome  profes¬ 
sional  competition. 

In  the  meantime,  the  Committee  of 
Poor-Law  Medical  Officers  have  taken 
the  only  step  which  was  open  to  them  : 
they  have  made  a  very  judicious  and 
temperate  appeal  on  the  subject  to  the 
President  of  the  Poor-Law  Board.  We 
fear,  however,  it  wull  end  in  nothing. 
The  evil  is  in  the  profession  itself :  the 
technical  objections  to  these  appoint¬ 
ments  suggested  by  the  Committee  may 
be  remedied,  and  the  great  grievance 
still  remain  unredressed.  The  true 
remedy  will  be  found  in  a  diminution 
of  the  number  of  licensed  practitioners, 
and  in  the  general  adoption  of  a  higher 
standard  of  medical  ethics.  Any  four 
barristers  acting  in  a  similar  way  to 
others  of  their  own  profession,  would 
have  soon  found  their  punishment  in  a 
total  exclusion  from  respectable  prac- 


*  Page  772. 


THE  MEDICAL  DIRECTORY.  INCREASE  OF  THE  ASIATIC  CHOLERA.  757 


tice,  and  from  the  society  of  their 
brethren.  There  are  some  evils  which 
no  laws  or  public  regulations  can  meet, 
and  this  mode  of  filling  up  vacant 
offices  in  Poor-Law  Unions  appears  to 
be  one  of  them.  It  cannot  fail  to 
create  violent  dissensions  in  the  profes¬ 
sion,  and  to  extinguish  those  charitable 
feelings  which  should  animate  all  who 
practise  the  healing  art. 

We  have  more  than  once  reminded 
practitioners  that  the  only  plan  of  re¬ 
gistration  now  open  to  them,  is  that 
wffiich  is  purely  voluntary.  Defective 
as  this  may  be  in  some  respects,  it  has 
been  found  of  very  great  service.  The 
Medical  Directory,  which  has  been 
published  for  several  years,  has  proved 
a  most  useful  guide  to  the  residence, 
qualifications,  and  status  of  practi¬ 
tioners  throughout  England  and  Wales. 
But  it  has  gone  further  than  this.  It 
embodies,  for  the  first  time,  an  attempt 
to  separate  qualified  from  unqualified 
practitioners,  and  this  we  consider  is 
of  such  importance  in  a  public  view, 
that  it  is  the  duty  of  every  qualified 
man  to  see  that  his  name  and  titles  are 
properly  entered  in  its  pages.  Some 
recent  revelations  have  shewn  that  un¬ 
principled  men  have  made  false  re¬ 
turns  ;  but  this  is  an  evil  inseparable 
from  the  want  of  an  Act  of  Parliament, 
and  a  penal  clause  to  assign  the  disci¬ 
pline  of  the  treadmill  to  these  wolves 
in  sheep’s  clothing.  In  spite  of  these 
necessary  defects,  we  believe  that  all 
who,  like  ourselves,  have  had  frequent 
occasion  to  refer  to  the  work,  must 
have  found  it  of  great  utility.  We  have 
therefore  to  invite  practitioners  to  for¬ 
ward  to  the  editors  without  delay,  their 
names  and  qualifications  :  the  latter 
should  in  all  cases  be  fully  and  accu¬ 
rately  described. 


Although  the  return  of  the  Registrar- 
General  for  Saturday  last  is  less  fa¬ 
vourable  than  that  of  the  preceding 


week,  yet,  it  will  be  observed,  the 
weekly  deaths  still  fall  short  of  the 
autumnal  average  by  4/.  An  analysis 
of  the  causes  of  death  shews  us  that 
the  increase  is  chiefly  due  to  scarlet 
fever  and  typhus.  The  registered 
deaths  from  Cholera  amounted  to  34, 
of  which  23  occurred  among  adults, 
and  11  at  the  infantile  period.  On 
Monday  there  were  eight  cases  in  the 
metropolis,  of  which  one  was  fatal ;  on 
Tuesday  there  were  eighteen,  of  which 
seven  were  fatal ;  and  on  Wednesday 
nine,  of  which  seven  also  terminated 
fatally.  From  these  facts  it  may  be 
inferred  that  the  disease  is  on  the  in¬ 
crease  ;  but,  at  the  same  time,  its 
attacks  are  limited  to  a  few  localities, 
and  to  a  comparatively  small  number 
of  persons.  We  cannot,  however, 
speak  so  favourably  of  the  city  of 
Edinburgh.  The  cholera  appears  to 
have  shewn  as  much  malignancy  in 
the  northern  metropolis  as  in  Mos¬ 
cow  or  St.  Petersburgh.  The  attacks 
may  not  have  been  relatively  so  nume¬ 
rous,  but  they  have  been  equally  fatal. 
Thus  up  to  the  last  date  before  us, 
October  31,  there  had  occurred  in  Edin¬ 
burgh  290  cases,  and  no  less  than 
169  of  these  had  ended  fatally — a  mor¬ 
tality  equal  to  58  per  cent!  In  addi¬ 
tion  to  these,  ten  cases  had  occurred  in 
Portobello,  of  which  five  were  fatal. 

At  the  time  of  going  to  press,  we 
have  received  the  suggestions  respect¬ 
ing  the  treatment  of  cholera’  patients, 
which  have  just  been  issued  by  a  Com¬ 
mittee  of  the  Royal  Colleges  of  Phy¬ 
sicians  and  Surgeons  of  Edinburgh. 
The  details  regarding  treatment  are 
very  explicit,  and  appear  to  us  to  be 
very  appropriate.  We  shall  publish 
this  document  next  week.  Among  the 
medicines  ordered,  the  pills,  formed  of 
acetate  of  lead  and  opium,  suggested 
by  Dr.  Graves,  occupy  the  first  place. 

By  a  second  notification  issued  from 
the  General  Board  of  Health,  in  Lon¬ 
don,  the  provisions  of  the  “  Nuisances 
removal  and  Diseases  prevention  Act,” 
are  directed  to  be  enforced  throughout 
the  whole  of  Great  Britain. 


758 


CHOLERA  AN  IMPORTED  DISEASE. 


3£cbtcfos. 


Clinical  Lectures  on  the  Practice  of 

Medicine.  By  R.  J.  Graves,  M.D. 

M.R.I.A.  &c.  2d  Edition.  Edited 

by  J.  M.  Neligan,  M.D.  M.R.I.A. 

&c.  In  two  volumes.  8vo.  pp.  586, 

570.  Dublin  :  Fannin  and  Co. 
1848. 

We  depart  from  our  usual  plan,  in 
taking  this  work  out  of  its  turn,  for  the 
reason  that  we  are  desirous  of  giving 
to  our  readers  the  views  of  its  author 
on  the  treatment  of  cholera — a  subject 
which,  as  the  editor  remarks  in  his 
preface,  is  now  engrossing  the  attention 
of  the  profession  and  the  public 
throughout  Europe.  It  will  be  our 
duty,  however,  in  the  first  instance,  to 
make  a  few  remarks  npon  the  plan  and 
object  of  these  lectures.  The  first  edi¬ 
tion  of  the  work  appeared  in  one  vo¬ 
lume  in  1843,  and  it  has  been  so  fa¬ 
vourably  received,  that  the  author,  on 
the  present  occasion,  by  the  addition 
of  many  more  lectures,  has  found  it 
necessary  to  publish  it  in  two  vo¬ 
lumes.  The  work  is  essentially  what 
its  title  implies — a  record  of  cases  on 
all  points  of  practice,  with  comments 
and  suggestions  such  as  would  be  likely 
to  be  made  by  a  man  of  the  author’s 
experience  and  professional  standing. 
More  than  one  half  of  the  first  volume 
is  occupied  by  the  lectures  on  Fever , 
and  in  these  Dr.  Graves  gives  us  a  full 
and  accurate  account  of  the  fatal  form 
of  typhus  which  has  been  of  late  years 
so  prevalent  in  Ireland.  One  lecture 
is  devoted  to  Yellow  Fever,  three  to 
Scarlet  Fever,  and  two  to  Intermittent 
Fever.  We  shall  only  remark  of  these, 
that  the  cases  selected  are  well  calcu¬ 
lated  to  illustrate  the  effects  of  treat¬ 
ment.  Two  lectures  are  assigned  to 
Cholera ,  and  it  is  here  perhaps  that 
the  labours  of  the  author  will  be  found 
to  have  the  greatest  interest  at  the  pre¬ 
sent  time. 

Dr.  Graves  believes,  in  common  with 
most  professional  men,  that  Spasmodic 
cholera  is  an  imported  disease.  His 
description  of  its  origin  and  progress  is 
one  of  the  best  summaries  of  the  his¬ 
tory  of  this  pestilence  which  we  have 
seen,  and  the  facts  which  he  has  ad¬ 
duced  of  its  obviously  contagious  cha¬ 
racter  are  only  confirmatory  of  what 


has  been  already  published  by  Copland, 
Watson,  and  other  eminent  observers 
He  justly  remarks  that  the  disease  has 
never  been  known  to  traverse  the  ocean 
at  a  rate  exceeding  that  of  ships — a 
fact  difficult  to  explain,  if  the  spread¬ 
ing  of  the  cholera  is  to  be  referred  to 
mere  atmospheric  diffusion  in  an  epi¬ 
demic  form.  He  also  proves  that  the 
disease  is  really  contagious,  from  the 
facts  adduced  by  non-contagionists. 
We  cannot  enter  into  his  analysis  of 
Dr.  Jackson’s  statements,  which  were 
intended  to  shew  that  the  cholera  in 
the  United  States  was  not  contagious; 
but  with  respect  to  one  argument  to 
which  an  undue  value  has  been  at¬ 
tached,  he  remarks — 

“  Why  the  cholera,  if  an  imported  dis¬ 
ease,  should  have  broken  out  nearly  simulta¬ 
neously  in  Quebec  and  Montreal,  is  very 
easily  accounted  for,  since  both  are  the  re¬ 
ceptacles  of  British  and  other  foreign  emi¬ 
grants  ;  on  the  same  principle  we  must 
explain  its  appearance  so  soon  after  at  New 
York,  where  no  doubt  it  arrived  by  a  sepa¬ 
rate  importation  from  Europe — a  circum¬ 
stance  which  will  prevent  us  from  feeling 
the  same  surprise  with  Dr.  Jackson,  that 
between  Quebec  and  New  York  all  the  in¬ 
termediate  cities  on  the  sea-board  escaped , 
at  least  for  a  lew  months.  This  is  analogous 
to  the  exemption  of  Waterford  and  Wexford 
during  several  months  that  cholera  raged  in 
Dublin  and  Cork.*  I  gave  Dr.  Jackson’s 
Report  at  much  length,  because  it  is  in¬ 
tended  to  be  conclusive  against  the  theory 
of  contagion  ;  while  it,  in  my  opinion,  con¬ 
tains  strong  internal  evidence  of  a  contrary 
tendency.”  (pp.  409-10.) 

Many  observers  have  remarked  on 
the  singular  fact  that  cholera  has 
shewn  itself  but  little  in  countries 
south  of  the  equator.  Dr.  Graves  ob¬ 
serves — 

“  Cholera  did  not  reach  South  America 
at  all,  a  fact  explicable  by  the  great  length 
of  the  voyage  from  the  infected  countries, 
which  reason  also  protected  the  Cape  of 
Good  Hope,  the  West  Indies,  and  New 
Holland.  It  is  a  curious  fact  that  New  Hol¬ 
land,  for  the  same  reason,  has,  until  lately, 
been  free  from  measles,  scarlatina,  and 
hooping-cough,  although  the  colony  is  fifty 
years  old.  But  now  that  the  intercommu¬ 
nication  between  it  and  other  parts  of  the 
world  has  become  much  shorter  and  more 
frequent,  owing  to  the  rapid  spread  of  steam 


*  The  same  fact  has  been  recently  observed  in 
the  ports  of  the  Baltic.  The  disease  has  appeared 
in  distant  ports  simultaneously. 


CHOLERA  A  CONTAGIOUS  DISEASE. 


759 


navigation,  it  has  been  visited  by  all  these 
diseases.”  (p.  410.) 

The  manner  in  which  the  author 
extracts  proofs  of  contagion  out  of 
statements  which  are  intended  to  dis¬ 
prove  this  doctrine,  may  be  illustrated 
by  the  following  paragraph : — 

“  Mr.  Lardner,  a  very  intelligent  surgeon, 
and  formerly  a  pupil  of  mine,  has  written  a 
very  interesting  paper  on  the  progress  of 
cholera  in  Portugal. — Lancet,  1834-5,  p. 
314.  He  is  a  decided  non-contagionist,  but 
his  facts  seem  to  me  to  be  strongly  corrobo¬ 
rative  of  the  doctrine  of  contagion.  Among 
other  admissions,  the  following  is  almost 
conclusive  : — ‘  Lisbon  was  not  visited  by 
cholera  for  a  considerable  time  after  Aveiro, 
which  fact  may  give  the  contagionist  a  lift, 
for  during  the  siege  there  existed  no  direct 
communication  by  water  between  Oporto  and 
Lisbon.  The  Miguelite  batteries  would  not 
allow  a  ship  to  enter  the  Tagus,  and  Donna 
Maria’s  ships  kept  a  strict  blockade  outside 
the  bar.’  The  epidemic  took  siv  months  to 
travel  slowly  by  land  from  Oporto  to  Lis¬ 
bon.  Had  the  communication  by  sea  be¬ 
tween  these  two  ports  been  open,  no  doubt 
it  would  have  reached  Lisbon  sooner  :  in 
America  how  quickly  it  extended  from  one 
seaport  to  another. 

“  It  is  a  remarkable  circumstance,  and 
one  which  ought  to  have  great  weight  in  the 
discussion  respecting  the  contagiousness  of 
cholera,  that  cholera  has  in  no  recorded 
instance  appeared  in  any  place  sooner  than 
the  ordinary  modes  of  communication  mig ht 
have  brought  it  from  some  infected  station. 
Again,  it  can  easily  be  proved  that  the  rate 
at  which  cholera  travels  varies  with  the 
rapidity  of  that  communication.  A  few 
weeks  were  sufficient  to  transport  it  from 
the  ports  of  Britain  more  than  three  thou¬ 
sand  miles  across  the  Atlantic  to  Canada, 
while  it  took  six  months  to  creep  along  the 
interrupted  line  of  communication  between 
Oporto  and  Lisbon. 

“  From  the  preceding  observations  it  will 
appear,  1st,  that  cholera  has  had  no  fixed 
rate  of  progress  ;  2d,  that  it  has  spread  in 
every  direction,  sometimes  northwards,  some¬ 
times  southwards,  and  at  other  times  east 
and  west,  its  route  being  determined  not  by 
the  points  of  the  compass,  but  by  the  great 
lines  of  internal  and  international  communi¬ 
cation. 

“  Cholera  never  got  to  any  of  the  West 
Indian  islands,  nor  to  British  (formerly 
Dutch)  Guiana,  Demerara,  nor  any  of  the 
embouchures  of  the  great  South  American 
rivers,  Amazon,  Orinoco,  or  La  Plata, 
though  the  soil  and  climate,  with  the  im¬ 
mense  tracts  of  inundated  and  swampy  lands, 
would  there  seem  most  favourable  to  its 
development.”  (pp.  411-12.) 


The  last  proposition  we  assign  to  the 
consideration  of  those  sanitarians  who 
rail  against  the  Thames  and  the  Ser¬ 
pentine. 

As  another  proof  that  the  disease 
does  not  observe  the  points  of  the  com¬ 
pass,  but  rather  the  lines  of  human 
intercourse,  it  may  be  stated — 

“  That  cholera  began  at  Naples,  which 
carries  on  a  perpetual  commercial  inter¬ 
course  with  Marseilles,  about  a  year  before 
it  commenced  in  Rome !  August,  1837. 
The  disease  travelled  southwards  in  the 
north  of  Italy,  setting  out  from  France ; 
northwards  in  the  south  of  Italy,  starting 
from  Naples.”  (p.  412.) 

We  shall  remark,  on  leaving  this  part 
of  the  subject,  that  we  are  glad  to  have 
“the  support  of  so  able  an  observer  as 
Dr.  Graves,  to  the  views  uniformly  ad¬ 
vocated  in  the  pages  of  this  journal. 

In  respect  to  treatment,  Dr.  Graves 
tells  us  that  he  has  tried  calomel,  and 
seen  it  tried  in  every  form  and  dose, 
but  it  has  signally  failed ;  and  from 
having  witnessed  the  good  effects  of 
full  doses  of  acetate  of  lead  and  opium, 
in  a  case  of  obstinate  diarrhoea,  he  was 
induced  to  employ  these  medicines  for 
the  purpose  of  arresting  the  purging  in 
cholera.  It  is  well  known  that  there 
are  some  cases  in  which  no  medical 
treatment  will  be  of  any  avail.  As  the 
author  observes — 

“  It  is  known  that  there  are  some  cases  in 
which  the  disease  at  once  assumes  so  frightful 
a  malignity,  that  the  patient  is  lost  from  the 
very  moment  of  his  seizure.  This  hopeless 
and  intractable  malignity  is  not  peculiar  to 
cholera  ;  it  is  seen  in  fever,  scarlatina,  croup, 
measles,  and  hydrocephalus  ;  in  fact,  there 
are  certain  forms  of  all  diseases  in  which  the 
best  directed  efforts  of  medical  skill  not  only 
fail  in  curing  the  disease,  but  even  in  re¬ 
tarding  its  progress.  But  there  are  cases  of 
cholera  wffiere  the  patient  is  not  struck  down 
at  once,  where  the  disease  is  not  developed 
at  once  in  all  its  awful  intensity,  and  where 
time,  briefthoughthespacemaybe,is  allowed 
for  the  play  of  therapeutic  agencies.  It  is  in 
such  cases  the  acetate  of  lead  may  be  given 
with  some  prospect  of  success,  and  it  is  by 
such  cases  alone,  and  not  by  those  which  are 
necessarily  fatal  ab  initio ,  that  its  value  is  to 
be  tested. 

“Before  we  proceed  further,  I  may  ob¬ 
serve,  that  the  principle  on  which  the  calo¬ 
mel  treatment  was  employed  in  cholera  arose 
from  almost  constantly  obsei’ving  that  there 
was  a  total  deficiency  of  bile  in  the  stools. 
Soon  after  the  supervention  of  an  attack,  the 
alvine  discharges  were  observed  to  be  white. 


760  TREATMENT  OF  CHOLERA - ACETATE  OF  LEAD  AND  OPIUM. 


and  without  the  slightest  tinge  of  bile  ;  and 
on  this  very  remarkable  symptom  practi¬ 
tioners  dwelt  almost  exclusively,  thinking 
that  the  patient’s  only  chance  lay  in  restoring 
the  secretion  of  the  liver.  Now  it  is  obvious 
that  the  absence  of  bile  in  the  stools  is  no 
more  a  cause  of  the  disease  than  is  the  de¬ 
ficiency  of  urea  in  the  kidneys  or  of  serum 
in  the  blood.  Viewing  the  disease  in  this 
light,  it  would  be  just  as  reasonable  to  give 
a  diuretic  to  restore  the  secretion  of  the  kid¬ 
neys,  as  to  give  calomel  to  produce  a  flow  of 
bile.  The  liver  ceases  to  secrete,  not  only 
in  consequence  of  the  injury  done  to  its  vi¬ 
tality  by  the  proximate  cause  of  cholera, 
whatever  that  may  be,  but  also  from  a  me¬ 
chanical  cause — namely,  from  a  diminution 
in  its  supply  of  blood. 

“  It  may  appear  strange  that  when  the 
same  given  number  of  vessels  go  to  the  liver 
and  come  from  it  at  all  times,  that  the  quan¬ 
tity  of  blood  circulating  in  it  should  be 
greater  at  one  time  than  another.  I  have 
not  time  at  present  to  enter  fully  into  this 
subject ;  but  it  is  a  fact  admitting  of  sufficient 
proof,  that  the  quantity  of  blood  circulating 
in  any  organ  is  very  much  modified  by  the 
state  of  its  capillaries.  The  quantity  of 
blood  also  which  goes  to  a  gland  varies  ac¬ 
cording  to  the  peculiar  state  of  that  gland, 
being  greater  during  its  period  of  active 
secretion  than  when  it  is  at  rest.  But  in  a 
case  of  cholera,  where  the  capillary  vessels 
of  the  intestinal  canal  from  the  stomach  to 
the  rectum  are  actively  engaged  in  taking  up 
the  serum  from  the  whole  mass  of  blood,  and 
pouring  it  into  the  cavity  of  the  digestive 
tube,  there  is  an  enormous  drainage  from 
the  system,  and  there  must  be,  consequently, 
a  deficiency  of  blood  somewhere.  Now  it 
would  appear  that  a  quantity  of  blood,  suffi¬ 
cient  for  the  purposes  of  secretion,  is  ab¬ 
stracted,  not  only  from  the  biliary,  but  also 
from  the  urinary  system  ;  and  hence  it  ap¬ 
pears  just  as  reasonable  to  give  diuretics  to 
restore  the  urinary  secretion,  as  to  give 
calomel  to  excite  the  secretion  of  the  liver. 
It  would  be,  a  priori ,  as  original  a  mode  of 
treatment,  and  be  equally  as  successful.  I 
have  therefore  no  hesitation  in  saying,  that 
the  calomel  treatment  has  no  claim  to  merit 
on  the  ground  of  theory,  and,  as  far  as  I  have 
observed  the  results  of  it  in  this  country,  it 
seems  to  be  of  no  practical  value  in  the 
treatment  of  cholera.”  (p.  417-18.) 

We  commend  these  remarks  to  the 
notice  of  our  readers.  No  rational 
therapeutical  principle  can,  it  appears 
to  us,  be  assigned  to  justify  the  exhibi¬ 
tion  of  calomel  in  cholera.  Even  the 
pretence,  that  without  reference  to 
theory,  the  mercurial  treatment  has 
been  successful,  will  not  justify  its  ad¬ 
ministration.  The  experience  of  Dr. 


Graves  and  numerous  other  practition¬ 
ers,  shews  that  it  has  not  succeeded. 
Dr.  Graves  has  the  credit  of  having 
first  suggested  the  use  of  the  acetate  of 
lead  in  large  and  effectual  doses.  We 
shall  here  allow  him  to  describe  his 
plan  of  treatment : — 

“  The  mode  in  which  I  administered  it 
was  this  : — a  scruple  of  the  acetate  of  lead, 
combined  with  a  grain  of  opium,  was  divided 
into  twelve  pills,  and  of  these,  one  was  given 
every  half  hour,  until  the  rice-water  dis¬ 
charges  from  the  stomach  and  rectum  began 
to  diminish.  In  all  cases  where  medicine 
promised  any  chance  of  relief,  this  remedy 
was  attended  with  the  very  best  effects.  It 
gradually  checked  the  serous  discharges  from 
the  bowels,  and  stopped  the  vomiting.  I 
need  not  say  of  what  importance  this  is  :  as 
long  as  these  exhausting  discharges  continue, 
as  long  as  the  serum  of  the  entire  body  con¬ 
tinues  to  be  drained  off  by  the  intestinal  ex- 
halants,  what  hope  can  we  entertain  ?  What 
benefit  can  be  expected  from  calomel  and 
stimulants,  when  every  function  of  the  di¬ 
gestive  mucous  membrane  seems  to  be 
totally  extinguished,  except  that  of  exhala¬ 
tion,  and  while  profuse  discharges,  occurring 
every  five  or  ten  minutes,  are  reducing  the 
patient  to  a  state  of  alarming  prostration  ? 
Knowing  the  inevitable  fatality  of  all  cases 
where  these  discharges  went  on  unchecked, 

I  was  happy  at  having  discovered  a  remedy 
which  seemed  to  possess  more  power  in  ar¬ 
resting  them  than  any  yet  devised,  and  this 
impression  was  confirmed  by  the  results  of 
subsequent  experience. 

“  That  the  acetate  of  lead  will  succeed 
where  all  other  astringents  fail,  was  proved 
by  the  case  of  Mr.  Parr,  of  this  hospital. 
Having  got  an  attack  of  threatening  diarrhoea, 
at  a  time  when  cholera  was  prevailing  in 
Dublin,  this  gentleman  used  various  kinds  of 
astringents,  and  took  so  large  a  quantity  of 
opiates,  that  he  became  quite  narcotized, 
but  without  any  relief  to  his  symptoms. 
When  I  saw  him  he  was  as  bad  as  ever,  and 
was  beginning  to  exhibit  appearances  of  col¬ 
lapse.  I  advised  the  use  of  pills  composed 
of  acetate  of  lead  and  opium,  in  the  propor¬ 
tions  already  mentioned,  and  had  the  satis¬ 
faction  of  finding  that  before  night  the 
diarrhoea  had  ceased.  The  pills  are  to  be 
used  one  every  half  hour  while  the  diarrhoea 
remains  unchecked,  but  as  it  begins  to  di¬ 
minish,  the  intervals  between  each  pill  may 
be  prolonged,  and  in  this  way  the  patient 
may  be  gradually  prepared  for  leaving  off 
the  remedy  altogether.  1  have  frequently 
given  in  this  way  as  much  as  forty  grains  of 
acetate  of  lead  in  twenty-four  hours,  with 
great  advantage  to  the  patient,  and  without 
any  bad  consequences  ensuing. 

“  It  is  unnecessary  for  me  to  say  any  more 


TREATMENT  OF  CHOLERA - ACETATE  OF  LEAD  AND  OPIUM.  761 


on  this  subject ;  if  I  chose  to  mention  names, 
I  could  bring  forward  the  names  of  many- 
medical  men  in  Dublin,  whose  lives,  I  am 
happy  to  state,  were  saved  by  the  use  of  this 
remedy.  I  may,  however,  observe,  that  this 
mode  of  treatment  has  now  become  universal 
here,  and  that  it  has  almost  completely  su¬ 
perseded  the  use  of  calomel  and  opium.  I 
will  confess  that  this  fact  is  a  source  of  high 
gratification  to  me,  and  I  point  also  with 
pleasure  to  the  fact,  that  since  it  became  ex¬ 
tensively  known  (as  it  did  during  the  last 
invasion  of  the  epidemic),  the  profession  has 
gained  more  credit  than  before,  and  the 
number  of  cures  has  been  proportionally 
greater. 

“I  may  remark  that  the  most  convenient 
way  of  making  the  pills  is  to  add  five  or  six 
grains  of  powdered  liquorice  to  the  scruple 
of  acetate  of  lead,  and  mixing  into  a  mass  by 
means  of  mucilage  of  gum-arabic.  Year 
after  year  since  I  first  made  public  the  value 
of  this  plan  of  treatment  in  cholera,  I  have 
received  the  most  gratifying  letters  as  to  its 
successful  employment,  from  practitioners  in 
India.  The  following  observations  of  Dr. 
Parkes,  who  had  the  opportunity  of  witness¬ 
ing  two  recent  outbreaks  of  cholera  in  India 
in  1843  and  1845,  while  serving  as  assistant- 
surgeon  in  one  of  H.  M.’s  regiments,  I  look 
on  asamostvaluable  testimony.  I  quote  from 
his  essay  on  Cholera,  to  which  I  have  al¬ 
ready  referred.  At  page  207  lie  says  : — 

“  ‘Of  all  the  astringents  which  have  been 
used  in  cholera,  none  has  appeared  so  effi¬ 
cacious  as  the  one  recommended  by  Dr. 
Graves,  viz.  the  acetate  of  lead.  It  is  true 
that  it  did  not  arrest  the  purging  in  all  cases, 
but  it  possessed  this  great  advantage,  that  in 
the  form  of  pill  with  opium,  it  did  not  seem 
to  increase  the  irritability  of  the  stomach, 
but  rather  to  allay  it.  I  used  to  give  two  or 
three  grains  with  a  quarter  of  a  grain  of 
opium,  every  half  hour  for  the  first  two  or 
three  hours,  and  then  every  hour  for  a 
variable  period  according  to  the  intensity  of 
the  case.  It  was  often  found  that  the 
vomiting  first  ceased,  and  then  the  purg¬ 
ing  ;  the  algide  symptoms  were  of  course  un¬ 
altered,  but,  as  already  said,  no  remedy  yet 
known  possesses  any  influence  over  them,  and 
it  is  the  best  way  to  leave  them  altogether  to 
themselves,  and  take  the  chance  of  their  not 
advancing  to  their  full  extent.  The  only  bad 
effect  I  ever  noticed  after  the  employment  of 
these  large  doses  of  lead,  was  subacute  gas¬ 
tritis  ;  but  this  is  a  comparatively  trifling 
affair,  and  can  generally  be  overcome  by  re¬ 
lays  of  leeches  to  the  epigastrium  during  the 
period  of  reaction. ’ 

“  Dr.  Thom,  surgeon  of  the  86th  regi¬ 
ment,  in  an  account  of  the  cholera  as  it 
affected  that  regiment  at  Kurrachee  in  1846, 
thus  speaks  of  the  combination  : — 

“  ‘  The  acetate  of  lead,  in  doses  of  one, 


two,  or  three  grains,  and  one-eighth  of  a 
grain  of  acetate  of  morphia,  was  employed 
to  stop  those  profuse  watery  dejections 
which  continued  in  some  cases  after  reac¬ 
tion  had  taken  place  ;  and  in  this  point  of 
view  it  was  a  most  useful  remedy.  Of 
course  in  those  cases  where  vomiting  and 
purging  are  the  first  symptoms,  and  collapse 
appears  to  be  their  consequence,  the  early 
use  of  this  remedy  was  resorted  to,  and  with 
very  good  encouragement/  ”  (pp.  419-21.) 

It  is  no  small  compliment  to  Dr. 
Graves,  that  the  suggestions  for  the 
treatment  of  cholera  patients,  just 
issued  to  the  Parochial  Boards  by  the 
Royal  Colleges  of  Physicians  and  Sur¬ 
geons  ofEdinburgh,  include  among  the 
medicines,  the  pills  of  acetate  of  lead 
and  opium,  which  are  directed  to  be 
kept  constantly  at  each  station.  This 
will  ensure  a  full  and  fair  trial  for  this 
mode  of  treatment. 

The  lectures  on  cholera  are  followed 
by  a  good  description  of  the  Influenza. 
The  first  volume  is  concluded  by 
the  lectures  on  Diseases  of  the  Ner¬ 
vous  System. 

The  second  volume  includes  an  ac¬ 
count  of  Diseases  of  the  Respiratory 
Organs,  of  the  Heart  and  Digestive 
Organs,  —  the  Kidneys, — Diseases  of 
Females, — and  Syphilis. 

Our  readers  will  perceive  from  this 
brief  analysis,  that  Dr.  Graves’s  work 
is  not  a  systematic  treatise  on  the 
practice  of  physic.  It  comprises  the 
results  of  clinical  practice,  as  illus¬ 
trated  by  actual  cases;  and  these  are  so 
numerous,  and  are  so  fully  detailed, 
that  these  volumes  will  be  found  most 
valuable  for  reference.  Great  praise  is 
due  to  Dr.  Neligan  for  the  care  with 
which  he  has  performed  his  part  as 
editor. 


VISITING  MEDICAL  OFFICERS  OF  LUNATIC 
ASYLUMS. 

The  following  gentlemen  were  appointed  at 
the  Michaelmas  General  Quarter  Sessions 
for  Gloucestershire.  Visiting  medical  offi¬ 
cers  for  the  various  Lunatic  Asylums  in  that 
county: — William  Philpot  Brookes,  M.D. 
Cheltenham — Gilbert  Lyon,  M.D.,  Clifton 
— Chas.  Cornwall,  Esq.,  Fairford. 

OBITUARY. 

October  10th,  from  prussic  acid,  taken, it 
is  supposed,  in  an  over-dose,  Frederick 
Nesbitt,  M.D.  M.R.C.S.,  Yeovil,  Somerset. 


762  DR.  ward’s  CASE  OF  PLEURISY - EMPYEMA — PARACENTESIS. 


^vocccOmg;3  of  isoctettcs. 


PATHOLOGICAL  SOCIETY  OF 

LONDON. 

Monday,  Oct.  16th,  1848. 

Dr.  Copland  in  the  Chair. 


Dr.  Ogier  Ward  read  the  following  case 
of 

Pleurisy  —  Empyema  —  Paracentesis  — 
Spontaneous  evacuation  of  pus  through 
the  walls  of  the  chest ;  and ,  after  closure 
of  the  opening ,  evacuation  of  pus  by  the 
bronchi,  producing  pneumothorax — Re¬ 
covery. 

The  patient  was  exhibited  to  the  Society. 
August  6th,  1848,  a  boy,  set.  6,  about 
six  months  ago  had  pleurisy  of  the  left 
side,  which  was  followed  by  empyema  in 
about  a  month  afterwards,  when  first  seen. 
At  this  time  there  was  a  hectic  condition, 
the  bowels  being  pretty  regular,  urine  de¬ 
positing  lithates  in  excess.  The  upper  part 
of  the  left  side  of  the  chest  had  sunk  con¬ 
siderably,  and  the  lower  bulged  out,  with 
much  less  motion  of  the  intercostal  muscles 
than  on  the  right.  The  heart  was  pushed 
towards  the  right  side,  so  that  its  pulsations 
were  visible  in  the  epigastrium,  while  there 
was  dulness  on  percussion  considerably  to 
the  right  of  the  median  line  ;  there  was  also 
dulness  more  or  less  over  the  whole  of  the 
left  side  of  the  chest,  particularly  below  the 
level  of  the  fifth  rib,  over  which  oegophony 
was  audible,  and  also  at  the  back  of  the 
chest,  below  the  scapula,  the  respiration 
being  bronchial,  with  mucous  rattle  over  the 
tipper  part,  except  a  small  space  in  the 
interscapular  region,  where  the  vesicular 
murmur  was  still  audible.  The  internal 
and  external  use  of  mercury,  with  bark  and 
iodide  of  potassium,  were  used,  without  re¬ 
moving  the  empyema,  though  it  seemed 
occasionally  to  vary  in  quantity ;  and  as  it 
had  threatened  to  point  externally  once  or 
twice,  and  there  was  oedema  of  the  parietes, 
the  operation  of  paracentesis  was  performed 
May  19th,  about  six  weeks  from  the  time  of 
his  being  first  seen,  with  a  trocar  and  canula 
inserted  between  the  sixth  and  seventh  ribs. 
About  half  a  pint  of  healthy  pus  wTas 
evacuated.  The  child’s  health  immediately 
improved,  though  the  fluid  again  collected 
in  a  few  (lays,  the  external  wound  having 
healed. 

After  the  operation,  the  heart  returned  to 
the  left  side  of  the  chest,  but  much  higher 
than  natural,  its  whole  surface  appearing  to 
be  applied  to  the  wall  of  the  chest  from  the 
interval  between  the  second  and  third  ribs 


to  an  inch  below  the  nipple,  over  the  whole 
of  which  space  its  pulsations  were  perceptible 
to  sight,  and  it  has  retained  this  position 
ever  since.  In  other  respects  the  left  side 
seemed  to  be  much  the  same  as  before  the 
operation ;  for  though  the  fluid  was  eva¬ 
cuated,  yet  the  stomach  and  colon  seemed 
to  occupy  the  vacant  space  up  to  the  level 
of  the  point  where  the  trocar  entered  the 
chest,  so  as  to  render  the  lower  part  of  the 
chest  very  resonant,  while  the  upper  part 
still  continued  contracted,  as  though  the 
lung  were  bound  down  by  adhesions.  The 
physical  signs  also  remained  much  as  before 
the  operation,  with  the  exception  that  the 
dulness  did  not  occupy  such  a  great  extent 
of  the  lower  part  of  the  chest. 

In  about  six  weeks  after  the  operation,  the 
skin  over  the  space  between  the  fifth  and 
sixth  ribs,  where  it  had  threatened  to  point 
previously,  again  became  inflamed,  and  gave 
way,  giving  exit  to  a  considerable  quantity 
of  healthy  pus,  which  has  continued  to  flow 
ever  since  in  varied  quantity,  with  five  or 
six  intermissions  of  a  week  or  nine  days,  on 
which  occasions  he  has  had  cough,  with 
fever  and  dyspnoea,  until  the  discharge  re¬ 
turned.  At  present  it  scarcely  amounts  to 
a  drachm  a  day. 

The  left  side  of  the  chest  is  now  much 
contracted  at  the  upper  part,  the  shoulder 
having  sunk,  and  the  ribs  being  quite  flat  to 
a  level  with  the  discharging  orifice  ;  but  it 
bulges  considerably  below,  from  the  presence 
of  the  stomach  high  up  in  the  hypochon- 
drium.  The  spine  is  much  curved  laterally, 
so  that  in  walking  he  seems  as  if  suffering 
from  disease  of  the  hip.  He  has  become 
extremely  emaciated,  and  the  hair  over  his 
body  and  limbs  has  grown  very  thick  and 
long.  Percussion  is  dull  over  the  flat  part 
of  the  chest,  but  sonorous  below.  Respira¬ 
tion  is  bronchial,  with  mucous  rattles  over 
the  dull  part,  and  down  the  side  of  the  spine, 
but  towards  the  base  of  the  lung  the  vesi¬ 
cular  murmur  is  still  audible. 

Sept.  28th, — Three  weeks  ago,  the  wound 
being  still  open,  a  probe  did  not  penetrate 
above  three-quarters  of  an  inch,  and  in  a 
few  days  afterwards,  it  healed  up,  and 
ceased  to  discharge  for  ten  days,  during 
which  time  the  cough  became  very  trouble¬ 
some,  with  great  dyspnoea ;  and  when  he 
expectorated,  the  matter  resembled  the 
purulent  discharge  from  the  wound,  instead 
of  being  simple  mucus  as  heretofore. 

To-day  the  side  is  still  more  collapsed 
below  the  clavicle,  and  the  shoulder  thrown 
more  forward.  The  sore  still  discharges  a 
little  healthy  pus.  Upon  percussion,  the 
whole  space  from  the  clavicle  to  the  fourth 
rib,  which  has  hitherto  been  dull,  is  now 
preternaturally  resonant,  far  exceeding  the 
sound  of  the  right  side  in  clearness,  and 
having  such  a  complete  amphoric  character 


SPONTANEOUS  RUPTURE  OF  THE  AORTA — DISSECTING  ANEURISM.  763 


as  to  strike  the  attention  of  his  mother,  who 
compared  it  to  the  sound  emitted  by  a  bottle 
when  struck  ;  and  there  is  cavernous  re¬ 
spiration,  and  distinct  pectoriloquy,  with 
mucous  rattles  over  the  same  space,  but  no 
metallic  tinkling.  The  respiratory  and 
vocal  sounds  elsewhere  remain  as  before. — 
Ordered  to  lie  as  much  on  the  affected  side 
as  possible  ;  but  if  he  is  placed  on  that  side 
in  bed,  he  turns  to  the  other  before  he  falls 
asleep.  He  is  gaining  flesh  and  strength. 

Oct.  4th. — The  discharge  ceased,  and  the 
orifice  closed  on  the  29th  ult.,  and  since 
that  time  his  improvement  has  been  more 
rapid  than  it  has  ever  been  before,  having 
neither  fever,  cough,  nor  expectoration,  nor 
any  night  sweats. — Omit  all  medicine. 

14th. — The  orifice  is  depressed,  and  closed 
by  a  scab.  He  is  fatter  and  stronger,  and 
can  now  sleep  on  either  side.  The  left  side 
of  the  chest  is  more  expanded,  though  there 
is  still  a  difference  of  4  to  2  inches  in  its 
circumference,  compared  to  the  right  side. 
The  shoulder  is  higher,  and  the  spine 
straighter,  and  he  is  less  hairy  than  before. 
The  pectoriloquy  and  resonance  still  exist, 
but  the  latter  in  a  less  degree,  and  the  seat 
of  the  mucous  rattle  is  now  confined  to,  or 
is  loudest  at,  a  point  an  inch  and  a  half  to 
the  left,  and  one  inch  below  the  level  of  the 
nipple.  Percussion  is  still  painful  over  the 
resonant  part,  particularly  near  the  orifice. 

Dimensions  of  chest : — 

Inches. 

Right  side.  Left  side. 

Under  arm -pits  ...  10^  9£ 

Round  chest,  over  epi¬ 
gastrium  ....  11^  91- 

Round  base  of  chest  .  .  10^  9J 

The  sternum  is  projected  forward  and 
towards  the  right  side  by  the  increased  ex¬ 
pansion  of  the  x’ight  side,  which  is  very  re¬ 
sonant.  The  respiratory  murmur  is  puerile 
over  the  whole  of  that  side  of  the  chest. 

Oct.  16th. — The  resonance  on  percussion 
of  the  left  side  of  the  chest  is  much  less 
in  front  and  above  the  cicatrix  of  the 
orifice  ;  but  the  back  of  the  chest  is  still 
dull,  though  the  respiratory  murmur  is  au¬ 
dible  over  this  part.  In  front  the  respira¬ 
tion  is  less  cavernous,  and  the  mucous  rattle 
is  chiefly  heaid  at  the  close  of  the  inspira¬ 
tion,  and  is  still  loudest  at  the  point  above 
mentioned  below  the  nipple  ;  behind  it  is 
most  audible,  below  the  spine  of  the  scapula, 
where  the  respiration  has  somewhat  of  a 
whistling  or  blowing  character.  Pectoriloquy 
is  very  distinct  over  the  resonant  part,  but 
in  every  respect  there  is  improvement  since 
last  report  in  the  physical  signs,  indicative 
that  the  lung  is  again  expanding  itself,  and 
that  the  opening  into  the  bronchi  is  closing. 

The  main  point  of  interest  in  this  case  is 
the  improvement  of  the  patient  after  the 


establishment  of  so  severe  a  lesion  as  em¬ 
pyema,  with  perforation  of  the  walls  of  the 
chest,  and  fistulous  communication  with  the 
bronchi.  Cases  of  pneumo-thorax  are  not 
very  rare,  but  I  have  never  seen  an  instance 
of  recovery  from  such  a  complication  as  the 
present,  and  I  can  only  find  two  recorded 
by  Mr.  Guthrie  in  his  lectures — viz.  one 
mentioned  by  Dr.  Davy,  and  the  other  in 
the  case  of  Lord  Beaumont.  The  absence 
of  metallic  tinkling  in  this  case  (unless  the 
mucous  rattle  or  clicking  sound  at  the  close 
of  inspiration  may  be  supposed  to  represent 
it)  is  worthy  of  note,  as  throwing  some  doubt 
upon  the  physical  cause  of  this  sound,  as  is 
also  the  rapid  improvement  of  the  patient 
immediately  after  the  closure  of  the  external 
wound,  though  at  the  same  time  a  complica¬ 
tion  of  usually  far  more  fatal  character  was 
established  by  the  perforation  of  the  bron¬ 
chus. 

The  rapid  growth,  and  again  the  falling  off 
of  the  hair  of  the  body  and  limbs,  is  interest¬ 
ing  in  a  case  that  has  not  exhibited  any 
scrofulous  complications. 

Dr.  Peacock  exhibited  a  specimen  of 

Spontaneous  rupture  of  the  aorta ,  dissect¬ 
ing  aneurism. 

This  preparation  was  removed  from  the 
body  of  a  man,  44  years  of  age,  who  had 
been  of  intemperate  habits,  but  had  never 
suffered  from  rheumatism.  He  dated  the 
first  symptoms  of  cardiac  disorder  to  a  blow 
which  he  had  received  on  the  chest  twelve 
years  before.  When  admitted  a  patient  of 
the  City  of  London  Hospital  for  Diseases  of 
the  Chest,  on  the  30th  of  June  last,  he 
stated  that  he  had  been  very  subject  to  pal¬ 
pitation  of  the  heart  for  the  previous  year 
and  a  half,  but  had  been  much  worse  since 
December  1847.  He  was  at  that  time  in 
much  pecuniary  embarrassment,  and  when 
out  one  morning  was  suddenly  seized  with 
extreme  difficulty  of  breathing,  palpitation, 
pain  in  the  region  of  the  heart,  and  faintness, 
and  with  difficulty  reached  home.  From 
this  time  he  was  never  able  to  sleep  in  the  re¬ 
cumbent  position,  and  was  subject  to  attacks 
of  a  similar  description,  generally  once  a 
.  week.  These  attacks  usually  came  on  at 
about  one  o’clock  in  the  morning,  and  after 
continuing,  with  variable  severity,  for  half 
an  hour  or  more,  gradually  subsided.  The 
difficulty  of  breathing  and  palpitation  under 
which  he  at  all  times  laboured  were  much 
increased  on  exertion,  and  especially  by 
ascending  stairs.  Latterly  he  had  a  hard 
dry  cough,  and  scanty  expectoration,  very 
rarely  tinged  with  blood.  On  examining  the 
chest,  the  dulness  on  percussion  in  the  re¬ 
gion  of  the  heart  was  found  much  extended 
beyond  its  natural  limits,  and  there  was  a 
loud  and  rough  double  murmur  over  the 
whole  of  the  front  of  the  chest,  but  most 


764  SPONTANEOUS  RUPTURE  OF  THE  AORTA — DISSECTING  ANEURISM. 


distinctly  between  the  left  nipple  and  ster¬ 
num.  The  pulse  was  equal  in  the  two  wrists, 
feeble,  but  not  of  the  regurgitant  character. 

At  the  end  of  August,  after  having  been 
some  time  in  the  country,  he  was  suddenly 
called  to  town.  On  his  way  to  the  railway 
station,  he  became  much  excited,  fearing  he 
•would  be  too  late  for  the  train,  and  soon 
after  he  had  started  he  suddenly  experienced 
a  peculiar  sensation  commencing  in  the  lower 
part  of  the  abdomen,  followed  by  pain  in 
the  praecordia,  and  extending  thence  to  the 
spine  of  the  back  :  he  became  faint,  and 
breathed  with  great  difficulty.  When  he 
arrived  at  home,  he  was  seen  by  Mr.  Mackey, 
and  found  very  much  collapsed  ;  the  extre¬ 
mities  cold ;  he  had  entire  suppression  of 
urine,  and  complained  of  pain  in  the  region 
of  the  heart  and  in  the  back.  He  was 
visited  by  Dr.  Peacock  in  the  evening.  At 
that  time  the  collapse  had  in  some  degree 
subsided  ;  he  was  completely  collected,  and 
was  kneeling  on  a  sofa,  with  his  head  hanging 
over  the  end.  The  respiration  was  extremely 
difficult,  the  pulse  was  feeble  and  somewhat 
vibratory  ;  the  extremities  were  cool,  and  he 
complained  of  agonizing  pain  in  the  region 
of  the  heart,  and  extending  thence  to  the  back 
and  down  the  spine  from  the  occiput.  The 
suppression  of  urine  continued.  A  loud  and 
rough  murmur  attending  the  impulse  of  the 
heart  was  audible  over  the  whole  front  of  the 
chest.  It  was  less  distinct  beneath  the  nip¬ 
ple  than  at  the  upper  part  of  the  sternum. 
A  softer  murmur  was  also  heard  with  the 
diastole  of  the  heart,  more  especially  at  the 
lower  part  of  the  sternum.  He  experienced 
some  relief  from  the  means  had  recourse  to, 
but  about  one  o’clock  the  following  morning 
suddenly  expired. 

On  examination,  the  pericardium  was 
found  greatly  distended  with  serum,  and  the 
heart  was  enveloped  in  a  firm  dark-coloured 
coagulum.  On  removing  this,  a  ragged  slit, 
about  an  inch  in  length,  was  detected  in  the 
pericardial  covering  of  the  origin  of  the 
aorta,  extending  transversely  immediately 
above  the  base  of  the  right  ventricle.  The 
heart  was  of  large  size,  weighing  not  less 
than  20  oz.  The  attached  pericardium  dis¬ 
played  some  concretions  of  old  lymph  on  the 
surface  of  the  left  ventricle,  and  was  thick¬ 
ened  and  opaque  on  the  right  ventricle.  The 
right  ventricle  was  large,  but  its  walls  of  the 
natural  thickness  ;  the  left  ventricle  was 
hypertrophied  and  dilated.  The  auricles 
were  natural.  The  folds  of  the  mitral  valve 
were  thickened  and  opaque.  The  aortic 
valves  were  much  thickened  and  slmrtened 
at  their  free  edges,  and  the  angles^Pf  the 
right  and  left  valves  were  adherent,  so  as 
to  leave  an  aperture  when  the  valves  were 
expanded  allowing  of  slow  regurgitation. 
The  ascending  aorta  was  dilated,  and  its  coats 
thin  and  studded  in  places  with  atheroma¬ 


tous  deposit.  At  the  anterior  and  right  side 
of  the  vessel,  about  one  inch  above  its  ori¬ 
gin,  there  was  an  irregular  slit  f  of  an  inch 
in  length,  extending  obliquely  across,  and 
involving  the  internal  and  nearly  the  whole 
of  the  middle  coat.  From  this  rupture 
blood  had  escaped,  and  had  become  exten¬ 
sively  infiltrated  into  the  subserous  cellular 
tissue,  and  had  finally  escaped  through  the 
rupture  in  the  serous  covering  into  the  sac 
of  the  pericardium.  At  the  posterior  part 
of  the  root  of  the  arteria  innominata,  there 
was  found  a  second  rupture,  about  one-third 
of  an  inch  long,  which  extended  through 
only  part  of  the  middle  coat,  and  from  which 
the  blood  had  insinuated  itself  between  the 
laminae  of  the  middle  coat,  producing  a 
separation  extending  round  a  considerable 
portion  of  the  circle  of  the  transverse  and 
descending  aorta,  for  a  distance  of  about  two 
inches  behind  the  origin  of  the  left  subcla¬ 
vian  artery.  The  descending  aorta  was  de¬ 
cidedly  small  in  capacity. 

The  remarks  made  by  Dr.  Peacock,  in  re¬ 
ference  to  this  case,  were — first,  that  the 
occurrence  of  two  ruptures  in  different  parts, 
of  the  vessel  sufficiently  attested  the  ready 
lacerability  of  the  arterial  coats.  The  rup¬ 
ture  at  the  root  of  the  arteria  innominata 
was  probably  that  which  had  first  occurred, 
while  the  production  of  the  second  and  larger 
laceration  in  the  ascending  aorta  might  be 
due  to  the  obstruction  to  the  flow  of  blood 
along  the  transverse  and  descending  portions 
of  that  vessel  occasioned  by  the  pressure  of 
the  blood  which  had  escaped  between  the 
laminae  of  the  middle  coat.  The  second 
point  of  interest  consisted  in  the  separation 
of  the  coats  of  the  vessel,  constituting  the 
first  step  in  the  product  of  a  dissecting  aneu¬ 
rism,  having  occurred  in  the  laminae  of  the 
middle  coat.  This,  there  is  reason  to  believe, 
is  always  the  case  in  dissecting  aneurisms, 
though  in  some  cases  on  record  the  sac  has 
been  described  as  situated  between  the  mid¬ 
dle  and  external  coat.  In  two  cases  so 
described,  Dr.  Peacock  had  satisfied  himself 
that  there  had  been  an  error  in  the  descrip¬ 
tion  given,  the  sac  being  situated  in  the 
laminae  of  the  middle  coat  in  both. 

Mr.  Birkett  exhibited  a  specimen  of 

Extensive  disease  of  the  urinary  organs , 

taken  from  the  body  of  a  man  jet.  43,  ad¬ 
mitted  into  Guy’s  Hospital,  under  Mr. 
Cock,  with  constitutional  symptoms  of  the 
absorption  of  urea.  He  had  been  married 
five  years,  and  a  year  or  two  prior  to  mar¬ 
riage  had  contracted  gonorrhoea,  for  which 
affection  he  underwent  no  treatment.  The 
urine  was  very  scanty,  and  loaded  with  pus, 
and  a  very  small  instrument  only  could  be 
passed  into  thebladder.  He  died  on  the  fourth 
day  after  admission.  On  the  post-mortem 
examination,  the  meningeal  vessels  were 


INTUSSUSCEPTION  OF  SEVEN  INCHES  OF  THE  ILEUM. 


765 


found  congested  :  there  was  more  serous  i 
fluid  than  usual  in  the  ventricles,  as  well 
as  subarachnoid  effusion.  Both  kidneys 
were  greatly  disorganized  and  dilated  ;  the 
secreting  structure  alternately  soft  and  hard, 
with  much  yellow  deposit  and  incipient 
suppuration.  The  pelvis  and  calyces  filled 
with  pus,  but  the  mucous  membrane  not 
abraded.  The  ureters  enormousiy  dilated 
and  convoluted.  The  bladder  hyper¬ 
trophied,  and  containing  some  puriform 
fluid.  The  prostate  enlarged,  the  interior 
being  filled  with  pus,  and  the  ducts  much 
dilated.  The  corpora  cavernosa,  and  the 
corpus  spongiosum,  almost  black  from 
congestion  ;  the  latter  more  rigid  than  usual. 
The  prostatic  portion  of  the  urethra  was 
dilated  ;  the  membranous  and  remaining 
portion  contracted.  The  seat  of  the  stricture 
was  at  the  angle  formed  by  the  crura  penis, 
and  by  its  left  side  the  urethra  was  pushed 
forwards,  forming  a  kind  of  pouch,  doubt¬ 
less  from  the  continued  efforts  of  the  man  to 
void  his  urine.  No  trace  of  a  false  passage. 

Dr.  Hake  exhibited  a  specimen  of 

Intussusception  of  seven  inches  of  the  ileum , 

together  with  the  appendix  vermiformis, 

into  the  colon,  through  the  ileo-ccecal 

valve. 

Frederick  H.,  set.  4§  years,  was  admitted 
into  the  St.  Mary-le-Bone  Dispensary,  on 
Monday,  October  2nd,  and  was  first  seen  by 
Dr.  Hare  about  4  o’clock  p.m.  He  from 
the  age  of  eighteen  months  had  been 
troubled  with  ascarides.  When  six  months 
old,  he  had  an  inflammation  of  the  chest, 
accompanied  with  some  cough  :  since  then 
he  had  been  subject  at  times  to  a  cough,  but 
not  to  a  constant  one.  For  a  week  previous 
to  his  present  attack,  he  had  not  seemed 
quite  so  well  and  lively  as  usual,  but  he 
continued  his  play  as  before,  and  did  not 
complain  of  any  pain. 

On  Thursday  evening,  Sept.  28th,  before 
going  to  bed,  he  complained  somewhat  of 
soreness  about  the  anus.  On  examining  it, 
a  few  thread-worms  were  seen,  as  had  fre¬ 
quently  been  the  case  before.  On  the  follow¬ 
ing  morning  he  got  up  and  played  with  some 
other  children  in  the  house  till  between  ten 
and  eleven  o’clock,  when  he  suddenly  com¬ 
plained  of  great  pain  in  the  lower  part  of  the 
abdomen,  to  which  he  pressed  his  hands.  He 
said  he  wanted  to  go  to  stool,  and  went  two 
or  three  times  in  the  ensuing  quarter  of  an 
hour,  but  did  not  pass  anything ;  his  eyes 
looked  wild ;  the  pain  continued  severe, 
and  about  eleven  o’clock  he  vomited  all  he 
had  taken  during  the  morning.  Every  half 
hour  or  less  he  continued  to  go  to  stool, 
but  fruitlessly,  except  that  about  one  o’clock, 
and  passed  a  small  lump  or  two  of  faecal 
matter.  The  pain  then  for  a  while  became 


apparently  somewhat  less  than  at  first,  and 
from  about  2  till  3§  p.m.  he  had  some  sleep. 

At  4  p.m. ,  he  passed  a  clot  of  blood,  and 
still  continued  to  go  to  stool  two  or  three 
times  an  hour,  till  a  little  after  12  on  the 
Saturday.  On  many  of  those  occasions  he 
passed  some  pure  dark-coloured  blood,  with 
a  little  slimy  matter,  the  whole  of  which  to¬ 
gether,  amounted,  it  was  said,  to  eight  or 
ten  ounces.  The  pain  in  the  abdomen  re¬ 
mained  intense  ;  he  would  only  stay  for  a  very 
short  time  in  any  one  position,  resting  most 
frequently  doubled  up  on  his  hand  and  knees, 
so  as  to  relax  as  much  as  possible  the  abdo¬ 
minal  muscles.  He  drank  a  great  deal,  and 
with  avidity,  but  always  vomited  soon  after. 
On  the  Saturday  afternoon  he  went  much 
less  frequently  to  stool,  and  on  the  Sunday 
only  twice,  but  the  other  symptoms,  the 
pain  and  vomiting,  remained  much  as  before, 
up  to  the  time  when  first  seen  by  Dr.  Hare 
(Monday  afternoon).  When  he  was  first 
attacked,  the  vomited  matter  contained  a 
considerable  quantity  of  bile,  but  not  after¬ 
wards  ;  it  was  said  to  have  smelt  sour,  but 
no  faecal  odour  was  observed. 

His  countenance  was  expressive  of  the 
greatest  anxiety  and  pain  ;  the  eyes  were 
somewhat  sunken,  and  the  skin  around  the 
orbits  rather  dark  ;  he  was  constantly 
calling  out  and  moaning  with  pain,  which 
he  referred  to  the  abdomen,  especially 
about  and  below  the  umbilicus.  His  in¬ 
tellect  clear ;  no  delirium  or  convulsions. 
Pulse  very  quick.  Complained  of  constant 
thirst,  and  drank  frequently,  but  he  almost 
always  retched  and  vomited  after  taking 
anything.  The  abdomen  was  more  swollen 
and  prominent  above  the  umbilicus  than 
below  it ;  the  prominent  part  was  distinctly 
marked  by  two  swellings  going  transversely 
across  the  epigastric  and  upper  part  of  um¬ 
bilical  regions,  and  separated  from  one 
another  by  a  slight  depression  :  both  were 
tympanitic  on  percussion, *as  was,  indeed,  all 
the  rest  of  the  abdomen  ;  fluctuation  per¬ 
ceptible.  There  was  much  tenderness  on 
percussion  or  pressure  over  the  whole  of  the 
abdomen,  but  none  on  simply  pinching  up 
the  integuments. 

No  cause  could  be  assigned  for  the  com¬ 
mencement  of  the  attack. 

He  obtained  but  little  relief  from  the 
treatment  adopted,  and  gradually  sank,  and 
died  about  1  a.m.  on  Tuesday,  Oct.  3rd. 

The  abdomen  presented  externally  the 
same  aspect  as  during  life.  On  opening  it, 
the  two  transverse  prominences  between  the 
ends  of  the  sternum  and  umbilicus  were 
found  to  be  caused,  the  upper  one  by  the 
stomach,  whose  larger  curvature  was  tilted 
unusually  forwards  and  upwards  ;  the  lower 
one  by  the  ascending  colon,  which  had  be¬ 
come  so  displaced  as  to  occupy  nearly  the 
position  of  the  transverse  colon,  the  caput 


766  GUN-SHOT  FRACTURE  OF  SKULL — SINGULAR  COURSE  OF  THE  BALL. 


coli  being  situated  just  above  and  but  a  very 
little  to  the  right  of  the  umbilicus.  Both 
this  portion  of  the  colon  and  the  sto¬ 
mach  were  much  distended  with  wind,  as 
was  also  one  coil  of  the  small  intestines. 
Scarcely  any  effusion  into  the  peritoneum  ; 
no  lymph  ;  marked  redness  of  most  parts  of 
the  small  intestines,  especially  where  the 
different  coils  of  them  were  in  contact  with 
each  other.  No  redness  of  colon  or  of  peri¬ 
toneum  covering  the  walls  of  abdomen.  On 
examining  the  intestines  it  was  discovered 
that  there  was  a  very  considerable  intussus¬ 
ception  of  ileum,  and  of  the  accompanying 
mesentery,  throughthe  ileo-caecal  valve  into 
the  colon,  and  that  the  appendix  vermiformis 
was  likewise  carried  through  the  valve  ;  two 
of  the  mesenteric  glands  close  to  the  point 
of  strangulation  of  ileum  were  enlarged. 
When  the  caecum  was  opened,  the  ileum  was 
found  to  have  protruded  into  it  to  the  depth 
of  three  and  a  half  inches,  so  that  at  least 
seven  inches  of  the  small  intestines  must 
thus  have  been  forced  through  the  valve. 
The  intussuscepted  portion  was  of  a  deep- 
red  colour,  and  contrasted  remarkably  with 
the  pale  colour  of  the  mucous  membrane  of 
the  colon  :  but  there  was  no  appearance  of 
gangrene  or  sloughing.  The  strangulated 
portion  was  so  swollen  and  so  firmly  en¬ 
circled  by  the  ileo-csecal  valve,  that  any 
effort  to  withdraw  it  seemed  more  likely  to 
tear  the  substance  than  to  succeed.  Close 
to  the  valve,  on  the  portion  of  the  mucous 
membrane  reflected  from  the  colon  on  to  the 
ileum,  there  were  several  shreds  of  lymph, 
some  of  them  nearly  half  an  inch  in  length. 
The  mucous  membrane  of  the  rest  of  the 
ileum  was  red  in  patches,  while  the  solitary 
glands,  as  well  as  those  of  Peyer,  were  much 
diseased  throughout  its  whole  length.  At 
about  the  middle  of  the  ileum  there  wTas 
another  slight  intussusception;  this  one 
could  be  very  easily  reduced,  and  had  pro¬ 
bably  only  occurred  towards  the  last  periods 
of  life.  There  was  a  little  fluid,  but  scarcely 
any  faecal  matter  in  the  small  intestines,  and 
none  in  the  large. 

Mr.  Morton  exhibited  a  specimen  of 

Gun-shot  fracture  of  skull :  singular  course 
of  the  ball. 

A  gentleman  was  brought,  in  August 
1848,  to  University  College  Hospital,  hav¬ 
ing  committed  suicide  by  discharging  a 
pistol  into  his  mouth.  The  ball  had  tra¬ 
versed  the  hard  palate,  and  ascending 
through  the  nares  passed  into  the  skull, 
breaking  the  sphenoid  bone  on  the  right  side 
of  the  mesial  line,  shattering  the  right  an¬ 
terior  clinoid  process  and  adjacent  part  of 
the  sella  turcica  and  optic  foramen.  After 
piercing  the  right  hemisphere  of  the  brain, 
the  ball  had  struck  the  inside  of  the  calva¬ 


rium,  dividing  the  dura  mater  on  the  right 
of  the  longitudinal  sinus,  and  breaking  the 
parietal  bone  to  the  extent  of  a  crown 
piece,  producing  a  stellated  fracture,  the 
central  portions  of  which  were  elevated  con¬ 
siderably  underneath  the  pericardium,  which 
remained  intact.  The  ball  had  then  changed 
its  course,  being  driven  downwards  and 
outwards  through  the  right  hemisphere 
again,  and  was  found  lying  in  the  middle 
lobe,  close  to  the  foramen  spinosum. 
The  outer  table  of  the  parietal  bone  was 
broken  into  eight  fragments,  each  of  consi¬ 
derable  size,  while  the  inner  table  pi’esented 
but  one  fragment,  and  that  of  the  size  of 
half  a  crown.  The  ball  was  completely 
flattened  and  jagged. 

2.  Salivary  calculus  taken  from  the  sub¬ 

lingual  duct  of 

A  middle  aged  woman,  who  came  under 
the  care  of  Mr.  Morton.  She  stated  that  for 
about  a  year  previous  she  had  experienced 
considerable  inconvenience  underneath  her 
tongue,  chiefly  felt  while  eating  her  food, 
when  the  sensation  was  as  though  the  secre¬ 
tion  of  the  saliva  was  rapidly  increased. 
About  three  months  since,  notwithstanding 
she  had  frequently  examined  the  part 
affected,  she  discovered  a  little  tumor, 
which  was  hard  to  the  touch,  and  of  a 
whitish-yellow  colour.  Of  late  ithadincreased 
in  size  much  more  rapidly  than  at  first. 
Its  presence  interfered  with  her  powers  of 
mastication,  but  not  with  her  speech.  After 
incising  the  mucous  membrane  which  co¬ 
vered  it,  the  calculus  was  readily  removed. 
It  was  of  the  size  of  a  horse  bean,  of  white 
colour,  and  irregular  shape. 

3.  Enchondroma  of  the  ffth  metacarpal 

bone ,  of.  considerable  size. 

A  boy,  aged  16,  was  admitted  into  Uni¬ 
versity  College  Hospital,  under  Mr.  Mor¬ 
ton.  He  was  the  subject  of  numerous 
swellings  on  the  fingers  and  metacarpal 
bones  of  both  hands.  There  were  fifteen  or 
sixteen  of  these  swellings,  all  but  one,  how¬ 
ever,  of  small  size,  and  not  interfering  with 
his  comfort ;  one,  however,  occupying  the 
ulnar  border  of  the  left  hand,  was  so  large 
as  to  prevent  him  from  following  his  occu¬ 
pation.  It  was  of  the  size  of  an  orange, 
and  situated  over  the  fourth  and  fifth  meta¬ 
carpal  bones,  the  former  of  which  it  over¬ 
lapped  in  such  a  manner  as  to  render  it 
doubtful  whether  it  might  not  be  attached 
to  it.  The  shell  of  the  tumor  appeared  to 
be  semi-elastic,  as  if  formed  by  the  gradual 
distention  of  the  hard  dense  portion  of  the 
metacarpal  bone. 

The  tumor  was  exposed  by  dissection, 
and  the  extensor  tendons  of  the  little  finger 
were  found  spread  out  into  a  broad  thin 
tissue  over  it.  The  first  intention  was,  if 


THE  CHOLERA  AT  PECKHAM - USE  OF  CHLOROFORM. 


767 


possible,  to  remove  the  new  growth,  and  to 
preserve  the  finger,  but  this  was  found  to  be 
impracticable.  Therefore  the  finger  and 
metacarpal  bone  were  removed  together, 
with  the  tumor,  which  last  measured  six 
inches  in  circumference  in  both  directions, 
being  of  an  ovoid  figure. 

On  making  a  section,  the  tumor  consisted 
of  a  white  cartilaginous  mass,  with  here  and 
there  small  cellular  cavities,  which  had  ap¬ 
parently  commenced  its  growth  in  the 
medullary  cavity  of  the  metacarpal  bone, 
and  slowly  distended  the  more  dense  walls 
into  a  thin  shell,  which  slightly  yielded,  with 
a  crackling  sensation,  under  the  pressure  of 
the  finger.  Though  overlapping  the  ends  of 
the  bone,  the  articular  extremities  were  free 
from  the  disease.  The  patient  stated  that 
the  slightest  blow  was  certain  to  be  followed 
by  a  tumor  of  the  same  kind.  All  the 
other  tumors  had  been  stationary  for  a  con¬ 
siderable  time,  and  although  they  gave  his 
hands  a  knotty  appearance,  they  did  not 
prevent  him  from  performing  his  work. 

The  Meeting  adjourned  to  November  6, 
at  8  p.m. 


MEDICAL  SOCIETY  OF  LONDON. 

Monday,  October  23,  1848. 

Mr.  Hancock,  President. 

Cholera  at  Peckham. — Use  of  chloroform. 

Dr.  Clutterbuck  had  seen,  since  last 
week,  several  cases  of  cholera  at  the  Lunatic 
Asylum  at  Peckham,  which  contains  500 
patients  ;  of  these,  about  30  had  been  at¬ 
tacked,  and  five  had  died.  Many  of  the 
cases  had  been  of  the  most  severe  kind,  with 
all  the  symptoms  of  malignant  cholera.  At 
the  beginning  of  the  attack,  two  severe  cases 
were  treated  with  acetate  of  lead  and  opium, 
and  both  died.  He  had  found  a  simple  plan 
of  treatment  the  best.  Calomel  and  opium 
could  not  be  administered  with  safety,  and 
large  doses  of  laudanum  did  great  mischief. 
The  administration  of  chloroform  had  been 
productive  of  the  greatest  benefit.  The 
spasms  and  pain  were  almost  immediately 
relieved,  and  the  patients  became  composed, 
and  enjoyed  a  kind  of  sleep.  These  results 
took  place  after  the  use  of  chloroform  for 
about  a  quarter  of  an  hour.  The  effects,  so 
far,  had  been  immediately  and  uniformly 
good.  He  considered  it  much  to  be  pre¬ 
ferred  to  opium,  for  the  relief  of  the  painful 
spasms  attendant  upon  cholera.  In  answer 
to  questions,  Dr.  Clutterbuck  said  the 
Asiatic  cholera,  in  his  opinion,  differed 
from  the  common  cholera  of  this  country 
only  in  degree.  In  the  fatal  cases  at  Peck¬ 
ham,  all  the  worst  features  of  what  was 
called  the  Asiatic  cholera  presented  them¬ 
selves.  The  pulse  was  imperceptible;  the 


skin  cold  and  blue ;  the  features  sunken ; 
the  depression  complete ;  and  the  evacua¬ 
tions  watery.  The  case  was  quickly  fatal. 
There  was  no  ground  for  questioning  the 
identity  of  the  disease.  He  insisted  upon 
the  necessity  and  value  of  treating  the  dis¬ 
ease  by  simple  remedies.  Moderate  doses 
of  brandy,  and  the  application  of  external 
heat,  were  the  chief  indications  in  the  early 
stages.  He  believed  that  there  was  no 
specific  for  the  disease. 

Mr.  Dendy  differed  from  Dr.  Clutter¬ 
buck,  as  to  the  identity  of  Asiatic  and 
English  cholera.  He  had  thought,  years 
ago,  that  Dr.  Clutterbuck  had  acknowledged 
a  difference  between  these  diseases.  It  had 
been  his  intention  to  try  chloroform  in  the 
first  cases  of  cholera  which  he  might  see  ; 
but  he  considered  it  would  only  act  as  a  sub¬ 
stitute  for  opium  by  relieving  spasm.  This 
was,  however,  an  important  point  in  the 
treatment,  and  he  was  glad  to  hear  of  the 
success  of  the  remedy.  He  considered  it  a 
great  mistake  to  suppose  that  cholera  was  al¬ 
ways  preceded  by  diarrhoea ;  in  the  worst 
cases  there  was  sometimes  no  disturbance  of 
the  bowels.  The  disease  would  come  on 
suddenly  without  any  premonitory  symp¬ 
toms,  and  the  patients  would  succumb.  He 
regarded  cholera,  in  its  essential  nature,  as 
dependent  on  an  alteration  in  the  crasis  of 
the  blood  ;  and  if  we  could  not  get  blood, 
the  patient  would  soon  sink.  He  had,  in 
some  cases,  scraped  away  the  solid  particles 
of  the  blood  which  had  assumed  the  consis¬ 
tence  of  pitch.  If  you  could  get  rid  of  all 
the  watery  constituents  of  the  blood,  you 
would  produce  a  state  similar  to  cholera. 
As  to  treatment,  why  should  not  large  doses 
of  calomel,  said  to  be  so  effective  in  India, 
be  equally  beneficial  here  ?  He  was  quite 
sure  that  what  was  called  “  simple  treat¬ 
ment”  would  have  no  effect  in  the  blue 
stage  of  cholera.  With  respect  to  the  hot¬ 
air  bath,  he  was  quite  sure  that  in  the  last 
visitation  many  patients  were  boiled  and 
baked  to  death. 

Dr.  Clutterbuck  said  that  no  proof  ex¬ 
isted  of  the  cholera  being  dependent  on  a  con¬ 
dition  of  the  blood.  Previous  to  the  appear¬ 
ance  of  the  disease  at  Peckham,  the  drains  and 
cesspools  had  been  cleaned  out.  All  were 
more  or  less  affected  by  the  smells  arising 
from  this  proceeding,  and  cholera  made  its 
appearance  in  thirty  persons. 

Mr.  Headland  agreed  with  the  remarks 
of  Mr.  Dendy  respecting  diarrhoea  as  a  pre¬ 
monitory  symptom  of  cholera  in  its  more 
malignant  form.  Was  there  suppression  of 
urine  in  Dr.  Clutterbuck's  cases  ?  He 
hoped  that  chloroform  might  prove  a 
valuable  agent  in  this  disease,  not  only  as 
relieving  one  of  the  more  painful  symptoms, 
but  exerting  a  sort  of  antiseptic  influence  on 
the  blood.  If  the  cases  mentioned  really  de- 


768  DR.  WEBSTER  ON  CHOLERA,  AND  THE  HEALTH  OF  LONDON. 


r 


pended  on  the  effect  of  the  sulphuretted  hy¬ 
drogen  evolved  from  the  drains,  we  could 
understand  why  chloroform  should  do  good 
in  the  cases  detailed.  This,  however,  he  did 
not  regard  as  a  common  cause  of  cholera, 
because  it  existed  independent  of  this  cause. 
If  chloroform  did  good  in  cholera  generally, 
then  indeed  we  had  made  one  important  dis¬ 
covery. 

Dr.  Clutterbuck  did  not  think  diarrhoea 
as  essentially  a  forerunner  of  cholera.  In 
some  cases  it  had  hardly  existed  at  all ;  in 
some  it  was  severe ;  in  some,  again,  there 
was  vomiting  ;  in  others,  none.  He  regarded 
the  term  cholera  as  a  misnomer.  He  did 
not  recommend  chloroform  as  a  specific,  but 
to  relieve  the  painful  symptoms.  It  was 
often  given  from  time  to  time  by  the  expe¬ 
rienced  nurses  of  the  establishment  alluded 
to  ;  and  always  afforded  relief.  The  urine, 
in  these  cases,  had  been  scanty,  but  not 
quite  suppressed. 

Dr.  L.  Stewart  concurred  that,  like 
opium,  chloroform  would  be  advantageous  in 
relieving  symptoms,  but  it  did  not  address 
itself  to  the  cause  of  the  disease.  With 
respect  to  the  cases  of  cholera  at  Peckham, 
he  was  by  no  means  inclined  to  undervalue 
the  influence  of  pure  air,  but  this  could  not 
be  the  chief  cause  of  cholera,  though  it  was 
an  auxiliary,  for  cholera  occurred  in  districts 
where  the  air  was  pure  and  good,  and  there 
was  plenty  of  ventilation.  As  to  the  cause  it 
was  a  morbific  poison. 

Mr.  Garrett  described  the  cases  which 
had  occurred  in  Peckham  Asylum.  Some 
of  them  were  of  the  most  malignant  kind, 
and  the  patients  must  have  died  in  the  stage 
of  collapse  had  not  assistance  been  at  hand. 
The  attack  came  on  very  suddenly,  and  all 
the  worst  symptoms  of  the  disease  imme¬ 
diately  developed  themselves.  Brandy  and 
capsicum  were  first  administered,  the  patient 
being  in  bed.  Chloroform  was  then  resorted 
to  :  this  agent  he  considered  to  be  beneficial 
by  producing  reaction.  By  forced  respira¬ 
tions  the  pulse  rose,  and  by  the  time  the 
patient  became  fully  under  the  influence  of 
the  chloroform,  the  body  was  warm.  He 
believed  that  without  the  chloroform  there 
would  have  been  no  reaction,  for  opium 
would  not  have  developed  its  effects  under 
two  hours.  The  cases  were  undoubtedly 
those  of  spasmodic  cholera.  The  opening  of 
the  drains  only  acted  by  developing  the  dis¬ 
ease,  and  did  not  produce  it  per  se  ;  for  the 
drains  were  opened  on  the  Monday,  and  the 
first  case  of  cholera  developed  itself  on 
Thursday.  The  urine  was  scanty,  but  not 
suppressed. 


WESTMINSTER  MEDICAL 
SOCIETY. 

October  21,  1848. 

J.  Webster,  M.D.,  F.R.S.,  President. 

The  Society  commenced  its  meetings  for  the 
session  this  evening.  The  rooms  in  Saville- 
row  were  completely  crowded,  reminding  us 
of  the  society  in  its  most  palmy  days.  About 
sixty  fellows  and  visitors  were  present. 

The  President,  on  taking  the  chair,  gave 
an  inaugural  address  on  the  state  of  the 
society,  which  was  in  everyway  prosperous  ; 
in  the  course  of  his  remarks,  he  made  the 
following  observations  with  reference  to 

CHOLERA,  AND  THE  HEALTH  OF  LONDON. 

Before  dismissing  the  subject  of  cholera, 
it  must  be  interesting  for  the  fellows  to 
know,  notwithstanding  the  anxiety  now  pre¬ 
valent  respecting  that  malignant  disease,  that 
hitherto  it  has  not  made  much  progress  in 
the  metropolis  ;  and  if  its  present  fatality  be 
compared  with  other  epidemic  maladies,  we 
have  as  yet  really  not  much  reason  for  alarm, 
as  proved  by  the  fact,  that  during  the  six 
weeks  ending  on  Saturday,  the  16th  of 
October  last  year,  the  number  of  fatal  cases 
of  this  disease  in  London  was  twenty-six  ; 
whilst  the  total  number  of  deaths  caused  by 
the  same  malady  throughout  the  entire  me¬ 
tropolitan  population,  during  the  six  weeks 
ending  on  Saturday  last,  the  14th  instant, 
amounted  to  sixty-seven,  being,  as  yet,  only 
a  little  more  than  double  the  mortality  by 
cholera  during  the  same  number  of  weeks  in 
the  previous  year.  Compared  with  this,  it 
is  instructive  to  mark  the  different  results 
observed  in  another  epidemic  now  prevail¬ 
ing  in  London  with  great  severity,  but 
which,  notwithstanding,  does  not  call  forth 
much  remark,  or  causes  anxiety  to  the  ex¬ 
tent  it  deserves — I  mean  scarlatina,  also  dis¬ 
cussed  last  year  in  the  society  ;  but  which, 
unfortunately,  is  now  so  malignant,  that 
hundreds  of  victims  have  been  recently  sent 
to  an  untimely  grave,  according  to  the 
registrar-general’s  reports.  In  these  tables 
it  is  stated,  that  during  the  six  weeks  ter¬ 
minating  on  Saturday,  the  16th  of  October, 
1847,  already  quoted  in  reference  to  cholera, 
302  individuals  died  in  London  from  scar¬ 
latina  ;  whereas,  during  the  six  weeks  ending 
on  Saturday  last,  the  14th  inst.,  as  many  as 
972  persons  have  sunk  under  that  virulent 
complaint ;  or  upwards  of  quadruple  the 
average  mortality  by  the  same  disease 
in  the  previous  five  autumns.  Without 
undervaluing  the  importance  of  the  epidemic 
which  attracts  so  much  notice,  I  think  such 
a  dangerous  malady  as  scarlatina  deserves 
even  as  great  attention  from  medical  men 
and  the  public  as  cholera — more  especially 


MR.  HIRD  ON  THE  PATHOLOGY  AND  TREATMENT  OF  CHOLERA.  769 


seeing  the  subjects  of  its  attacks  are  usually 
children,  or  young  people  just  entering 
upon  the  morning  of  life  ;  whereas  the  vic¬ 
tims  of  cholera  are  generally  drunkards  and 
persons  of  worn-out  constitutions,  or  those 
who  have  set  every  hygienic  rule  at  defiance. 
Scarlatina  being,  however,  a  disease  of  fre¬ 
quent  occurrence  in  this  country,  and  al¬ 
though  it  annually  carries  off  thousands  of 
individuals,  hitherto  no  boards  of  health 
have  existed ;  no  quarantine  laws,  and  very 
few  sanitary  measures,  have  been  put  in 
force  by  public  bodies  for  preventing  the 
approach  of  this  malady,  the  scourge  of 
youth,  notwithstanding  its  highly  infectious 
nature.  But  this  is  only  another  illustra¬ 
tion  of  the  prevailing  disposition  in  the 
minds  of  many  persons  to  view  whatever  is 
familiar  with  indifference,  whilst  anything 
new  or  uncommon  is  sure  to  attract  atten¬ 
tion.  It  will  also  be  instructive  to  recal  to 
our  recollection  the  invasion  of  the  epidemic 
influenza,  which  was  so  fatally  prevalent  in 
the  metropolis  at  the  early  part  of  last 
winter,  when  1213  persons  died  from  that 
complaint  during  six  weeks  ending  on  Sa¬ 
turday,  the  8th  of  January  last.  At  the 
same  time,  the  total  deaths  registered  from 
all  causes  were  increased  to  an  extraordinary 
extent,  being  so  high  as  2454  in  one  week, 
and  2416  in  the  subsequent — instead  of 
1046,  the  ordinary  weekly  average  of  pre¬ 
vious  seasons.  Contrasted  with  this  plague¬ 
like  mortality,  it  must  be  gratifying  to  hear 
that  London,  comparatively  speaking,  is  not 
at  present  unusually  unhealthy,  notwith¬ 
standing  the  actual  presence  of  cholera,  the 
great  malignity  of  scarlatina,  and  the  preva¬ 
lence  of  typhus,  by  which  disease  424  per¬ 
sons  have  died  in  the  metropolis  during  the 
last  six  weeks,  instead  of  260,  the  averaged 
deaths  by  typhus  of  a  similar  period  during 
the  five  preceding  autumns.  Such  facts  are 
important  ;  and  although  the  cholera  now 
occasions  considerable  anxiety,  the  total 
deaths  from  all  causes,  throughout  the  me¬ 
tropolitan  population,  have  actually  dimi¬ 
nished,  especially  during  the  last  for!  night, 
notwithstanding  the  prevalent  epidemics. 
This  satisfactory  state  of  the  public  health 
in  London  is  proved  by  the  mortality  tables, 
which  show,  that  instead  of  the  weekly 
average  of  1154  deaths,  as  in  the  last  five 
seasons,  during  the  week  ending  on  Satur¬ 
day,  the  7th  October  instant,  1005  persons 
died  from  all  causes  in  the  metropolis,  and 
only  991  in  the  week  terminating  last  Satur¬ 
day,  the  14th  ;  thus  making  an  actual  dimi¬ 
nution  of  not  less  than  312  deaths  in  the 
two  weeks  now  referred  to,  being  an  increase 
of  fifteen  and  a  half  per  cent,  last  year  over 
the  two  similar  weeks  of  the  present  season. 

I  now  mention  these  important  facts  to  the 
Society,  not  to  paralyse  exertion,  but  as 
useful  statistical  data,  to  which  reference 


should  be  made  in  order  to  arrive  at  correct 
conclusions  when  an  epidemic  like  the 
cholera  prevails  in  the  community ;  and  to 
show  how  far  the  average  mortality  is 
thereby  affected. 

Case  of  Prolapsus  of  the  Funis  at  the  Se~ 
cond  Month  of  Pregnancy . 

Mr.  I.  B.  Brown  related  a  case  of  this 
rare  phenomenon.  The  subject  of  it  was 
thirty  years  of  age,  and  the  mother  of  three 
children.  She  was  threatened  with  abortion, 
and  after  two  or  three  attacks  of  haemor¬ 
rhage,  attended  with  expulsive  pains,  in  one 
of  these  the  cord  was  found  to  be  presenting 
in  a  loop.  The  following  day  a  severe  pain 
came  on,  and  the  cord  burst.  This  was 
followed  by  profuse  haemorrhage,  and  the 
expulsion  of  the  foetus.  The  placenta  was 
found  to  be  nearly  bloodless.  In  conse¬ 
quence  of  the  severe  pain  experienced  in  re¬ 
moving  the  placenta,  the  patient  was  placed 
under  the  influence  of  chloroform  .  It  was 
quite  successful,  and  she  is  doing  well. 

Mr.  Hird  afterwards  read  a  paper  on  the 
Pathology  and  Treatment  of  Cholera. 

After  giving  an  account  of  the  disease,  and 
describing  the  symptoms  in  a  highly  graphic 
manner,  he  proceeded  to  detail  the  post¬ 
mortem  appearances  which  he  had  observed 
in  twelve  cases  of  the  disease.  In  speaking 
of  the  treatment,  he  reviewed  the  various 
remedies  that  had  been  proposed  for  the  dis¬ 
ease,  and  stated  his  conviction  that  no  known 
remedies  have  any  specific  power  of  counter¬ 
acting  the  peculiar  agency  of  the  poison.  In 
order  to  attain  even  a  moderate  amount  of 
success  in  the  treatment,  he  considered  it 
absolutely  essential  to  the  appropriate  ad¬ 
ministration  of  remedies,  that  the  pathologi¬ 
cal  condition  of  the  several  internal  organs 
of  the  body  should  be  carefully  observed, 
and  the  treatment  directed  in  accordance 
with  our  views  of  the  actual  state  of  the 
malady.  On  the  first  appearance  of  symp¬ 
toms  of  cholera,  three  grand  objects  are  to 
be  attained — viz.  the  arrest  of  the  frequent 
evacuations  from  the  bowels ;  the  rousing  of 
the  vital  energies  of  the  patients,  so  as  to 
enable  them  to  resist  the  influence  of  the 
morbific  poison  ;  and  the  return  to  a  healthy 
condition  of  the  secretions  and  excretions  of 
the  body.  In  the  first  stage  of  the  disease, 
Mr.  Hird  found,  in  those  cases  where  bile 
was  plentiful  in  the  evacuations,  that  scruple 
doses  of  the  compound  chalk  powder,  with 
opium,  in  infusion  of  cusparia,  with  a  little 
compound  spirit  of  ammonia  and  spirit  of 
cinnamon,  were  of  great  service,  and  fre¬ 
quently  checked  the  further  progress  of  the 
disease  ;  and  in  cases  where  the  evacuations 
were  watery,  and  contained  very  little  or  no 
bile,  a  powder  containing  five  grains  of 
calomel  and  half  a  grain  of  opium,  adminis- 


770 


TREATMENT  OF  CHOLERA.  TREATMENT  OF  HYPOPION. 


tered  immediately,  and  followed  up  with  a 
grain  of  calomel,  a  quarter  of  a  grain  of 
opium,  two  grains  of  cayenne,  and  five 
grains  of  sugar,  every  half-hour  or  hour,  in 
proportion  to  the  symptoms,  tended  to  re¬ 
store  the  secretions  much  more  effectually 
than  the  one  or  two  scruple  doses  of  calomel, 
and  two  or  three  grains  of  opium,  repeated 
at  longer  intervals ;  and  that  the  rapid 
exhaustion  which  frequently  followed  the 
use  of  the  latter  was  rarely  observed.  When 
the  symptoms  increased  in  violence,  and 
were  not  checked  after  about  three  doses  of 
the  above,  and  when  the  characteristic  rice- 
water  evacuations,  and  other  symptoms  of 
the  second  stage,  set  in,  Mr.  Hird  found  the 
greatest  benefit  from  the  acetate  of  lead,  in 
two  or  three  grain  doses,  in  combination 
with  five  minims  of  Battley’s  solution  of 
opium  and  spirits  of  cinnamon,  every  half- 
hour.  Immediately  before  administering 
the  acetate  of  lead,  a  mustard  emetic  was 
given ;  and  simultaneously  with  the  use  of 
the  medicine,  an  enema  of  starch,  turpen¬ 
tine,  and  a  little  laudanum.  A  mustard 
poultice,  or  a  flannel  wrung  out  of  hot 
water,  and  saturated  in  a  mixture  of  equal 
parts  of  liquor  ammonise  and  turpentine,  and 
frictions  to  the  chest,  abdomen,  and  extremi¬ 
ties,  were  steadily  persevered  in.  By  these 
means  the  functions  of  the  heart  and  lungs 
were  kept  up  ;  internal  congestions  were,  as 
far  as  possible,  prevented,  and  time  thus 
afforded  for  the  system  to  overcome  the 
morbific  poison.  In  the  stage  of  reaction, 
the  treatment  applicable  to  typhoid  fever 
was  called  for.  Bloodletting,  the  author 
considered,  required  great  discrimination  in 
its  use ;  the  abstraction  of  blood  generally 
was  equivalent  to  the  abstraction  of  life,  and 
never  ought  to  be  resorted  to,  except  the 
patients  had  been  in  robust  health,  were 
young,  and  where  the  blood  had  not  been 
deprived  of  a  very  large  quantity  of  its 
albuminous,  serous,  and  saline  constituents. 

Mr.  Hird  objected  to  the  use  of  large 
doses  of  opium  in  every  stage  of  the  disease. 
He  believed  that  it  interfered  with  the  re¬ 
storation  of  the  renal,  biliary,  and  other  se¬ 
cretions,  and  that  it  invariably  increased  the 
tendency  to  coma  consequent  on  the  non¬ 
action  of  the  depurating  organs. 

Dr.  Peregrine  had  seen  three  cases  of 
the  disease  in  the  present  invasion  :  two  of 
these  occurred  at  the  Lock  Hospital.  He 
regarded  all  the  symptoms  of  the  disease  as 
the  result  of  the  draining  of  the  serum  from 
the  system.  He  believed  the  more  simple 
our  treatment  the  more  effective  it  would 
he.  He  spoke  of  the  importance  of  arrest¬ 
ing  diarrhoea  in  its  early  stages,  and  believed 
that  the  compound  chalk  powder,  with 
opium,  was  one  of  the  best  remedies  to  effect 
this.  In  the  advanced  stages  of  the  disease 
it  was  important  to  keep  up  the  warmth  of 


the  surface  of  the  body  by  the  application 
of  heat. 

Dr.  Snow  objected  to  the  application  of 
warmth  in  cases  of  cholera,  and  founded  his 
objection  to  its  employment  on  the  fact  that 
in  cases  of  asphyxia  such  application  was 
injurious.  Cholera  was  not  asphyxia,  but 
in  some  points  resembling  it,  so  far  as  the 
internal  congestion  was  concerned. 

Dr.  Carr  referred  to  two  cases  of  cho¬ 
lera  recorded  by  himself  in  The  Lancet  of 
that  day,  and  recommended  the  treatment 
therein  employed  to  be  followed  by  other 
practitioners. 

Dr.  Murphy  inquired  if  cholera  had 
been  found  to  be  prevalent  in  any  district ; 
but  no  one  present  had  seen  it. 

Dr.  Skiers  entered  at  much  length  into 
the  pathology  of  the  disease,  and  of  the 
mode  of  its  treatment  in  Paris.  He  re¬ 
garded  the  fatal  symytom  to  be  suppression 
of  urine.  It  was  essential  to  arrest  the  first 
symptom  of  diarrhoea.  In  the  advanced 
stages,  the  administration  of  cold  water,  ad 
libitum,  and  the  application  of  warmth  to 
the  surface,  was  the  most  effectual  plan  of 
treatment. 

The  debate  was  adjourned. 


£?omsponDcnce. 


ON  THE  TREATMENT  OF  HYPOPION. 

Sir, — I  beg  to  forward  for  publication  in 
your  journal,  some  remarks  upon  the  treat¬ 
ment  of  hypopion  ;  the  plan  which  I  have 
recommended  in  the  notes  attached  to  the 
second  edition  of  Morgan’s  Lectures  on  Dis¬ 
eases  of  the  Eye  having  been  objected  to  by  a 
writer  in  the  last  number  of  the  British 
and  Foreign  Medical  Review.  The  object 
of  my  addressing  you  is,  1st,  to  defend 
the  practice  of  puncturing  the  cornea 
in  cases  of  hypopion,  under  certain 
given  circumstances,  in  the  mode  directed 
in  my  note  ;  and,  2d,  to  record  my  earnest 
protest  against  the  mode  of  operating  which 
the  reviewer  would  substitute  in  its  place. 

When  medicinal  treatment,  properly  ma¬ 
naged,  fails  to  check  the  progress  of  a 
hypopion,  which,  on  the  contrary,  progres¬ 
sively  increases,  so  as  to  mount  above  the 
level  of  the  axis  of  vision  ;  and  in  combina¬ 
tion  with  this,  severe  inflammation,  severe 
hemicranial  and  ocular  pain,  and  tenderness, 
persist  unrelieved,  I  do  not  hesitate  to  re¬ 
peat,  that  the  matter  should  be  evacuated 
artificially.  If  this  measure  be  not  taken,  and 
some  sudden  unaccountable  amelioration  do 
not  occur,  disorganization  of  the  globe  must 
ensue.  If  it  be  taken,  putting  out  of  view 
the  immediate  relief  of  suffering,  the  patient 


MR.  FRANCE  ON  THE  TREATMENT  OF  HYPOPION. 


771 


is  afforded  the  only  probable  chance  of  sav¬ 
ing  his  eye. 

Cases  so  intractable  as  to  fulfil  the 
conditions  just  specified,  are,  as  I  have 
said,  rare:  they  are  always  severe  cases; 
and,  upon  this  ground, — not  that  the  mere 
puncture  of  the  cornea  exerts  any  pecu¬ 
liarly  pernicious  influence — the  prognosis 
after  this  operation  should,  of  course,  be 
very  guarded.  Some  of  these  cases  un¬ 
doubtedly  will  continue  to  pursue  that  on¬ 
ward  course  to  destruction  of  the  globe,  after 
evacuation  of  the  anterior  chamber,  which 
had  been  pursued  before.  Others,  however, 
as  I  can  testify  from  personal  observation, 
will,  from  the  moment  of  operation,  advance 
steadily  to  entire  convalescence.  To  punc¬ 
ture  the  cornea,  then,  in  ordinary  cases  of 
hypopion,  is  utterly  unjustifiable,  because 
they  may  be  otherwise  cured ;  and,  on  the 
other  hand,  not  to  puncture  under  the  cir¬ 
cumstances  just  supposed  is  also  wrong, 
because  such  inaction  virtually  abandons  the 
organ  to  almost  inevitable  destruction.  I 
am  fully  aware  of  Scarpa’s  opinion  upon 
this  subject,  and  believe  he  has  done  good 
service  by  bringing  operative  interference 
with  hypopion,  as  a  rule,  into  disrepute  ;  at 
the  same  time,  experience  compels  me  to 
vindicate  the  utility  of  the  practice,  when 
the  conditions  specified  exist. 

The  reviewer  recommends  as  follows — “  If 
the  surgeon  is  bent  on  evacuating  the  pus  of 
an  hypopion,  let  him  puncture  the  opposite 
edge  of  the  cornea  to  the  extent  of  two  lines 
in  length,  and  draw  out  the  tenacious  matter 
with  a  hook ;  in  any  other  way  he  will  be 
foiled.”  Against  this  recommendation  I 
must  strenuously  protest.  If  the  cornea  be 
pierced  beneath  a  hypopion,  as  I  have  ad¬ 
vised  ;  and  the  cataract-knife,  when  suffi¬ 
ciently  advanced  into  the  anterior  chamber, 
be  slightly  turned  on  its  axis  ; — the  gush  of 
superincumbent  aqueous  fluid  forces  out  a 
far  larger  proportion  of  the  effusion  than 
would  otherwise  escape ;  while  gravitation 
favours  the  slow  washing  away  of  the  re¬ 
mainder  as  long  as  the  aqueous  secretion 
continues  to  exude.  The  effect,  however, 
of  the  proceeding  advocated  by  the  reviewer 
must  necessarily  be — first,  to  give  vent  to 
the  aqueous  humour  ;  next,  if  the  matter 
prove  of  tenacious  quality,  to  cause  its 
diffusion  between  the  surfaces  of  the  iris  and 
capsule  of  the  lens,  and  that  of  the  cornea 
(for  these  parts  fall  into  contiguity  imme¬ 
diately  the  aqueous  humour  is  discharged)  ; 
and,  lastly,  if  the  operator,  agreeably  to 
instructions,  fish  for  the  effusion  with  a 
hook,  to  subject  the  inflamed  organ  to  an 
indefinite  amount  of  irritation  and  injury. 
To  remove  the  tension  of  an  inflamed  organ 
is  undoubtedly  an  object  of  high  importance 
in  its  treatment  ;  and  hence  mere  evacuation 
of  the  aqueous  humour  might  in  these  cases 


prove  of  service ;  but  when  the  method  sug¬ 
gested  involves  the  certainty  of  spreading 
across  the  pupil  a  layer  of  puro -lymph,  of 
which  it  is  impossible  to  predict  that  all 
shall  subsequently  escape  through  the  ex¬ 
ternal  aperture,  or  be  absorbed,  and  that 
none  shall  become  organized  into  a  perma¬ 
nent  false  membrane,  what  duly  cautious 
practitioner  would  choose  to  incur  the  re¬ 
sponsibility  of  such  a  serious  contingency  ? 
When  further  forewarned  that  the  use  of 
a  hook  may  be  required  to  effect  the  removal 
from  the  temporarily  (almost)  obliterated 
anterior  chamber  of  a  substance  too  viscid 
indeed  to  flow  spontaneously  through  the 
distant  opening,  but  neither  cohesive  enough 
to  hold  upon  the  hook  when  caught,  nor 
firm  enough  to  sheath  the  point  of  that  in¬ 
strument,  and  prevent  its  entanglement  in  the 
capsule  iris  or  cornea,  what  prudent  surgeon 
would  commit  himself  to  such  an  under¬ 
taking  ?  Few  who  have  ever  experienced  the 
nicety  of  manipulation  requisite  in  the  ma¬ 
nagement  of  the  curette  when  extracting 
a  cataract  from  an  uninfiamed  eye,  would 
think  of  thus  hazarding  the  introduction  of 
a  hook  within  an  inflamed  and  consequently 
irritable  one.  I  feel  convinced,  that,  upon 
reconsideration,  the  reviewer  himself  would 
not  urge  such  a  proceeding  as  this. 

I  must  also  dissent  from  the  writer  as  to 
the  use  of  belladonna  in  ordinary  cases  of 
hypopion,  unconnected  with  inflammation 
of  the  iris.  If  the  iris  be  healthy,  and  the 
effusion  into  the  anterior  chamber,  as  is  most 
common,  be  limited  in  amount,  I  deem  it  in¬ 
expedient,  by  the  application  of  belladonna, 
to  withdraw  the  septum  interposed  between 
the  inflammatory  product  of  which  some 
portion  may  be  of  plastic  nature,  and  the 
crystalline  capsule  upon  which  the  deposit  of 
any  plastic  effusion  is  calculated  to  be  highly 
detrimental.  In  cases,  however,  where  hy¬ 
popion  has  overpassed  the  lower  margin  of 
the  pupil,  and  in  every  case,  without  excep¬ 
tion,  where  iritis  is  either  recognised  or 
suspected,  belladonna  should  be  sedulously 
employed. — I  am,  sir, 

Your  obedient  servant, 

John  F.  France. 

41,  Finsbury  Square,  Oct.  1848. 


POOR  LAW  MEDICAL  RELIEF. - THE  IN¬ 

JUSTICE  OF  THE  POOR  LAW  IN  RESPECT 
TO  MEDICAL  OFFICERS  AND  THE  POOR. 

Sir, — I  know  not  whether,  after  vour  stren- 
uous  and  persistent  advocacy  of  our  cause, 
your  columns  are  still  open  to  our  numerous 
complaints,  or  rather  to  the  exposure  of  that 
which  forms  a  heavy  item  of  sin  committed 
against  the  poor ;  however,  if  space  be  al¬ 
lowed  me,  I  wish  to  detail  a  case,  which,  as 
the  Poor-law  stands  at  present,  is  strictly 
legal,  but  which  has  been  made  the  instru- 


772  THE  UPTON-ON-SEVERN  UNION — NEW  MEDICAL  OFFICERS. 

-  ^  ■  .  -  '  —  ■  . . t 


ment  of  gross  oppression  to  an  industrious 
man,  and  is  calculated  to  drive  all  poor 
women  labouring  with  child  to  seek  any 
aid  rather  than  that  of  the  parochial  surgeon. 

A.  T.  is  removed  some  time  back  to  his 
own  parish,  but  returns  again  to  the  one 
from  which  he  is  removed,  finding  no  em¬ 
ployment  elsewhere ;  he  works  on  indus¬ 
triously  till  his  wife  is  taken  in  labour,  and 
help  has  to  be  procured  from  the  parochial 
surgeon ;  he  becomes,  in  consequence, 
chargeable  and  amenable  to  the  law,  which 
is  executed  against  him  with  all  rigour  ;  he 
is  summoned  before  a  magistrate,  convicted, 
and  sentenced'  to  a  month’s  imprisonment, 
and  hard  labour  ;  the  home  of  the  man  is 
broken  up  ;  the  wife  and  five  children  be¬ 
come  inmates  of  the  union  workhouse  ;  the 
treadwheel  supplies  the  place  of  the  loom  ; 
industrious  habits  are  tainted  with  the  de¬ 
pravity  of  the  prison ;  he  becomes  hence¬ 
forth  an  outcast  of  society,  and  the  children 
become  paupers  from  the  moment  of  their 
birth  :  and  for  what  is  all  this  misery  brought 
upon  him  ?  Simply  that  those  heavy  items 
in  the  parish  accounts,  the  “extras,”  may 
be  curtailed, — simply  that  puerperal  women 
may  learn  that  they  have  no  sympathy  in 
their  distress, — can  expect  no  aid  in  their 
hour  of  trouble,  except  by  their  husbands 
facing  the  law  and  its  revolting  punishment. 
Whilst  the  wheel  revolves  under  the  devoted 
feet  of  the  above  pauper,  my  eye  glances 
over  my  list  of  orders,  and  I  find  A.  B., 
previously  removed  from  this  parish,  ordered 
to  be  attended  by  me  for  sickness  ;  nothing 
more  has  to  be  paid  to  the  surgeon,  the  case 
is  lumped  into  the  contract,  and  consequently 
the  patient  is  not  imprisoned.  M.  H.,  also 
removed,  has  my  attendance  freely  given,  as 
also  G.  S.  and  E.  L.,  without  the  prison, 
not  being  extras. 

Is  this  glaring  inconsistency  to  be  carried 
on  longer  ?  Will  the  Poor-law  Board  suffer 
the  medical  men  to  be  imposed  upon  in  their 
contracts,  and  that  every  art,  every  strata¬ 
gem,  should  be  used  to  lessen  the  only 
emolument  they  can  possibly  derive  from 
holding  their  present  offices  ?  Is  it  right — is 
it  just  or  equitable — to  cast  the  husband  of  a 
puerperal  woman  into  prison  because  her 
confinement  entails  expense,  and  leave  other 
persons  unpunished  who  are  equally  guilty 
in  returning  to  the  parish,  but  have  not  a 
payable  disease  ?  Is  it  right,  in  fact,  to 
throw  a  man  into  the  company  of  felons  for 
any  sickness  at  all  with  which  the  Almighty 
may  be  pleased  to  afflict  either  himself  or 
wife  ? 

There  should  be  a  distinction  made  be¬ 
tween  real  and  fictitious  poverty,  between 
the  deserving  and  designing  beggar.  That 
limited  parochial  rating,  which  makes  men 
look  to  their  purses  rather  than  to  the  side 
of  right  and  just  dealing,  should  be  done 


away  with  ;  and  poverty,  the  result  of  sick¬ 
ness,  should  be  made  a  state-burden,  not  a 
local  one.  So  long  as  the  Poor-law  Board 
delay  a  strict  inquiry  into  the  treatment  of 
the  sick  poor  throughout  England ;  so  long  as 
they  support  the  parsimonious  policy  of  local 
Boards,  or  sanction  oppression,  exercised  by 
officious  parochial  officers, — so  long  will  a 
great  and  heavy  sin  be  at  their  door. 

Public  sympathy  has  been  excited;  the 
cholera  is  amongst  us  ;  the  public  voice  de¬ 
mands  some  extensive  remedial  measure ; 
and,  until  our  position  is  altered,  we  shall 
never  cease  to  have  cause  to  publish  cases  of 
injustice  towards  ourselves,  and  particularly 
against  the  poor  committed  to  our  charge. 

I  remain,  Sir, 

Yours  respectfully, 

C.  E.  F. 

Oct.  1848. 


THE  UPTON-ON-SEVERN  UNION. - ELECTION 

OF  NEW  MEDICAL  OFFICERS. 

Sir, — Since  our  last  communication  to 
you  of  August  15,  events  have  occurred  in 
this  Union,  which  it  is  now  our  duty  to  re¬ 
port.  On  the  17th  of  August,  Mr.  Greaves, 
the  Assistant  Commissioner,  was  here  for 
the  purpose  of  investigating  the  recent  ap¬ 
pointments  made  by  the  Board  of  Guar¬ 
dians  :  the  result  of  this  investigation  was 
not  fully  known  until  the  28th  September, 
when  a  communication  was  received  by  the 
Upton  Board  of  Guardians  from  the  Poor- 
Law  Board  in  London,  and  Mr.  Greaves 
was  again  present.  The  Poor-Law  Board 
cashiered  the  appointment  of  Mr.  Marsh, 
for  the  Kempsey  District ;  of  Mr.  Nelson 
Thomas,  for  the  Eldersfield  District ;  of  Mr. 
West,  for  the  Powick  District ;  and  ordered 
the  Board  of  Guardians  to  re-advertise  these 
Districts — the  salaries  to  be  increased  20 
per  cent.,  unless  a  satisfactory  reason  could 
be  given  for  not  doing  so  !  !  A  loop-hole  was 
thus  left  with  an  obvious  intention.  The 
Guardians  rejected  this  order  by  a  majority 
of  9  to  7,  and  determined  on  re-advertising 
the  Districts  at  the  late  salaries.  Mr. 
Mears  tendered  for  the  Powick  District,  and 
Mr.  White  did  the  same  for  the  Kempsey 
District,  at  the  20  per  cent,  increase,  to 
meet  this  concession  of  the  Poor-Law  Board  ; 
and  on  Thursday,  October  12,  the  appoint¬ 
ments  were  filled  up.  Mr.  Wadham,  of  Mal¬ 
vern,  was  appointed  to  the  Powick  District ; 
Mr.  Crosse  applied  for  and  secured  the 
Kempsey  District.  Mr.  Crosse  has  been 
brought  forward  as  a  new  importation,  under 
the  auspices  of  Mr.  H.  B.  Marsh,  the 
“  sympathizer  with  the  too  numerous  vic¬ 
tims  to  medical  relief  injustice,”*  and  is 
now  placed  at  Kempsey,  with  the  express  and 
only  object  of  opposing  Mr.  White,  in  the 

*  See  Mr.  Marsh’s  letter  in  Lancet,  2d  Sept. 
1848. 


THE  UPTON-ON-SEVERN  UNION’ — NEW  MEDICAL  OFFICERS.  773 


centre  of  his  neighbourhood,  where  there  has 
been  only  one  resident  medical  man  for 
many  years  past.  A  threat  of  this  kind  was 
long  held  out  as  the  inevitable  punishment 
of  Mr.  White’s  obstinacy  in  rejecting  the 
District  at  the  advertised  salary :  thus  the 
crime  of  upholding  the  dignity  and  honour 
of  the  profession  has  been  avenged,  and 
official  favour  secured. 

On  Monday  evening,  October  16th,  we 
called  on  Mr.  Crosse,  for  the  purpose  of  as¬ 
certaining  if  he  were  fully  cognizant  of  the 
peculiar  circumstances  which  had  induced 
the  resignation  of  the  late  medical  officers  of 
this  Union.  We  saw  Mr.  Crosse,  and  with 
him  Mr.  Marsh.  In  reply  to  our  question 
to  Mr.  Crosse,  whether  he  had  accepted  his 
appointment  with  a  full  knowledge  of  all  the 
circumstances  connected  with  the  recent 
movement  of  the  medical  officers,  Mr. 
Crosse  replied,  that  he  felt  himself  quite 
taken  aback,  that  he  was  much  fatigued, 
and  would  rather  wave  any  discussion  then, 
but  would  be  happy  to  afford  us  an  inter¬ 
view  on  the  following  day.  We  said  that 
there  really  appeared  to  us  no  necessity  for 
delay,  as  we  only  desired  a  plain  answer  to  a 
very  simple  question.  After  much  hesita¬ 
tion  (and  the  introduction  of  much  extra¬ 
neous  and  irrelevant  matter,  most  intempe- 
rately  intruded  by  Mr.  Marsh),  Mr.  Crosse 
stated  that  he  was  aware  of  all  the  circum¬ 
stances  of  the  case.  We  asked  him  if  he  had 
read  our  published  statements  in  the  medi¬ 
cal  journals.  He  replied  he  had  not,  and 
professed  himself  too  much  of  a  sceptic  to 
place  much  reliance  on  the  statements  of 
the  press  ;  he  preferred  the  public  rumour 
of  the  neighbourhood  ;  and  had  heard  all 
particulars  from  Mr.  Marsh,  whose  word  he 
could  not  doubt.  We  deemed  it  our  duty 
to  have  an  interview  with  Mr.  Crosse,  from 
the  circumstance  of  his  being  a  stranger  to 
the  neighbourhood,  and  possibly  unac¬ 
quainted  with  the  peculiar  nature  of  the 
case.  Mr.  Charles  Sheward,  notwith¬ 
standing  his  public  repudiation  of  a  previous 
nomination,  has  now  thought  proper  to  ac¬ 
cept  the  Eldersfield  District ;  and  thus  the 
Upton  Board  of  Guardians  has  been  suc¬ 
cessful  in  obtaining,  upon  their  own  terms, 
from  some  quarter  or  another,  a  sufficient 
number  of  officers  to  undertake  the  different 
medical  Districts.  Truly  was  it  said  of  old, 
“  a  man’s  enemies  are  chiefly  they  of  his 
own  household.”  A  “heavy  blow,  and  a 
sore  discouragement”  have  been  inflicted  on 
the  prospects  of  Union  surgeons  throughout 
this  kingdom,  by  the  disgraceful  conduct  of 
the  profession.  We  say,  profession,  for 
until  the  whole  body  adopts  a  summary  mode 
of  ridding  itself  of  such  members  as  have 
here  sold  themselves  individually  to  do  the 
work  and  obey  the  behests  of  those  who 
oppress  them  generally,  the  crime  and  its 


consequences  must  be  charged  on  the  whole 
profession.  Four  gentlemen  have  been  found 
capable  of  betraying  their  brethren,  and  of 
sacrificing  a  great  cause  for  the  sake  of  a  few 
paltry  pounds.  As  long  as  the  profession 
includes  such  individuals,  of  what  possible 
use  are  representations  to  Government,  ex¬ 
postulations  with  Poor-Law  Boards,  or 
memorials  to  Boards  of  Guardians  ?  The 
more  the  question  is  agitated,  the  more 
notorious  does  the  degraded  state  of  the  pro¬ 
fession  become.  We  invoke  on  our  own 
heads  the  contumely  of  the  many,  and  win 
by  our  own  exertions  and  personal  sacrifices 
the  disrespect  and  reproaches  of  the  public. 
The  utter  hopelessness  of  any  appeal  to  the 
Poor-Law  Board  for  the  redress  of  our 
grievances,  has  been  1’endered  apparent  by 
the  Upton  case.  We  have  appealed  to  that 
Board.  It  has  admitted  the  justice  of  our 
claims,  and  yet  allows  the  Guardians  to 
continue  to  perpetuate  their  injustice;  the 
Poor-Law  Board  recommends,  without  the 
power,  or  at  any  rate  the  courage,  to  enforce 
its  recommendation.  It  orders,  and  yet 
lacks  the  spirit  to  compel  obedience  to  its 
mandates.  Where,  then,  is  the  remedy  ?  It 
lies  in  the  hands  of  the  profession,  and  there 
only.  We  were  aware  of  this  at  the  onset, 
and  we  tried  the  experiment  of  appealing  to 
our  own  body,  and  truly  it  has  been  an  ex¬ 
periment,  and  one  which  has  signally  failed. 
The  partial  countenance  and  support  which 
were  at  first  afforded  us  have  been  with¬ 
drawn  ;  the  medical  officers  of  the  Upton 
Union  have  been  defeated,  and  by  their 
defeat  the  deepest  possible  injury  has 
been  inflicted  on  the  cause  of  Poor-Law 
Medical  Reform.  A  more  insane  act  of 
suicide  (to  the  destruction  of  the  best  in¬ 
terests  of  the  profession)  was  never  in  our 
judgment  perpetrated,  than  that  which  has 
just  been  committed  by  Messrs.  Marsh, 
Sheward,  Waddam,  and  Crosse.  To  the 
medical  profession  we  say,  and  we  say  it 
emphatically,  “  awake,  arise,  or  be  for  ever 
fallen”  !  ! 

We  remain,  sir, 

Your  obedient  servants, 

Chas.  Braddon, 

Wm.  Todd  White. 

The  Deputation  of  the  late 
Medical  Officers  of  the 
Upton-on-Severn  Union. 

Oct.  17th,  1848. 


GERANIUM  MACULATUM  A  CURE  FOR  MER¬ 
CURIAL  SALIVATION. 

Dr.  Geo.  M.  Maclean  has  used  in  one 
case  of  mercurial  salivation,  he  says  (New 
York  Journ.  Med.,  May  1848),  an  infusion 
of  the  Geranium  Maculatum  as  a  lotion  with 
speedy  and  entire  relief. — American  Journal 
of  Med.  Sciences ,  July  1848. 


774 


MEMORIAL  OF  THE  POOR  LAW  MEDICAL  OFFICERS. 


.puts teal  intelligence. 


MEMORIAL  OF  THE  POOR-LAW  MEDICAL 

OFFICERS  TO  THE  RIGHT  HON.  CHARLES 

BULLER.  (COPY.) 

To  the  Right  Honourable  Charles  Buller , 
M.P.,  President  of  the  Poor-Law  Board. 
The  Memorial  of  the  Committee  of  the 
Convention  of  Medical  Officers  of  Poor-Law 
Unions  in  England  and  Wales — 

Sheweth — 

That  your  Memorialists,  being  deputed 
and  authorized  at  a  Convention  of  Delegates 
representing  nearly  three  thousand  medical 
officers  of  Unions,  assembled  at  the  Hanover 
Square  Rooms,  on  the  27th  October,  1847, 
to  act  in  their  behalf,  with  a  view  to  obtain 
an  amelioration  of  the  present  system  of 
Poor-Law  Medical  Relief,  feel  it  their  duty 
respectfully  to  draw  the  attention  of  the 
Poor-Law  Board  to  the  following  state¬ 
ment  : — 

Your  Memorialists  have  watched  with 
deep  interest  the  circumstances  connected 
with  the  recent  resignation  of  the  medical 
officers  of  the  Upton-on-Severn  Union,  and 
the  subsequent  appointment  of  others  by  the 
Guardians  of  that  Union  to  fill  the  vacancies 
thus  created  ;  and  the  feelings  entertained 
by  your  Memorialists  on  this  subject  are  so 
strong  that  they  do  not  hesitate  to  address 
your  honourable  Board,  to  the  effect  that 
the  case  may  be  thoroughly  investigated 
prior  to  those  appointments  receiving  its 
sanction  and  confirmation. 

Your  Memorialists,  in  thus  calling  atten¬ 
tion  to  the  subject,  desire  in  the  first  instance 
particularly  to  state  that  they  have  taken  no 
part  whatever  with  the  medical  officers  of 
the  Upton  Union,  as  respects  any  special 
grievance  which  they  may  have  laboured 
under,  and  that  their  resignation  has  ema¬ 
nated  from  themselves,  without  any  bias  or 
influence  being  used  by  your  Memorialists, 
who  make  this  appeal  upon  public  grounds, 
considering  the  following  reasons  amply 
sufficient  to  justify  their  doing  so  : — 

1st.  That  although  the  total  amount  of 
the  salaries  paid  to  the  medical  officers  of 
the  Upton  Union,  may  not  be  below  the 
average  paid  to  medical  officers  of  agricul¬ 
tural  districts,  the  scale  of  remuneration 
which  is  made  the  standard  is  so  miserably 
degrading  and  inadequate,  as  to  give  general 
offence  to  the  medical  profession,  and  both 
jeopardise  the  interests  of  the  sick  poor  and 
prove  a  short-sighted  economy  to  the  rate¬ 
payers. 

2d.  That  the  order  limiting  the  extent  of 
the  districts  of  medical  officers,  as  ordered 
by  your  Board,  has  been  violated  by  the 


Guardians  of  the  Upton  Union,  in  assigning 
to  their  officers  two  districts  exceeding  the 
prescribed  acreage. 

3d.  That,  as  your  Memorialists  are  cre¬ 
dibly  informed,  one  at  least  of  the  medical 
officers  appointed  by  the  said  Union  is  not 
qualified,  in  accordance  with  the  judicious 
order  of  your  honourable  Board,  for  securing 
efficient  medical  aid  for  the  sick  poor,  and 
that  another  of  the  medical  men  submitted 
for  your  approval  was  once  suspended  when 
holding  office  on  a  former  occasion,  and  was 
even  set  aside  by  the  very  Board  of  Guar¬ 
dians  who  now  consider  him  eligible  to 
fulfil  the  onerous  duties  which  his  appoint¬ 
ment  necessarily  imposes  upon  him. 

4th.  That  the  circumstances  of  the  whole 
case  are  such  as  to  foster  dissensions  amongst 
the  members  of  the  medical  profession,  and 
seriously  to  obstruct  their  cordial  co-opera¬ 
tion  for  the  benefit  of  the  sick  poor. 

For  these  reasons  your  Memorialists  pray 
that  you  will  be  pleased  to  withhold  your 
confirmation  of  the  said  appointments. 

(Signed)  Thos.  Hodgkin,  M.D. 

Chairman  of  the  Committee. 

Charles  F.  J.  Lord, 

Hon.  Secretary. 

Sept.  1848. 

society  for  relief  of  widows  and 

ORPHANS  OF  MEDICAL  MEN  IN  LONDON 

AND  ITS  VICINITY. 

A  half-yearly  General  Court  of  this 
Society  was  held  at  the  Gray’s  Inn  Coffee 
House  on  Wednesday  evening,  the  18th 
ultimo  ;  Martin  Ware,  Esq.,  V.  P.,  in  the 
chair.  It  appeared  from  the  minutes  which 
were  read,  that  since  the  last  half-yearly 
meeting,  twenty-one  members  had  joined  the 
society,  one  widow  had  died,  another,  with 
four  children,  had  applied  for  and  received 
relief.  Thirty-three  widows  and  sixteen 
children  of  deceased  members,  were  re¬ 
ceiving  half-yearly  relief,  for  which  purpose 
,£629  had  been  distributed.  Benefactions 
to  the  amount  of  £325  had  been  received, 
principally  at  the  annual  dinner ;  besides 
the  subscriptions  of  members,  leaving  a 
balance  at  the  Banker’s  of  £753,  in  addition 
to  the  capital  stock  invested  in  government 
securities.  This  account  shews  that  the  in¬ 
come  of  the  society  keeps  pace  with  the 
increased  and  increasing  claims  upon  its 
funds. 

It  was  announced  that  John  Hunter,  Esq., 
of  Mincing  Lane,  had  resigned  the  office  of 
acting  treasurer,  and  that  the  six  senior 
directors  on  the  list  had  retired  in  rotation. 

A  very  cordial  vote  of  thanks  to  Mr. 
Hunter  was  resolved  upon  unanimously,  and 
the  ballot  for  officers  for  the  ensuing  year 
took  place. 

Dr.  S.  W.  Merriman  was  elected  Acting 
Treasurer,  and  Sir  James  Eyre,  Dr.  Seth 


APPLICATION  OF  THE  DISEASES  PREVENTION  ACT  TO  EDINBURGH.  775 


Thompson,  Wm.  Pennington,  Esq.,  James 
York,  Esq.,  John  Hunter,  Esq.  (late  Acting 
Treasurer),  and  A.  M.  Randall,  Esq.,  were 
elected  Directors. 

After  the  meeting  was  dissolved,  a  letter, 
stating  that  the  wife  and  four  children  of  a 
medical  man,  just  arrested  for  debt,  were  in 
most  urgent  distress  :  the  case,  which  does 
not  come  at  all  within  the  scope  of  this 
Society’s  operations,  was  referred  to  the 
kind  consideration  of  Mr.  Newnham,  of 
Farnham,  the  Hon.  Secretary  of  the  Medical 
Benevolent  Fund.  A  small  subscription  was 
raised  amongst  the  persons  present. 

MANCHESTER  MEDICAL  SOCIETY. 

The  following  gentlemen  were  elected  office¬ 
bearers  for  the  ensuing  session  : — President 
— Dr.  Radford.  Vice-Presidents — Mr.  R. 
T.  Hunt,  Mr.  Noble,  Dr.  C.  W.  Bell,  Mr. 
Wilson.  Treasurer — Dr.  Ashton.  Hon. 
Secretaries — Dr.  Renaud,  Dr.  H.  Reid. 
Hon.  Librarian — Mr.  Stone.  Councillors 
— Messrs.  Brownbill,  J.  B.  Harrison, 
Dumville,  Lomas,  Southam,  Catlow, 
Spence,  Allen,  Bowman,  Golland,  Dr.  M. 
A.  E.  Wilkinson,  Mr.  Franklin. 

APPLICATION  OF  THE  PROVISIONS  OF  THE 

DISEASES -PREVENTION  ACT  TO  EDIN¬ 
BURGH. 

The  General  Board  of  Health  have  agreed 
to  the  following  regulations,  under  the 
“  Nuisances  Removal  and  Diseases  Preven¬ 
tion  Act,  1848,”  11th  and  12th  Victoria, 
chap.  123,  applicable  to  the  parochial  boards 
for  the  management  of  the  poor  in  the  fol¬ 
lowing  parishes  in  and  near  Edinburgh — 
viz.  the  city  of  Edinburgh,  St.  Cuthbert’s, 
Canongate,  North  Leith,  and  South  Leith. 

Whereas  by  the  act  of  the  11th  and  12th 
Victoria,  chap.  123,  intituled  “  An  Act  to 
improve  and  amend  an  Act  of  the  10th  year 
of  her  present  Majesty,  for  the  more  speedy 
removal  of  certain  nuisances ,  and  the  pre- 
ventionof  epidemic  and  contagious  diseases,” 
the  General  Board  of  Health  is  empowered 
to  issue  such  directions  and  regulations  for 
carrying  into  effect  the  provisions  of  the  said 
act  as  to  them  may  seem  fit ;  now  we,  the 
said  General  Board  of  Health,  do  hereby 
authorize  and  direct  the  parochial  boards  for 
the  management  of  the  poor  in  the  following 
parishes  in  and  near  Edinburgh — namely, 
the  city  of  Edinburgh,  St.  Cuthbert’s, 
Canongate,  North  Leith,  and  South  Leith, 
to  execute,  or  see  to  the  execution  of,  the 
directions  and  regulations  following,  viz.  : — 

1.  We  hereby  authorize  and  require  the 
said  parochial  boards  to  provide  dispensaries 
in  suitable  stations  with  sufficient  medical 
aid,  such  dispensaries  to  be  accessible  at  all 
times,  by  night  and  by  day,  to  persons  re¬ 
quiring  medical  aid  for  themselves  or  others 
attacked  by  cholera,  or  by  any  of  its  pre¬ 


monitory  symptoms  ;  and  to  provide  the 
medicines  to  be  distributed  to  such  appli¬ 
cants  at  such  dispensaries,  and  such  medi¬ 
cines  and  cordials  as  may  be  required  else¬ 
where  in  their  respective  parishes,  for 
necessitous  persons  attacked  as  aforesaid  who 
may  be  under  medical  treatment. 

2.  And  we  do  further  authorize  and  re¬ 
quire  the  parochial  boards  of  the  said  parishes 
and  places  to  make  arrangements  for  the 
distribution  of  notices,  stating  the  places 
where  the  dispensaries  shall  have  been  pro¬ 
vided. 

3.  Whereas  it  has  heretofore  been  found 
to  be  impracticable  to  ensure  proper  treat¬ 
ment  in  their  own  houses  to  many  of  the 
poorer  classes,  we  authorize  and  require  the 
said  parochial  boards  respectively  to  provide 
houses  or  suitable  rooms,  capable  of  accom¬ 
modating  necessitous  cases,  to  which  persons 
attacked  by  cholera,  who  cannot  be  properly 
treated  in  their  own  houses,  may  be  con¬ 
veyed. 

4.  We  authorize  and  require  the  said 
parochial  boards  to  provide  houses  of  refuge, 
to  which  may  be  removed  the  families  of 
such  necessitous  persons  as  have  been  at¬ 
tacked  with  cholera,  and  also  such  necessi¬ 
tous  persons  living  under  the  same  roof  or 
in  the  vicinity  of  persons  so  attacked,  as  the 
medical  officers  acting  under  the  authority  of 
the  said  parochial  boards  may  deem  it  ne¬ 
cessary  to  remove;  the  houses,  rooms,  or 
dwellings  from  which  persons  may  have  been 
so  removed  to  the  houses  of  refuge,  to  be 
cleansed  and  purified  by  the  owners  or  per¬ 
sons  having  the  care  or  ordering  thereof,  or 
in  their  default,  by  the  said  parochial  boards 
respectively. 

5.  And  we  hereby  authorize  and  require 
the  said  parochial  board  to  provide  for  the 
frequent  visitation  by  themselves  or  their 
officers,  or  such  person  as  they  may  appoint 
in  this  behalf,  of  the  several  houses  and 
dwellings  throughout  the  bounds  of  their 
several  parishes,  and  to  inquire  into  the  con¬ 
dition  and  matters  affecting  the  health  of 
the  inmates  of  such  houses  and  dwellings 
respectively,  and  their  liability  to  contagious, 
epidemic,  or  endemic  diseases,  and  especially 
as  to  the  existence  among  them  of  bowel 
complaints. 

6.  And  we  authorize  and  require  the  said 
parochial  board,  on  their  own  inspection,  or 
the  report  of  the  officers  or  persons  by  whom 
such  visitations  may  be  made,  or  other  in¬ 
formation  which  they  may  acquire  from 
their  own  committees,  or  from  visitors  or 
others,  as  to  the  condition  of  the  poor  who 
may  be  affected  with,  or  threatened  by,  the 
cholera  or  other  epidemic  disease,  to  supply 
such  medical  aid  as  may  appear  requisite. 

7.  And  we  hereby  authorize  and  require 
the  parochial  board,  or  the  officer  or  person 
visiting  as  aforesaid,  subject  to  the  special 


776  THE  THAMES  AND  THE  SERPENTINE  AS  FOCI  OF  PESTILENCE. 


instructions  of  the  parochial  board,  in  each 
case  where  symptoms  are  found  of  a  pre¬ 
monitory  attack  of  bowel  complaint,  to  send 
the  person  so  affected  to  the  nearest  dispen¬ 
sary  within  the  bounds  of  the  parish,  or, 
where  this  may  be  inexpedient,  to  despatch 
some  member  of  the  family,  or  other  person, 
for  advice  and  medical  aid,  and  immediately 
report  to  the  medical  officer  the  case  of 
every  such  person  found  so  affected  who 
shall  not  have  proceeded  to  the  dispensary. 

8.  And  we  do  authorize  and  direct  the 
several  parochial  boards  to  make  arrange¬ 
ments  for  obtaining  daily  lists  of  persons 
attacked  by  cholera  within  their  respective 
parishes,  with  the  particulars  of  their  case 
and  treatment,  and  for  communicating  the 
same  daily  to  the  other  boards  respectively, 
and  to  the  President  of  the  Royal  College 
of  Physicians  of  Edinburgh. 

9.  And  we  do  hereby  authorize  and  direct 
the  said  parochial  boards  to  appoint  such 
additional  medical  officers,  and  also  to  ap¬ 
point  such  other  officers  as  may  be  necessary 
to  carry  out,  execute,  and  superintend  the 
execution  of  these  regulations. 

Given  under  our  hands,  and  under  the 
seal  of  the  General  Board  of  Health, 
this  20th  day  of  October,  1848. 

Edwin  Chadwick, 

T.  Southwood  Smith. 

THE  THAMES  AND  THE  SERPENTINE  AS 
FOCI  OF  PESTILENCE. 

Until  it  had  been  satisfactorily  demon¬ 
strated  by  a  staunch  sanitarian  in  the  Times, 
we  had  not  the  least  idea  that  there  were  in 
the  very  heart  of  this  metropolis  two  rivers 
as  foul  and  pestilential  as  the  Niger  and  the 
Gambia  !  The  Thames  is  unquestionably 
responsible  for  the  cholera.  Hear  the  gen¬ 
tleman  of  the  press  on  a  subject  which  is 
now  exciting  alarm  from  Hampstead  to 
Peckham,  and  from  Kensington  to  Strat¬ 
ford  : — 

“  Nobody  can  possibly  have  overlooked 
that  there  is  one  constant  element  in  the 
circumstances  of  all  these  several  attacks — 
the  river  Thames.  We  are  not  going  to 
insist  further  upon  this  point  at  present, 
but  the  fact  cannot  be  blinked,  that,  whether 
the  patients  are  marines,  convicts,  prisoners, 
or  sailors,  there  is  always  one  condition 
found  fulfilled — that  they  have  been  breath¬ 
ing  the  atmosphere  of  the  river.’' 

Who  can  doubt,  after  this,  that  Father 
Thamesis  responsible  for  the  wholeof  the  mis¬ 
chief  ?  We  would  only  suggest,  by  way  of 
palliative,  that  the  sanitary  condition  of  those 
thin  and  spare-looking  beings,  the  Thames 
watermen,  should  be  immediately  examined 
by  the  Statistical  Society.  As  they  work 
within  a  few  feet  of  the  surface  of  the  water, 
the  figure  of  mortality  among  them  will 
serve  as  a  good  criterion  of  the  fatal  effects 


produced  by  the  stagnant  waters  of  this  pes¬ 
tilential  river.  It  is  strange,  too,  that  the 
Faculty  has  been  under  such  a  delusion  as 
to  suppose  that  the  cholera  was  progressing 
towards  us  from  the  east,  when  the  poison 
was  all  the  time  locked  up  in  the  mud  on  the 
banks  of  the  Thames.  The  sanitarian  writer 
who  has  raked  up  this  muddy  theory  tells  us 
that — 

“  There  is  little  more  reason  for  believing 
the  cholera  to  be  an  Asiatic  production  than 
a  Baltic  importation.  It  is  but  a  modifica¬ 
tion  of  the  ordinary  results  of  impurity  and 
want,  and  should  be  met  by  the  ordinary 
appliances  of  cleanliness  and  care.” 

As  to  the  Serpentine,  the  lake  Avernus  and 
the  river  Styx,  both  of  which  we  have  had  an 
opportunity  of  personally  inspecting,  must  be 
the  types  of  purity  compared  with  its  waters. 
We  cannot,  however,  join  in  running  down 
our  rivers  just  because  the  cholera  happens 
to  have  made  its  appearance  among  us  ;  and 
we  therefore  reprint  a  letter  address,  d  to  the 
Times  by  a  professional  man  in  defence  of 
the  calumniated  Serpentine  : — 

“  I  hope,  in  justice  to  this  neighbourhood, 
that  you  will  allow  me  a  few  lines  on  the 
Serpentine.  If  all  that  is  said  about  this  pond 
be  true,  a  man  might  as  well  settle  at  once  on 
the  banks  of  the  Gambia.  To  breathe  its 
vapours,  and  escape  pestilence,  must  be 
miraculous.  You  lately  copied  from  a  me¬ 
dical  journal  an  emanation  from  some  au¬ 
thor’s  brain,  and  dignified  it  by  a  notice  in 
your  leader.  Wbat  a  fearful  compot  of 
putrefying  matters  !  What  a  focus  of  cor¬ 
ruption  !  What  a  Pandora’s  box !  But, 
really,  this  is  all  romance.  I  live  hard  by 
these  waters,  walk  about  them  daily,  and,  being 
a  doctor,  have  an  eye  to  the  sources  of  disease, 
animal  and  vegetable  effluvia  !  dead  fish  and 
rotten  confervse  !  Why  there  is  not  as  much 
fish  in  the  whole  pond  (many  a  patient  pis¬ 
catory  soul  can  testify  it)  as  would  fill  a 
costermonger’s  donkey- cart ;  and  as  for  dead 
fish,  there  was  only  one  to  be  seen  on  its 
surface  all  this  summer.  Now,  really,  a  man 
might  as  well  pretend  that  a  dead  rat 
stretched  in  Piccadilly  would  infect  the  parish, 
of  St.  James,  or  that  we  should  suffer  Irom 
the  sudden  decay  of  the  two  innocent-looking 
pisces  in  the  zodiac.  As  for  the  vegetables, 
if  we  object  to  their  decay,  we  had  better  at 
once  make  a  clean  thing  of  the  gardens,  for 
more  decaying  leaves  are  shed  in  them  every 
fall  than  there  are  drops  of  water  in  the  Ser¬ 
pentine.  Sulphuretted  hydrogen,  too  !  You 
create  more  every  time  you  eat  an  egg  for 
breakfast,  as  your  blackened  spoon  can  tes¬ 
tify,  than  any  chymist  could  find  in  a  day’s 
search  about  the  Serpentine.  Be  assured, 
that  whatever  disease  is  to  be  got  out  of  this 
water  is  to  be  found  beneath  its  surface,  and 
not  above  it :  its  banks  are  hard  and  dry, 
and  its  bed  covered  ;  that  nespio  quid,  which 


SUCCESSFUL  EMPLOYMENT  OF  CHLOROFORM  IN  CHOLELA.  777 


laughs  at  doctors  and  withers  generations, 
does  not  emanate  from  the  flowing  waters, 
but  from  the  rich  swamps  and  the  teeming 
morasses  of  the  Orinoco  and  the  Niger  ;  ay, 
and  from  the  muddy  banks  of  the  Thames, 
when  the  receding  tide  has  left  them  bared  to 
the  sun.  It  is  from  such  moist,  heated 
masses  of  corruption  that  pestilential  fever 
springs.  Far  be  it  from  me  to  defend  mud 
and  duck  ponds  ;  I  would  rejoice  if  your 
efforts  could  make  the  waters  under  us  and 
the  air  above  us  clear  as  a  Parisian  sky.  My 
only  wish  is  here  to  allay  the  misgivings 
which  your  paper  has  created  in  the  anxious 
mother’s  breast  when  she  despatches  her 
little  brood  of  a  morning  to  feed  the  ducks  in 
the  Serpentine. 

“Your obedient  servant, 

“  Euexia.” 

Paddington,  Oct.  27. 

CHLOROFORM  IN  CHOLERA. 

Dr.  Hill,  of  Peckham  House  Asylum,  has 
addressed  a  letter  to  the  Times,  setting 
forth  the  benefits  derivable  from  the  use  of 
chloroform  vapour  in  cholera.  We  make 
the  following  extract  from  his  letter  : — 

“  The  following  is  our  usual  mode  of 
treatment : — Place  the  patient  in  bed  in 
warm  blankets  ;  give  a  glass  of  brandy  in 
hot  water,  with  sugar  and  spice  ;  apply  fric¬ 
tion  to  the  body  by  means  of  warm  flannels  ; 
and  an  embrocation  composed  of  Liniment. 
Saponis  Comp.,  Liniment.  Camphorse 
Comp.,  Tinct.  Opii  and  Extract.  Bella- 
donnse  ;  apply  to  the  whole  surface  of  the 
body  bags  filled  with  heated  bran  ;  place  the 
patient  under  the  influence  of  chloroform  by 
inhalation,  and  keep  him  gently  under  its 
effect  as  long  as  the  bad  symptoms  recur 
(which  they  frequently  do  on  its  effect 
ceasing  and  his  regaining  consciousness). 
Give  in  the  intervals  small  quantities  of 
brandy-and- water,  and  thin  arrow-root  or 
milk  for  nourishment,  along  with  milk  and 
water,  or  soda-water  with  a  little  brandy  for 
drink.  Avoid  everything  else  in  the  shape 
of  medicine,  and  trust  to  the  efforts  of  na¬ 
ture  in  rallying  from  the  poison  of  the  dis¬ 
ease. 

“Of  course  great  caution  is  necessary  in 
administering  the  chloroform,  and  in  not 
pushing  it  too  far.  In  some  instances  the 
patient  will  sleep  for  twenty  minutes  or  half 
an  hour ;  in  others  for  several  hours,  and, 
on  awaking,  will  again  be  seized  with  a 
return  of  the  vomiting  and  cramps,  when 
the  chloroform  must  again  be  resorted  to, 
and  the  patient  kept  in  a  great  measure 
under  its  influence  till  these  symptoms 
abate.  One  of  our  cases  required  its  use  at 
intervals  for  24  hours.  Again,  the  reaction 
after  its  use  may  be  so  great  as  to  require 
general  blood-letting,  which  occurred  in  two 
of  our  cases,  both  being  persons  of  full 
habit  of  body  and  sanguine  temperament — 


the  one  a  nurse,  and  the  other  a  male  farm 
servant.” 

The  Doctor  states  that  chloroform  vapour 
has  been  employed  by  him  in  ten  cases  of 
cholera  with  complete  success,  six  having  per¬ 
fectly  recovered,  and  four  being  convalescent. 
In  the  asylum  there  have  been  in  all  seventeen 
cases  of  malignant  cholera;  of  whom  five 
have  died,  eight  have  recovered,  and  four 
remain  under  treatment,  but  are  now  con¬ 
valescent.  The  only  explanation  which  can 
be  suggested  of  the  therapeutical  action  of 
this  universal  agent  is,  that  it  suspends  the 
effect  of  the  choleraic  poison  on  the  nervous 
ystem,  and  gives  time  for  vital  reaction. 
Chloroform  has  been  already  employed  in¬ 
ternally,  and  it  is  said  with  good  effect,  in 
some  severe  cases  of  English  cholera. 

THE  CHOLERA  IN  THE  HULKS. 

Woolwich,  Oct.  29. — The  medical  report 
up  to  12  o’clock  to-day,  gives  one  new  case 
since  yesterday’s  report,  being  the  only  one 
since  Monday  last.  The  total  number  of 
cases  is,  44  attacked,  14  deaths,  14  recove¬ 
ries,  and  19  convalescent,  all  convicts. 

Oct.  30. — Three  new  cases  have  been 
reported  as  having  taken  place  on  board  the 
Unite  hospital-ship,  from  12  o’clock  yester¬ 
day  to  12  o’clock  to-day,  and  two  have  been 
reported  as  discharged.  There  have  been 
no  deaths,  and  the  new  cases  are  now  stated 
to  have  assumed  a  milder  form  that  hitherto 
prevailed.  Almost  all  the  cases  of  deaths, 
and  even  attacks,  amongst  the  convicts  have 
occurred  amongst  those  who  have  been  sub¬ 
jected  to  punishments  or  confinements  in  the 
black  hole,  or  whose  constitutions  have  been 
greatly  injured  by  their  previous  course  of  life. 

Nov.  1. — There  was  one  new  case  reported 
up  to  12  o’clock  yesterday,  and  one  death 
up  to  12  o’clock  to  day,  making  a  total  of 
48  admitted,  15  deaths,  16  discharged  as 
recovered,  and  10  convalescent.  The  death 
which  occurred  to-day  was  of  an  infirm 
patient,  paralytic  in  one  leg,  and  was  owing 
to  a  relapse.  The  fatal  illness  lasted  118§ 
hours.  The  deceased  was  about  60  years  of 
age,  if  not  more,  as  most  of  the  prisoners  at 
that  time  of  life  appear  ignorant  of  their 
precise  ages.  There  are  still  two  severe 
cases  under  treatment,  one  of  the  sufferers 
is  aged  and  infirm,  and  the  other  young,  but 
feeble  and  sickly.  Dr.  Dabbs,  surgeon  of 
the  Unite  convict  hospital  ship,  reports  that 
the  disease  is  certainly  on  the  decline. 

APOTHECARIES’  HALL. 

Names  of  Gentlemen  who  passed  their  exa¬ 
mination  in  the  science  and  practice  of  me¬ 
dicine,  and  received  certificates  to  practise, 
on  Thursday,  26th  October,  1848  : — James 
Henry  Lakin,  Hattlerd,  Atherstone,  War¬ 
wickshire — Edward  Gylles  Crooke,  Edin¬ 
burgh — William  James  Williams,  India— 
Henry  Potter. 


778  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY,  ETC, 


BIRTHS  &  DEATHS  in  the  Metropolis 

During  the  week  ending  Saturday ,  Ocu  28. 

Av.  of  5  Aut. 
Males....  581 
Females. .  573 


Births. 
Males....  718 
Females. .  693 


1411 


Deaths. 
Males....  568 
Females. .  539 


1107 


1154 


5. 

6. 


the 


Causes  of  Death. 

All  Causes . 

Specified  Causes . 

1.  Zymotic(orEpidemic, Endemic, 

Contagious)  Diseases . . 

Sporadic  Diseases,  viz. — 

2.  Dropsy,  Cancer,  &e.  of  uncer¬ 
tain  seat  . 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  . 

4.  Lungs  and  other  Organs  of 

Respiration . 

Heart  and  Bloodvessels 
Stomach,  Liver,  and  other 
Organs  of  Digestion  . 

7.  Diseases  of  the  Kidneys,  &c.. . 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c . 

9.  Rhematism,  Diseases  of 
Bones,  Joints,  &c . 

10.  Skin,  Cellular  Tissue,  &c... 

11.  Old  Age . 

12.  Violence,  Privation,  Cold,  and 

Intemperance  . . 

The  following  is  a  selection  of  the  numbers  of 
Deaths  from  the  most  important  special  causes: 


I  Av.  of 
5  Aut. 

1107 

1154 

1106 

1149 

455 

270 

36 

52 

114 

127 

120 

222 

26 

38 

61 

67 

12 

12 

7 

14 

12 

8 

1 

2 

34 

64 

19 

32 

Small-pox  .  47 

Measles  .  16 

Scarlatina  . 182 

Hooping-cough..  33 

Diarrhoea  .  38 

Cholera  .  34 

Typhus  .  74 

Dropsy .  19 

Sudden  deaths  . .  3 

Hydrocephalus . .  18 
Apoplexy .  34 


Paralysis .  20 

Convulsions  ....  25 

Bronchitis .  48 

Pneumonia .  51 

Phthisis . 124 

Dis.  of  Lungs,  &c.  5 

Teething .  5 

Dis.  Stomach,  & c.  8 
Dis.  of  Liver,  &c.  10 

Childbirth .  3 

Dis.  of  Uterus,&c.  3 


Remarks. — The  total  number  of  deaths  was 
47  below  the  weekly  autumnal  average.  See 
page  757. 


METEOROLOGICAL  SUMMARY. 

Mean  Height  of  Barometer .  29‘45 

“  “  Thermometer1  .  5D5 

Self-registering  do. b _ max.  75T  min.  30* 

“  in  the  Thames  water  —  51*  —  45’8 

a  From  12  observations  daily.  b  Sun. 


Rain,  in  inches,  1*35 :  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological. — Tie  mean  temperature  of  the 
week  was  about  2'6  above  the  mean  of  the  month. 


BOOKS  &  PERIODICALS  RECEIVED 

during  the  week. 

An  Introduction  to  Botany.  By  John  Lindley, 
Ph.D.  F.R.S.  4th  edition,  2  vols. 

A  Short  Account  of  a  Case  of  Disease  of  the  Ap¬ 
pendix  Cseci.  By  Henry  Hancock,  F.R.C.S.E. 
Wonders  displayed  by  the  Human  Body,  in  its 
Endurance  of  Injury.  From  the  Portfolio  of 
Delta. 

Casper’s  Wochenschrift.  No.  41,  7th  Oct.  1848. 
Tracts  for  the  Improvement  of  Popular  Litera¬ 
ture.  No.  3 — Physiology. 

British  Record  of  Obstetric  Medicine.  No.  21, 
Nov.  1848. 

Remarks  on  Chloroform  in  alleviating  Human 
Suffering.  By  W7.  H.  Bambrigge,  Esq. 

(The  remainder  will  be  given  in  our  next  No.) 


NOTICES  to  CORRESPONDENTS. 

The  letter  of  Mr.  J.  Mackenzie,  Archangel 
(Oct.  2,  O.S.),  has  come  to  hand.  We  shall  be 
glad  to  receive  the  report. 

The  subject  referred  to  by  M.  M.  Minter,  of 
Folkstone,  shall  receive  our  attention. 

Dr.  G.  Robinson,  Newcastle.  It  will  give  us 
great  pleasure  to  publish  the  reports  of  the 
new  Society. 

The  circular  from  the  Central  Board  o:'  Health, 
Dublin,  has  reached  us. 

We  have  to  apologise  to  several  correspondents — 
among  others,  to  Drs.  Parkes,  Dick,  C.  H. 
Jones,  and  Snow,  for  the  delay  in  the  insertion 
of  their  papers,  rendered  unavoidable  by  the 
lehgthy  documents  on  cholera,  for  which  we 
have  been  compelled  to  find  space.  They  are 
in  type,  and  will  be  inserted  in  the  following 
number. 

The  second  communication  of  Dr.  Milroy  has 
been  received,  and  will  be  inserted  at  the 
earliest  opportunity. 

Mr.  Atkinson’s  letter  on  Electrical  Phenomena 
in  Cholera  next  week. 

The  Report  of  the  Parisian  Academy  of  Sciences 
was  too  late  for  this  number.  Will  our  corre¬ 
spondent  be  so  good  as  to  put  the  date  to  each 
report  ? 

Mr.  N.  Davey’s  letter,  and  the  Suggestions  on 
Cholera  from  Edinburgh,  next  week. 

J. — The  paper  on  the  Contagion  of  Cholera  shall 
receive  our  attention ;  and  a  letter  will  be  sent, 
or  notice  of  insertion  given  in  the  usual  way. 

Received. — Dr.  Seaton,  Dr.  Dick,  SirC.  Scuda¬ 
more,  Mr.  Hicks,  Mr.  P.  Richardson,  Mr.  W. 
Bailey. 


THE  GENERAL  INDEX. 

We  have  to  announce  to  onr  Subscribers  that  a  General 
Index  to  the  first  40  Volumes  of  the  London  Medical  Gazette 
will,  it  is  calculated,  form  a  large  Volume  of  about  700  pages. 
The  cost  of  the  Index  Volume,,  respecting  which  many  inquiries 
have  been  made,  will  be  Twenty-four  Shillings ;  and  it  is  proposed 
to  commence  it  so  soon  as  the  Names  of  Five  Hundred  Subscribers 
have  been  obtained. — The  printers,  Messrs.  Wilson  and  Ogilvy, 
57,  Skinner  Street,  will  receive  the  Names  of  Subscribers. 


779 


&  option  JBrtriral  €a:mtr 

_ 


Scftuvcs. 


COURSE  OF  SURGERY, 
Delivered  in  the  years  1846  and  1847, 

By  Bransby  B.  Cooper,  F.R.S. 

Surgeon,  and  Lecturer  on  Surgery  at  Guy’s 
Hospital. 


Lecture  XLII. 

CONTINUATION  OF  DISEASES  OF  THE  REC¬ 
TUM. —  GENITO-URINARY  ORGANS. 

Rectum  —  Fistula  in  ano — premonitori / 
symptoms — preparation  of  the  patient 
before  operation — case.  Mode  of  operat¬ 
ing — modification  of  the  operation  by 
ligature — constitutional  means  to  prevent 
the  return  of  the  disease  Recto-vaginal 
fistula — cases.  Recto-vesical  fistula — 
lacerations  of  the  rectum — mode,  of  pro¬ 
moting  the  cure — stricture  of  the  rectum 
— liability  to  stricture  in  all  excretory 
outlets — spasmodic  stricture — permanent 
stricture — symptoms — treatment.  Geni- 
to-urinary  organs  —  anatomical  rela¬ 
tions — urethra — its  conformation — na¬ 
tural  dilatations  and  contractions — their 
situation — lacunce. 

Fistula  in  ano. — This  diease  is  usually 
first  manifested  externally  by  the  presence  of 
an  abscess,  or  perhaps  only  slight  swelling 
or  hardness  at  the  side  of  the  anus.  This  is 
not,  however,  the  true  commencement  of  the 
complaint,  which  I  believe  begins  invariably 
in  the  bowel  itself,  immediately  above  the 
sphincter  muscle.  The  individuals  most 
liable  to  this  disease  are  those  who  lead 
sedentary  lives,  and  are  also  irregular  in  their 
diet:  such  persons  easily  .  acquire  a  con¬ 
gested  state  of  the  liver,  the  rectum  very 
soon  becoming  affected  in  consequence. 

The  first  symptom  of  fistula  is  a  deep- 
seated  pain  and  sensation  of  uneasiness 
about  the  anus ;  this  continues  for  an  hour 
or  two  after  evacuation  of  the  bowels,  and  is 
sometimes  attended  by  a  slight  discharge  of 
blood.  I  have  also  known  slight  rigor  to 
be  a  precursor  of  fistula.  When  a  patient 
to  whom  yon  are  called  describes  the  symp¬ 
toms  just  detailed,  you  should  at  once  pro¬ 
ceed  to  examine  the  region  of  the  anus,  and 
although  there  may  be  nothing  appreciable 
by  the  eye,  if  the  finger  be  forcibly  pressed 
between  the  tuberosity  of  the  ischium  and 
the  verge  of  the  anus  an  unnatural  hardness 
will  frequently  be  felt,  and  considerable  pain 
produced  by  the  pressure.  If  these  symp¬ 
toms  present  themselves,  a  lancet  should  be 
plunged  into  the  swelling,  upon  which  a 
small  quantity  of  matter  generally  escapes, 

XLII.— 1093.  Nov .  10,  1848. 


or  perhaps  the  lancet  will  be  merely  stained 
by  it  :  this  would,  however,  be  sufficient  to 
prove  satisfactorily  that  suppuration  has  been 
the  cause  of  the  symptoms. 

These  indications  are  supposed  to  mark 
the  commencement  of  fistula  in  ano  ;  but 
the  disease  itself  no  doubt  commences  in  the 
rectum  as  an  ulcer,  immediately  above  the 
sphincter  ani,  the  original  cause  probably 
arising-  from  the  retention  of  the  feces, 
which  excites  ulceration  through  all  the 
tissues  of  the  parietesof  the  rectum,  extend¬ 
ing  into  the  cellular  tissue,  where  it  pro¬ 
duces  those  external  signs  which  are  gene¬ 
rally  regarded  as  the  commencement,  instead 
of.  the  consequence,  of  the  disease.  If  at 
this  stage  the  fistula  be  neglected,  it  extends 
upwards  by  the  side  of  the  rectum,  isolating 
a  large  portion  of  the  bowel  from  its  cellular 
connection,  and  ultimately  bursting  through 
the  skin  by  the  side  of  the  anus,  converts 
that  which  was  at  first  termed  a  blind,  info  an 
open  fistula  :  sometimes  the  ulcerated  open¬ 
ing  is  formed  at  a  considerable  distance 
from  the  anus,  or  three  or  four  fistulous 
openings  may  be  established  by  the  burrow¬ 
ing  of  the  matter.  It  does  not  invariably 
follow,  gentlemen,  however  evident  it  may 
be  that  nothing  but  an  operation  can  cure 
a  fistula,  that  that  operation  is  to  be  at 
once  performed,  although  it  is  advisable  to 
ascertain  immediately  the  extent  of  the 
fistula  :  if  irregularity  of  the  bowels,  en¬ 
larged  liver,  and  a  jaundiced  complexion, 
indicate  a  cachectic  habit,  medicinal  means 
must  be  employed  to  restore  the  health  be¬ 
fore  it  would  be  safe  to  venture  upon  the 
operation  ;  the  remedies  which  I  have  gene¬ 
rally  found  most  effective  for  this  purpose 
are  small  repeated  doses  of  mercury  and 
sarsaparilla,  quinine,  or  other  tonic  medi¬ 
cines.  Not  many  months  ago  I  had  a  strong 
illustration  of  the  danger  of  operating  in 
fistula  without  being  previously  made  ac¬ 
quainted  with  the  peculiar  habits  of  life 
of  the  patient.  An  artist  who  resided  at 
Chelsea  was  brought  to  me  by  his  usual 
medical  attendant,  in  consequence  of  his 
being  the  subject  of  fistula  in  ano.  I  ascer¬ 
tained  the  condition  of  the  local  disease,  and 
at  once  stated  that  a  cure  could  only  be 
effected  by  operation.  I  inquired  as  to 
his  usual  health,  and  was  informed  that  it 
was  generally  good,  his  appearance  also 
seemed  to  corroborate  this  statement ;  I 
therefore  merely  ordered  a  slight  aperient, 
and  four  days  after  performed  the  operation  at 
his  own  house.  The  fistula  was  not  very  ex¬ 
tensive,  and  the  operation  in  every  way  less 
severe  than  usual ;  but  directly  after,  the 
patient  betrayed  so  much  irritability  that  I 
ordered  him  to  take  thirty  drops  of  laudanum, 
and  an  ounce  and  a  half  of  camphor  mixture  : 
the  next  morning  I  found  that  he  had  had 
no  sleep,  and  although  not  complaining  of 


OPERATION  FOR  FISTULA  IN  ANO. 


7P0 


pain  he  was  in  a  very  restless  state,  and  his 
manner  was  indicative  of  extreme  anxiety ; 
no  secondary  bleeding  had  occurred,  and  the 
wound  appeared  perfectly  healthy.  I  or¬ 
dered  him  a  grain  and  a  half  of  calomel  and 
a  grain  of  opium  to  be  taken  directly, 
and  also  the  following  mixture . — Trae. 
Hyoscy.  5'j.;  Liqr.  Ammon.  Acet.  3jss.  ; 
Julep  Ammon,  ^vjss.  M.  Capt.  cochl. 
larga  ij.  quaque  quart,  hora.  The  next  day  he 
was  in  much  the  same  state;  he  had  never 
closed  his  eyes  the  whole  night ;  he  had 
been  delirious,  and  during  my  visit  was  in 
the  condition  of  one  in  great  mental  alarm, 
and  symptoms  of  delirium  tremens  were 
beginning  to  manifest  themselves.  I  now 
inquired  of  his  wife  whether  his  habits  were 
intemperate,  and  after  some  hesitation  she 
informed  me  that  he  frequently  drank  as 
much  as  a  bottle  of  brandy  in  a  day,  com¬ 
mencing  at  an  early  hour  in  the  morning. 
He  remained  in  the  state  I  have  described 
for  five  days,  at  the  end  of  which  he  died. 
This  case,  gentlemen,  affords  abundant  in¬ 
struction  :  it  shows  the  necessity  for  scru¬ 
pulously  investigating  the  condition  of  the 
heal  h  of  the  patient,  and  also  his  general 
habits  of  living,  before  you  proceed  to  the 
performance  of  an  operation  ;  for  had  I  been 
acquainted  with  the  excessive  intemperance 
of  the  individual  in  the  case  just  quoted, 
I  should  never  have  dreamt  of  performing 
the  operation  until  I  had  taken  measures  to 
improve  the  tone  of  his  health  by  the  use  of 
constitutional  remedies,  restricting  him  at 
the  same  time  in  the  inordinate  use  of  in¬ 
toxicating  liquors. 

Operation  for  fistula  in  ano. — The  effec¬ 
tiveness  of  this  operation  depends  entirely 
upon  the  complete  division  of  the  sphincter 
ani  mus.le,  for  by  its  contractions  it  offers 
resistance  to  the  free  passage  of  the  contents 
of  the  bowel,  which  thus  have  a  tendency  to 
pass  through  the  abnormal  opening,  and 
keep  up  its  fistulous  character.  If  a  probe 
be  introduced  into  the  opening  through  the 
skin,  it  can  generally  be  pushed  two  or  three 
inches  upwards  by  the  side  of  the  rectum, 
and  if,  at  the  same  time,  the  finger  be  placed 
in  the  bowel,  the  point  of  the  probe  can  be 
readily  felt  through  the  parietes.  I  believe, 
however,  that  no  communication  is  ever 
formed  between  the  bowel  and  the  fistula  so 
far  above  the  sphincter  ;  no  advantage  is 
therefore  derived  from  this  extensive  explo¬ 
ration,  and  it  is,  in  my  opinion,  very  bad 
practice  to  make  an  incision  in  the  bowel  so 
high  up,  for  if  a  very  extensive  wound  is 
unnecessarily  made,  large  vessels  are  exposed 
to  danger,  and  nature  is  called  upon  to 
repair  a  much  greater  lesion  than  is  really 
requisite.  The  operation  should  consist  in 
merely  introducing  the  probe  into  the  ex¬ 
ternal  opening,  and  in  seeking,  by  gentle 
manipulation,  for  the  ulceration  into  the 


bowel  itself :  this  will  usually  be  found  im¬ 
mediately  above  the  upper  edge  of  the 
sphincter  muscle,  but  if  there  should  be  any 
difficulty  in  discovering  it,  the  probe- pointed 
bistoury  may  be  gently  forced  through  the 
parietes  of  the  rectum,  and  the  point  of  the 
knife  being  in  contact  with  the  finger,  which 
has  been  already  passed  up  the  anus,  the 
division  of  the  sphincter  may  be  effected  by 
drawing  both  hands  simultaneously  down¬ 
wards  from  the  body  of  the  patient,  still 
keeping  the  finger  and  point  of  the  instru¬ 
ment  in  firm  contact.  This  operation  re¬ 
moves  the  obstruction  the  sphincter  muscle 
offered  to  the  free  passage  of  the  faeces, 
which  were  consequently  forced  into  the  fistu¬ 
lous  openings,  but  as  the  latter  are  destroyed 
by  the  operation  the  sinuses  readily  heal, 
and  in  a  short  time  the  disease  is  completely 
removed.  To  secure  the  granulation  of  the 
wound,  and  prevent  the  mere  adhesion  of  its 
cutaneous  surface,  the  whole  of  the  divided 
part  should  be  filled  with  lint,  and  the 
bowels  kept  in  a  state  of  constipation  for 
some  days,  so  that  there  may  be  no  inter¬ 
ference  with  the  reparative  action.  When 
aperients  are  administered,  the  patient 
should  be  made  aware  that  he  will  have  no 
power  to  restrain  the  evacuation  of  the 
feeces  :  this  must,  of  course,  be  the  result  of 
the  division  of  the  sphincter  ani.  In  cases 
of  neglected  fistula  in  ano,  the  sinuses  some¬ 
times  open  at  a  considerable  distance  from 
the  verge  of  the  anus ;  so  that,  if  the  opera¬ 
tion  be  performed  precisely  according  to  the 
above  description,  a  very  extensive  incision 
would  have  to  be  made  through  the  gluteal 
region,  to  comprehend  the  whole  length  of 
the  sinus.  To  avoid  this,  the  operation 
may  be  modified  as  follows : — A  probe  is  to 
be  passed  along  the  fistula  into  the  bowel, 
and  then  bent  by  the  finger  in  the  rectum 
so  as  to  brin^  the  point  out  at  the  anus;  the 
two  ends  should  be  drawn  downwards  to 
bring  the  sinus  towards  the  surface ;  the 
probe  is  then  to  be  cut  down  upon,  just  as 
it  is  entering  the  intestine  above  the 
sphincter,  and,  the  probe-pointed  bistoury 
being  directed  along  the  probe  into  the 
bowel,  the  probe  may  be  withdrawn,  and 
the  bistoury  made  to  divide  the  sphincter  as 
already  described.  By  this  manner  of  pro¬ 
ceeding  two-thirds  of  the  length  of  the 
fistula  may  remain  undivided,  and  will 
readily  heal,  as  there  is  no  longer  any  cause 
for  the  feces  to  pass  into  it.  There  is  still 
another  modification  of  the  operation,  wLich 
it  may  sometimes  be  advisable  to  adopt  in 
certain  cases  of  fistula,  and  I  have  myself 
had  recourse  to  it.  If  on  passing  the 
finger  into  the  bowel,  for  instance,  for 
the  purpose  of  examining  the  situation 
of  the  ulcerated  opening,  you  discover 
that  the  haemorrhoidal  vessels  are  ab¬ 
normally  enlarged,  as  indicated  by  the 


781 


RECTO-VAGINAL  FISTULA - CASES. 


strength  of  their  pulsation,  you  may  employ 
a  ligature,  instead  of  a  knife,  for  the  purpose 
of  dividing  the  sinus  and  sphincter  ani.  The 
mode  of  performing  this  operation  is  by 
passing  an  eyed  probe  (furnished  with  a 
strong  silk)  through  the  sinus  into  the 
bowel,  bringing  one  end  of  the  silk  out  of 
the  anus,  and  leaving  the  other  hanging  from 
the  orifice  through  which  the  probe  had 
entered.  The  probe  should  then  be  with¬ 
drawn,  and  the  two  ends  of  the  silk  tied 
tightly  so  as  to  compress  all  the  intervening 
structures  :  the  ligature  requires  to  be 
tightened  daily,  for  the  constriction  becomes 
lessened  as  the  ulceration  advances.  In 
the  cases  in  which  I  have  performed  this 
operation,  I  was  surprised  to  find  that  the 
patients  complained  of  even  less  suffering 
than  in  the  usual  plan  of  proceeding ;  that 
the  wound  healed  as  readily,  and  did  not 
require  to  be  filled  with  lint,  as,  of  course, 
there  could  be  no  tendency  to  unite  by  ad¬ 
hesion.  I  may  also  tell  you,  gentlemen, 
that  the  haemorrhage  which  sometimes 
follows  the  division  of  a  fistula  by  incision  is 
not  only  most  alarming,  but  occasionally 
proves  fatal  ;  and  there  ore,  in  cases  where 
there  are  indications  that  a  larger  quantity 
of  blood  than  usual  is  sent  to  the  part,  it 
is  highly  important  to  avoid  incising  these 
vessels  ;  and  this  may  be  done  by  substi¬ 
tuting  the  ligature  for  the  operation  by  the 
knife. 

The  term  fistula  in  itself  merely  expresses 
the  sinuous  form  of  the  abscess;  but  it  is 
from  its  specific  character  that  the  surgical 
operation  affords  the  only  means  of  perma¬ 
nent  relief ;  for,  being  lined  with  an  adven¬ 
titious  mucous  membrane,  it  becomes  con¬ 
verted  into  a  supernumerary  excretory 
outlet,  which  would  remain  permanent  as 
long  as  any  communication  with  the  rectum 
continued  ;  and  therefore  it  is  that  it  de¬ 
mands  the  operation  as  described.  A  patient 
who  has  once  been  the  subject  of  this  dis¬ 
ease  must  be  considered  as  very  liable  to 
its  recurrence;  and,  therefore,  every  means 
should  be  employed,  by  strict  attention  to 
diet,  and  to  the  natural  state  of  the  bowels, 
to  prevent  any  source  of  irritation  from 
acting  upon  the  cicatrix  ;  for,  should  that 
give  way,  it  would  be  found  extremely  diffi 
cult  to  reunite  it,  and  the  failure  in  this 
effort  would  lead  to  the  establishment  of  a 
permanently  loathsome  condition,  produced 
by  the  existence  of  a  passage  for  the  faeces 
by  the  side  of  the  anus. 

A  fistulous  opening  from  the  rectum  may 
possibly  communicate  with  the  bladder,  or 
with  the  vagina,  causing  the  most  distressing 
results ;  and  such  a  state  frequently  occurs 
in  cases  of  difficult  parturition.  I  am  ac¬ 
quainted  with  a  case  in  which  a  lady  was 
the  subject  of  this  lesion  ;  and,  after  every 
attempt  had  been  made  to  sevy  up  the  fistu¬ 


lous  openings  of  the  rectum  and  vagina,  and 
other  plastic  operations  had  been  ineffec¬ 
tually  resorted  to,  Mr.  Copland  restored  the 
patient  to  health  by  the  mere  division  of  the 
sphincter  ani,  which  not  only  prevented  re¬ 
tention  of  the  faeces  within  the  rectum,  but, 
at  the  same  time,  precluded  the  necessity 
for  the  action  of  the  levator  ani  muscle. 
The  contents  of  the  rectum,  no  longer 
meeting,  therefore,  with  any  obstruction  to 
their  passage  from  the  anus,  had  no  ten¬ 
dency  to  pass  into  the  vagina,  the  fissure  in 
which  immediately  healed.  A  lady  was 
lately  under  my  care,  who  was  the  subject 
of  a  fistulous  opening  from  the  rectum  into 
the  vulva,  through  which  the  faeces  in  part 
escaped.  On  examining  the  case,  I  passed 
a  probe  from  the  vulva  into  the  rectum,  and 
found  both  openings  were  so  near  to  the 
outlets  of  the  rectum  and  vagina,  that,  by 
passing  a  bistoury  and  dividing  the  peri¬ 
neum,  I  should  completely  lay  open  the 
whole  length  of  the  fistula  and  the  sphincter 
ani  at  the  same  time  ;  and  this  operation  I 
was  at  the  moment  much  disposed  to  per¬ 
form,  as  it  seemed  at  once  to  afford  the 
readiest  and  simplest  mode  of  insuring  a 
speedy  cure ;  still,  I  had  some  misgiving  as 
to  the  certainty  of  effecting  the  ultimate 
filling  up  of  the  wound  ;  and  I  consulted 
Mr.  Copland  on  the  subject:  he  recom¬ 
mended  me  by  no  means  to  adopt  this  plan, 
as  he  had  known  it  upon  three  or  four  occa¬ 
sions  to  be  had  recourse  to,  and  in  none  of 
them  did  the  patients  ever  recover  the 
power  of  retention  of  the  faeces ;  so  that 
they  were  in  a  much  worse  condition  from  the 
operation  than  from  the  original  disease. 
The  mode  I  ultimately  adopted,  therefore, 
was,  to  divide  the  fibres  of  the  sphincter  ani 
muscle,  and  pass  a  probe  covered  with  po- 
tassa  fusa  through  the  sinus,  so  as  perfectly 
to  destroy  the  mucous  surface  of  the  fistula. 
As  the  granulations  thus  produced  did  not 
seem  to  fill  up  the  opening,  I  brought  the 
surfaces  of  the  fistula  in  contact  by  means  of 
a  ligature,  which  came  away  in  a  few  days, 
and  the  opening  into  the  vulva  was  much 
diminished,  but  still  the  communication  be¬ 
tween  the  two  organs  was  not  obliterated. 
I  then  daily  applied  the  tincture  of  lytta  to 
the  granulating  surfaces,  and  the  lady  left 
London,  although  it  could  not  be  said  per¬ 
fectly  cured,  with  the  prospect  of  the  granu¬ 
lations  becoming  ultimately  converted  into 
permanent  tissue. 

These  cases,  gentlemen,  as  well  as  those 
of  lesions  between  the  bladder  and  vagina, 
are  most  difficult  to  cure ;  and  I  believe 
that,  unless  the  division  of  the  sphincter  ani 
itself  promotes  their  obliteration,  although 
other  means  may  be  somewhat  accessory, 
they  are  never  sufficient  to  produce  a  cure. 
My  colleague,  Dr.  Lever,  has  had  severaL 
cases  of  recto-vaginal  and  vesico-vaginal 


782 


STRICTURE  OF  THE  RECTUM. 


fistuise,  which  he  has  attempted  to  obliterate 
by  plastic  operations,  and  by  sutures, 
caustic,  and  actual  cautery :  the  result  of 
his  experience  is,  however,  that  very  few 
cases  are  ever  permanently  cured,  although, 
by  means  of  actual  cautery,  he  has  fre¬ 
quently  reduced  the  abnormal  openings  to 
the  size  of  a  pin’s  head,  but  I  believe  that 
only  in  one  or  two  cases  has  he  succeeded 
in  producing  a  permanent  cure. 

Lacerations  of  the  rectum  sometimes 
occur  from  external  injuries,  and  one  of  the 
most  frequent  causes  which  I  have  known 
leading  to  this  laceration  is  the  extraction 
of  stone  from  the  bladder  in  the  operation 
of  lithotomy ;  but  it  is  remarkable  that 
these  lacerations  do  not  seem  to  offer  the 
same  difficulty  in  reparation  as  that  which 
results  from  internal  causes,  although  I 
have  known  one  case  in  which  a  fistulous 
opening  between  the  rectum  and  peri¬ 
neum  remained  permanent.  The  division 
of  the  sphincter  ani  in  such  cases  affords 
the  best  prospect  of  cure.  I  have  ad¬ 
mitted  patients  into  Guy’s  Hospital,  with 
laceration  of  the  rectum  occurring  from  a 
fall  on  a  sharp  pointed  body,  such  as  a  paling  ; 
and  in  two  instances  I  have  known  the 
injury  produced  by  the  goring  of  an  ox. 
Under  these  circumstances,  the  treatment 
consists  in  keeping  the  bowels  moderately 
open,  and  the  rectum  completely  cleansed 
from  all  faecal  matter  after  each  evacuation  : 
this  must  of  course  be  done  by  means  of 
injections.  Should,  however,  the  lesion  in 
the  rectum  remain  obstinately  unhealed  in 
consequence  of  the  sphincter  ani  still  retain¬ 
ing  some  contraction  from  its  fibres  having 
been  but  incompletely  divided,  the  entire 
division  of  the  latter  should  be  effected  ;  and 
this,  unless  some  very  untoward  circum¬ 
stances  occur,  is  almost  certain  to  produce 
a  cure. 

Stricture  of  the  rectum. — All  excreting 
outlets  are  furnished  with  a  lining  of  mucous 
membrane,  and  appear  to  be  susceptible  to 
obstruction  from  abnormal  contraction  in 
the  size  of  their  canals,  owing  to  the  de¬ 
position  of  adhesive  matter  in  the  sub¬ 
mucous  cellular  tissue.  This  liability  to 
become  obstructed  from  an  adventitious 
deposit  seems  universal  in  these  outlets 
from  the  puncta  lachrymalia  to  the  rec¬ 
tum  itself.  The  oesophagus,  especially  in 
hysterical  females,  is  subject  to  a  difficulty 
in  propelling  the  food,  simulating  in  many 
respects  the  symptoms  of  stricture,  but 
depending  in  reality  upon  temporary  spas¬ 
modic  action,  which  can  be  readily  relieved 
by  the  use  of  narcotics  and  tonics.  The 
rectum  is,  I  believe,  sometimes  subject  to 
the  same  kind  of  affection,  which  may  also 
be  relieved  by  the  employment  of  similar 
anti-spasmodic  remedies.  Permanent  ob¬ 


struction  in  the  rectum  is,  however,  of  fre¬ 
quent  occurrence.  A  strong  symptom  of 
this  is  constipation,  which  is  produced 
partly  by  the  influence  of  the  physical  ob¬ 
struction  to  the  passage  of  the  faeces,  and 
partly  by  the  voluntary  suppression  of  them 
by  the  patient,  from  the  dread  of  the  acute 
pain  so  frequently  experienced  in  the  act  of 
defecation.  The  egesta  in  stricture  of  the  rec¬ 
tum  are  passed  in  small  rounded  portions,  or 
if  “figured,”  of  very  small  diameter,  from 
being  forced  through  the  contracted  part  : 
the  patient  usually  complains  of  distension 
of  the  abdomen,  interference  with  the 
function  of  respiration,  and  loss  of  appetite. 
With  these  symptoms  an  examination  should 
be  made  per  anum,  at  first  with  the  finger 
alone,  and  this  will  probably  lead  to  the  de¬ 
tection  of  the  obstruction,  which  is  often 
very  firm,  and  resists  the  entrance  of  the 
finger  into  the  bowel.  This  excessive  hard¬ 
ness  may  be  produced  either  by  scirrhus,  or 
by  a  mere  attack  of  inflammation,  and, 
therefore,  the  hardness  alone  is  not  to  deter¬ 
mine  the  judgment  of  the  surgeon  as  to  the 
disease  being  malignant,  as  that  question 
will  be  best  decided  by  the  age  of  the  patient, 
the  length  of  time  the  disease  has  existed,  and 
by  the  nature  of  the  pain.  If,  for  instance, 
the  patient  be  old,  the  pain  constant,  severe, 
and  of  a  lancinating  character,  and  he 
has  great  dread  of  exciting  the  muscu¬ 
lar  action  necessary  to  the  evacuation  of  the 
bowels,  and  if  at  the  same  time  there  is  an 
appearance  of  what  is  termed  malignant  dia¬ 
thesis,  the  prognosis  would  be  unfavourable. 
But,  if  the  obstruction  results  from  simple 
inflammation  in  a  youthful  patient,  it  will 
be  indicated  by  the  suddenness  of  its  ap¬ 
pearance,  by  the  febrile  symptoms  attendant 
upon  it,  and  by  the  peculiar  sensation  con¬ 
veyed  to  the  finger  ;  for  although  there  is 
considerable,  hardness,  it  is  not  of  the  stony 
character  that  marks  scirrhus,  but  gives  the 
idea  of  its  being  a  dense  projection  of  the 
natural  structures  into  the  bowel,  rather  than 
an  adventitious  deposit.  When  the  disease 
is  malignant,  bleeding  is  frequent,  particu¬ 
larly  upon  examination  either  by  the  finger 
or  instrument,  and  the  pain  lasts  for  a  con¬ 
siderable  time  after,  which  is  not  the  case 
with  common  stricture.  The  treatment  in 
the  non-malignant  disease  consists  in  the 
occasional  application  of  leeches  around  the 
anus,  the  patient  being  kept  in  the  recum¬ 
bent  posture,  and  I  believe  that  enemata 
will  be  generally  found  better  than  bougies, 
as  the  mechanical  means  of  overcoming  the 
obstruction,  unless  they  act,  indeed,  too 
much  upon  the  bowels,  in  which  case  bou¬ 
gies  must  of  course  be  employed. 

The  introduction  of  a  bougie  is  a  matter 
requiring  considerable  skill  and  anatomical 
knowledge  ;  and  in  this  particular  case  also, 
a  competent  acquaintance  with  the  change  of 


DISEASES  OF  THE  GENITOURINARY  ORGANS. 


783 


the  relative  situation  of  the  rectum  consequent 
upon  the  position  in  which  the  patient  is 
placed.  From  want  of  this  knowledge,  indeed, 
unskilful  practitioners  often  do  great  mis 
chief,  sometimes  wounding  the  rectum,  from 
•which  accident  extravasation  of  fasces,  peri¬ 
tonitis,  and  death,  may  be  produced.  The 
bougie  should,  therefore,  only  be  employed 
by  scientific  surgeons.  Leeches,  the  re¬ 
cumbent  posture,  injections,  and  in  some 
cases  the  use  of  the  bougie,  and  cupping  in 
the  loins  when  the  pain  is  severe,  are  the 
means  to  be  had  recourse  to  in  non-malig- 
nant  obstruction.  And  often,  by  such  mea¬ 
sures,  a  disease  which  at  first  appeared  to  be 
of  an  alarming  character,  is  quickly  re¬ 
moved.  In  malignant  disease  but  little  can 
be  done  :  the  adventitious  matter  indefinitely 
increases,  so  as  at  length  completely  to  ob¬ 
literate  the  bowel,  and  the  patient  dies  from 
the  insuperable  barrier  opposed  to  the  escape 
of  the  excretions,  unless  an  artificial  anus  be 
made  in  the  colon,  or  as  some  surgeons 
have  recommended,  a  cutting  gorget,  or 
some  instrument  of  the  kind  be  forced' 
through  the  obstruction  ;  but  this  if  it  afford 
any  relief,  can  only  do  so  temporarily. 
Scirrhous  stricture  generally  destroys  the  pa¬ 
tient,  however,  by  the  propagation  of  the 
malignant  disease  through  the  medium  of 
the  absorbents  to  some  distant  part :  thus, 
perhaps,  transplanting  it  to  important  vital 
organs,  in  which  case  the  reaction  on  the 
constitutional  powers  is  very  rapid,  and  the 
patient  soon  sinks  beneath  its  influence. 

DISEASES  OF  THE  GENTTO- URINARY 
ORGANS. 

The  most  frequent  of  all  the  diseases  to 
which  these  organs  are  liable  is  stricture  of 
the  urethra.  The  urethra  can  scarcely, 
however,  be  considered  as  a  genital  organ 
with  reference  to  stricture,  since,  in  case  of 
its  obstruction,  the  symptoms  relate  only  to 
its  function  as  an  apparatus  of  micturition. 
At  the  same  time  the  procreative  power  is 
sometimes  to  a  certain  extent  interfered 
with,  and  therefore  it  is  that  I  have  thought 
it  proper  to  treat  of  stricture  of  the  urethra 
under  the  above  heading. 

The  genito-urin ary  organs  are  placed 
partly  within  the  abdomen,  and  partly  ex¬ 
ternal  to  it  :  thus  the  prostate  gland,  the 
vesiculse  seminales,  portions  of  the  vasa 
deferentia,  and  part  also  of  the  urethra  and 
the  bladder,  are  internal  to  the  abdominal 
cavity,  while  the  remainder  of  the  urethra 
and  the  testicles  are  external.  Our  attention 
is  now,  however,  to  be  directed  to  the  ure¬ 
thra,  which  has  to  perform  a  double  function, 
viz.,  that  of  micturition,  and  that  of  procrea¬ 
tion.  As  a  micturating  organ  the  urethra  is 
passive,  but  as  one  of  generation  it  is  en¬ 
dowed  with  great  excitability  ;  and  it  is  when 
in  a  state  of  excitement  that  it  is  chiefly 


susceptible  to  the  influences  that  induce  ob¬ 
struction  it  it,  although  when  thus  affected 
the  symptoms  relate  entirely  to  the  difficulty 
in  passing  the  urine. 

You  are  doubtless  aware,  gentlemen,  that 
the  calibre  of  the  canal  of  the  urethra  is  not 
equal  throughout  its  whole  extent :  it  has, 
indeed,  three  points  of  contraction,  and 
three  of  dilatation.  This  peculiar  conforma¬ 
tion  of  the  urethra  should  always  be  borne 
in  mind  in  introducing  the  catheter  or  bou¬ 
gie,  otherwise  the  slight  obstruction  offered 
to  the  entrance  of  the  instrument  by  the 
natural  contraction  in  the  canal,  may  be 
mistaken  for  an  abnormal  condition.  The 
first  contraction  of  the  canal  is  found  at  its 
entrance  in  the  glans,  and  this  contraction 
sometimes  produces  a  difficulty  in  the  very 
first  step  in  the  operation  for  lithotomy  and 
lithotrity,  as  the  meatus  may  in  consequence 
be  so  small  as  to  prevent  the  entrance  of  a 
sufficiently  large  instrument ;  this  is,  how¬ 
ever,  a  d^culty  that  can  easily  be  removed 
by  enlarging  the  meatus  with  a  probe-pointed 
bistoury,  when,  as  the  contraction  usually 
exists  merely  at  the  urethral  orifice,  the  in¬ 
strument  may  be  readily  introduced.  The 
second  contraction  is  situated  at  the  mem¬ 
branous  part  of  the  urethra,  and  at  this 
point  there  is  always  some  little  difficulty  in 
passing  a  catheter,  not  only  from  the  natu¬ 
ral  diminution  in  the  size  of  the  canal,  but 
also  on  account  of  the  curved  direction  which 
the  urethra  takes  in  its  passage  through 
the  deep  fascia  of  the  perineum  :  this  curve 
can,  however,  be  overcome,  by  slightly 
stretching  the  penis,  and  holding  it  at  an 
angle  of  about  4.r)°  while  the  catheter  is 
being  passed.  The  third  contraction  is 
within  the  prostate  gland,  just  behind  the 
vera  montanum  ;  this  offers,  however,  no 
impediment  to  the  passage  of  an  instrument. 
With  respect  to  the  dilatations  alternate  with 
the  contractions,  I  do  not  know  of  any 
important  points  for  your  study  and  consi¬ 
deration.  The  first  of  them  is  situated  just 
within  the  glans  penis,  and  is  termed  the 
fossa  navicularis  ;  the  second  in  the  corpus 
spongiosum,  and  the  third  within  the  pros¬ 
tate  gland  ;  in  the  latter,  the  vasa  deferen- 
lia  and  ducts  of  the  vesiculse  seminales  ter¬ 
minate.  Within  the  urethra  there  are  also 
small  valvular  openings  termed  lacunae ; 
they  are  placed  upon  the  upper  surface  of 
the  canal,  and  are  for  the  purpose  of  secreting 
a  fluid  for  its  lubrication.  The  largest  of 
these  openings  is  placed  about  an  inch  and 
a  half  below  the  meatus  ;  it  is  termed  the 
lacuna  magna,  and  is  the  principal  seat  of 
j  gonorrhoea.  The  surgeon  should  pay  parti¬ 
cular  attention  to  the  position  of  this  open¬ 
ing,  as  in  passing  small  bougies  they  often 
become  entangled  in  it,  so  as  to  induce  the 
belief  that  a  stricture  exists,  whereas  the  ob¬ 
struction  arises  only  from  the  natural  for- 


784  DR.  hughes’  cases  of  pneumonia  variously  treated. 


mation  of  the  part  resulting  from  the  free 
edge  of  the  valve  being  directed  forwards 
towards  the  opening  of  the  urethra. 


©rtgtnal  ©ommumcattonsL 


CASES  OF  PNEUMONIA,  VARIOUSLY 
TREATED; 

WITH  BRIEF  OBSERVATIONS. 

Read  at  the  South  London  Medical  Society, 
Oct.  12  th,  1848. 

By  H.  M.  Hughes,  M.D. 

Assistant  Physician  to  Guy’s  Hospital,  and  late 
President  of  the  Society. 

[Concluded  from  p.  747*] 


Case  X. —  Pneumonia — Pleuritic  effu¬ 
sion  doubtful — Almost  entire  absence 
of  characteristic  constitutional  symp¬ 
toms.  (From  the  Report  of  Mr. 
Tassell.) 

M.  N.,  aged  43,  admitted,  under  my 
care,  into  the  hospital,  June  4th,  1  S’4S. 
A  thin,  sallow-looking  woman,  of  light 
complexion.  She  had  last  year  been 
an  out-patient  at  St.  Thomas’s  Hos¬ 
pital  for  cough  and  pain  in  the  side; 
and,  though  she  got  much  better,  she 
never  quite  lost  her  cough.  Six  weeks 
ago  she  was  admitted  into  this  hospital 
for  tertian  ague,  and  in  three  weeks 
became  well  enough  to  undertake  the 
duties  of  a  night-nurse,  though  she  had 
not  even  now  got  completely  rid  of  her 
ague.  Three  days  ago,  after  exposure 
to  cold  while  in  a  heated  state,  she  was 
seized  with  rigors  and  vomiting,  fol¬ 
lowed  by  heat,  headache,  and  perspira¬ 
tion,  and  subsequently  suffered  from 
alternate  chills  and  heats,  with  copious 
perspiration  at  night,  violent  cough  in 
paroxysms,  and  pain  of  the  left  side, 
for  which  she  was  ordered,  by  Mr. 
Stocker,  Cataplasma  sinapis  lateri 
sinistro  ;  Pil.  Antim.  Opiat.  c.  Hydrarg. 
Chlorid.  gr.  iij.  statim  sumend  ;  Vin. 
Ipecacuanh.  n^xxx.  ;  Tr.  Hyosciam. 
TRxx.  ex  Julep.  Ammon.  Acetatis  6ta 
quaque  hor&. 

June  5th. — When  she  was  first  seen 
by  myself,  she  complained  of  cough, 
preventing  sleep,  and  of  pain,  in¬ 
creased  on  pressure,  in  the  lowest  part 
of  the  left  side  anteriorly,  though  no 


abnormal  physical  signs  existed  there. 
Posteriorly,  at  the  lowest  part  of  the 
left  subscapular  region,  there  existed 
absolute  dulness  on  percussion,  absence 
of  the  respiratory  murmur  and  of  re¬ 
sonance  of  the  voice;  while,  upon  a 
level  with  the  inferior  angle  of  the 
scapula,  near  to  the  spine,  were  easily 
recognised  tubular  breathing,  and  very 
marked  oegophonic  bronchophony  (over 
a  limited  space),  around  the  greater 
part  of  which  was  heard  distinct  mueo- 
crepitating  rattle.  The  rhyihm  and 
sounds  of  the  heart  were  normal,  but 
the  impulse  was  feeble.  The  skin  was 
hot,  but  perspiring;  the  tongue  furred, 
white,  and  moist ;  the  pulse  frequent 
and  feeble.  Ordered  —  C.  C.  part,  in¬ 
dicate  ad  ^ v j . ;  Pil.  Antim.  Opiat. 
fort.  c.  Hydrarg.  Chlorid.  gr.  ij. 
quaque  nocte;  Vin.  Antim.  Potassio- 
tart.  TTfxl.  ex  Julep.  Menthee  6ta 
quaque  flora. 

6th. — She  had  been  relieved  by  the 
cupping,  felt  better,  and  had  passed 
an  easier  night ;  the  bowels  had  not 
been  opened  for  two  days;  the  cough 
was  still  troublesome;  the  physical 
signs  were  the  same  as  before  ;  pulse 
80. — Capt.  Olei  Ricini,  5vj.  Pergat. 

7th.— No  remarkable  change;  she 
continued  to  perspire  freely  ;  still  com¬ 
plained  of  pain  in  the  left  side,  and  of 
cough;  tongue  furred ;  pulse  feeble. — 
Cap.  Pil.  Antim.  Opiat.  6tis  horis  ; 
Em  pi.  Cantharid.  lateri  sinistro  appli¬ 
cant!. 

10th. — Complained  now  of  pain  in. 
the  left  lumbar  region.  The  dulness 
on  percussion,  the  bronchophony,  and 
the  tubular  breathing,  were  less  dis¬ 
tinct,  and  healthy  respiration  w'as  gra¬ 
dually  becoming  distinctly  audible 
inferiorly ;  pulse  70.  The  pain,  sup¬ 
posed  to  depend  upon  flatulent  disten¬ 
sion  of  the  colon,  was  at  once  removed 
by  an  assafcetida  enema.  Ordered— 
Hydrarg.  Chlorid.  gr.  j. ;  Opii,  gr.  ss.  ft. 
Pil.  quaque  nocte  sumend;  Ltq.  Potas. 
npx.  ;  Inf.  Cal  urn  bee,  giss.  ter  die 
sumend. 

14th.— All  the  physical  signs  had 
diminished,  and  muco-crepitating  rat¬ 
tles  were  now  heard  in  the  very  spot 
in  which  tubular  breathing  and 
bronchophony  formerly  existed.  — 
Pergat. 

After  this,  all  the  symptoms  gra¬ 
dually  decreased,  the  dulness  disap¬ 
peared,  and  pure  respiratory  murmur 
was  distinctly  audible  throughout  the 


DR.  HUGHES’  CASES  OF  PNEUMONIA  VARIOUSLY  TREATED.  785 


entire  left  side  of  the  chest.  She 
afterwards,  however,  suffered  from 
dyspnoea,  which  was  easily  checked 
by  chalk  mixture;  and  subsequently 
had  a  return  of  her  ague,  which  was 
Stopped,  and  her  strength  w7as  im¬ 
proved  by  fifteen-drop  doses  of  the 
solution  of  the  amorphous  quinine. 
She  was,  how'ever,  quite  well,  and 
“  presented”  by  the  end  of  the 
month. 

This  case  was  probably  considerably 
modified  by  the  miasmatic  affection  of 
the  patient.  The  ague  w7as  suspended, 
though  the  skin  was  always  moist 
during  the  progress  of  the  inflamma¬ 
tory  complaint  of  the  chest,  and  re¬ 
appeared  upon  its  removal.  I  think  it 
at  least  probable  that,  without  the  aid 
of  physical  signs,  the  nature  of  the 
affection  of  the  lungs  would  not  have 
been  discovered.  It  wTas  only  by  mi 
nute  examination  that  the  cause  of  the 
symptoms  was  ascertained,  and  that 
the  treatment  above  recorded  was  with 
confidence  adopted. 

Case  XI. — Pleuro-pneumoiia  suddenly 

stop-ed  by  venesection ,  Sfc.  (From 

the  Report  of  Mr.  Tassell.) 

R.  B..  aged  17,  admitted  into  the 
hospital,  under  my  care,  June  14th, 
1848.  A.  girl  of  lull  habit,  florid  com¬ 
plexion,  and  light  blue  eyes  ;  had 
always  enjoyed  good  health,  and  had 
been  a  “  teetotaller”  for  six  years. 
Two  months  ago  she  got  cold  from 
damp  feet,  and  was  afterwards  troubled 
with  hoarseness,  which  continued  till 
five  days  ago,  when,  after  getting  hot, 
and  being  exposed  to  cold,  she  was 
attacked  with  shivering,  headache, 
and  pain  in  the  right  side,  for  wdiich 
she  had  taken  medicine  without  re¬ 
lief. 

On  admission,  her  face  w7as  full  and 
flushed ;  her  expression  heavy  and 
languid;  her  skin  hot;  her  tongue 
loaded,  moist,  and  white,  with  red  tip 
and  edges;  her  respiration  hurried; 
her  pulse  95,  and  soft  ;  she  had  a 
hacking  cough  upon  inspiration,  and 
complained  of  pain  in  the  right  side. 
Dulness  on  percussion  existed  both 
before  and  behind,  below  the  right 
scapula  and  mamma.  Anteriorly  was 
heard,  upon  auscultation,  pleuritic 
rubbing;  and  posteriorly,  crepitating 
and  muco-crepitating  rattles.  Ordered 
— Y.  S.  sed  prima  signa  deliquii ;  Pil. 
Antim.  Opiat.  c.  Hydrarg.  Chlorid. 


gr.  j.  6tis  horis  c.  Julep.  Ammon.  Ace- 
tatis. 

1 5th. — All  inflammatory  symptoms 
had  disappeared,  andshe  felt  and  looked 
quite  a  different  person.  The  dulness 
on  percussion  and  posterior  crepitation 
had  vanished,  though  the  anterior  pleu¬ 
ritic  rubbing  remained.  Pulse  70, 
soft ;  tongue  clean  :  breathing  easy ; 
pain  almost  gone. — Pergat. 

11  tli. — Pain  had  quite  ceased;  a 
pleuritic  creaking  (“  craquement  de 
cuir”)  in  the  situation  of  the  former 
rubbing,  alone  remained  of  the  physi¬ 
cal  signs,  and  a  slight  loose  cough  was 
the  single  constitutional  symptom  now 
existing.  Pulse  GO. — Emplast.  Lyttse 
lateri  dextro  ;  Rep.  Pi  1.  quaque  nocte. 

2 L st.  —Pleuritic  creaking  had  dis¬ 
appeared  ;  she  made  no  complaint,  and 
appeared  quite  well ;  “presented”  a 
few  days  after. 

This  appeared  to  myself  to  be  a 
genuine  though  not  very  severe  case  of 
pleuro  pneumonia,  in  a  strong,  healthy 
young  person,  cut  short  by  the  opera¬ 
tion  of  venesection. 

Case  XI I. — Pneumonia  —  absence  of 

general  symptoms  —  treatment  by 

opium  —mild  mercurials  — ammonia , 

and  poultices. 

In  the  afternoon  of  Sept.  2nd,  1848, 
I  was  requested  by  Mr.  Rendle  to  visit 
Mrs.  S.,  aged  32,  of  whose  history  I 
was  politely  furnished  with  the  followr- 
ing  particulars  by  that  gentleman  : — 
She  was  a  per-on  of  light  complexion, 
delicate  in  appearance,  and  of  nervous 
temperament,  and  had  been  occasionally 
liable  to  attacks  of  neuralgia,  hysteria, 
and  hypochondriasis,  and  previously 
also  to  slight  hemoptysis,  which  had 
induced  her  medical  attendant  to  be¬ 
lieve  her  phthisical.  In  consequence 
of  severe  affection  of  the  bowels,  she 
left  Hull  on  the  26th  of  August  by  sea, 
and  suffered  very  severely  from  sea 
sickness,  from  the  effects  of  which  she 
w'as  continuously  inconvenienced,  till 
seen  by  Mr.  Rendle  on  August  30th, 
when  she  had  pain  at  the  scrobiculus 
cordis,  increased  upon  pressure,  and 
occasional  vomiting,  &c.  & c.,  for  which 
appropriate  remedies  were  prescribed. 
On  Sept.  1st,  the  cough,  w7hich  was 
habitual,  had  increased,  the  pain  had 
extended  to  the  right  side,  and  w7as 
severe  and  lancinating:  for  this  four 
leeches  were  twice  applied,  and  calomel 
and  opium,  and  an  aperient  draught, 


786  DR.  hughes’  cases  of  pneumonia  variously  treated. 


administered.  During  the'  succeeding 
night  evidence  of  want  of  power  ap¬ 
peared ;  the  surface  was  clammy,  the 
cough  constant;  she  complained  of 
constriction  of  the  chest,  sinking  and 
distressing  restlessness,  for  which  Liq. 
Opii  and  Ammonia,  with  warmih  to  the 
surface,  w  ere  appropriately  and  advan¬ 
tageously  prescribed.  I  saw  heron  the 
following  day,  and  found  her  with  a 
sunken  countenance,  a  frequent  cough, 
with  mucous  expectoration  ;  a  moist 
and  not  very  loaded  tongue;  a  cool 
moist  skin,  and  pulse  varying  from  120 
to  126,  without  any  physical  evidence 
of  disease  anteriorly  in  the  former  seat 
of  pain,  but  with  obvious  signs,  poste¬ 
riorly,  of  consolid  tion — as  dnlness  on 
percussion,  tubular  breathing  mixed 
with  muco-crepitating  rattle,  and  bron¬ 
chophony  in  the  whole  of  the  right  side 
below’  the  scapula.  Ordeied — Cata- 
plasma,  Lini.  magn.  lateri  dextro ; 
Ext.  Papaver.  gr.  ij.  ;  Hydrarg.  c. 
Creta,  gr.  ij.  nocte  maneqne  ;  Potass. 
Nit  rat.  gr.  v. ;  Potass.  Bicarb  gr.  xij ; 
Vin.  Ipecac.  ITfxv. ;  Sp.  Ammon,  c. 
tt|xx.  ex.  Aq.  6tis  horis. 

Sept.  3d. — Mr.  Rendle’s  report  was, 
that  she  was  improving,  and  the  pulse 
decreasing  in  frequency.  He  applied 
a  blister,  and  continued  the  medi¬ 
cine. 

On  the  4th  I  saw  her  again,  when 
all  evidence  of  consolidation  had  ceased, 
and  a  little  mucous  rattle  alone  re 
mained  in  the  part  previously  affected, 
though  some  suspicious  indications  of 
latent  phthisis  were  observed.  The 
treatment  was  continued  till  the  10th. 
As  I  did  not  see  her  afterwards,  I  may 
add,  in  the  words  of  Mr.  Rendle, 
that  the  physical  signs  of  the  pul¬ 
monary  affection  diminished  daily,  and 
her  pulse  was  reduced  in  number  to 
80  or  85.  Erom  this  time  the  patient’s 
convalescence  was  complete.  Mr. 
Rendle  adds,  in  his  observations,  “  1 
believe  that  the  general  distress  in  this 
case  depended  in  some  degree  upon  a 
highly  nervous  temperament,  and  that 
the  leeches  and  antiphlogistic  treatment, 
tended  in  no  way  to  abate  the  disease. 
If  it  had  been  still  treated  actively  and 
antiphlogistically,  I  have  no  doubt  that 
this  patient  would  have  died  ;  and  I 
believe  that  opium  and  ammonia  were 
administered  with  the  happiest  effect.” 
To  these  observations  of  Mr.  Rendle, 
1  think  it  necessary  to  add  nothing,  as 
with  them  I  entirely  concur. 


Case  XIIT. — Pleuro-pneumonia  —  ab¬ 
sence  of  general  symptoms  —  treat¬ 
ment  by  mild  mercurials,  opium,  and 
poultices  and  blisters.  (From  the 
notes  of  Mr.  "Waterworth,  Jun.) 

M.  M.,  a  female  servant,  aged  42,  un¬ 
married,  was  admitted  under  my  care 
(for  Dr.  Addison)  September  6th,  1848. 
About  ten  days  since,  after  being 
troubled  with  cough  for  some  days  pre¬ 
viously,  she  was  seized  with  dyspnoea, 
shivering,  and  pain  in  the  left  side. 
Upon  admission  she  still  complained  of 
these  symptoms  ;  the  pulse  was  quick 
and  small  ;  the  tongue  white,  but 
moist,  and  the  respiration  hurried,  but 
the  skin  soft,  and  perspiring.  Upon 
examination  of  the  chest,  dulness  ex¬ 
isted  below  the  left  mamma,  together 
with  marked  crepitating  rattle,  and 
oegophonic  bronchophony.  Posteriorly 
the  percussion,  and  sounds  upon  aus¬ 
cultation,  were  normal. 

Ordered  — Hydrarg.  c.  Creta,  Pulv. 
Ipecac.  C.  aa.  gr.  ij.  nocte  maneqne  ; 
Mist.  Conii  c.  Vin.  Antim.  Tart.  ntxv. 
6ta  qnaque  hora;  Cataplasm.  Lini. 
lateri  sini-tro. 

13th. — Up  to  this  date  she  continued 
gradually  to  improve,  and  the  physical 
signs  to  diminish  under  the  same  treat- 
ment.  Upon  this  day  the  gums  were 
slightly  affected  by  the  mercury.  She 
still  complained  of  pain  in  the  side, 
and  was  ordered  Empl.  Lyttee  lateri 
si  nbt.ro.  Pergat. 

16th. — All  crepitation,  dulness,  and 
bronchophony  had  entirely  disap¬ 
peared,  but  she  still  complained  of 
cough. 

20 1  h . — The  gums  w’ere  sore,  and  she 
felt  much  better.  Ordered — Inf.  Gpn- 
tian.  c.  c.  Potassii  lodidi,  gr.  ij.;  Tr. 
Camph.  c.  5SS*  *er  die.  Omitt.  Pil. 
From  this  time  she  had  no  indication 
of  her  inflammatory  complaint,  though 
it  appeared  probable  that  she  would 
ultimately,  like  the  subject  of  the  for¬ 
mer  case,  fall  a  sacrifice  to  tubercular 
disease  of  the  lungs.  She  was  soon 
after  presented. 

Here,  as  in  the  former  case,  it  was 
believed  that  active  antiphlogistic 
treatment  would  have  been  decidedly 
injurious.  Here,  as  in  several  others 
of  the  cases  which  have  preceded,  the 
disease  was  of  an  asthenic  form,  was 
accompanied  by  few  of  the  ordinary 
constitutional  symptoms,  and  its  ex¬ 
istence  was  determined  almost  solely 

l 


DR.  HUGHES’  CASES  OF  PN’EtJMONIA  VARIOUSLY  TREATED.  787 


by  physical  signs.  To  have  bled,  or 
even  largely  to  have  leeched  or  cupped 
the  patients,  who  were  the  subjects  of 
the  8th,  10ih,  12th,  and  13th  cases, 
would  probably,  to  say  the  least,  have 
rendered  their  recovery  much  more 
tedious,  if,  indeed,  it  had  materially  in¬ 
terfered  with  its  completion  ;  whereas 
in  the  girl  the  subject  of  the  llth 
case,  and  in  another,  venesection  ap¬ 
peared  at  once  to  stop  the  progress 
of,  if  not  entirely  and  immediately 
to  cure  the  disease.  In  the  juxta¬ 
position  of  these  and  similar  facts  con¬ 
sists  one  main  object  of  the  present 
communication. 

Thirteen  cases  of  pneumonia  have 
been  here  presented  to  the  notice  of 
the  Society.  If  they  constitute  not  all 
the  cases  of  primary  pneumonia,  or 
pleuro- pneumonia,  which  have  been 
under  my  care  during  the  last  year,  1 
certainly  possess  notes  of  none  others. 
No  selection  has  been  made.  Of 
these  thirteen  cases,  one  died  during 
the  progress  of  the  disease  indeed, 
but  I  believe  not  of  the  disease  itself. 
For,  whatever  might  have  been  the 
ultimate  result  of  the  pneumonia  in 
this  lady,  which  must  of  course  remain 
doubtful,  I  think  it  must  be  obvious  to 
all  that,  the  immediate  cause  of  death 
was  the  exceedingly  acute  pleurisy  of 
the  left  side,  and  the  pericarditis  occur¬ 
ring  in  a  person  whose  respiratory 
functions  were  already  greatly  embar 
rassed  by  the  almost  entire  consolida¬ 
tion  of  the  right  lung.  1  am  not  about 
herein  to  insist  upon  the  importance  of 
the  physical  signs  of  disease.  I  have 
already  in  this  communication,  and  re¬ 
peatedly  on  former  occasions,  dwelt 
upon  the  indiscretion,  and  even  danger, 
of  trusting  entirely  to  such  indications 
of  disease,  without  taking  due  cogni¬ 
zance  of  the  previous  hi>tory  and 
general  symptoms.  I  do  not,  therefore, 
fe  a*  becoming  obnoxious  to  the  charge 
of  taking  too  great  an  account  of,  or 
of  giving  undue  importance  to,  auscul¬ 
tation  and  percussion,  in  submitting 
the  following  brief  summary  of  the 
thirteen  cases  succinctly  related  above, 
to  the  notice  of  the  Society  : — 

In  eleven  of  the  thirteen  patients, 
pain  was  felt,  and  two  had  none.  Of 
cough,  two  patients  had  none;  in  two, 
the  cough  was  very  trifling  indeed,  and 
in  seven  it  was  more  or  less  constant 
and  severe.  As  to  the  expectoration, 
seven  out  of  the  thirteen  patients  had 


none,  or  none  could  be  preserved,  or 
was  ever  seen  by  the  physician  or  his 
clerk  :  in  four  it  was  white  and  frothy, 
and  more  or  less  viscid,  and  in  two 
only  it  presented  the  characteristic  red, 
or  rusty  colour,  combined  with  viscidity. 
In  eight  cases  out  of  the  thirteen  the 
skin  was  hot  and  dry,  and  more  or  less 
pungent  to  the  hand  ;  in  one  it  was 
hot,  and  at  the  same  time  perspiring; 
and  in  four  it  was  cool  and  moist. 
Physical  signs  of  disease,  more  or  less 
characteristic  and  obvious,  were  pre¬ 
sent  in  all  the  cases. 

Having  in  the  opening  paragraph 
of  this  communication  already  directed 
the  attention  of  the  Society  to  the 
variety  of  treatment  adopted,  with  the 
view  of  insisting  upon  the  importance 
of  investigating  each  individual  case 
of  disease,  and  more  particularly  of 
acute  disease,  by  itself,  and  upon  the 
injudiciousness,  to  say  the  least,  of 
being  directed  in  our  method  of  treat¬ 
ment  by  mere  figures,  or,  in  other 
words,  of  combatting  by  our  remedies 
a  mere  name,  without  being  influenced 
therein  by  peculiar  attendant  circum¬ 
stances  ;  it  is  not  necessary  that  I 
should  say  more  in  conclusion,  than 
that,  proper  and  desirable  as  venesec¬ 
tion  may  be  in  some  cases  of  pneu¬ 
monia,  I  feel  assured,  that  had  some  of 
these  patients  been  bled,  they  would 
almost  infallibly  have  died,  or,  at  any 
rate,  would  have  been  the  subject  of  a 
most  lingering  and  tedious  convales¬ 
cence  ;  and  that,  on  the  other  hand, 
had  some  of  these  patients  not  been 
bled,  their  recovery  would  have  been 
in  the  highest  degree  doubtful.  Per¬ 
haps  even  cupping,  and  calomel  and 
opium,  are,  as  antimony  most  assuredly 
is,  to  a  certain  degree,  at  least,  obnox¬ 
ious  to  the  same  observations  as  reme¬ 
dies  in  this  complaint :  yet  all  these 
cases  were,  1  firmly  believe,  cases  of 
pneumonia.  If  such  be  truths,  how', 
in  actual  practice,  can  be  available  the 
“  methode  numerique,”  at  least  in  re¬ 
ference  to  the  treatment  of  disease? 
What  becomes  of  the  so-called  philo¬ 
sophical  school  of  medicine  ?  How 
is  it  possible  to  act  upon  the  theoretical 
dogmas  of  “young  physic”  with  justice 
to  the  patients  committed  to  our 
charge  ? 


1 


788  CASES  OF  PURPURA - ANALYSES  OF  THE  VENOUS  BLOOD. 


TWO  CASES  OF 

PURPURA,  WITH  ANALYSES  OF 
THE  VENOUS  BLOOD. 

By  E.  A.  Parkes,  M.D. 

Assistant  Physician,  University  College  Hospital. 


So  few  analyses  of  the  blood  in  pur¬ 
pura  have  been  published,  and  so  many 
will  be  required  before  the  constant 
and  essential  changes  in  this  fluid  can 
be  determined,  that  the  two  following 
observations,  incomplete  as  they  are  in 
many  respects,  may  be  acceptable  to 
those  who  are  interested  in  ihat  im¬ 
portant  class  of  diseases,  which  seem 
to  have  their  commencement  in  altera¬ 
tion  of  the  blood.  I  selected  these  two 
cases  for  analysis,  because  they  were 
well  marked  and  undoubted  instances 
of  the  disease  ;  they  appeared  to  be 
without  complic  tion,  and  as  they  oc¬ 
curred  in  young  persons  of  different 
sexes,  who  had  previously  enjoyed 
good  health,  I  believed  I  should  obtain 
the  blood  as  near  the  standard  of  health 
as  possible,  except  in  so  far  as  it  was 
altered  by  the  disease  itself. 

Case  I.  William  Marsh,  set.  23,  an 
out-patient.  University  College  Hos¬ 
pital,  July  25th,  1848. — A  stout,  robust, 
healthy-looking  young  man,  with  a 
fresh,  ruddy  complexion.  He  gave  the 
following  account  of  himself.  He  had 
always  had  excellent  health,  and  was 
of  temperate  habits.  His  trade  was 
that,  of  selling  fruit  in  the  street,  and 
he  had  been  consequently  somewhat 
exposed  to  weather,  but  he  had  never 
suffered  from  this,  except  in  having  an 
occasional  sore  throat.  Up  to  the  six 
months  previous  to  his  coming  to  the 
hospital,  he  had  lived  well ;  since  that 
time  his  trade  had  been  slack,  and  he 
had  lived  rather  indifferently.  During 
these  six  months  he  had  had  meat  about 
once  a  fortnight,  about  Ibj  of  bread 
every  day  ;  2  or  3  potatoes  3  or  4  times 
a  week  ;  beer  0>s.  to  Oj.  daily.  He 
had  also  had  currant  puddings,  and 
puddings  of  flour  and  water,  nearly 
every  day.  He  had  been  accustomed 
to  eat  the  fruit  off  his  stall,  and  wh’le 
in  season,  had  eaten  gooseberries, 
cherries,  currants,  and  apples.  He  had 
taken  no  oranges,  or  milk,  butter,  or 
eggs.  He  had  never  been  in  want  of 
the  kind  of  food  staled  above,  and  had 
not  known  what  it  was  to  feel  decidedly 


in  want.  Till  the  night  before  he 
came  to  the  hospital,  he  felt  as  well  as 
usual ;  he  then  experienced  slight 
shivering;  he  had  no  pain  in  the  back 
or  aching  of  the  limbs;  during  the 
night  an  eruption  appeared  on  the  legs. 
When  he  came  to  the  hospital  he  said 
he  was  frightened  about  the  eruption, 
but  otherwise  he  felt  perfectly  well; 
there  was  no  shivering,  muscular  weak¬ 
ness  or  weariness,  or  aching  of  the 
limbs.  Over  the  whole  of  both  legs 
were  hmmorrhagic  spots,  and  large 
patches  of  a  deep  port  wine  colour; 
tiie  smallest  spot  was  a  mere  point ;  the 
largest  about  the  size  of  a  sixpence. 
They  were  very  slightly,  if  at  all,  ele¬ 
vated  above  the  level  of  the  skin,  and 
were  unaltered  by  pressure  ;  the  large 
spots  were  in  some  parts  of  their  peri¬ 
pheries  abruptly  defined;  in  others, 
little  prolongations, which  were  plainly 
formed  by  dilated  and  rather  tortuous 
vessels,  were  sent  off  into  the  surround¬ 
ing  pale  skin.  The  spots  were  not 
connected  with  the  hairs;  they  were 
most  marked  on  the  anterior  surface  of 
the  leg,  and  commenced  immediately 
below  the  knee;  they  were  less  nu¬ 
merous  on  the  calf;  there  was  no  pain 
or  hardness  in  the  hams  ;  there  was  a 
little  stiffness  in  the  left  knee,  which 
he  seemed  not  to  have  noticed  till 
asked  about  it ;  there  uTere  no  bruises 
or  ecchymoses.  The  gums  were  pale 
and  perfectly  healthy;  the  pulse  was 
natural.  Skin  of  trunk  and  arms 
normal. 

He  was  directed  to  remain  quiet  in 
the  horizontal  position,  to  take  meat 
daily,  and  he  was  ordered  10  grains  of 
Potash  three  timesa day.  He  was  direct¬ 
ed  to  return  on  the  27th  July,  when  it 
was  thought  the  disease  would  be  still 
more  developed. 

On  the  27th  of  July  he  came  down 
again  ;  the  old  spots  were  paler,  but 
some  fresh  ones  had  appeared:  these 
were,  however,  smaller  than  the  origi¬ 
nal  ones.  He  had  taken  the  previous 
day  4  pound  of  beef  for  dinner,  with 
bread,  but  no  vegetables;  for  supper  he 
had  bread  and  cheese,  and  for  break¬ 
fast  bread  and  tea,  without  milk. 

He  was  now  carefully  examined  with 
a  view  to  the  detection  of  any  iocal 
lesion  or  complication  ;  the  chest  was 
well  formed, expanded  well,  andsounded 
every  where  well  on  percussion  ;  the 
breath  sound  was  normal  ;  there  was 
no  cough  or  expectoration  ;  the  heart 


CASES  OF  PURPURA - ANALYSES  OF  THE  VENOUS  BLOOD.  789 


was  of  its  natural  size,  in  its  normal  re¬ 
gion,  and  the  sounds  were  natural  in 
rhythm  and  tone;  the  abdomen  was 
supple  and  not  tender;  the  liver  was 
in  its  natural  limits.  There  was  no 
pain  across  the  loins,  nor  tenderne>s 
on  grasping  the  kidneys  ;  the  urine  was 
ron-sedimentous,  acid,  without  albu¬ 
men,  and  of  specific  gravity  1032.  The 
gums  were  perfectly  healthy  ;  the  lips 
red  ;  there  was  no  venous  or  arterial 
murmur;  the  muscles  were  firm,  and 
largely  developed.  The  only  altera¬ 
tion  which  could  be  made  out  was 
slight  chronic  enlargement  of  both 
tonsils,  which  were,  however,  nearly 
pale;  he  had  never  had  any  hemorr¬ 
hages.  He  had  taken  no  medicine  ex¬ 
cept  one  drachm  of  Nitrate  of  Potash. 
When  asked  to  assign  a  cause  for  the 
present  attack,  he  was  unable  to  do  so. 

Blood  was  now  taken  from  the  arm, 
and  was  received  into  three  bottles ;  the 
blood  came  out  in  a  full  stream,  and  did 
not  trickle  down  the  arm  ;  it  was  of  its 
natural  colour.  The  blood  in  the  first 
bottle  was  beaten,  the  others  were  al¬ 
lowed  to  coagulate.  Coagulation  com¬ 
menced  in  the  usual  time.  Three  hours 
subsequently  the  clots  had  shrunk  and 
expelled  some  natural-looking  clear  or 
slightly  opalescent  serum.  24  hours 
afterwards  the  separation  was  complete, 
the  clots  were  rather  voluminous, 
not  buffed  or  cupped.  The  serum  was 
alkaline,  slightly  yellow  in  colour. 

Specific  gravity  of  the  defibri- 

nated  blood .  1055*5 

Specific  gravity  of  the  serum  .  1023-5 
Temperature  65°  Fah. 

Solidsof  the  blood  in  1000  parts 
estimated  from  the  2nd  bot¬ 
tle  .  200-97 

Water . .  79903 

Thefibrinewasestimatedin  two  ways, 
from  the  beaten  blood,  and  by  wash¬ 
ing  the  clot  of  the  third  hot  tie;  this 
was  done  both  to  check  the  experiment 
and  to  ascertain  if  the  fibrine  varied  at 
different  periods  of  the  bleeding.  The 
fibrine,  after  boiling  in  alcohol  and 
ether,  was  found  from  the  first  method 
to  be  in  the  proportion  of  2*066 ;  and 
from  the  second  method,  to  be  in  the 
proportion  of  2*11  in  1000  of  blood, — a 
sufficiently  exact  approximation.  The 
average  of  the  two  was  2’088. 

The  solids  of  the  serum  were  esti¬ 
mated  by  evaporating  the  serum  of  the 
third  bottle.  The  total  amount  of 


solids  was  90-15  in  the  1000  of  serum. 
The  salts  were  obtained  by  incinerating 
the  dried  serum  with  nitric  acid  ;  their 
proportion  was  7*691  in  the  1000  of 
serum.  In  order  to  test  this  result,  a 
weighed  portion  of  serum  was  coagu¬ 
lated  rapidiy,  and  was  then  repeatedly 
washed  with  boiling  distilled  water; 
the  solution  was  evaporated  ;  the  or¬ 
ganic  matter  burnt  off,  and  the  inor¬ 
ganic  contents  obtained  in  the  propor¬ 
tion  of  7  104  per  1000  of  serum,  a  result 
which,  with  an  allowance  for  the  salts 
which  either  enter  intimately  into  the 
composition  of  the  albumen,  or  adhere 
to  it  so  strongly  as  not  to  be  detached 
by  washing,  may  be  considered  suffi¬ 
ciently  near  to  the  proportion  obtained 
by  incinerating  the  dried  serum.  My 
friend  Dr.  Garrod,  who  was  kindenough 
to  examine  the  serum,  determined  the 
salts  to  be  7’699.  By  the  experiment 
of  washing  the  coagulated  serum,  I  also 
obtained  the  proportion  of  incoagulable 
soluble  organic  matters  as  604  in  1000 
parts.  In  the  1000  parts  of  serum, 
there  were  therefore  76'4l  parts  of 
coagulable  organic  matters,  6*04  parts 
of  incoagulable  organic  matters,  and 
7*69 1  of  inorganic  substances.  In  1000 
of  blood,  these  three  series  of  numbers 
are  as  follows: — 67'103,  5-304,  and 
6864. 

The  coagulating  point  of  the  serum 
was  between  164  and  166°  Fah. 

By  deducting  the  weights  of  the 
fibrine  and  the  solids  of  the  serum  in 
1000  parts  of  blood,  from  the  weightof 
the  solids  of  the  blood,  the  red  parti¬ 
cles  are  given  in  the  proportion  of 
119-611  in  the  1000  parts. 

The  examination  into  the  organic 
constituents  was  not  conducted  farther. 
The  several  fats  were  left  undeter¬ 
mined. 

The  principal  inorganic  constituents 
only,  were  determined. 

In  consequence  of  Dr.  Garrod’s  in¬ 
genious  hypothesis,  that  scurvy,  a 
disease  perhaps  allied  to,  though  dis¬ 
tinctly  different  from  purpura,  depends 
upon  deficiency  in  the  potash  salts,  I 
was  anxious  accurately  to  estimate  the 
amount  of  potash  in  the  serum.  This 
was  done  in  two  experiments.  In  the 
first,  the  salts  of  the  serum  were  dis¬ 
solved  in  distilled  water;  a  few  drops  of 
hydrochloric  acid,  and  an  excess  of 
chloride  of  platinum  were  added;  the 
solution  was  evaporated  to  dryness,  and 
the  excess  of  the  chloride  of  platinum, 


790  CASFS  OF  PURPURA — ANALYSES  OF  THE  VENOUS  BLOOD. 


and  the  other  salts,  washed  out  with  re¬ 
peated  relays  of  alcohol.  The  remain¬ 
ing  double  salt  weighed  at  the  rate  of 
2*84  per  1000  parts:  this  gives  ‘5637  of 
potash  (KO).  In  the  second  experi¬ 
ment  the  washings  of  the  coagulated 
serum,  freed  from  organic  matters, 
were  treated  in  the  same  way  ;  2*08  of 
the  double  salt  was  procured,  which 
gives  .388  on  the  proportion,  in  1000 
parts;  this  is  ’1728  less  than  that  ob¬ 
tained  by  the  former  experiment,  but 
still  within  the  limits  of  health.  The 
averageof  the  two  experiments  is  .4758 

The  other  inorganic  constituents 
were  estimated  from  the  dried  blood. 
A  portion  of  dried  blood  was  incine¬ 
rated,  and  well  washed  with  boiling 
distilled  water:  the  difference  of  its 
weight  after  incineration,  and  after 
washing,  was  considered  as  the  weight 
of  the  soluble  salts.  The  soluble  salts 
in  the  blood  in  three  experiments 
seemed  to  have  the  proportion  of  8*8 
parts  in  the  1000,  thus  exceeding  the 
entire  of  the  salts  of  the  serum  in  1000 
of  blood  by  1936.  The  chlorides  were 
estimated  by  precipitating  the  chloride 
of  silver.  The  quantity  of  chlorine 
obtained  was  nearly  the  same  in  three 
analyses  :  the  chlorides  of  sodium  and 
potassium  together  were  determined  at 
3*731  per  1000  of  blood;  and  calculat¬ 
ing  the  proportion  of  potassium  in  1000 
of  blood  as  about  *426,  the  latter  salt 
maybe  supposed  to  be  about  *811  of 
this  quantity.  The  phosphoric  acid 
was  precipitated  as  phosphate  of 
alumina  in  the  manner  recommended 
by  Frick  :  the  quantity  of  phosphate 
of  soda  (estimating  it  as  3  atoms  of 
fixed  base,  since  the  atom  of  water  is 
driven  off  by  incineration)  was  *625  in 
1000  of  blood.  The  sulphuric  acid  was 
estimated  in  a  single  analysis,  and  the 
proportion  of  sulphate  of  soda  in  1000 
of  blood  appeared  to  be  *363.  It  thus 
appears  that  there  were  other  soluble 
salts  remaining  undetermined,  or 
possibly  that  the  above  figures  did  not 
express  the  true  amount  of  the  chlo¬ 
rides,  phosphates,  and  sulphates.  This 
point,  however,  was  not  inquired  into. 

Of  the  insoluble  salts,  the  iron  and 
lime  were  alone  determined. 

After  washing  out  all  the  insoluble 
salts  from  the  incinerated  blood,  the 
remainder  of  the  carbon  was  carefully 
burnt  off  with  nitric  acid  :  the  residue 
consisted  of  all  the  insoluble  salts,  the 
iron,  lime,  copper,  &c.  The  iron  was 


estimated  in  two  ways;  by  dissolving 
out  the  lime  with  boiling  acetic  acid, 
and  considering  the  insoluble  portion, 
as  consisting  of  phosphate  and  peroxide 
of  iron,  and  also  by  dissolving  the 
whole  residue  in  hydrochloric  acid,  and 
after  separation  of  the  lime  pre¬ 
cipitating  the  iron  as  peroxide,  which 
was  then  collected,  washed,  heated  to 
redness,  and  weighed.  The  two  pro¬ 
cesses  gave  closely  approximative  re¬ 
sults.  Thus  by  the  first  method  in. 
three  trials  the  iron  was  found  to  be  in 
the  proportion  of  l  38,  14,  and  1*205 
per  1000  of  blood.  By  the  second 
method  in  one  trial,  the  proportion  was 
1*2  per  1000.  The  average  of  the 
whole  was  1*296. 

The  lime  was  estimated  by  precipita¬ 
tion  as  oxalate  and  as  sulphate  :  the 
average  of  two  experiments  which 
nearly  agreed,  was  *077  in  the  1000 
parts. 

The'* general  summary  of  these  re¬ 
sults  may  be  thus  given  : — 

Fibrine . 2*088 

Coagnlable  organic  matters 

of  serum,  albumen,  &c.  .  67*103 
Incoagulable  organic  matters 
of  serum,  extractive,  &c.  .  5*304 

Salts  of  the  serum  ....  6*864 

Red  particles . 119  611 

Water .  799.03 


1000*000 


Chloride  of  sodium  ....  2*938 
Chloride  of  potassium  .  .  .  *811 

Phosphate  of  soda  ....  *625 

Sulphate  of  soda  ....  *363 

Peroxide  of  iron  ....  1*296 

Lime . ‘077 


In  reviewing  this  analysis,  the  most 
important  points  appear  to  be  — 1st, 
that  there  is  a  general  lowering  of  the 
proportion  of  the  solid  parts  in  the 
blood  ;  2nd,  that  the  relative  propor¬ 
tion  of  the  organic  materials  to  each 
other  seems  nevertheless  to  have  been 
preserved  ;  3rd,  that  the  most  striking 
alteration  in  the  inorganic  compounds 
consists  in  a  marked  increase  in  the 
quantity  of  iron. 

The  solid  contents  in  the  blood  of 
this  robust,  and,  with  the  exception, 
of  purpura,  healthy  young  man,  should 
have  been  at  the  rate  of  at  least  208  in 
the  1000  of  blood:  the  fibrine  would 
then  have  been  at  the  rate  of  2*1 71, 
which,  although  below  Andral’s  stan- 


CASES  OF  PURPURA - ANALYSES  OF  THE  VENOUS  BT.OOD.  791 


dard,(3)  is  nearly  equal  to  Becquerel’s, 
(2-^)  and  is  above  Simon’s  healthy 
average,  when  the  solids  are  203  per 
1000;  the  red  particles  would  have 
been  124*395 —  a  porportion  which, 
although  below  Andral’s  average, 
(127)  and  much  below  Becquerel’s, 
(141)  is  yet  considerably  above  Nasse’s 
healthy  standard,  ( 1 1 6*529)  and  is  in 
fact  obviously  very  close  on  the  normal 
amount.  The  organic  principles  oft  he 
serum  would  have  been  75' 303,  which 
may  be  considered  as  the  proper 
amount. 

The  salts  of  the  serum  are,  if  any 
thing,  a  little  above  the  mean  ;  and  it 
is  an  interesting  point,  that  the  soluble 
salts  of  the  blood  are  greater  in  amount 
than  both  the  soluble  and  insoluble 
salts  of  the  serum  in  1000  parts  of 
blood,  and  are  even  a  little  over  the 
amount  of  the  salts  of  the  serum  in 
1000  parts  of  serum — viz.  as  8'8  is 
to  7*69 1 .  The  difference  is,  I  presume, 
to  be  attributed  to  a  difference  in  the 
composition  of  the  salts  of  the  red  par¬ 
ticles,  or  of  the  fluid  contained  in  them  ; 
but  the  exact  nature  of  this  alteration 
I  did  not  determine.  The  proportion 
of  lime  is  below  Nasse’s  average,  (483) 
but  still,  perhaps,  within  the  limits  of 
health.  The  increase  in  the  iron  is 
very  conspicuous  :  the  average  quantity 
of  peroxide  may  be  taken  as  ’800  in  the 
1000  of  blood.  Becquerel  gives  it  as 
*56(1.  Frick,*  in  a  very  able  paper 
on  the  blood  in  several  diseases,  makes 
the  amount  '582.  In  any  case  the 
proportion  of  T2  in  the  1000  parts 
is  excessive.  If  we  disregard  the 
small  portion  of  iron  uncombined  with 
the  red  particles,  and  consider  the  iron 
to  bear  a  constant  relation  to  t  he  amount 
of  particles,  as,  indeed,  it  seems  nearly 
to  do,  and  suppose,  with  Frick,  127  par¬ 
ticles  to  correspond  to  *58  of  iron  in  the 
present  instance,  as  there  were  only 
119*6  of  corpuscles,  the  iron  should 
properly  have  been  reduced  to  *541, 
whereas  in  the  lowest  of  the  analyses  it 
is  l  2.  The  quantity  of  potash  appeared 
to  be  nearly  normal  ;  but  as  the  pa¬ 
tient  had  taken  5j*  of  nitre  in  the  two 
days  previous  to  being  bled,  the  expe¬ 
riment  was  not  conclusive.  The  point 
With  which  I  was  least  satisfied  in  the 
analysis  was  the  determination  of  the 
phosphates  :  the  phosphate  of  alumina, 
although  an  insoluble  salt, has  in  other 

*  American  Journal  of  Medical  Sciences  for 

January,  1848. 


analyses  given  me  a  lower  amount 
of  phosphoric  acid  than  that  obtained 
by  other  methods  ;  unfortunately  I  had 
not  time  to  repeat  the  experiment. 

The  inferences  from  this  analysis 
will  be  presently  alluded  to. 

On  the  same  day  that  this  man  was 
bled,  he  brought  down  the  whole  quan¬ 
tity  of  urine  he  had  passed  from  the 
rime  of  his  going  to  bed  at  10  p.m.  July 
26th,  to  9  a.m.  July  27th.  This  urine 
measured  1 7i  oz.,  and  had  a  specific 
gravity  of  1032.  It  was  clear,  and  had 
an  acid  action.  The  solid  contents  in 
1000  grains  were  by  calculation  52  8, 
and  bv  actual  evaporation  and  weigh¬ 
ing.  536.  This  made  the  whole  solid 
contents  of  the  171  oz.  to  amount  to 
450  24  grain*,  all  of  w  hich  had  been 
passed  in  eleven  hours.  There  was 
abundance  both  of  urea  and  of  uric 
acid  in  it  ;  but  there  was  no  time  to 
make  a  quantitative  analysis.  The 
man  stated  that  he  had  passed  an 
equal  amount  of  urine  from  9  a.m.  July 
26th — viz.  in  the  other  1 3  hours  of  the 
24;  and  supposing  that  the  density  of 
this  was  the  same  as  the  night  urine, 
w7hich  is  perhaps  unlikely,  he  would 
have  excreted  in  24  hours  more  than 
900  grains  of  solid  matters.  After 
standing  for  24  hours  there  was  no 
sediment. 

The  patient  was  directed  to  continue 
the  nitrate  of  potash.  On  the  29th 
July,  he  came  down  again  :  the  finger 
was  now  pricked,  and  the  blood  cor¬ 
puscles  examined  under  the  micro¬ 
scope;  they  were  in  every  respect 
natural;  the  purpuric  patches  were 
much  paler,  and  only  a  fewT  small  fresh 
spots  had  appeared  ;  he  said  he  felt 
perfectly  well.  He  brought  the  urine 
he  had  passed  from  9  o’clock  on  the 
previous  evening  to  10  a.m.  It  mea¬ 
sured  21  oz.,  and  had  a  specific  gravity 
of  1030,  which  gave  by  calculation 
495  of  solids  in  1000  parts.  The  large 
excretion  of  solids  was,  therefore,  still 
continuing.  It  was  clear,  acid,  with¬ 
out  sediment  or  albumen. 

On  the  1st  of  August  the  old 
patches  had  nearly  disappeared,  only 
two  or  three  fresh  purpuric  spots  had 
appeared:  the  patient  said  he  con¬ 
sidered  himself  well,  and  returned  to 
his  work.  He  has  not  since  been  seen 
at  the  hospital,  so  that  there  has  been 
no  relapse. 

[To  be  continued.] 


792  .ABSORPTION  OF  OPTTJM  INTO  THE  BLOOD  THROUGH  THE  SKIN 


ON  THE 

NARCOTIC  POISONS, 

PARTICULARLY  OPIUM,  AND  THEIR 
ANTIDOTES. 

By  Francis  Sibson. 
[Continued  from  p.  582.] 


1.  Alston's  and  Monro's  experiments 
proving  that  opium  can  be  absorbed  into 
the  circulation  through  the  skin  of  l he 
frog ,  and  that  they  can  onli /  act  on  the 
whole  organism-  through  the  medium  of 
the  circulation.  2.  Whytt' s  experiment, 
apparently  opposed  to  the  universality  of 
the  last  inference.  3.  Absorption  into 
the  circulation  from  the  stomach  and 
intestines.  4.  On  the  treatment  oj  nar¬ 
cotic  poisoning  by  the  elimination  of  the 
poison  from  the  blood.  5.  Action  of 
opium  on  the  capillaries,  arteries,  and 
veins.  6.  Perspiration  in  poisoning  by 
opium.  7.  Obstruction  to  the  circula¬ 
tion  in  the  capillaries  caused  by  other 
narcotic  poisons.  8.  Asphyxia,  pro¬ 
ducing  obstruction  to  the  circulation  in 
the  systemic  capillaries.  9.  Inflamma¬ 
tion,  producing  the  same  ejfect. 

1.  I  particularly  solicit  a  re-perusal 
of  the  very  interesting  experiments  by 
Dr.  Alston,  and  the  experiment  by 
myself,  in  which  I  combined  both  of 
those  bv  Dr.  Alston,  in  the  paper  of 
which  this  is  a  continuation  (Medical 
Gazette,  p.  581). 

Before  studying  the  effect  of  opium 
on  the  circulation,  I  shall  inquire  into 
the  proofs  that  that  poison,  and  in¬ 
deed  other  ]  oisons,  are  received  into 
the  circulation,  wherever  they  are  ap¬ 
plied,  before  they  can  act  on  the  sys¬ 
tem. 

In  Dr.  Alston’s  first  experiment,  he 
put  a  frog  into  a  pot  containing  an 
aqueous  solution  of  opium,  and  the 
resu't  was,  that  next  morning  the  frog 
was  dead. 

This  experiment  tended  to  prove  that 
the  opium  might  penetrate  and  poison 
the  system  through  the  skin.  Dr. 
Monro  remarks,  that  in  this  way  of 
making  the  experiment,  the  water  with 
the  opium  might  enter  the  mouth.  To 
obviate  this  objection,  and  to  prove 
that  the  animal  is  affected  in  the  same 
way,  whether  the  opium  is  applied  in¬ 
wardly  or  outwardly,  Dr.  Monro  per¬ 
formed  the  following  experiment  : — 

“  About  a  hundred  drops  of  a  watery 


solution  of  opium  were  applied  on 
scraped  linen  to  the  skin  of  the  belly 
and  hind  legs  of  a  frog.  After  two 
hours  the  animal  began  to  be  con¬ 
vulsed  and  extended,  and  the  blood  had 
entirely  ceased  from  motion  in  the 
hind  legs.  After  three  hours  it  was 
more  violently  convulsed,  and  unable 
to  move  its  body  out  of  the  place 
where  it  lay.  After  five  hours  it 
shewed  no  outward  sign  of  life;  and 
though  the  solution  was  removed,  and 
the  legs  washed,  the  animal  did  not 
recover.”  (Physical  Essays,  iii.  305.) 

I  tried  the  plan  adopted  by  Dr. 
Monro,  but  did  not  observe  the  results 
described  by  him  until  I  plunged  one 
leg  into  a  test  tube  containing  a  solu¬ 
tion  of  opium,  as  I  detailed  in  the 
previous  paper.  Dr.  Monro’s  and  Dr. 
Alston’s  experiments,  of  which  my 
own  is  merely  a  modification,  prove 
that  animals  “may  be  affected  by  the 
absorption  of  opium,  and  its  mixture 
with  their  circulation.” 

That  he  might  ascertain  whether 
opium  could  act  on  the  whole  system 
through  the  medium  of  the  nerves 
alone,  Dr.  Monro  performed  the  fol¬ 
lowing  experiment : — 

“  I  cut  all  the  organs  at  the  pelvis, 
except  the  large  nerves  that  go  to  the 
hind  extremities.  Then  l  tacked  the 
hind  legs  by  threads  to  the  trunk  of 
the  body,  to  prevent  the  nerves  from 
being  over-stretched  or  torn  ;  after 
which  I  injected  thirty  drops  of  the 
solution  of  opium  under  the  skin  of 
both  hind  extremities. 

“Ten  minutes  thereafter,  the  hind 
legs  were  less  sensible,  and  much 
weakened,  and,  in  a  quarter  of  an  hour 
more,  they  were  quite  insensible  and 
motionless;  yet  the  fore  part  of  the 
body  was  not  observably  affected  six 
hours  thereafter,  and  the  animal  lived 
until  the  next  day.” 

This  experiment  proves  that  opium 
applied  to  the  hinder  limbs  will  not 
act  on  the  anterior  part  of  the  body, 
when  the  current  of  the  circulation  is 
cut  off,  although  the  nervous  connec¬ 
tion  be  preserved. 

The  following  experiment  by  Monro 
is  the  reverse  of  the  last  one  :  in  that 
he  divided  the  vessels,  leaving  the 
nerves  intact;  in  this  he  destroyed 
the  spinal  marrow,  leaving  the  vessels 
intact : — 

“  I  cut  the  spinal  marrow  across  at 
its  middle,  and  then  destroyed,  with  a 


ABSORPTION  OF  OPIUM  INTO  THE  BLOOD  THROUGH  THE  SKIN.  793 


red  not  wire,  the  hind  half  of  it;  and, 
twenty  hours  after  this,  applied  about 
a  hundred  drops  of  the  solution,  on 
scraped  linen,  to  both  hind  legs.  After 
three  hours,  the  animal  cried  when  the 
fore  part  of  it  was  touched.  After  four 
hours  it  began  to  be  convulsed,  and 
the  blood  had  ceased  from  motion  in 
the  hind  feet.  After  eight  hours  it 
showed  no  outward  sign  of  life. 

“This  experiment  demonstrates  that 
opium  can  affect  animals  universally 
after  all  communication  of  the  nerves  to 
which  the  opium  is  primarily  applied, 
with  the  rest  of  the  nervous  system,  is 
cut  off,  by  destroying  the  origin  of 
those  nerves,  or  cutting  them  through 
in  their  progress.  Whence  it  follows 
that  the  opium  must  have  produced 
these  deleterious  effects  by  being  ab¬ 
sorbed  and  conveyed  with  the  blood 
to  organs  of  the  body  distant  from 
those  to  which  it  was  primarily  ap¬ 
plied.”  (Loc.  cit.  337.) 

I  make  no  apology  for  introducing 
these  experiments  and  remarks ;  so 
clear  are  they,  compact  and  conclusive, 
that  they  spare  any  extended  reference 
to  the  many  valuable  and  more  recent 
experiments  which  go,  with  them  to 
establish  these  laws — that  narcotics 
may  be  absorbed  into  the  circulation 
from  the  external  surface,  and  that 
they  can  only  act  on  the  whole  or¬ 
ganism  through  the  medium  of  the  cir¬ 
culation. 

2.  Dr.  Whytt  details  an  experiment 
—it  was  confirmed  by  Dr.  Monro, — 
which  apparently  upsets  the  univer¬ 
sality  of  this  law,  that  poisons  can 
only  act  on  the  whole  organism  through 
the  medium  of  the  circulation. 

“A  frog  continued  to  move  its 
limbs  and  leap  about  for  above  an 
hour  after  I  had  cut  out  its  heart,  and 
Was  not  quite  dead  after  two  hours  and 
a  half. 

Five  minutes  after  taking  out  the 
heart  of  another  frog,  I  injected  a  solu¬ 
tion  of  opium  into  its  stomach  and  guts. 
In  less  than  half  an  hour  it  seemed  to 
be  quite  dead,  for  neither  pricking 
nor  teasing  its  muscles  produced  any 
Contraction  in  them,  or  any  motion  in 
the  members  to  which  they  belonged !” 
— Physical  Essays,  11  282. 

Fontana  repeated  and  contrasted  this 
experiment  in  the  following  manner  : — 
“  I  made  twelve  frogs  swallow  each 
about  twenty  drops  of  the  aqueous, 
solution  of  opium,  and  instantly .  se¬ 


parated  the  heart  from  the  thorax.  I 
opened  the  thorax  in  twelve  others, 
but  did  not  remove  the  heart :  all  of 
these,  as  well  as  the  others,  had  pre¬ 
viously  swallowed  opium.  I  noted  the 
time  of  its  action  on  all  the  twenty-four, 
and  found  that  the  effects  of  the  opium 
discovered  themselves  much  sooner  in 
the  frogs,  the  heart  of  which  remained 
in  the  thorax,  than  in  those  from  which 
I  had  removed  it.  The  difference  in 
time  was  more  than  one  half.” 

The  above  experiment  of  Whytt’s,  I 
own,  puzzled  me  for  a  long  time,  as  it 
apparently  contradicted  what  was 
otherwise  so  completely  established. 
But  I  imagine  that  the  difficulty  may 
be  got  over  thus.  From  the  observa¬ 
tions  of  Dr.  Wilson  Philip  and  others, 
and  as  was  instanced  in  my  own  ex¬ 
periment  detailed  in  the  previous 
paper,  the  movement  of  the  blood 
through  the  capillaries,  from  the  ar¬ 
teries  to  the  veins,  continues  for  some 
minutes  after  the  removal  of  the  heart. 
By  imbibition  some  of  the  poison  would 
probably  find  its  way  into  the  aorta, 
and  thence  to  the  capillaries  of  the 
limbs.  By  imbibition  also  the  poison 
would  come  into  direct  contact  with 
the  internal  organs,  and  possibly  with 
the  limbs.  At  all  events,  Fontana’s 
repetition  of,  and  contrast  to,  this  very 
interesting  experiment,  shew  that  the 
poison  acts  much  more  speedily  when 
the  heart  is  not  removed,  ar.d  the  cir¬ 
culation  is  entire. 

3.  The  absorption  of  narcotic  poi^pns 
into  the  circulation  through  the  skin, 
so  conclusively  proved  by  the  above 
experiments,  is  necessarily  much  less 
rapid  than  the  absorption  from  the 
stomach  and  intestines  into  the  circu¬ 
lation. 

Pannizza,  quoted  by  Matteucci  (sur 
les  Phenomenes  Physiques  des  Corps 
Vivants,p.  76),  injected  a  small  portion 
of  strong  hydrocyanic  acid  into  a  small 
portion  of  the  small  intestine  of  a 
horse;  the  blood  which  was  imme¬ 
diately  afterwards  taken  from  the  vein 
returning  from  the  intestine,  was  al¬ 
ready  charged  with  hydrocyanic  acid. 

Solutions  of  most  of  the  organic  salts, 
and  several  of  the  inorganic  salts,  have 
been  detected  in  the  urine  some  time 
after  being  received  into  the  stomach. 
Dr.  Percy  detected  alcohol  in  the  blood 
and  urine  after  the  injection  of  that 
fluid  into  the  stomach.  Monro  says, 
“I  applied  camphor  to  the  hind  legs  of 


794  ACTION  OF  OPIUM  ON  THE  CAPILLARIES,  ARTERIES,  AND  VEINS 


two  frogs  for  an  hour  and  a  half,  and 
then  I  cut  off  the  hind  legs  and  the 
whole  of  the  skin  ;  and  on  opening  the 
abdomen,  I  distinctly  perceived  the 
smell  of  the  camphor  in  it,  and  after 
infusing  the  bowels  in  spirits  and  in 
water,  I  plainly  perceived  its  taste  in 
those  liquors.”  For  the  details  of  the 
chemical  proofs,  that  inorganic  salts 
and  some  organic  salts  have  been  dis¬ 
covered  in  the  urine  after  being  received 
into  the  stomach,  I  refer  to  Simon’s 
Chemistry,  Dr.  Day’s  translation,  and 
to  Dr.  Taylor’s  work  on  Poisons. 

From  the  physiological  proofs  detail¬ 
ed  above,  and  from  the  chemical  proofs 
referred  to,  it  rn.iy  be  laid  down  as  a 
received  law,  that  narcotic  poisons  are 
received  into  the  circulation,  whether 
they  are  presented  to  the  stomach  and 
intestines,  the  skin,  or  the  lungs,  and 
that  it  is  only  through  the  medium  of 
the  circulation  that  they  can  act  on  the 
whole  system. 

4.  I  shall  scarcely  be  premature  if  I 
insist  here  on  the  importance,  in  a 
therapeutical  point  of  view,  of  recogniz¬ 
ing  habitually  and  practically  that  every 
poison  is  diffused  through  the  whole 
circulating  mass  of  the  blood,  so  long 
as  the  blood  is  taking  into  itself  fresh 
supplies  of  poison,  whether  from  the 
stomach  and  intestines,  the  rectum,  the 
skin  or  the  lungs  (as  in  the  inhalation 
of  ether  and  chloroform)  ;  and  that  the 
blood  is  constantly  and  necessarily 
eliminating  from  itself  the  poison 
diffused  through  it;  and  that  every 
means  should  be  resorted  to,  short  of 
exhausting  the  vital  energies  of  the 
patient,  to  hasten  the  elimination  of 
the  poison  from  the  blood,  through  the 
usual  channels,  the  kidneys,  the  skin, 
the  liver  and  intestines,  the  salivary 
glands,  and,  when  the  poison  is  va- 
porisable  (prussic  acid,  ether),  the 
lungs. 

This  is  not  the  place  to  enter  into 
details  on  what  may  be  termed  the 
treatment  by  elimination,  but.  a  recog¬ 
nition  of  the  importance  of  that  branch 
of  the  treatment  here  is  well,  as  it  fixes 
the  attention  on  the  broad  fact,  that 
poisons  are  detectable  by  the  chemist 
in  the  liver,  the  lungs,  the  brain,  the 
heart,  the  kidneys,  the  blood  itself,  the 
bile,  the  urine,  the  serous  fluid  in  trie 
serous  cavities,  and  that  their  removal 
during  life  from  each  and  all  of  these 
places,  in  their  aggregate  from  the 
whole  system,  may  be  materially  aided 


by  a  rightly  directed  system  of  treat¬ 
ment. 

Having  gained  a  practical  recogni¬ 
tion  of  the  fact,  that  the  poison  is  ad¬ 
mitted  into  the  circulation,  and  carried 
by  it  through  the  whole  frame,  the 
ground  is  prepared  for  an  inquiry  into 
the  effects  of  the  poison  on  the  circula¬ 
tion. 

Action  of  opium  on  the  capillaries ,  ar¬ 
teries,  and  veins. 

5.  In  the  experiment  performed  by 
myself,  detailed  in  the  former  paper, 
and  which  was  a  modification  of  those 
of  Allston  and  Monro,  I  found  it  of 
very  great  advantage  to  have  the  ani¬ 
mal  so  arranged  on  Mr.  Goadby’s  frog 
holder,  that  I  could  withdraw  the  test 
tube  containing  the  solution  of  opium, 
or  that  holding  water,  from  either  of 
the  legs  respectively  immersed  in  those 
fluids,  and  examine  the  progress  and 
changes  in  the  circulating  currents, 
without  in  the  least  degree  disturbing 
the  creature,  and  so  modifying  the  flow 
of  the  blood. 

The  first  change  observed  was  mani¬ 
festly  a  dilatation  of  the  capillaries: 
those  capillaries  which  were  previously 
so  small  that  the  corpuscles  could  only 
press  slowly  through  in  single  file,  each 
thinned, lengthened,  and  bending  in  the 
narrow  t  ube,  w-ere  now  so  much  enlarged, 
that  the  corpuscles  moved  quickly 
through  them  ;  and  the  blood  circulated 
through  many  capillaries  previously 
too  small  to  admit  corpuscles.  The 
opium  was  in  contact  with,  and  im¬ 
pregnated  the  texture  of  the  capillaries, 
and  the  evident  effect  was  a  yielding  of 
their  walls,  and  the  necessary  result 
the  enlargement  of  the  area  of  the  ca¬ 
pillaries.  While  the  blood  in  the  ca¬ 
pillaries  moved  more  quickly  and  ex¬ 
tensively,  that  both  in  the  arteries  and 
veins  moved  manifestly  more  slowly. 

In  the  progress  of  the  experiment, 
the  capillaries  became  much  farther 
distended,  their  enlarged  walls  yield¬ 
ing  to  the  vis  a  teryo  from  the  heart ; 
the  quantity  of  blood  in  them  was  much 
increased,  several  corpuscles  moving 
side  by  side  in  capillaries  that  w’ere 
previously  empty;  and  the  motion  of 
the  blood,  both  in  the  arteries,  capil¬ 
laries,  and  veins,  was  very  materially 
diminished. 

The  cause  of  the  diminished  motion 
in  the  arteries  and  the  distended  capil¬ 
laries,  is  rendered  clear  by  an  experi- 


PERSPIRATfON  IN  POISONING  BY  OPIUM 


795 


ment  of  Dr.  J.  C.  B.  Williams,  which 
proves  that  “  flaccidity,  and  increased 
length  and  size  of  a  tube,  afford  impedi¬ 
ments  to  the  passage  of  liquid  through 
it.”  Dr.  Williams  attached  a  tube 
with  two  arms  to  a  syringe;  to  one  arm 
was  fitted  a  brass  tube  two  feet  long, 
having  several  right  angles  in  its 
course  ;  to  the  other  arm  was  fitted  a 
portion  of  rabbits’  intestine,  four  feet 
long,  and  of  calibre  (when  distended 
with  water)  double  that  of  the  brass 
tube.  The  tubes  were  both  filled  by 
successive  strokes  of  the  piston;  and 
when  they  both  began  to  discharge,  the 
quantity  discharged  from  the  small 
brass  tube  was  from  two  to  five  times 
the  quantity  from  the  larger  but  mem¬ 
branous  tube. 

The  experiment  proves,  that  the  in¬ 
creased  tortuosity,  and  number  of  ves¬ 
sels  in  a  congested  part,  the  greaier 
mass  of  their  contents,  and  the  atonic 
flaccidity  of  their  coats,  do  truly  form 
additional  obstacles  to  tlie  passage  of 
blood  through  them.  (Principles  of 
Medicine,  page  144). 

This  experiment  explains  perfectly 
certain  of  the  successive  phenomena 
observed  in  the  circulation  of  the  foot 
of  the  frog  which  was  immersed  in  a 
solution  of  opium.  When  the  coats  of 
the  finest  capillaries  became  flaccid, 
they  admitted  corpuscles  freely,  al¬ 
though,  underexaclly  thesame pressure, 
many  of  them  admitted  none  before. 
As  the  capillaries  increased  in  size,  and 
their  coats  in  flaccidity,  the  increased 
mass  of  corpuscles  in  them,  having  still 
only  the  original  amount  of  pressure 
from  behind,  moved  forward  much 
more  slowly,  a  great  portion  of  their 
moving  force  being  expended  in  ex¬ 
panding  the  yielding  walls.  The  arte¬ 
ries,  as  well  as  the  veins,  partook  of 
the  diminished  motion  :  the  former,  be¬ 
cause  the  blood  in  them  had  to  push 
before  it  a  greatly  increased  mass  of 
corpuscles;  the  latter  received  less 
blood  from  the  swollen  capillaries,  be¬ 
cause  a  great  part  of  the  blood  which 
they  received  was  detained  in  them, 
and  because  less  blood  entered  them 
from  the  arteries.  The  phenomena 
aie  in  part  illustrated  by  the  rapidity 
with  which  soldiers  in  single  file  can 
pass  through  a  narrow  doorway,  which, 
on  the  other  hand,  becomes  almost 
blocked  up  by  the  striving  pressure  of 
a  disorderly  crowd. 

It  was  very  interesting  to  remark, 


during  the  progress  of  the  experiment, 
that  the  circulation  in  the  capillaries  of 
the  limb  in  water,  which  was  at  first 
unchanged,  became  gradually  affected 
precisely  in  the  same  manner  with  the 
circulation  of  the  limb  immersed  in 
opium.  The  changes  were  exactly  the 
same  in  character,  but  they  were  at 
any  given  time  less  in  amount,  even  to 
the  end  of  the  experiment. 

This  change  in  the  circulation  of  the 
limb  in  water,  was  manifestly  due  to 
the  opium,  which,  having  found  its 
way  through  the  circulation,  over  from 
the  left  limb  to  the  right,  produced  on 
that  limb  thesame  characteristic  effects. 
The  opium  acted  on  the  capillaries  of 
the  left  or  medicated  limb,  to  use  Fon¬ 
tana’s  expression,  from  without,  while 
it  acted  on  those  of  the  opposite  limb 
from  within,  their  walls  being  bathed 
with  the  blood  holding  in  it  the  opium 
in  solution. 

6.  From  this  observation,  we  learn 
that  opium  causes  congestion  in  all  the 
systemic  capillaries;  and  we  may  in¬ 
fer  w'ith  certainty  that  the  same 
effects  extend  to  the  pulmonic  capilla¬ 
ries,  in  which  the  resistance  to  the 
circulation  is  probably  greater  than  it 
is  in  the  systemic  capillaries.  There 
is  one  interesting,  and,  in  a  therapeutic 
point  of  view,  important  symptom  in 
poisoning  by  opium,  which  is  referable 
to  the  congestion  induced  by  it  in  tne 
systemic  capillaries,  and  that  is,  pro¬ 
fuse  perspiration,  which  usually  breaks 
out  over  the  whole  surface  of  persons 
under  the  poisonous  influence  of 
opium.  Neiiher morphia  nor  meconic 
acid  have  as  yet  been  detected  in  the 
perspiration  ;  but  there  can  be  no 
doubt  that  the  perspiration  is  one  of 
the  channels  by  which  the  poison  is 
eliminated  from  the  system.  I  am,  in¬ 
deed,  convinced,  botfi  from  the  con¬ 
sideration  of  the  matter,  and  from  ex¬ 
perience,  that  it  is  of  very  great  im¬ 
portance  to  promote  by  external 
warmth  copious  perspiration  in  cases 
of  poisoning  by  opium.  I  need  scarcely 
say,  that  this  must  not  interfere  with 
other  steps  in  the  treatment,  and  must 
not  be  pushed  so  far  as  to  exhaust  the 
system  ;  and  that  the  perspiration  must 
not  be  allow'ed  to  remain  on  the  surface, 
so  as  to  chill  it  by  evaporation. 

Opium  is  not  the  only  narcotic 
poison  that  produces  congestion  in  the 
capillaries;  indeed,  I  feel  assured 
nearly  all,  perhaps  all,  the  narcotic 


706  OBSTRUCTION  TO  THE  CIRCULATION  IN  THE  CAPILLARIES. 


poisons  have  the  same  effect,  though 
the  effects  are  doubtless  somewhat 
modified  in  each  instance.  It  would 
form  an  interesting  and  valuable  series 
of  experiments  to  observe  the  effect  of 
each  of  the  narcotic  poisons  on  the 
circulation  in  the  web  of  the  frog’s  foot, 
adopting  in  each  the  plan  employed 
in  the  experiment  detailed  above. 

Monro,  in  fact,  adopted  this  plan 
with  alcohol  and  with  camphor;  Dr. 
Wilson  Philip  with  tobacco  (I  have 
not  seen  the  details  of  his  experiments) ; 
and  Mr.  Wharton  Jones  with  carbonic 
acid  gas,  directing  a  stream  of  it  on  the 
web  of  the  frog’s  foot :  in  all  these  in¬ 
stances  (I  cannot  speak  with  certainty 
as  to  Dr.  Wilson  Philip’.'')  the  circula 
tion  was  retarded  and  checked  by  the 
action  of  the  poison. 

The  experiments  of  Mr.  Nunneley, 
of  Leeds,  show  that  the  invariable  ac¬ 
tion  of  prussic  acid  is  to  cause  conges 
tion  of  the  capillaries  of  the  surface  to 
which  it  is  applied ;  and  Professor 
Simpson  has  observed  the  same  with 
regard  to  chloroform.  The  invariable 
effect  of  chloroform  and  ether,  when  it 
has  penetrated  from  the  lungs  into  the 
systemic  capillaries,  is  at  first  to  pro¬ 
duce  active  congestion  of  those  capilla¬ 
ries,  as  may  be  always  witnessed  on  the 
conjunctiva. 

Dr.  Blake  has  made  some  interesting 
experiments,  which  exhibit,  by  a  dif¬ 
ferent  mode  of  inquiry,  the  resistance 
to  the  circulation  in  the  systemic  capil¬ 
laries.  He  observed  by  the  hsemody- 
namometer  that  in  animals  poisoned  by 
injecting  tobacco,  digitalis,  and  eu- 
phorbium  into  their  blood,  that  the 
pressure  on  the  haemodynamometer  is 
about  doubled:  this  increase  in  pres¬ 
sure  appears  to  be  due  to  the  resistance 
to  the  circulation  in  the  capillaries. 

In  addition  to  the  narcotic  poisons 
just  instanced,  the  following  showed 
their  effect  in  increasing  the  volume  of 
the  blood  in  the  capillaries,  and  ob¬ 
structing  the  capillary  circulation  by 
certain  symptoms  during  life: — 

Belladonna — in  many  of  the  recorded 
cases  the  face,  and  in  some  the  whole 
surface,  was  rendered  red. 

Stramonium — the  face  was  reddened 
in  the  majority  of  cases. 

Hvoscvamus,  I  believe,  has  the  same 
effect,  from  its  general  analogy  to  the 
action  of  belladonna,  but  I  Cannot 
meet  with  any  note  of  such  a  symp¬ 


tom  in  my  analysis  of  cases  poisoned 
by  it. 

In  one  or  more  instances  the  follow¬ 
ing  symptoms  were  excited  by  the 
following  poisons  :  — 

Cicuta  virosa  .  the  face  was  bloated. 
(Enanthe  crocata  the  face  was  bloated 

and  livid. 

Aconite  .  .  .  the  face  was  swollen. 
Strychnos  .  .  the  face  was  swollen. 
A  poisonous  fun¬ 
gus  ....  the  face  was  swollen. 

It  may  be  considered,  then,  that  the 
following  narcotic  poisons  cause  con¬ 
gestion  in  the  capillaries:  —  opium, 
alcohol,  ether,  chloroform,  carbonic 
acid  gas,  prussic  acid,  tobacco,  digitalis, 
belladonna,  stramonium  (hyosciamus), 
cicuta  virosa,  cenanthe  crocata,  aconite, 
and  strychnos. 

8.  In  asphyxia  there  is  congestion 
and  obstruction  in  the  pulmonic,  and 
also  in  the  systemic  capillaries.  This 
congestion  is  of  the  same  character, 
alike,  indeed,  in  its  essential  pheno¬ 
mena,  with  that  produced  by  opium 
and  the  narcotic  poisons;  and  in  Mr. 
Wharton  Jones’  experiment,  in  which 
the  capillary  circulation  in  the 
web  of  a  frog’s  foot  was  retarded  or 
even  checked  by  directing  on  it  a 
stream  of  carbonic  acid  gas,  it  may  be 
said  that  local  asphyxia  was  produced. 

It  has  long  been  understood  that  in 
asphyxia  the  pulmonic  capillaries  are 
obstructed,  but  Bichat  was,  I  believe, 
the  first  to  point  out  the  obstruction  in 
the  systemic  capillaries  as  an  essential 
feature  in  the  chain  of  morbid  changes, 
instancing  in  support  of  this  view  the 
fulness  and^  livid  colour  of  divers 
parts,  such  as  the  face,  tongue,  and 
lips,  and  also  putting  it  partially  to 
the  test  of  experiment  by  exposing  the 
mesentery  in  the  living  animal  during 
asphyxia. 

Dr.  Reid  found  that  in  asphyxia, 
there  wTas  increased  distension  in  the 
arterial  system,  as  indicated  by  the 
haemodynamometer,  evidently  due  to 
the  resistance  to  the  circulation  in  the 
systemic  capillaries.  Mr.  Erichsen 
has  observed  under  the  microscope  the 
resistance  to  the  circulation  in  the 
capillaries  during  asphyxia.  I  re¬ 
peated  his  experiment,  and  found 
where  the  air  was  shut  off  from  the 
lungs  by  a  stop  tap  in  the  trachea,  that 
the  circulation  *in  the  arteries  and 
veins,  which  was  previously  quick, 


STATE  OF  HEALTH  OF  THE  COUNTRY  DURING  THE  LAST  QUARTER.  707 


became  gradually  slow,  and  that  the 
flow  of  blood  through  the  capillaries 
was  at  first  increased  and  then  ob¬ 
structed :  on  again  permitting  respira¬ 
tion, the  circulation  speedily  quicnened. 

In  asphyxia  it  appears  that  the  ob¬ 
struction  is,  in  part  at  least,  due  to  the 
increased  size  and  adhesiveness  to  each 
other  of  the  red  corpuscles ;  those 
being  the  changes  effected  by  carbonic 
acid  on  those  corpuscles,  according  to 
that  accurate  observer,  Mr.  Gullher. 
Besides  this,  the  tonicity  of  the  capilla¬ 
ries  is  doubtless  diminished,  and  their 
relaxation  consequently  increased,  by 
the  continued  presenceof  unoxygenated 
blood.  May  we  not  say,  and  say  truly, 
that  asphyxia  is,  in  part  at  least,  the 
action  on  the  capillaries  of  a  narcotic 
poison  diffused  through  the  blood  ? 

9.  The  phenomena  presented  by  the 
circulation  in  the  capillaries  in  conges¬ 
tion  and  inflammation  are  very  similar 
to  those  in  narcotic  poisoning  and 
asphyxia.  For  interesting  details  on 
this  subject,  I  refer  to  Dr.  C.  J.  B. 
‘Williams’  Principles  of  Medicine. 

[To  be  continued.] 


CASK  OF  POISONING  BV  STRYCHNINE - 

STRYCHNINE  MISTAKEN  FOR  SALICINE. 

A  verdict  of  manslaughter  has  been  re¬ 
turned  by  a  coroners  jury  against  a  Mr. 
Jones,  druggist,  of  Romsey,  under  the  fol¬ 
lowing  circumstances.  On  the  30th  Octo¬ 
ber,  he  was  required  to  prepare  for  a  lady 
a  tonic  mixture,  into  the  composition  of 
which  salicine  entered.  Owing  to  some  un¬ 
fortunate  mistake,  nine  grains  of  strychnine 
were  used  instead  of  salicine.  A  portion  of 
the  mixture  was  taken  by  the  patient  at 
7  o’clock  in  the  morning,  and  it  is  stated 
that  she  became  suddenly  ill,  was  seized 
with  convulsions,  and  died  (in  less  than  two 
hours)  before  medical  assistance  could  be 
procured.  On  inspection,  the  body  is  re¬ 
ported  to  have  been  found  perfectly  healthy, 
and  no  strychnine  was  discovered,  although 
this  poison  was  detected  in  the  mixture. 
The  quantity  taken  is  not  mentioned. 

The  report  of  this  singular  ease,  which 
has  appeared  in  the  daily  journals,  is,  as 
usual,  very  imperfect.  The  medical  gentle¬ 
man  who  was  called  in,  would  confer  a 
benefit  on  science  by  sending  an  accurate 
account  of  the  facts  to  one  of  the  medical 
journals. 

ASSISTANT-SURGEON  TO  MIDDLESEX 
HOSPITAL. 

Mr.  Mitchell  Henry’  was  yesterday,  (the 
9th),  elected  to  the  above  office  by  a  consi¬ 
derable  majority. 


MEDICAL  GAZETTE. 


FRIDAY,  NOVEMBER  10,  1848. 


The  Quarterly  Return  of  the  Registrar- 
General  is  brought  down  to  September 
30.  It  contains,  therefore,  no  infor¬ 
mation  respecting  the  prevalence  and 
fatality  of  Asiatic  cholera  in  the 
metropolis  and  other  parts  of  the 
country.  Nevertheless,  the  informa-- 
tion  furnished  by  the  return  is  of 
interest,  as  it  enables  us  to  review  our 
sanitary  position  immediately  before 
the  outbreak  of  this  disease.  Our 
readers  are  probably  aware  that  the 
return  is  made  up  from  117  districts, 
of  which  36  are  in  the  metropolis,  and 
the  remaining  81  comprise,  with  some 
agricultural  districts,  the  principal 
towns  and  cities  of  England.  The 
population,  in  1841,  was  6,662,958; 
hence  the  results  may  be  taken  as 
fairly  representing  the  sanitary  condi¬ 
tion  of  England  and  Wales. 

“The  mortality  in  the  quarter  was 
below  the  average.  Only  43,445  deaths 
were  registered;  which  is  less,  by 
6,034,  than  the  49,479  deaths  registered 
in  the  corresponding  quarier  of  1847, 
and  7960  less  than  51,405,  the  number 
registered  in  the  September  quarter 
of  1846.  The  mortality  of  the  coun¬ 
try,  it  should  he  recollected,  was  low 
in  the  three  years,  1843,  1844,  1845, 
and  in  the  first  quarter  of  1846;  a 
slight  increase  took  place  in  the  spring 
quarter  of  1846;  in  the  summer  a 
great  mortality  broke  out,  and  con¬ 
tinued  through  the  autumn,  as  well  as 
the  whole  of  the  year  1847,  until  in¬ 
fluenza  raged  epidemically  at  the  close 
of  the  year  1847,  and  was  then,  and  in 
the  winter  of  1848,  fatal  to  thousands. 
A  remarkable  improvement  was  appa¬ 
rent  in  the  spring  of  the  year  1848,  and 
was  still  more  obvious  in  the  summer 
quarter.  While  the  deaths  in  the 
Mimmers  of  1846,  1847,  were  8  660  and 
5,986  above,  the  deaihs  in  the  summer 
of  1848  were  809  below ,  the  corrected 
average.” 


798  STATE  OF  HEALTH  OF  THE  COUNTRY  DURING  THE  LAST  QUARTER 


Taking  the  four  quarters  of  1846  7, 
and  the  three  quarters  of  1848,  the 
number  of  registered  deaths  will  be  as 
follows  : — 


Quarters 

ending 

1846. 

1847. 

1848. 

M  arch 

43,850 

56,105 

57,710 

June  . 

43,734 

51.585 

46,552 

September 

51,405 

49.479 

43,445 

December 

53,093 

57,925 

•  •  •  • 

Total  . 

192,082 

215,094 

•  •  •  • 

The  returns  show  that  in  all  quar¬ 
ters,  excepting  London,  there  has  been 
a  great  improvement  in  the  public 
health.  Thus,  we  are  informed — 

“  The  pressure  of  mortality  has 
slightly  increased  in  London,  though 
it  has  abated  in  the  country.  While 
the  deaths  of  the  four  summer  quarters, 
1845  -  8,  in  the  country  districts  were 
25,152,  38,804,  36,292,  and  29,942,  the 
deaths  in  London  were  10  987,  12,601, 
13,187,  and  13,503.  Influenza,  it  will 
he  recollected,  was  much  more  fatal  in 
London  than  in  the  country.  The 
increased  mortality  of  London  is 
principally  owing  to  the  deaths  from 
diseases  of  the  zymotic  class,  increasing 
in  the  four  summers,  1845 — 8,  from 
2,437  to  5,162.  Scarlatina  has  been 
more  fatal  in  the  last  than  in  any 
previous  summer  quarter  since  the 
new  tables  commenced.  It  destroyed 
1,560  lives  in  13  weeks,  or  1,079  more 
than  the  average.  The  epidemic  pre¬ 
sented  this  singularity,  that  the  deaths 
in  the  summer  quarters  1841 — 4,  were 
193,  392,  548,  1,020;  and  again,  194, 
208,  316, 1,560,  in  the  summer  quarters 
1845 — 8;  which  justifies  the  hope  that 
the  mortality  from  this  disease  next 
year  will  not  be  considerable.  Small¬ 
pox,  notwithstanding  the  facilities  for 
vaccination,  was  fatal  to  435  persons  : 
children  chiefly  who  had  never  been 
vaccinated.  Typhus  destroyed  882 
lives  in  London  ;  the  epidemic  has 
prevailed  since  1846,  and  is  but  slowly 
declining.  Consumption,  the  enemy 
of  mature  life,  carried  off  1,534  victims. 
The  fatality  of  this  and  of  other  dis¬ 
eases  of  the  tubercular  class  remains 
aim1  st  invariable,  allowing  for  differ¬ 
ences  of  nomenclature ;  the  deaths  in 


the  eight  various  summers  of  1841 — 8, 
were  2  400,  2,511,  2,428.2,275,2,199, 
2,659,  2,370,  2,221.  Dysentery  was 
rather  more  fatal  than  in  previous 
years.  Every  summer  there  have  been 
many  deaths  from  diarrhoea;  in  the 
summers  of  1846  7-8,  diarrhoea  was 
epidemic,  and  fatal  to  1,549,  1,198, 
and  1,048  lives;  cholera  was  fatal  in 
the  same  season  to  197.  98,  and  153 
lives.  The  mortality  from  these  dis¬ 
eases  for  the  last  9  years  is  shown  in 
the  annexed  tables: — 


Deaths  from,  Diarrhoea  in  each  of  the  Four 
Quarters  of  the  Years  1840 — 48. 


Quarters 

ending. 

March. 

June. 

Sept. 

Dec. 

1840 

57 

62 

279 

62 

1 S4 1 

68 

65 

228 

112 

1842 

81 

63 

489 

87 

1843 

69 

50 

455 

268 

1844 

79 

83 

414 

129 

1845 

109 

84 

449 

199 

1846 

119 

153 

1549 

331 

1847 

178 

202 

1196 

400 

1848 

244 

239 

1048 

- 

Deaths  from  Cholera  in  each  of  the  Four 
Quarters  of  the  Years  1840 — 48. 


Quarters 

ending. 

March. 

June. 

Sept. 

Dec. 

1840 

3 

4 

53 

6 

1841 

1 

1 

23 

3 

1842 

— 

7 

106 

13 

1843 

6 

8 

60 

14 

1844 

4 

9 

47 

5 

1845 

4 

2 

26 

11 

1846 

7 

9 

197 

15 

1847 

3 

4 

98 

12 

1848 

9 

17 

153 

“  Cases  of  cholera  and  diarrhoea,  as 
it  will  be  seen  by  these  tables,  have 
been  every  year  registered  in  London. 
Both  these  diseases  were  fatal  to  adults 
between  the  ages  15—60,  and  to  old 
people;  but  the  great  majority  of  the 
cases  occurred  in  children.  In  the  13 
weeks  of  the  present  year  ending 
September  30th,  the  deaths  of  90 
children  under  15,  3 7  men  and  women 
of  the  age  of  15 — 60,  and  30  of  the  age 
of  60  and  upwards,  were  referred  to 
cholera.  The  duration  of  the  attack 
in  adults  varied  from  16  hours  to 
several  days.” 


INSURANCE  OFFICES  AND  MEDICAL  REFEREES. 


799 


These  are  the  principal  medical  facts 
with  which  this  table  makes  us  ac¬ 
quainted.  At  the  date  of  the  return 
there  was  no  trace  of  what  is  termed 
epidemic  cholera  in  England.  The 
next  quarterly  table  will,  no  doubt, 
contain  a  full  history  of  the  reappear¬ 
ance  of  this  malignant  disease  among 
us. 


It  has  been  a  long  agitated  question 
whether  insurance  offices  or  the  party 
whose  life  it  is  proposed  to  insure, 
should  remunerate  the  medical  gentle¬ 
man  who  was  called  upon  to  give  a 
confidential  history  of  his  patient’s 
health  and  habits.  Every  one  ad¬ 
mitted  that  the  medical  referee  ought 
to  receive  a  fee  for  his  opinion  ;  but  the 
two  parties  most  interested  in  the  re¬ 
sult,  declined  paying  it.  Each  became 
a  repudiator,  and  either  the  opinion  was 
not  given,  or  it  was  used  and  not  paid 
for.  Medical  practitioners  have  latterly 
taken  the  matter  into  their  own  hands, 
and  we  have  heard  of  several  instances 
where,  with  a  proper  degree  of  inde¬ 
pendence,  the  schedule  of  inquiries 
was  returned  to  the  Office,  as  it  was  un¬ 
accompanied  by  a  fee.  This  is  the 
right  way  of  dealing  with  the  subject, 
because  a  medical  man  has  other 
matters  to  occupy  his  attention  than 
those  which  refer  to  the  equitable  ad¬ 
justment  of  pecuniary  differences  be- 
tween’insurers  and  insured.  The  most 
respectable  Offices,  we  are  glad  to  per¬ 
ceive,  are  beginning  to  view  the  matter 
in  its  true  light,  and  the  subjoined  cir¬ 
cular,  which  has  been  forwarded  to  us, 
shews  that  medical  men  are  not  hence¬ 
forth  to  incur  trouble  and  responsibility 
without  payment. 

Westminster  and  General 
Life  Assurance  Association, 

27,  King  Street,  Covent  Garden, 
24th  October,  1848. 

Sir, — I  am  instructed  to  in lorm  you, 
that  the  directors  of  this  as*ociation 
having  taken  into  consideration  the 
trouble  and  responsibility  incurred  by 


the  medical  profession  in  furnishing  to 
Life  Assurance  Companies  their  opi¬ 
nion  as  to  the  eligibility  of  the  lives  of 
their  patients  for  assurance,  have  de¬ 
cided  upon  allowing  a  fee  of  £1.  Is.  to 
every  medical  referee  who  shall  give  a 
certificate  in  reply  to  an  application 
from  the  office  of  this  association. 

1  remain,  sir, 

Your  most  obedient  servant, 

Wm.  Browne, 

Actuary. 

We  shall  take  care  from  time  to  time 
to  publish  the  names  of  all  the  Offices 
which  adopt  this  fair  course  of  pro¬ 
ceeding.  When  five  or  sis  respectable 
Insurance  Offices  admit  the  propriety 
of  payment  under  the  circumstances, 
the  recusant  companies  will  soon  be 
compelled  to  give  up  an  illiberal  oppo¬ 
sition  to  claims  which  are  based  on 
reason  and  justice. 


The  General  Board  of  Health  is  de¬ 
cidedly  in  an  unfortunate  predicament. 
Its  notifications  please  no  one,  either 
in  the  profession  or  out  of  it.  They 
possess  the  demerits  of  being  lengthy, 
inconsistent,  and  contradictory.  Atone 
time  they  lay  down  a  sort  of  national 
dietary,  which  ruins  market-gardeners, 
and  various  trades.  In  this  they  are 
set  right  by  the  Royal  College  of  Phy¬ 
sicians  of  London.  On  another  occa¬ 
sion  they  enter  most  unnecessarily  into 
the  question  of  contagion,  and  promul¬ 
gate  on  this  subject  dogmatical  views 
which  are  not  only  in  opposition  to  the 
experience  and  observation  of  many 
medical  practitioners,  but  are  liable  to 
give  rise  to  great  practical  mischief. 
We  had  intended  to  take  up  this  part 
of  the  case  in  extenso,  but  a  correspon¬ 
dent,  to  whose  letter  we  this  week 
willingly  give  insertion,*  has  antici¬ 
pated  us  ;  and  he  has  so  ably  analysed 
the  doctrines  of  the  non-medical  Board, 
that  we  shall  for  the  present  merely 
refer  our  readers  to  his  letter.  Then, 


*  Dr.  Reid,  page  813. 


800  ADDITIONAL  LABOUR  THROWN  ON  UNION  MEDICAL  OFFICERS. 


with  respect  to  treatment,  various  sorts 
of  astringents,  including  the  use  of 
opiate  preparations,  in  order  to  remove 
« looseness  of  the  bowels,”  were 
specially  recommended  to  the  public  ; 
but  on  this  general  mode  of  prescribing, 
the  Cholera  Committee  of  the  Royal 
College  of  Physicians  wisely  remark, 
that  they  are  unable  to  recommend 
any  uniform  plan  of  treatment  to  be 
adopted  in  such  cases.  Looseness  of 
the  bowels  may  arise  from  various 
causes  of  which  a  medical  man  can 
alone  judge  ;  and  hence  “it  is  safer  that 
persons  thus  affected,  should  apply  at 
once  for  medical  assistance,  than  that 
they  should  indiscriminately  use  of 
their  own  accord,  or  on  the  suggestion 
of  unprofessional  persons,  powerful 
medicines  in  large  and  frequently-re¬ 
peated  doses.”  This  is  the  language  of 
common  sense,  and  it  would  have  been 
at  once  adopted  by  any  properly  con¬ 
stituted  Board  of  Health. 

From  a  notification,  which  was  pub¬ 
lished  in  the  Gazette  of  Friday  last, 
it  appears  that  additional  labour  is  to 
be  thrown  on  the  medical  officers  of 
Unions,  without  an  adequate  additional 
remuneration.  The  General  Board  of 
Health  have  in  this  document  issued 
certain  directions  and  regulations,  and 
have  made  them  applicable  to  G21 
Unions.  The  following  clauses  con¬ 
cern  the  duties  of  the  medical  officers :  — 

“  10.  And  we  authorize  and  require 
such  guardians  to  cause  the  medical 
officers  employed  by  them,  or  specially 
appointed  for  the  purpose ,  to  visit  the 
places,  of  which  a  list  shall  be  made 
out  as  aforesaid,  and  all  such  neigh¬ 
bouring  and  other  places  within  such 
union  or  parish,  as  shall  appear  to  such 
medical  officers  (from  being  under  like 
circumstances  with  the  places  included 
in  such  list  or  otherwise)  to  require 
visitation  or  examination. 

“11.  And  each  such  medical  officer 
shall,  where  it  may  be  nectssary,  certify 
in  writing  to  the  Board  of  Guardians, 
and  to  the  surveyors,  trustees,  or  occu¬ 
piers,  or  others  required  to  execute 


these  directions  and  regulations,  all 
such  places  as  are  in  a  state  dangerous 
to  health,  or  need  frequent  and  effec¬ 
tual  cleansing  by  way  of  preservation 
against  disease ;  and  such  dwelling- 
houses  as  are  in  a  filthy  and  unwhole¬ 
some  condition,  and  all  such  nuisances 
and  matters  injurious  to  health  as  ought 
to  be  abated,  cleansed,  and  removed 
under  these  regulations. 

“  12.  And  each  such  medical  officer 
shall  forthwith  upon  any  case  of  cho¬ 
lera  or  of  typhus  or  other  epidemic, 
endemic,  and  contagious  diseases  be¬ 
coming  known  to  him  within  the 
parish,  union,  or  district  under  his 
visitation,  report  the  same  to  the  Board 
of  Guardians. 

“13.  And  we  do  hereby  authorize 
and  direct  the  said  guardians,  where  it 
may  appear  needful,  to  appoint  such 
additional  medical  officers,  and  also  to 
appoint  such  other  officers  as  may  be 
necessary  to  execute  and  superintend 
the  execution  of  these  regulations,  and 
to  publish  and  circulate  by  printed 
handbills,  or  other  means,  notices  of 
the  provisions  of  the  said  act  for  the 
prevention  of  nuisances,  and  of  our 
regulations  and  instructions,  or  of  such 
part  of  any  of  them,  as  it  may  appear 
desirable  to  make  publicly  known.” 

“  And  where  it  shall  be  certified  to 
the  guardians  by  their  medical  officer 
or  officers,  or  where  it  shall  otherwise 
sufficiently  appear  to  such  guardians, 
that  extraordinary  medical  aid  is  re¬ 
quired  for  persons  attacked  or  threat¬ 
ened  by  cholera,  or  epidemic,  endemic, 
or  contagious  disease,  we  authorize  and. 
require  such  guardians  to  provide  suffi¬ 
cient  medical  aid,  and,  in  suitable 
places,  such  medicines  as  may  be  re¬ 
quired  within  their  respective  unions 
for  necessitous  persons  attacked  by 
cholera  or  by  premonitory  symptoms, 
and  to  make  arrangements  for  the  dis¬ 
tribution  of  notices,  stating  the  places 
where  aid  and  medicines  shall  have 
been  provided.” 

It  will  be  perceived  that  the  order 
for  the  appointment  of  additional  me¬ 
dical  officers  is  drawn  up  in  so  loose  a 
form  that  it  easily  admits  of  evasion. 
The  terms  “  where  it  may  appear  need¬ 
ful ,”  which  we  have  italicised,  are  too 
vague,  and  offer,  according  to  Clause 
10,  a  great  temptation  to  Boards  of 


PROGRESS  OF  THE  CHOLERA  IN  THE  METROPOLIS. 


801 


Guardians  to  procure  as  much  addi¬ 
tional  work  from  “  the  medical  officers 
employed  by  them”  as  they  possibly 
can,  without  adding  one  farthing  to 
their  expenses.  The  invasion  of  a 
disease  which  is  of  sufficient  impor¬ 
tance  to  draw  forth  such  stringent 
orders  respecting  the  drainage  and 
ventilation  of  houses,  and  the  provision 
of  medicines  for  the  sick  at  the  charge 
of  ratepayers,  would  surely  suffice  to 
justify  the  compulsory  appointment  of 
additional  medical  officers.  The  rule 
should  have  been,  that  so  soon  as 
cholera  appeared  in  a  district,  either 
another  officer  should  be  appointed  to 
superintend  specially  the  progress  of 
the  disease ;  or,  where  the  attendance 
required  by  the  sick  poor  furnishes 
no  impediment,  this  superintendence 
should  be  assigned  to  the  Union  me¬ 
dical  officer,  with  a  proportionate  in¬ 
crease  of  salary.  The  only  reference 
to  additional  payment  which  we  have 
met  with  is  in  a  previous  order  of  the 
General  Board,  dated  October  31  : — 

“  It  appears  to  the  General  Board  of 
Health  to  be  absolutely  necessary,  in 
the  present  emergency,  to  concentrate 
responsibility  on  the  medical  officers, 
and  to  entrust  them  with  discretionury 
powers ,  because  the  rapidity  of  the 
course  of  cholera  will  not  allow  them 
to  wait  for  directions  from  the  guar¬ 
dians  at  their  weekly  meetings;  and 
seeing  the  many  and  arduous  duties 
that  devolve  upon  the  medical  officers, 
the  General  Board  of  Health  cannot 
but  express  a  hope  that  tiie  remunera¬ 
tion  of  these  officers  will  be  more  pro¬ 
portionate  to  the  value  of  the  services 
required  than  it  was  on  the  former 
occasion.” 

We  think  that  there  should  have  been 
something  more  than  a  recommenda¬ 
tion.  No  Board  of  Guardians  can  be 
met  except  by  a  positive  order  as  to 
payment.  This  has  been  long  under¬ 
stood  practically  by  those  who  have 
had  any  dealings  with  them  ;  but  the 
members  of  the  Board  of  Health  do 
not  appear  to  be  acquainted  with  it 
even  theoretically.  It  is  unjust  to  ad 


vise  the  concentration  of  responsibility 
and  the  accumulation  of  professional 
labour  on  the  medical  officers,  and  to 
make  the  remuneration  for  extra-ser¬ 
vices  an  open  question  with  men  who 
have  hitherto  manifested  the  most 
painstaking  ingenuity  to  evade  a  fair 
and  liberal  scale  of  payment  for  ordi¬ 
nary  services.* 


The  cases  of  cholera  during  the  past 
week  have  not  been  numerous  in  com¬ 
parison  to  the  population  ;  but  they 
have  been  marked  with  that  great 
fatality  which  appears  to  be  the  uni¬ 
versal  character  of  this  disease  in  its 
advanced  stage.  On  Thursday  (Nov. 
2nd)  there  were  fifteen  cases  in  the 
metropolitan  districts,  of  which  twelve 
were  fatal ;  and  on  Friday  (Nov.  3rd) 
there  were  ten  new’  cases,  of  which  six 
proved  fatal.  A  more  formal  report 
was  issued  on  Tuesday  last,  from  which 
we  learn,  that  there  weie  on  the  6th 
inst.,  in  London  and  its  vicinity , twenty 
cases,  and  twelve  deaths  ;  on  the  7th, 
seventeen  cases,  and  ten  deaths  ;  and 
on  the  8th,  nine  cases  and  three  deaths. 
The  disease  appears  to  make  no  pro¬ 
gress  in  the  provinces*;  but  .Scotland  is 
at  present  severely  visited.  The  new 
cases,  which  are  reported  in  Edinburgh 
and  its  vicinity,  amount  daily  to  an 
average  of  from  fifty  to  sixty;  and 
about  one  half  of  these  prove  fatal. 
Up  to  the  present  date  (Nov.  8th) 
there  have  been  in  and  around  Edin¬ 
burgh  468  cases,  of  which  no  less  than 
243  have  terminated  fatally. 

The  weekly  return  of  the  Registrar- 
General,  notwithstanding  the  gieat 
prevalence  of  zymotic  diseases,  still 
shows  a  favourable  result  on  the  total 
mortality.  The  deaths  were  39  below 
the  weekly  autumnal  average.  If 
zymotic  diseases  have  increased  the 

*  It  is  reported  that  some  remuneration  will 
be  granted  for  these  extra-sen  ices. 

f  On  the  8th  inst.  there  were  reported  9  cases 
and  8  deaths,  including  some  previously  attacked. 


802 


PRISON  DISCIPLINE,  AND  THE 


deaths  from  270  (aut.  av.)  to  423.  the 
deaths  from  pulmonary  diseases  are 
reduced  from  222  (aut.  av.)  to  125. 

Scarlet  fever  proved  fatal  in  135 
cases,  of  which  133  were  at  the  infan¬ 
tile  period  ;  and  Typhus  fever,  in  77 
cases,  to  an  autumnal  average  of  50 
The  deaths  from  Diarrhoea  and  Cholera 
were  as  follow's  :  — 


Under  15  yrs.  15  to  60  Ab.  60 


Diarrhoea 

21 

9 

8=38 

Cholera  . 

24 

36 

5  =  65 

45 

45 

13 

From  this 

statement  it 

will  be  seen 

that,  considering  these  few  cases  have 
occurredamong  two  millionsof  persons, 
there  is  at  present  nothing  alarming  in 
the  progress  of  the  epidemic.  The 
disease  owes  its  terrors  among  our¬ 
selves,  not  to  the  numbers  attacked, 
but  to  the  large  proportion  of  cases  in 
which  it  proves  fatal. 


THE  TREASURERSHIP  OF  GUY’S  HOSPITAL. 

On  Wednesday,  the  8th  inst.,  at  the  annual 
meeting  of  the  General  Court  of  Governors 
of  this  Hospital,  Bonamy  Dobree,  Esq.  was 
elected  Treasurer  in  the  room  of  Benjamin 
Harrison,  Esq.,  who  has  resigned  that  office, 
after  having  held  it  for  the  lo  g  period  of 
fifty-one  years.  In  the  Report  presented  to 
Parliament  in  June,  1837,  by  the  Commis¬ 
sioners  officially  appointed  to  investigate  the 
state  of  this  charitable  institution,  it  is  ob¬ 
served,  in  reference  to  Mr.  Harrison,  “  that 
his  whole  time,  talent,  and  energies,  have 
for  above  forty  years  been  devoted  to  the 
service  of  the  hospital ;  and  that  the  entire 
course  of  his  administration  has  been  marked 
by  zeal  the  most  active  and  efficient,  as  well 
as  by  the  most  scrupulous  and  disinterested 
integrity.  Not  only  have  his  services  been 
gratuitous,  but  his  connection  with  the  hos¬ 
pital  (in  the  absence  of  a  fund  for  the  assist¬ 
ance  of  distressed  patients  on  their  discharge, 
the  want  of  which  seems  to  be  seriously  felt) 
has  proved  to  him  a  constant  source  of  ex¬ 
pense,  numberless  destitute  persons  having 
been  relieved  by  his  private  benevolence. ” 
Notwithstanding  the  retirement  of  Mr.  Har¬ 
rison,  we  understand  that  the  institution  will 
still  receive  the  benefit  of  his  services  as  a 
governor,  rendered  valuable  by  his  long  ex¬ 
perience. 


Prison  Disci pl'ne,  and  the  advantages 
of  the  Separate  System  of  Imprison¬ 
ment,  with  a  detailed  account  of  the 
Discipline  vow  pursued  in  the  new 
County  Gaol  at  Reading.  By  the 
Rev.  J.  Field,  M.A.,  Chaplain.  2 
vols.  pp.  900.  London  :  Longman 
and  Co.  Reading  :  Welch.  1S48. 

The  author’s  object  in  the  publication 
of  this  work  is  to  call  attention  to  the 
great  importance  of  the  separate  con¬ 
finement  of  prisoners.  Formerly,  all 
prisoners  were  associated  together  in¬ 
discriminately.  Under  such  an  ar¬ 
rangement,  as  may  be  conceived,  the 
most  atrocious  malefactor  was  the  hero 
of  the  society,  and  a  school  was  formed 
for  the  study  of  vice,  in  which  the 
scholars  made  rapid  progress.  The 
poacher,  imprisoned  for  his  first  and 
perhaps  trivial  offence,  left  the  prison 
more  accomplished  in  crime — in  short, 
the  inmates  of  our  gaols  were  riot  re¬ 
formed,  but  rendered  greater  pests  to 
society. 

So  entirely  without  discipline  w'ere 
prisons,  that  at  that  period  the  office 
of  gaoler  was  often  held  by  women, 
and  the  gaolera  had  the  privilege 
of  selling  beer  and  spirits  to  the  pri¬ 
soners,  wdiich,  indeed,  constituted  the 
chief  emoluments  of  office.  The  time 
of  the  prisoners  was  wholly  unoccu¬ 
pied,  and  the  prison  was  the  perpetual 
scene  of  gambling,  riot,  blasphemy, 
and  debauchery. 

To  remedy  some  of  these  gross  abuses, 
what  is  called  the  silent  system  was 
adopted.  Thisconsists  in  strictly  forbid¬ 
ding  the  slightest  conversation  among 
the  prisoners  on  pain  of  punishment 
for  each  violation  of  the  rule.  Labour, 
in  the  shape  of  the  treadwheel,  forms 
part  of  the  penalty  under  this  system. 

“It  has,  however,  been  found  by  experi¬ 
ence  to  be  utterly  impossible  to  enforce 
silence  among  prisoners  ;  for  the  reason, 
that  it  is  in  opposition  to  one  of  the 
strongest  principles  of  our  nature  ;  it  is  in 
fact  an  impracticable  scheme  of  punishment. 
The  certain  effect  of  the  silent  system  is  to 
encourage  hypocrisy,  and  to  teach  fraud  of 
the  same  nature  as  those  evils  for  which  the 
criminals  are  imprisoned.  Thus,  during 
their  confinement,  the  prison  becomes  a 
school,  not  for  teaching  obedience  to  the 


ADVANTAGES  OF  THE  SEPARATE  SYSTEM  OF  IMPRISONMENT.  803 


law,  but  for  suggesting  plans  for  evading 
and  violating  it.”  (p.  31.) 

The  silent  syslem,  therefore,  while  on 
the  one  hand  it  fails  to  prevent  the 
evils  of  association,  on  the  other  is 
not  without  some  injustice;  for,  crimi¬ 
nals  who  were  sentenced  to  suffer  but 
one  punishment — viz.impibonment,are 
in  reality  condemned  to  a  great  many 
punishments  for  sinning  against  the 
rule  of  silence;  while  to  observe  it,  is 
in  reality  to  act  against  the  lawT 
of  nature.  To  demonstrate  how 
fruitless  it  is  to  attempt  to  stop  the 
evils  of  communication  by  this  plan, 
our  author,  among  numerous  proofs, 
quotes  the  evidence  of  Mr.  Baron 
Alderson  before  the  House  of  Lords, 
(1847)  where  he  says,  “  1  have  known 
an  instance  in  which  a  regular  plan  for 
a  robbery,  that  took  effect,  and  was 
tried  before  me,  was  laid  in  one  of 
what  is  called  our  best  regulated  gaols , 
and  on  the  treadmill.  The  instrument 
there  was  a  boy,  and  the  principals 
were  adult  thieves.” 

Mr.  Field  insists,  too,  upon  the  fact 
that  hard  labour  is  not  conducive  to 
reformation.  In  the  most  robust  he 
declares  that  it  only  produces  mental 
irritation  and  feelings  of  revenge; 
while  the  le-s  strong  sometimes  suffer 
so  severely  as  to  be  unable  to  walk 
from  the  prison  at  the  expiration  of 
their  period  of  confinement.  A  serious 
obstacle  to  the  reformation  of  those 
who  are  thus  imprisoned,  also  exists  in 
the  recognition  of  them  by  their  com¬ 
rades  in  gaol,  who  either  lure  them 
away  from  industrious  pursuits,  or,  if 
repulsed,  drive  them  from  their  posi¬ 
tion  by  proclaiming  their  former  dis¬ 
grace. 

The  confinement  of  each  prisoner  in 
a  separate  cell,  however,  overcomes  all 
these  objections,  and,  as  at  present 
conducted,  Mr.  Field  believes,  and 
endeavours  to  shew,  that  it  is  attended 
with  the  best  results.  The  prison  is 
dreaded,  reformation  advances,  and  re¬ 
commitments  are  greatly  reduced  in 
number.  It  may  be  here  remarked, 
that  v\hat  is  called  the  separate  system 
is  not  to  be  confounded  with  solitary 
confinement  —  a  measure  which,  as 
practised  in  America,  is  found  to  be 
fraught  with  evils  from  which  this  is 
perfectly  tree.  The  prisoner  daily  re¬ 
ceives  visits  from  the  governor,  the 


chaplain,  the  medical  attendant,  a 
trades- teacher,  and  schoolmaster:  he 
is  placed  in  a  well-ventilated  and  suffi¬ 
ciently-warmed  apartment,  and  he  is 
fed  and  exercised  with  reference  to  the 
maintenance  of  health.  To  bring 
about  such  objects  as  these,  the  labours 
of  those  great  philanthropists,  Howard, 
Wilberforce,  and  Buxton,  who  paved 
the  way,  have  not  been  exerted  in 
vain.  Every  possible  device  is  resorted 
to  which  can  tend  to  accomplish  re¬ 
formation.  The  feeling  of  shame  is 
attempted  to  be  awakened  and  kept 
al  ve;  habits  of  industry  are  cultivated, 
and  every  agreeable,  religious,  and 
moral  instruction  is  imparted. 

The  frightful  evil  of  sending  forth  a 
felon  population  to  our  penal  colo¬ 
nies  has  become  so  overwhelming  as  to 
render  its  abolition  absolutely  neces¬ 
sary  ;  and  the  subject  of  pris  m  disci¬ 
pline,  and  the  disposal  of  our  malefac¬ 
tors,  is  for  ed  on  the  government  as  a 
matter  which  admits  of  no  delay.  It 
has  been  suggested,  by  the  Home 
Secretary,  that  this  separate  syslem 
should  form  a  probationary  portion  of 
the  sentence  of  transportation,  at  the 
termination  of  which  the  convict  is  to 
be  banished  from  this  country,  as  an 
emigrant,  free  to  commence  a  new 
career  in  the  country  to  which  he  is 
permitted  to  go;  the  expense  of  his 
passage  thither  being  paid  out  of  the 
earnings  of  his  own  industry.  Expe¬ 
rience  has  already  shewn,  as  far  as  the 
scheme  has  been  tried,  thatthe-e  exiles , 
as  they  are  called,  quickly  find  em¬ 
ployment  at  the  places  where  they 
have  been  invited  by  the  local  authori¬ 
ties,  in  communications  to  our  govern¬ 
ment.  Mr.  Field’s  work  abounds  with 
facts  which  bear  out  the  importance 
and  value  of  the  scheme  which  is  now 
in  operation  in  many  of  our  prisons.  It 
is  written  without  much  regard  to  ar¬ 
rangement,  but  it  is  the  work  of  one 
who  has  had  great  experience  in  thesub- 
jecton  which  he  writes,  audit  contains 
much  valuable  information  in  reference 
to  prison  discipline.  To  the  medical 
profession  it  will  be  found  of  interest, 
in  reference  to  the  hygiene  of  prisons: 
but' the  facts  are  not  numerous  as  re¬ 
gards  this  part  of  the  subject.  It  is, 
however,  shewn  that  insanity  (fears 
respecting  which  formed  an  argument 
against  the  separate  system)  is  not 
more  common  among  prisoners  than. 


804  "REGISTER  OF  CASES  OF  CHOLERA.  DISCUSSION  ON  CHOLERA. 


in  the  selected  household  troops  ;  and 
that  precautions  with  reference  to  dusty 
trades  have  greatly  reduced  the  mor¬ 
tality  from  phthisis. 

The  author,  in  his  chapter  on  the 
causes  of  crime,  alleges  that  to  obtain 
the  prison  dietary  ( which  is  better  than 
the  homes  of  the  honest  and  industrious 
poor  afford), isthe  direct  inducement  for 
its  commission  in  some  instances,  and 
his  f  icts  bear  out  the  assertion.  To 
remedy  this,  and  as  a  safeguard  against 
gluttony,  he  suggests  that,  the  provi¬ 
sions  should  be  of  coarser  quality,  and 
that  the  quantity  should  be  regulated 
by  the  medical  officer  (as  in  the  matter 
of  flogging  in  the  army,  we  suppose), 
on  the  principle  of  how  much  penance 
can  be  borne.  We  think  it  unwise, 
however,  to  risk  the  chance  of  making 
prisons  schools  for  the  study  of  dys¬ 
pepsia,  or  in  any  way  reducing  the  very 
satisfactory  sanitary  condition  of  these 
establishments.  It  will  be  safer  to 
trust  to  the  judicious  experiments  of 
the  worthy  chaplain  on  the  consciences 
of  criminals  for  the  repression  of  crime; 
and  we  shall  be  glad  to  find  that  an 
office  like  that  winch  he  holds,  will  be 
always  allotted  to  men  who  possess  the 
same  amount  of  ability  and  enthusiasm 
in  so  philanthropic  a  cause. 


An  Introduction  to  Practical  Chemistry, 
including  Analysis.  By  John  E. 
Bowman,  Demonstrator  of  Chemistry 
in  King’s  College.  Small  8vo.  pp. 
280.  London  :  Churchill.  1848. 

This  is  one  of  a  class  of  books,  now  be¬ 
coming  numerous,  which  is  intended 
to  assist  the  medical  student  in  master 
ing  the  rudiments  of  Practical  Chemis¬ 
try.  The  experiments  are,  on  the 
whole,  well  devised, — the  illustrations 
are  numerous,  and  the  work  is  neatly 
got  up.  While  there  is  nothing  new 
in  the  volume,  we  must  do  the  author 
the  justice  to  say  that  he  has  treated  the 
subject  in  a  very  satisfactory  manner. 
Many  useful  tables  are  appended  to 
the  work. 


Register  of  Cases  of  Cholera  pro¬ 
fessionally  attended.  8*o.  London: 
Smith,  49,  Long  Acre.  1848. 

This  will  be  found  a  useful  volume  to 
those  who  are  disposed  to  keep  a  record 
of  the  experience  which  they  are  likely 
to  acquire  by  the  reappearance  of 
Asiatic  Cholera  in  this  country.  So 


little  is  really  kno^n  of  this  disease, 
that  every  medical  practitioner  called 
to  attend  cases  of  cholera,  will  confer 
a  benefit  on  science  by  registering  daily 
the  results  of  his  observations,  and  the 
effect  of  various  modes  of  treatment. 

The  volume  before  us,  which  is  of 
moderate  size,  and  adapted  for  the 
pocket,  consists  of  a  series  of  ruled 
pages,  with  columns  referring  to  the 
most  important  facts  which  require  re¬ 
gistration  We  recommend  it  to  the 
notice  of  medical  officers  of  unions,  and 
of  all  o'heis  who  may  be  called  upon 
to  treat  cases  of  cholera. 


^loccehtng^  of  j£octeftes. 


SOUTH  LONDON  MEDICAL 
SOCIETY. 

October  28,  1848. 

John  Hilton,  Esq.,  F.R.C.S.,  President, 
in  the  Chair. 


On  the  President  inquiring  if  the  members 
present  had  met  with  any  cases  of  Cholera 
in  their  own  immediate  neighbourhood — 

Dr.  Silvester  replied  that  he  had  seen 
one  case  at  Clapham  :  the  symptoms  were 
in  every  respect  those  of  Asiatic  cholera, 
and  that  nine  hours  only  elapsed  between 
the  attack  and  the  fatal  termination. 

Mr.  Owen  also  observed  he  had  met 
with  two  cases  in  the  same  house,  and  that 
one  died  in  three  days,  and  the  other  in  six¬ 
teen  hours. 

Mr.  Waterworth  inquired  if  there  were 
no  premonitory  symptoms  in  the  cases  pre¬ 
senting  themselves  to  the  different  practi¬ 
tioners,  as  he  could  scarcely  believe  in 
cholera  commencing  and  ending  fatally  in  a 
few  hours.  In  all  his  cases  a  premonitory 
symptom,  as  diarrhoea,  existed,  but  was 
forgotten  or  passed  over  as  not  worth  men¬ 
tioning.  At  the  present  time  he  believed 
there  was  a  great  tendency  to  diarrhoea,  and 
differing  from  the  common  form  in  the 
great  amount  of  mental  depression,  as  in 
almost  all  other  diseases  now  prevalent,  but 
that  the  symptom  of  diarrhoea,  if  not  ne¬ 
glected,  was  easily  under  control. 

Dr.  Silvester  observed,  there  was  slight 
diarrhoea  for  a  few  days  in  the  case  he  had 
related.  The  patient  had,  moreover,  been 
exposed  to  the  effluvium  of  a  drain  ;  but 
another,  who  was  more  so,  escaped  any  dis¬ 
ease. 

On  the  President  inquiring  of  Mr. 
Waterworth  what  were  the  remedies  he  em¬ 
ployed  in  the  early  stages,— 


DISCUSSION  ON  THE  TREATMENT  AND  SYMPTOMS  OF  CHOLERA.  805 


Mr.  Waterworth  said,  the.  remedies  he 
found  most  successful  were  small  doses  of 
calomel  with  opium  and  rhubarb,  followed 
by  Pulv.  Ipecac.  Comp,  every  three  hours, 
with  ris^id  diet.  Under  this  treatment  he 
found  the  disease  controllable,  but  tedious, 
requiring  care  and  watching,  getting  well 
for  a  few  days,  and  then  returning  from  the 
slightest  cause. 

Mr.  Evans  believed  there  must  be  some 
peculiar  atmospheric  influence  which  pro¬ 
duced  such  depression  of  the  spirits  and  of 
the  system  in  general,  in  the  persons  who  are 
now  ill,  and  inquired  of  the  members  if  they 
had  met  with  any  cases  where,  from  the 
aspect  of  the  patient,  they  would  be  led  to 
expect  there  had  been  severe  purging,  but 
where,  on  inquiry,  such  had  not  occurred, 
although  the  symptoms  were  those  of  a  feel¬ 
ing  as  if  they  should  be  violently  purged, 
together  with  a  furred  tongue  and  great  de¬ 
bility  ?  He  also  did  not  believe  in  the  cir¬ 
cumstance  alluded  to,  that  a  previous  diar¬ 
rhoea  always  existed,  as  he  remembered 
many  instances,  when  the  cholera  was  last 
in  this  country,  of  persons  being  attacked 
when  in  perfect  health,  and  dying  the  same 
day  ;  and  in  two  cases  he  saw,  the  patients 
were  thrown  into  a  complete  state  of  collapse 
after  only  two  copious  evacuations. 

Dr.  Lodge  said,  nine  cases  had  occurred 
at  Peckham,  and  that  four  had  died,  the 
time  elapsing  between  ihe  attack  and  death 
being  between  four  and  twelve  hours.  In 
these  cases  there  had  been  no  purging  pre¬ 
viously  to,  and  but  little  during  the  attack. 
For  the  relief  of  the  cramps,  chloroform  was 
had  recourse  to,  and  in  one  case  with  the 
greatest  benefit,  the  cramps  subsiding  and 
the  blueness  disappearing  ;  but  in  the  other 
patients  its  influence  was  only  temporary. 

Mr.  Wright  thought,  in  five  cases  out 
of  six,  diarrhoea  was  a  promonitory  symp¬ 
tom,  which  was  frequently  checked  by  a 
single  opiate;  but  in  some  cases  the  patients 
were  struck  down  suddenly  as  if  poisoned  ; 
and,  in  answer  to  Mr.  Robinson,  said  he 
had  usually  observed,  on  dissection,  a  papular 
eruption  on  the  inner  surface  of  the  small 
intestines  and  caecum  ;  no  bile  in  the  intes 
tines,  but  ’  sometimes  filled  with  a  large 
quantity  of  serous  fluid  to  the  amount  of 
a  few  gallons,  and  a  loaded  gall-bladder, 
although  he  was  unable  to  find  that  its  dis¬ 
tension  arose  from  any  obliteration  of  the 
duct. 

Mr.  Robinson  had  not  seen  any  cases 
during  the  latter  part  of  the  year,  but  in 
February  last  he  saw  a  case  where  a  lady 
died  in  his  presence  apparently  from  col¬ 
lapse  :  she  was  of  intemperate  habits,  had 
diarrhoea,  and  vomited.  Six  weeks  after¬ 
wards  two  other  cases  occurred,  with  rice- 
water  vomiting,  and  the  same  kind  of  stools. 
They  were  treated  with  large  doses  of  calomel 


(Dj.)  and  ammonia  to  begin  with,  and  fol¬ 
lowed  by  10  grs.  4tis  horis.  By  this  treat¬ 
ment  the  cramps  ceased,  and  the  secretions 
from  the  bowels  became  pitchy.  In  the 
cholera  of  1832,  the  gall  bladder  was  seen, 
on  dissection,  enormously  distended  with 
bile;  and  he  was  consequently  of  opinion 
that  there  is  some  connection  between 
spasm  and  distension  of  the  gall  bladder  and 
the  disease,  but  was  incompetent  to  explain 
the  phenomenon  :  he  believed  also  that  the 
use  of  op'um  was  highly  injurious. 

Dr.  Gull  said,  he  had  examined  a  mass 
of  evidence  placed  at  his  disposal  by  Dr. 
Babington,  and,  from  the  various  reports  of 
the  post-mortem  appearances,  it  appears’ 
that  the  most  frequent  is  the  papular  erup¬ 
tion  before  mentioned,  and  an  enlargement 
of  the  glands  of  the  small  intestines,  similar 
to  that  seen  on  the  mucous  membrane  in  the 
serous  discharge  of  Bright’s  disease  of  the 
kidney.  He  thought  also  it  was  Foville  who 
states  this  appearance  is  most  evident  in  the 
third  stage  ;  also  that  there  is  a  membranous 
inflammation  in  the  cranium  when  the  con¬ 
secutive  fever  follows,  and  that  the  heart  is 
empty,  but  the  veins  full. 

Mr.  Waterworth  could  not  help  ob¬ 
serving  that  a  most  peculiar  part  of  the  dis¬ 
ease  was  the  fact  of  the  patients  so  strongly 
denying  the  existence  of  any  previous  diar¬ 
rhoea. 

Dr.  Silvester  fully  agreed  with  Mr. 
Waterworth.  that  there,  was  a  great  dislike  to 
acknowledge  a  diarrhoea,  if  the  question  was 
asked  in  such  a  manner  as  to  give  rise  to 
the  idea  of  the  disease  being  cholera. 

Dr.  Murphy  stated  that  he  had  used 
transfusion  in  37  cases,  and  that  in  seven 
an  immediate  and  perfect  recovery  took 
place  ;  and,  in  answer  to  the  President,  said 
he  made  the  fluid  as  nearly  resemble  the 
serum  of  the  blood  as  possible  ;  that  it  was 
transfused  at  the  temperature  of  98°  Fah., 
and  to  the  extent  of  four  or  five  quarts,  but 
that  he  would  not  employ  it  again,  as  he 
saw  as  many  recover  without  its  use. 

Mr.  Wright  said  transfusion  had  been 
tried  in  St.  Peter’s  Hospital,  Birmingham, 
to  the  quantity  of  a  pint,  but  with  no  be¬ 
nefit. 

Dr.  Gull  said  his  reading  led  him  to 
think  that  most  cases  began  with  a  diarrhoea 
of  one  or  two  to  twenty-four  hours’  dura¬ 
tion.  In  hospital  practice  there  was  no  evi¬ 
dence  of  dysentery  or  erysipelas  being  more 
prevalent  than  usual,  so  that  atmospheric 
influence  was  not  considered  there  as  an 
exciting  cause.  He  inquired  also  if  any 
gentleman  had  tried  large  doses  of  quinine, 
as  he  was  aware  it  had  been  prescribed  in 
small  quantities. 

Mr.  Waterworth  recollected  a  gentle¬ 
man  in  Persia  had  recommended  the  use  of 
large  doses  of  quinine,  because  the  cold 


806 


DTSCCSSTON  ON  CHOLERA - TREATMENT. 


stage  of  cholera  presented  so  close  a  resem¬ 
blance  to  ague;  and,  in  alluding  to  the  great 
diversity  of  opinion  as  to  the  treatment, 
mentioned  the  circumstance  of  two  such 
opposite  remedies  as  opium  and  croton  oil 
being  equally  strongly  advised  by  their  advo¬ 
cates. 

Mr.  Wright  believed  that  in  India,  as 
in  England,  the  treatment  found  to  be  most 
successful  was  that  of  opium  combined  with 
stimulants,  as  the  Liq.  Ammon. ;  and  he 
thought  also  that  the  use  of  croton  oil  was 
now  quite  exploded. 

A  tew  remarks  were  then  made  by  Dr. 
Murphy  on  the  cause  of  the  cramps,  when 
the  Society  adjourned. 

In  consequence  of  the  subject  of  Cholera 
being  introduced,  Mr.  H.  K.  Owen’s  case  of 
“  Laceration  of  the  Liver”  was  postponed 
until  the  next  meeting,  Nov.  9th,  1848. 


MEDICAL  SOCIETY  OF  LONDON. 

Monday,  October  30,  1848. 

Mr.  Hancock,  President. 

Cholera. 

Mr.  Headland  said,  that  if  the  cases  in 
Peckham  Asylum,  alluded  to  at  the  last 
meeting  of  the  Society,  were  really  those  of 
genuine  cholera,  it  was  remarkable  that  the 
disease  had  been  confined  to  that  locality 
entirely.  He  could  hardly  help  expressing 
a  doubt  of  the  identity  of  the  disease,  which 
he  considered  not  to  be  genuine  cholera,  but 
the  result  of  the  sulphuretted  hydrogen. 

Mr.  Shearley’  mentioned  some  cases  in 
which  no  kind  of  premonitory  symptoms 
preceded  the  stage  of  collapse — he  spoke  of 
the  epidemic  of  1832. 

Mr.  Clarke  believed  that  very  few  cases 
of  cholera  indeed  had  occurred  in  London. 
Every  one  acquainted  with  the  disease,  as  it 
exhibited  itself  in  1832,  must  have  been 
convinced  that  many  of  the  cases  recorded 
as  malignant  cholera,  were  not  cases  of  that 
disease  at  all. 

Dr.  Chowne  had  seen  much  of  the  cho¬ 
lera  of  1832.  He  should  have  doubted,  if 
it  were  not  for  the  respectable  names  con¬ 
nected  with  some  of  the  reports,  whether 
any  cases  of  cholera  maligna  had  really 
occurred.  He  went  on  to  state  that  cases 
of  English  cholera,  particularly  in  the  fenny 
districts  of  Lincolnshire,  occasionally  pre¬ 
sented  symptoms  which,  to  the  uninitiated 
eye,  might  easily  be  mistaken  for  those  of 
Asiatic  cholera.  So  in  the  present  epidemic, 
cases  of  English  cholera  of  a  severe  form 
might  be  mistaken,  even  by  good  practi¬ 
tioners,  for  the  Asiatic  disease.  The  dis¬ 


eases,  indeed,  seemed  to  shale  off  into  one 
another.  He  spoke  of  the  influence  of  fear 
on  the  production  of  the  disease,  and  of  the 
disposition,  in  times  of  alarm,  to  aggravate 
all  cases. 

Dr.  Waller  thought  we  should  treat 
cholera  most  successfully  when  guided  in 
our  practice  by  general  principles.  Cases 
often  occurred  without  premonitory  symp¬ 
toms.  He  related  a  case  which  occurred  in 
1832,  in  which  he  was  induced  to  inject  a 
saline  fluid  into  the  veins.  Death  was  not 
averted,  but  made  more  terrible.  He  re¬ 
garded  the  English  and  Asiatic  forms  of 
cholera  as  perfectly  distinct  diseases. 

Mr.  Hooper  had  used  saline  injections 
in  one  case  in  1832.  The  effect  was  most 
decided  and  marked.  The  collapsed  state 
was  immediately  removed  on  three  succes¬ 
sive  applications  of  the  remedy,  and  though 
death  was  not  averted,  the  proceeding  gave 
him  a  favourable  opinion  of  the  plan  of 
treatment.  He  regarded  cholera  as  a  dis¬ 
ease  of  the  blood.  With  respect  to  the  pre¬ 
sent  epidemic,  he  had  seen  some  severe  and 
rapidly  fatal  cases,  but  they  were  not  the 
cholera  of  1832,  although  he  was  ready  to 
admit  he  had  seen  no  cases  of  cholera  so 
severe  since  the  epidemic  of  that  period. 
He  did  not  believe  it  contagious,  and  illus¬ 
trated  this  opinion  by  several  facts  bearing 
on  the  point. 

Dr.  Golding  Bird  said,  that  in  Guy’s 
Hospital,  situated  in  the  neighbourhood  of 
the  river,  and  much  crowded  places,  not  a 
single  case  of  Asiatic  cholera  had  presented 
itself.  A  man  had  been  brought  in  dead 
from  a  vessel  just  arrived  from  the  Baltic. 
We  seemed,  at  present,  puzzled  as  to  the 
treatment  of  this  disease,  the  very  opposite 
modes  being  recommended.  He  must  con¬ 
fess  that  he  looked  with  some  horror  at  the 
withdrawal  of  the  quarantine,  and  could  not 
help  thinking  positive  facts  showed  the  con¬ 
tagious  character  of  cholera  when  favourable 
circumstances  for  infection  presented  them¬ 
selves.  Last  year  he  had  seen  four  cases  of 
what  was  considered  malignant  cholera,  but 
no  official  notice  was  taken  of  it.  He  re¬ 
marked,  as  a  somewhat  curious  fact,  that  of 
late,  ozone,  or  peroxide  of  hydrogen,  had 
been  found  in  the  atmosphere.  Dr.  Schon- 
bein,  he  knew,  had,  at  one  time,  regarded 
this  agent  as  the  principle  of  malaria ;  he 
knew  not  whether  he  had  altered  that 
opinion. 

Mr.  Middleton  regarded  calomel  and 
opium  as  the  mainstay  in  cholera.  He  be¬ 
lieved  the  medical  gentlemen  at  Peckham 
had  seen  too  much  of  the  disease  in  1832,  to 
be  mistaken  in  the  identity  of  the  disease. 


DISCUSSION  ON  CHOLERA - TS  IT  CONTAGIOUS? 


807 


WESTMINSTER  MEDICAL 
SOCIETY. 

October  29,  1848. 

J.  Webster,  M.D.,  F.R.S.,  President. 

The  adjourned  discussion  of  this  evening, 
though  long  and  wearisome,  may  be  sum¬ 
med  up  in  a  very  few  words.  Dr.  Searle 
spoke  for  thirty-five  minutes  ;  the  result 
of  bis  discursive  oration  wTas  to  convey  to 
the  Society  that  he  had  not  the  most  re¬ 
mote  conception  that  cholera  was  contagious  ; 
that  it  essentially  consisted  of  a  congestion 
of  the  vital  organs ;  that  it  was  caused  by 
malaria,  or  electrical  conditions  of  the  atmo¬ 
sphere;  and  that  it  was  to  be  cured  by  large 
doses  of  calomel,  drinking  plentifully  of  cold 
water,  and  “attending  to  the  dictates  of 
Nature.  ” 

Dr.  King,  in  1832,  had  found  calomel  in 
large  doses,  and  drinking  cold  water  ad  libi¬ 
tum,  a  most  successful  plan  of  treatment. 

Dr.  Garrett  had  found  large  doses  of 
calomel  of  no  avail  in  India,  as  the  patients, 
in  the  really  bad  cases,  sunk  before  the  calo¬ 
mel  could  act.  To  establish  reaction  as 
quickly  as  possible,  was  the  most  effectual 
mode  of  arresting  the  fatal  termination.  This 
was  effected  in  many  cases  by  strong  stimu¬ 
lants.  This  plan  had  been  found  of  avail  in 
most  cases  in  Syria  :  he  read  an  extract  of  a 
letter  on  this  point  from  a  practitioner  in 
Syria. 

Mr.  O’Connor  made  some  judicious  re¬ 
marks  on  the  treatment  of  the  disease. 

Mr.  Wing  had  had  some  experience  in 
the  treatment  of  this  disease  ;  and  the  con¬ 
clusion  he  had  arrived  at  many  years  since 
was,  that  the  disease  essentially  consisted  of 
a  “  diverted  action” — the  function  of  one 
organ  being  preternaturally  excited,  at  the 
expense  of  the  functions  of  others.  He  illus¬ 
trated  this  by  reference  to  the  arrested  func¬ 
tion  of  the  kidney  and  liver,  and  the  in¬ 
creased  action  of  the  stomach  and  bowels. 
This  view  of  the  pathology  of  this  disease, 
which,  as  far  as  he  knew,  had  never 
been  broached,  simplified  our  treatment. 
This  showed  that  the  primary  object  of  the 
practitioner  was  the  arrest  of  the  bowel  dis¬ 
charge,  which  not  only  interfered  with  the 
secretion  of  urine,  but  abstracted  heat  from 
the  surface,  and  in  truth  was  the  immediate 
cause  of  the  collapse.  Of  course,  attention 
to  the  state  of  the  surface  was  necessary. 

Dr.  Webster  made  some  valuable  statis¬ 
tical  remarks,  which  shewed  that  the  fatal 
cases  of  cholera,  so  called,  had  been  much 
less  during  the  six  weeks  just  ended  than 
they  were  in  the  corresponding  period  last 
year. 

Mr.  Hird  having  replied,  the  Society  ad¬ 
journed. 


NEWCASTLE  AND  GATESHEAD 
PATHOLOGICAL  SOCIETY. 

October  9, 1848. 

A  new  Society  under  this  title  has  re¬ 
cently  been  formed  in  Newcastle-on-Tyne, 
and,  as  it  does  not  interfere  with  any  exist¬ 
ing  institution,  we  trust  that  the  copious 
materials  for  the  study  of  pathology  fur¬ 
nished  by  that  populous  and  important  dis¬ 
trict,  will  henceforth  be  made  available  for 
the  improvement  of  medical  science.  The 
first  meeting  was  held  on  the  9th  October 
last  —  Dr.  Headlam,  President,  in  the 
chair. 

Case  of  Aortic  Aneurism. 

Sir  John  Fife  exhibited  and  communi¬ 
cated  the  history  of  a  ca:  e  of  aortic  aneurism, 
which  had  perforated  the  sternum  and 
formed  a  large  subcutaneous  tumor, 
burst  externally.  The  patient,  a  strong, 
healthy  man,  aged  62,  a  pilot,  9  months 
before  death  first  observed  a  small  pulsating 
tumor  on  the  left  side  of  the  sternum,  be¬ 
tween  the  cartilages  of  the  third  and  fourth 
ribs  :  this  gradually  increased  in  size  until 
it  attained  an  extent  of  seven  inches  by  four 
and  a  half;  its  long  diameter  corresponding 
to  that  of  the  sternum.  On  his  admission 
into  the  Newcastle  Infirmary,  six  weeks 
before  death,  the  tumor,  which  occupied  the 
whole  of  the  superior  portion  of  the  left  half 
of  the  sternum,  was  divided  into  lobes  of 
nearly  equal  size :  the  lower  lobe  was  firm, 
and  the  integuments  covering  it  retained  their 
natural  appearance.  The  upper  lobe  was 
soft,  and  of  a  red  colour,  resembling  an 
ordinary  abscess  :  it  extended  an  inch  above 
the  clavicle,  distorting  the  left  sterno- mas¬ 
toid  muscle.  There  was  a  powerful  impulse 
on  placing  the  hand  upon  it  ;  and  this  im¬ 
pulse  was  perceptible  even  when  the  tumor 
was  covered  by  the  patient’s  dress.  A  loud 
bellows  murmur  was  heard  at  the  upper  part 
of  the  tumor  under  the  right  clavicle,  and 
also  over  the  right  carotid.  There  was  no 
bruit,  with  the  heart’s  sound  ;  the  patient 
suffered  from  occasional  fits  of  pain  in  the 
right  chest. 

About  a  week  before  death  there  was  an 
oozing  of  blood  from  the  upper  part  of  the 
tumor;  the  cuticle  was  described  as  crack¬ 
ling  at  each  pulsation.  On  the  30th  of 
September,  whilst  in  the  act  of  defecating, 
the  upper  lobe  burst,  the  blood  spouting  to 
a  distance  of  two  yards.  On  examination, 
the  arcti  of  the  aorta  was  found  greatly 
dilated ;  the  aneurism  arising  from  this 
dilated  portion  of  the  vessel  immediately 
below  the  origin  of  the  innominata.  The 
aneurismal  sac,  whilst  within  the  thorax, 
was  firmly  adherent  to  the  costal  cartilage 
of  the  right  side  and  adjacent  portion  of  the 
sternum,  and  had  consequently  perforated 


SG8  ON  THE  NATURE  AND  TREATMENT  OF  EPIDEMIC  CHOLERA. 


the  sternum  very  obliquely  from  right  to 
left,  so  as  to  project  anteriorly  on  the  left 
side  of  that  bone,  and  even  to  cause  the  ab¬ 
sorption  of  part  of  the  contiguous  costal  car¬ 
tilages.  This  is  probably  referable  to,  in¬ 
asmuch  as  it  corresponds  with,  the  direction 
which  the  jet  of  arterial  blood  would  assume 
on  entering  the  aneurismal  sac  obliquely. 

Aneurism  of  the  Arch  of  the  Aorta. 

Dr.  White  communicated  the  particu¬ 
lars  of  another  case  of  aneurism  of  the  arch 
of  the  aorta,  in  which  the  tumor  had  pressed 
upon  the  trachea  so  as  to  give  rise  to  some 
of  the  symptoms  of  chronic  tracheitis,  and 
to  induce  one  gentleman  who  saw  the  case 
to  regard  the  disease  as  an  inflammatory 
affection  of  the  large  air  tube.  The  patient, 
at  the  time  of  his  admission  into  the  Infir¬ 
mary,  had  been  unwell  for  two  months;  he 
complained  of  difficulty  of  swallowing,  and 
of  a  sensation  as  if  the  food  was  obstructed 
in  its  passage.  There  was  no  dyspnoea ,  but 
he  had  occasional  wheezing,  not  amounting 
to  cough,  with  pains  shooting  through 
the  upper  and  anterior  part  of  the  right  chest. 
There  was  some  dulness  on  percussion  below 
the  right  sterno-clavicular  articulation,  with 
increased  impulse  of  the  heart  in  that  direc¬ 
tion  ;  the  heart’s  sounds  being  as  distinctly 
audible  there  as  over  the  precordial  region. 
There  was  no  bruit  there,  nor  with  the 
heart’s  action.  A  very  slight  dulness  was 
perceptible  above  the  spine  of  the  right  sca¬ 
pula  near  to  the  spinal  column,  and  the 
heart  s  sounds  were  heard  there.  He  had 
lived  very  freely. 

About  a  month  after  his  admission  he 
was  for  the  first  time  affected  with  dyspnoea  ; 
the  cough  continued,  and  had  become  more 
severe,  occurring  in  paroxysms  ;  the  expec¬ 
toration  was  copious,  but  consisted  solely  of 
mucus.  It  was  now  suggested  that  the  con¬ 
stant  short  harassing  cough  might  arise 
simply  from  tracheitis  ;  and  though  retaining 
the  belief  that  the  disease  was  aneurismal, 
Dr.  White  consented  to  act  upon  this  sug¬ 
gestion,  on  the  ground  that  if  the  patient 
derived  no  permanent  benefit  from  the 
change  of  treatment,  he  might  perhaps  ob¬ 
tain  some  temporary  relief. 

The  ordinary  treatment  for  chronic  tra¬ 
cheitis — viz.  mercury,  leeches,  and  blisters, 
was  accordingly  pursued,  though  without 
any  advantage  ;  and  on  the  10th  of  August, 
nearly  two  months  after  admission,  whilst 
coughing,  he  for  the  first  time  brought  up 
a  mouthful  of  blood  of  a  florid  colour.  The 
haemorrhage  continued  for  a  quarter  of  an 
hour,  when  he  died. 

On  examination,  an  aneurism  of  the  size 
of  an  orange,  arising  from  the  arch  of  the 
aorta  opposite  the  origin  of  the  brachio¬ 
cephalic  artery,  was  found  to  extend  across 
the  trachea,  into  which  it  had  ultimately  burst 


by  a  small  aperture  about  the  size  of  a  crow's 
quill,  situated  half  an  inch  above  the  bifur¬ 
cation  into  the  bronchi. 

Diseased  Arachnoid  Membrane  taken  from 
the  brain  of  a  lunatic. 

Mr.  Furness,  in  exhibiting  a  diseased 
arachnoid  membrane  taken  from  the  brain 
of  a  lunatic,  related  the  particulars  of  the 
case.  The  patient,  who  had  been  a  soldier, 
and  whose  insanity  had  supervened  on  ex¬ 
cessive  drinking,  was  admitted  into  an 
asylum  three  weeks  after  the  commencement 
of  the  disease,  at  which  time  he  was  in  a 
state  of  considerable  excitement.  At  the 
end  of  a  m  mth  he  had  passed  into  the  op¬ 
posite  condition  of  extreme  stupidity,  from 
which,  alter  the  application  of  the  actual 
cautery  to  the  back  of  the  neck,  he  so  far 
recovered  as  to  become  civil,  tranquil,  and 
cleanly,  but  he  continued  in  a  state  of  de¬ 
mentia;  and  sixteen  months  after  his  ad¬ 
mission,  he,  without  any  apparent  cause, 
rapidly  decayed  both  in  mind  and  body,  and 
died  utterly  unconscious. 

His  head,  which  was  the  only  part  ex¬ 
amined,  presented  the  following  appear¬ 
ances  : — The  vessels  were  greatly  gorged 
with  blood  ;  the  dura  mater  was  firmly  ad¬ 
herent  to  the  calvarium.  The  arachnoid 
was  greatly  diseased,  being  immensely 
thickened,  so  as  closely  to  resemble  the  dura 
mater  in  bulk  and  firmness.  Between  the 
arachnoid  and  pia  mater,  a  thin  layer  of 
purulent  matter  was  deposited,  as  was  also 
the  case  between  the  brain  and  pia  mater. 
This  latter  membrane  also  appeared  thick¬ 
ened,  and  its  vessels  unnaturally  gorged 
with  blood.  The  brain  itself  was  healthy, 
but  presented  in  its  substance  numerous  vas¬ 
cular  spots. 

On  the  Nature  and  Treatment  of  Epidemic 
Cholera. 

The  Secretary  (Dr.  Robinson)  read  a 
short  review  of  the  opinions  which  have  been 
held  on  the  nature  and  treatment  of  epide¬ 
mic  cholera.  Having  briefly  alluded  to  the 
old  idea  that  the  disease  consists  in  disorder 
of  the  biliary  secretion,  the  writer  proceeded 
to  show  that  cholera  is  not  an  affection  of 
the  hepatic  system  only,  and  that,  as  still 
stronger  arguments  oppose  every  theory 
which  would  locate  the  disease  in  any  other 
particular  organ,  it  must  be  regarded  as  a 
general  or  constitutional  disease,  and  like  all 
other  diseases  of  that  class,  is  in  all  probabi¬ 
lity  seated  in  the  blood. 

That  epidemic  cholera  does  arise  from  the 
introduction  into  the  body  of  a  poison  sus¬ 
pended  in  the  atmosphere,  is  now  generally 
believed  ;  and  in  the  absence  of  any  positive 
information  as  to  the  specific  nature  and 
source  of  this  noxious  agent,  it  is  perhaps 
more  advantageous  to  regard  cholera  as  in- 


ON  THE  NATURE  AND  TREATMENT  OF  EP1DFMTC  CHOI  ERA.  809 


duced  by  an  extreme  development,  or  pecu¬ 
liar  modification  of  some  one  of  the  nume¬ 
rous  and  obscure  group  of  morbific  poisons, 
than  to  fall  into  the  vulgar  and  dangerous 
custom  of  investing  it  with  almost  super¬ 
natural  forms.  With  reference  to  those 
theories  which  ascribed  cholera  merely  to  an 
excess  or  deficiency  of  atmospheric  electricity , 
or  to  the  preponderance  of  a  particular  form 
of  that  agent,  the  writer,  while  admitting  the 
possibility  of  certain  electrical  states  favour¬ 
ing  the  propagation  of  this  and  other  morbid 
poisons  in  the  same  manner  as  other  physical 
conditions,  such  as  heat  and  moisture,  are 
known  to  operate  under  similar  circum¬ 
stances,  considered  this  view  as  not  only  op¬ 
posed  to  all  previous  experience  of  the  effects 
of  electricity  upon  the  human  body,  but  as 
peculiarly  objectionable,  from  its  affording 
another  example  of  the  very  prevalent  and 
irrational  error  of  explaining  all  unknown 
natural  phenomena  by  the  word  “  electri¬ 
city.’'  The  only  other  consideration  con¬ 
nected  with  the  nature  of  cholera  to  which 
the  writer  referred,  was  the  relation  existing 
between  it  and  more  familiar  diseases.  Some 
writers  argue  for  the  essential  identity  of 
cholera  with  common  intermittent  fever ; 
and  Dr.  Bell,  of  Manchester,  asserts  that  it 
is  merely  a  form  of  ague,  of  which  the  type 
is  quotidian  ;  but  his  chief  argument,  drawn 
from  a  comparison  of  the  successive  stages 
of  ague  with  those  of  cholera,  seems  very  in¬ 
adequate  to  the  establishment  of  his  posi¬ 
tion. 

In  the  physical  appearance  of  the  blood 
drawn,  malignant  cholera  closely  resembles 
that  described  by  Huxham  and  the  old  phy¬ 
sicians  as  occurring  in  putrid  fevers ;  and 
also  that  observed  in  the  worst  forms  of  ex¬ 
anthemata,  where  the  eruption  is  not  deve¬ 
loped,  but  from  the  peculiar  effects  of  the 
cholera  poison,  the  analysis  of  the  blood 
here  shows  a  greater  loss  of  serum  than 
would  be  found  in  the  other  affections.  A 
much  more  interesting  and  more  practical* 
question  is  the  degree  of  connection  existing 
between  Asiatic  or  malignant,  and  English 
cholera.  Are  they  the  same  disease,  and  is 
the  difference  merely  one  of  intensity  ?  The 
writer  inclines  to  this  opinion,  thinking 
it  possible  for  the  disease  generated  in 
localities  so  favourable  to  its  development 
in  a  virulent  form,  as  the  crowded  and  pesti¬ 
lential  swamps  of  India,  to  assume  an  epi¬ 
demic  character,  which  is  not  noticed  in 
that  produced  in  this  country.  Without 
discussing  the  question  of  contagion,  it  ap¬ 
peared  to  him  evident,  that  whether  the  dis¬ 
ease  be  propagated  by  personal  contact  or 
not,  the  collection  in  one  spot  of  a  large 
number  of  cholera  patients  must  add  mate¬ 
rially  to  the  danger;  in  the  one  case,  i.  e.  as¬ 
suming  it  to  be  infectious,  by  increasing  the 
power  or  intensity  of  the  poison,  as  we  find 


to  be  the  case  with  typhus,  &c.,  and  in 
either  case  by  disturbing  and  fatiguing  the 
patient  by  removal  at  a  time  when  delay 
may  be  death. 

With  respect  to  the  treatment,  the  writer 
merely  indicated  its  natural  division  into— 
1st,  that  of  the  premonitory  stage;  2nd, 
that  of  the  confirmed  disease  ;  3rd,  that  of  the 
malignant  form  of  the  disease;  4  th,  that  of  its 
sequelae  :  and  having  urged  the  importance 
of  not  relying  upon  general  specifics,  but 
rather  judiciously  adopting  the  particular 
remedies  employed  to  the  peculiar  form  and 
degree  of  severity  of  each  attack,  he  left 
the  further  consideration  of  the  treatment  to 
those  present,  who  had  possessed  the  advan¬ 
tage  of  practically  studying  the  disease  dur¬ 
ing  its  former  visitation. 

A  long  discussion  ensued  on  this  subject, 
in  which  the  President,  Mr.  Greenhow,  Dr. 
Bulman,  and  other  gentlemen,  took  part ; 
but  the  numerous  remedies  suggested,  and 
the  different  value  assigned  to  each  by  differ¬ 
ent  practitioners,  served  to  show  the  still  un¬ 
settled  state  of  medical  opinions  on  this 
question. 


PARIS  ACADEMY  OF  SCIENCES. 

On  the  Chemical  Statistics  of  the  Human 
Body. 

M.  Regnault  presented  a  communication 
from  M.  Barral,  entitled,  “  On  the  chemical 
statistics  of  the  human  body.”  M.  Barral 
states  in  this  communication  that  he  has  en¬ 
deavoured  to  resolve,  by  a  direct  analysis  of 
the  food  and  the  evacuations,  the  following 
problem: — “The  quantity  and  the  elementary 
composition  of  the  food,  solid  and  liquid, 
taken  per  diem  being  known,  to  determine 
the  quantity  and  the  elementary  composition 
of  the  evacuations,  perspiration,  and  other 
excretions,  so  as  to  ascertain  the  gains  and 
losses  of  the  human  body.”  The  following 
are  the  conclusions  and  the  resume  of  his 
experiments  : — 

1.  He  found  that  the  carbon  burnt  each 
day  by  the  oxygen  of  respiration  was  iden¬ 
tical  in  proportion  to  that  arrived  at  by 
another  mode  of  experiment  by  MM.  Andral 
and  Gavarret ;  but  to  the  causes  of  variation 
indicated  by  those  authors  he  adds  a  new 
one : — the  quantity  of  carbon  consumed  in 
winter  is  about  one-fifth  more  than  that  con¬ 
sumed  in  summer. 

2.  Tne  quantity  of  nitrogen  contained  in 
the  food  is  greater  than  that  of  the  evacua¬ 
tions,  so  that  a  part  of  this  gas  must  be  ex¬ 
haled  by  the  perspiration.  This  portion 
rises  as  high  as  one- third  or  one-fourth  of 
the  nitrogen  taken  into  the  system,  but  it  is 
only  one  hundredth  part  of  the  carbonic  acid 
produced.  In  a  healthy  state  of  the  system, 
the  relation  of  carbon  to  nitrogen  is  about 
100  to  8. 


810  ON  THE  CHEMICAL  STATISTICS  OF  THE  HUMAN  BODY. 


3.  The  hydrogen  and  the  oxygen  are  not 
found  in  the  exact  proportions  for  the  for¬ 
mation  of  water;  there  is  always  in  the  food 
an  excess  of  hydrogen  which  may  be  consi¬ 
dered  as  in  part  burnt  by  the  oxygen  of 
respiration.  The  hydrogen  thus  burnt  is  on 
an  average  equal  to  one- third  of  the  carbon 
transfot  med  into  carbonic  acid.  This  hydro¬ 
gen  burnt  in  respiration  is  not  all  the  hydro¬ 
gen  contained  in  the  food  :  the  evacuations 
are  richer  in  hydrogen  than  the  food,  in  the 
proportion  of  about  8  to  5. 

4.  The  oxygen  necessary  for  the  transfor¬ 
mation  into  carbonic  acid  and  water,  of  the 
carbon  and  hydrogen  of  the  food  burnt  in 
respiration,  is  to  the  food  as  1  to  3. 

5.  The  water,  as  well  natural  as  that 
formed  as  a  consequent  of  respiration  and 
digestion,  is  on  the  average  of  the  food, 
increased  by  the  oxygen  of  the  atmosphere 
combined  with  it.  The  water  of  perspiration 
is  generally  rather  more  than  that  of  the 
evacuations.  In  old  people,  however,  the 
water  of  perspiration  is  reduced  to  one-third 
of  the  water  of  the  urine  and  the  excrement. 

6.  In  three  experiments  a  larger  quantity 
of  chlorine  was  found  in  the  food  than  in  the 
evacuations;  in  two  other  experiments  a 
small  excess  of  chlorine  was  found  in  the 
evacuations.  A  certain  quantity  of  chloride 
of  sodium,  amounting  almost  to  one-third  of 
the  quantity  taken,  does  not  pass  off  by  the 
evacuations. 

7.  The  chemical  statistics  of  the  human 
body  may  thus  be  stated  : — 

Taken  into  the  system — 

Liquid  and  solid  food  .....  74-4 

Oxygen . 25*6 


100*0 

Passed  out  of  the  system — 

Wrter  of  perspiration . 34 ’8 


Carbonic  acid . 30  2 

Evacuations . 34 ‘5 

Other  losses . 0  5 


100-0 

In  general  the  perspiration  is  to  the  evacua¬ 
tions  as  2  to  1  ;  but  in  old  people  the  evacua¬ 
tions  exceed  the  perspiration. 

In  deducting  from  the  total  quantity  of 
heat  produced  each  day,  the  heat  taken  by 
the  evaporation  of  the  transnired  water, 
that  taken  by  the  air  of  the  respiration,  and 
lastly,  that  taken  by  the  food  and  the  eva¬ 
cuations,  it  is  found  that  on  an  average 
the  heat  lost  by  radiation  is  30000  per 
diem,  or  1250  per  hour,  in  summer,  and 
42000  per  diem,  or  1750  per  hour,  in 
winter.  The  following  will  serve  to  indicate 
the  heat  taken  by  the  body,  and  the  heat  lost 
by  radiation,  &c. : — 


Heat  taken  by  the  evaporation  of  the 

water  of  perspiration  ....  24*1 

Heat  carried  off  by  the  air  of  respira¬ 
tion  . 7‘3 

Heat  taken  by  the  food  ....  2-2 

Ditto  by  the  evacuations  ....  1*8 

Heat  lost  by  radiation  and  by  contact  64-6 

100-0 

Sitting  of  October  30. 

No  medical  communications  of  interest 
were  presented. 

M.  Edward  St.-Evre,  conservator  of  the 
chemical  museum  at  the  Polytechnic  school, 
read  a  paper  on  certain  new  chlorine  bodies 
derived  from  benzoic  acid. 

In  a  work  published  some  years  since,  M. 
Fremy  shewed,  that  by  combining  the  oxi¬ 
dizing  forces  of  chlorine,  and  of  the  alkalies 
in  concentrated  solution,  we  might  acidify 
certain  metallic  oxides.  More  recently, 
M.  Cahours,  in  studying  the  action  of  chlo¬ 
rine  and  bromine  on  organic  salts,  with  a 
potash  base,  discovered  several  bodies  of 
much  interest.  M.  St.-Evre  undertook  to 
examine  systematically  the  action  which 
chlorine  exercises  on  the  concentrated  alka¬ 
line  solutions  of  salts,  formed  by  the  organic 
acids  with  4  atoms  of  oxygen.  In  a  for¬ 
mer  communication,  he  announced  that  the 
body  obtained  a  new  acid,  derived  from 
benzoic  acid  by  the  elimination  of  4  atoms 
of  carbon,  and  the  substitution  of  2  atoms 
of  chlorine.  It  is  the  result  of  these  re¬ 
searches  which  St.-Evre  presented  at  this 
sitting.  A 


DIAGNOSIS  OF  AFTER-PAINS. 

The  diagnosis  of  after-pains  is,  generally 
speaking,  an  easy  matter,  but  the  practitioner 
may  sometimes  be  led  into  error  from  the 
patient’s  complaining  of  pain  upon  pressure 
being  made  over  the  uterus  ;  whereas,  in 
point  of  fact,  this  tenderness  arises  merely 
from  his  happening  to  feel  the  uterus  during 
its  contraction,  or  from  the  stimulus  of  the 
hand  exciting  an  after-pain.  To  treat  after- 
pains  for  inflammation  is  only  trifling,  when 
compared  writh  the  danger  of  mistaking  in¬ 
flammation  for  after  pains, — an  error  that 
might  involve  the  life  of  the  patient.  There 
is  one  circumstance  which  usually  exerts 
considerable  influence  upon  the  production 
and  severity  of  after-pains,  and  this  is,  the 
length  of  the  second  stage  of  the  labour; 
for  if  from  any  cause  this  has  been  tedious, 
the  subsequent  contractions  of  the  uterus 
will  generally  be  proportionately  less  painful ; 
and  so,  conversely,  if  the  second  stage  has 
been  precipitate,  after-pains  are  more  likely 
to  follow  or  be  more  severe. — M'Clintock 
and  Hardy's  Practical  Observations ,  p.  11. 


CHOLERA  AT  ARCHANGEL - FAILURE  OF  KREOSOTE  AS  A  REMEDY.  811 


(jTomspontience. 


THE  CHOLERA  AT  ARCHANGEL - FAILURE 

OF  KREOSOTE  AS  A  REMEDY. 

Sir, — I  should  have  written  some  time 
back,  to  report  progress  of  epidemic  cholera 
in  the  north  of  Russia,  but  that  1  have  been 
engaged  writing  a  report  of  this  pestilence  as 
it  has  lately  manifested  itself  at  Archangel, 
at  the  request  of  the  British  Consul,  Mr. 
Whitehead,  for  the  Foreign  Office.  As  the 
chances  are  that  it  will  be  doomed,  and  per¬ 
chance  deservedly,  to  profound  oblivion 
within  the  walls  of  that  Office,  and  as  it 
may  possibly  contain  something  worthy  of 
being  recorded,  the  Consul,  at  my  request, 
will  forward  a  copy  to  you.  As  my  object 
is  utility,  not  notoriety,  you  will  make  that 
use  of  it  which  you  may  deem  fit. 

It  gives  me  much  pleasure  to  find,  by  the 
public  papers,  that  the  light  of  truth  rela¬ 
tive  to  the  mode  of  progression  of  the  pesti¬ 
lence  in  question  begins  to  be  more  per¬ 
ceptibly  felt,  and  that  the  Government  is 
taking  protective  measures  against  importa¬ 
tion.  Had  a  strict  and  efficient  quarantine 
been  established  on  the  Persian  frontier  of 
Russia  in  1846,  there  is  little  doubt  but  the 
calamity  which  has  overtaken  this  empire, 
and  which  now  threatens  the  rest  of  Europe, 
might  have  been  averted,  and  two  per  cent, 
of  the  population  saved  from  an  untimely 
death. 

I  understand  that  the  instructions  relative 
to  vessels  arriving  from  an  infected  place, 
on  board  of  which  a  man  has  died  of  cholera, 
are,  to  subject  the  clothes  of  the  deceased  to 
submersion  in  the  sea.  The  most  prudent 
course  would  be  to  destroy  them.  Nor  is 
this  alone  sufficient :  the  vessel  ought  to  be 
put  in  quarantine,  and  the  wearing  apparel 
of  the  crew  subjected  to  a  disinfecting  pro¬ 
cess, — as  exposure  to  a  high  degree  of  heat. 
Experience  teaches  that  the  miasm  remains 
dormant  in  the  system  for  days,  and  even 
weeks,  and  generally  manifests  itself  on  the 
arrival  of  the  individual  infected  in  a  new 
place.  I  should  recommend  a  quarantine 
of  ten  days  to  a  fortnight  as  the  longest 
period  required. 

As  I  have  explained  my  views  respecting 
the  nature  of  this  disease,  and  the  best  method 
of  treatment,  in  the  report  above  alluded  to, 
I  shall  refrain  from  any  further  remarks  on 
the  subject  here.  I  may,  however,  mention 
that  all  the  much-vaunted  specifics  have 
been  found  to  fail.  I  am  an  enemy  to  any 
one  exclusive  medicine  for  the  treatment  of 
this  disease,  as  experience  has  taught  me 
that  it  is  irrational  and  inefficient,  and  that 
it  is  by  a  well-devised  combination  of  means, 


in  accordance  with  general  principles,  that 
we  can  best  combat  the  disease. 

A  remedy  has  been  brought  into  use  in. 
this  town  by  two  German  physicians,  which 
is  held  by  them  in  so  much  estimation  that 
ihey  look  upon  it  as  a  specific  :  they  pre¬ 
scribe  it  in  all  stages  and  in  all  grades  of 
the  disease,  with  the  most  surprising  success  ; 
yet,  strange  to  say,  in  other  hands,  though 
prescribed  and  administered  in  the  same 
manner,  it  loses  its  magic  virtue.  If  any 
death  takes  place  in  the  hands  of  the  dis¬ 
coverers,  it  is  invariably  owing  to  some 
extraordinary  concatenation  of  circumstances 
over  which  the  remedy  could  not  reasonably 
be  expected  to  have  any  control.  The  me¬ 
dicine  in  question  is  Kreosote,  administered 
every  half  or  every  hour,  according  to  the 
severity  of  the  case,  in  the  dose  of  half  a 
drop  in  syrup.  During  its  use  water  or 
drink  is  given  by  teaspoonfuls  ;  to  the  best 
of  my  recollection  a  teaspoonful  every  hour  : 
it  matters  not  if  the  patient  is  parched  to  a 
cinder  by  thirst,  or  if  his  blood  be  drained 
of  its  last  drop  of  water;  in  fact,  this  last 
consummation  is  regarded  as  the  most  success¬ 
ful  method  of  arresting  the  purging,  which  is 
looked  upon  as  a  species  of  haemorrhage,  con¬ 
sisting  of  albumen  chiefly.  That  this  sup¬ 
posed  fact,  should  have  escaped  a  host  of  great 
men  and  acute  observers,  Andral,  &c.  &c., 
who  could  discover  no  albumen  in  the  alvine 
evacuations  of  choleric  cases,  is  strange 
enough.  In  my  humble  way  I  have  boiled 
the  same  fluid  without  observing  any  ;  in¬ 
deed,  I  have  found  it  to  lose  its  rice  colour 
and  become  clear.  The  rice  colour  is 
chiefly  owing  to  oil  globules  absorbed  from 
the  system.  Another  surprising  feature  in 
the  character  of  the  remedy  in  question  is, 
that  it  manifests  great  predilection  for  pa¬ 
tients  living  in  the  obscurity  of  private 
practice,  and  seldom  indeed  condescends  to 
visit  with  its  benefits  patients  residing  with¬ 
in  the  walls  of  an  hospital. *  I  shali  furnish 
further  particulars  in  my  report;  meantime, 
my  own  opinion  is,  that  it  seems  to  answer 
remarkably  well  in  some  cases  of  no  severity, 
but  where  there  is  strong  congestion  and 
irritation  of  the  stomach  and  bowels,  as 
observed  during  the  height  of  the  epidemy, 
it  not  only  cannot  do  any  good,  but  it  is 
sure  of  doing  harm.  In  the  Russ  an  medi¬ 
cal  periodicals  mention  is  made  of  its  having 
been  found  useful  at  St.  Petersburg  to 
relieve  the  vomiting,  but  nothing  as  to  its 
specific  virtue. 

The  epidemic  cholera  broke  out  in  this 
town  on  the  8th  July,  O.  S.,  reached  its 


*  Kreosote  has  just  been  tried  in  our  hospital 
in  a  fair  case  for  experiment.  It  brought  ou 
tenesmus,  bloody  stools,  pain  over  the  whole 
abdomen,  terminating  in  death,  without  causing 
one  sign  of  reaction  during  thirty-two  hours. 


815S  PROOF  OF  THE  COMMUNICABILITY  OF  ASIATIC  CHOLERA. 


maximum  on  the  17th,  declining  slowly, 
disappearing  entirely  about  the  middle  of 
August,  and  reviving  again  in  September, 
with  the  appearance  of  cold  wet  weather. 
At  this  moment  there  are  only  a  few  cases  of 
severity,  but  a  good  many  suffer  from  diar¬ 
rhoea,  which,  if  neglected,  may  terminate  in 
a  seizure.  As  it  will  be  seen  by  my  report, 
the  present  epidemy  was  much  milder  at 
Archangel  than  that  of  1831,  that  is  to  say, 
fewer  sickened,  and  the  mortality,  on  the 
whole,  is  less.  It  is  a  great  satisfaction  to 
know  that  every  person,  even  the  most 
timid,  may,  by  proper  care,  be  saved  from  a 
choleric  seizure. — I  am,  sir, 

Your  obedient  servant, 

John  Mackenzie,  Surgeon, 
Naval  Hospital,  Archangel. 

Oct.  2d,  O.  S.,  1848. 

***  We  have  not  received  the  report. 

PROOF  OF  THE  COMMUNICABILITY  OF  ASIA¬ 
TIC  CHOLERA. 

Sir, — In  consequence  of  reading  your  ex¬ 
cellent  leading  article  of  October  13,  on 
Asiatic  cholera,  in  my  monthly  number  of 
the  Medical  Gazette,  I  feel  induced  to 
offer  the  following  case,  which  must  be  first 
set  aside  before  I  can  believe  in  the  non¬ 
contagion  of  Asiatic  cholera. 

In  1832,  I  was  called  upon  to  visit  a  man 
of  the  name  of  Stonehouse,  in  Bake-house 
yard,  of  this  borough,  who  had  just  been 
landed  from  a  ship.  I  found  it  a  decided 
case  of  foreign  cholera,  in  a  state  of  collapse, 
as  cold  as  ice,  and  of  a  leaden  hue.  This 
was  the  first  case  in  this  town,  and  imported. 
I  remember  well  telling  Stonehouse’s  wife 
to  be  cautious,  and  not  be  too  much  about 
her  husband,  as  it  was  not  yet  decided  about 
contagion.  The  result  was,  that  the  wife 
took  it  and  died  the  first.  Here  we  have  an 
isolated  case  imported  into  a  town  that  was 
free  from  cholera,  and  the  very  wife  who  was 
the  nurse  fell  the  first  victim. 

In  1833,  this  town  was  fearfully  visited  by 
Asiatic  cholera,  but  owing  to  the  valuable 
precautionary  measures  that  were  adopted  at 
that  time,  and  from  the  noble  manner  in 
which  the  rich  came  forward  in  aid  of  the 
poor,  this  scourge  was  wonderfully  mitigated. 
My  experience  leads  me  to  say  that,  if  every 
one  would  apply  for  medical  aid  immediately 
the  premonitory  symptcm  of  bowel  com¬ 
plaint  comes  on,  there  is  nothing  more  easy 
to  check.  If  the  Board  of  Health  were  to 
placard  all  the  towns  and  villages  in  Great 
Britain,  cautioning  and  intimating  to  all  the 
inhabitants,  that  the  choleraic  bowel  com¬ 
plaint  was  equivalent  to  bleeding  to  death, 
applications  would  be  made  at  once  for 
medical  relief,  instead  of  medical  men  being 
applied  to  too  late,  when  too  often  they  are 


called  upon  to  visit,  and  witness  all  the 
phenomena  arising  from  the  exudation  of 
s.  rum  from  the  stomach  and  bowels,  conse¬ 
quently  arresting  all  other  secretions : 
hence  the  frightful  shock  to  the  nervous  sys¬ 
tem  and  vital  powers. 

I  am,  sir, 

Your  obedient  servant, 

Geo.  Merryweather,  M.D. 

Whitby,  Nov.  2,  1848. 


REMARKS  ON  THE  LAST  SANITARY  MANI¬ 
FESTO  OF  THE  GENERAL  BOARD  OF 

HEALTH. 

Sir, — I  have  just  perused  in  the  Evening 
Express  of  this  day,  a  document  purporting 
to  be  from  the  Board  of  Health,  sanctioned 
by  them  apparently,  as  it  bears  the  signature 
of  their  secretary,  H.  Austin,  Esq.  Doubt¬ 
less,  this  lengthy  production  will  interest  the 
attention  of  all,  and  excite  the  consideration 
of  the  members  of  the  medical  profession  in 
no  small  degree,  from  the  very  painstaking 
manner  in  which  it  is  got  up,  and  the  pecu¬ 
liarly  contradictory  character  of  the  opinions 
or  dogmas  (whichever  term  you  choose,  it 
matters  little)  they  have  thought  proper  to 
enlighten  the  public  with,  and  which  they 
further  seem  to  consider  the  public  must 
place  implicit  confidence  in,  and  rely  on 
the  matured  belief  or  opinion  of  that  Board. 
Happily,  it  cannot  be  said  to  express  the 
opinion  of  the  whole  medical  profession  on 
the  subject  which  so  personally  now  interests 
every  one,  as,  contrary  to  all  established 
rules  in  such  matters,  there  is  only  one 
medical  person  in  that  commission.  What 
other  nations  may  say  on  such  a  constitution 
of  a  Medical  Board  of  Public  Health  I  shall 
not  stop  here  to  inquire  ;  and  as  idle  would 
it  be  to  express  what  the  general  opinion  of 
the  great  bulk  of  the  profession  here  is  on 
the  same  point. 

We  shall  not  pursue  the  whole  of  their 
prolix  document  through  the  tedious  laby¬ 
rinth  of  the  duties  of  guardians,  the  removal 
of  nuisances,  &c.,all  of  which  we  conceive 
to  be  deserving  of  the  highest  commendation, 
and  as  such  they  ought  to  be  rigidly  enforced 
for  the  benefit  of  every  one,  and  especially 
for  the  behoof  of  those  who,  from  their 
poverty  and  other  unfortunate  circumstances, 
are  less  unhappily  situated,  as  to  danger  from 
the  cholera,  than  their  more  affluent  fellow- 
countrymen  ;  and  which,  if  they  have  any 
basis  in  the  truthful  exposition  of  epidemic 
diseases,  apply  with  tenfold  force  to  the 
means  of  preventing  the  deadly  fevers  which 
desolate  the  length  and  breadth  of  the  land 
incessantly,  in  a  degree  to  which  the  cholera 
is  but  as  a  mere  passing  shadow  of  the 
hour ;  but  we  shall  shortly  inquire  into 
what  we  consider  to  be  the  contradictory 
statements  of  the  Board,  and  which,  if  such, 


THE  LAST  MANIFESTO  OF  THE  GENERAL  BOARD  OF  HEALTH.  813 


will  tend  very  much  to  depreciate  their 
value  in  the  eyes  of  a  discerning  public. 

Like  a  great  master  of  its  subject,  it  does 
not  hesitate  or  doubt,  but  speaks  its  opinion 
(by  the  way,  what  notion  had  it  on  the  sub¬ 
ject  in  1832 — and  may  not  some  future 
board,  say  in  1864,  rescind  the  authoritative 
declarations  of  1848  ?)  out  openly,  boldly, 
and  fearlessly,  in  the  following  words  : — 
“  Though  the  General  Board  of  Heath  have 
expressed  their  decided  opinion  that  cholera 
is  not  contagious,  in  the  common  sense  of 
the  term  (we  are  responsible  here  for  the 
italics ) ;  yet  neither  they,  nor  those  who 
coincide  in  their  opinion,  consider  that  there 
is  no  danger  of  overcrowding,  or  that  the 
disease  is  not  ‘  catching  ’  in  ill-ventilated 
and  ill-conditioned  placrs.” 

Now,  it  is  the  most  remote  from  our 
mind  to  excite  any  public  alarm  on  the 
subject,  but  we  would  ask,  does  not  the 
Board  itself  proclaim  this  alarm,  when  it 
states  that  “  they  do  not  consider  that  there 
is  no  danger  of  overcrowuing,  or  that  the 
disease  is  not  ‘  catching  ’  in  ill-ventilated 
and  ill  conditioned  places.”  But  the  Board 
says,  “  that  it  is  their  decided  opinion  that 
the  cholera  is  not  contagious,  in  the  common 
sense  of  the  word.”  What  then,  we  would 
respectfully  inquire,  is  the  common  sense 
of  the  word  “contagious”?  It  certainly 
does  not  mean  that  every  human  being, 
necessarily,  from  contact  or  communication 
with  the  individual  who  happens  to  be 
labouring  under  the  disease,  must,  ipso 
facto,  therefore  continuously  sicken  from  it. 
There  is  in  all  contagious  or  infectious 
diseases,  to  render  the  application  of  the 
peculiar  poison  essential  to  generate  the 
disease,  an  aptitude  or  predisposition  of  the 
constitution  equally  necessary  and  requisite, 
and  if  the  body  be  not  thereby  susceptible 
of  the  impression  of  the  poison,  no  effect 
whatever  is  produced  on  the  individual  so 
exposed.  Such,  we  know,  is  the  general  case 
in  exposure  to  typhus  fever  (with  which 
cholera  has  many  points  of  close  resem¬ 
blance),  and  such,  we  apprehend,  most 
medical  men  will  readily  concede  to  be  the 
common  law  in  contagious  or  infectious 
disorders  generally.  Toe  General  Board 
will  perhaps  then  please  to  define  what  they 
mean  by  the  expression  “  not  contagious  in 
the  common  sense  of  the  term  but  this 
requisition  is  altogether  uncalled  for,  inas¬ 
much  as  they  say,  “  catching  in  ill-ventilated 
and  ill-conditioned  places!” 

Why,  the  most  strenuous  supporter  of 
the  doctrine  of  contagion  cannot  go  fur¬ 
ther — he  admits  always  the  co-operation  of 
qualifying  circumstances  —  and  the  very 
typhus  fever,  which  the  members  of  the 
General  Board  will  not  deny  to  be  very 
infectious,  and  rapidly  spreading  in  the  ill- 
conditioned  and  densely  inhabited  dwellings 


of  the  poor,  cease  altogether  to  display  that 
property  when  it  occurs  in  rooms  well  aired 
and  freely  ventilated :  it  is,  in  fact,  per¬ 
fectly  analogous  to  cholera,  but  with  this 
most  important  qualifying  difference,  which 
the  Board  do  not  mention  when  they  state 
its  “  catching  ”  character  (though  they  pro¬ 
fess  themselves  desirous  not  to  create  un- 
neoes.-ary  alarm  in  the  public  mind),  that 
its  force  or  intensity  of  contagious  action  is 
remarkably  weak  indeed,  when  compared 
with  that  of  the  typhus  fever. 

There  are  many  other  points  in  the  Gene¬ 
ral  Board’s  statements  which  require  quali¬ 
fication,  and  especially  their  remarks  as  to 
the  distance  which  pestilential  miasmata 
extend  from  the  living  animal  body,  which 
we  believe  were  pretty  accurately  determined 
by  Drs.  Ryan  and  Haygarth,  some  60  or 
80  years  ago,  scarcely  to  exceed  half  a  yard 
from  the  focus  of  infection.  To  this  we 
may  advert  on  another  opportunity. 

The  General  Board,  holding  its  front  up 
fearlessly  to  the  support  of  the  dogma  of 
non-conlagion  in  cholera,  will  perhaps  ex¬ 
plain,  for  the  benefit  of  the  uninitiated 
members  among  the  medical  profession, 
how  far  the  annexed  extract,  which  they 
present  in  their  report,  is  compatible  with 
such  an  assertion.  “  As  certainly,”  says 
Mr.  Samuel  Rogers,  “  as  cholera  is  in 
many  instances  induced  by  the  congre¬ 
gation  of  large  bodies  of  men  (we  are  here 
again  culpable  for  the  italics)  so  will  the 
converse  be  found  to  hold  true.  The  dis¬ 
ease,  which  was  generated  by  the  assem¬ 
blage,  will  be  destroyed  by  their  separation.” 

An  apology  is,  perhaps,  requisite  for  the 
hurried  manner  in  which  these  remarks 
are  written  ;  but  the  extremely  contradictory 
character  of  the  statements  adverted  to, 
will,  I  conceive,  not  render  it  necessary  to 
observe  further  than  that  we  fondly  antici¬ 
pate  in  the  future  lucubrations  of  the  Board 
some  little  more  consistency  and  less  parade 
of  propositions  which  mutually  stultify 
each  other.  —  I  am,  sir, 

Your  veiy  obedient  servant, 

William  Reid,  M.D. 

8,  Great  Russell  Street, 

Covent  Garden,  Nov.  1848. 


ELECTRICAL  PHENOMENA  IN  CHOLERA. 

Sir, — I  am  desirous  at  the  present 
moment  of  directing  the  attention  of  your 
numerous  scientific  readers  to  a  very  in¬ 
teresting  phenomenon,  more  or  less  present 
in  the  collapse  stage  of  cholera,  which  seems 
to  have  hitherto  escaped  the  observation  of 
medical  men — viz.  animal  electricity,  or 
phosphorescence  of  the  human  body.  My 
attention  was  first  attracted  to  the  subject 
during  the  former  visitation  of  that  fearful 
disease  in  the  metropolis,  it  was,  indeed, 


814  CASE  OF  POISONING  BY  THE  SEEDS  OF  THE  SUN-FLOWER. 


singular  to  notice  the  quantity  of  electric 
fluid  which  continually  discharged  itself  on 
the  approach  of  any  conducting  body  to  the 
surface  of  the  skin  of  a  patient  labouring 
tinder  the  collapse  stage,  more  particularly 
if  the  patient  had  been  previously  enveloped 
in  blankets.  Streams  of  electricity ,  many 
averaging  an  inch  arid  a  half  in  length, 
could  be  readily  educted  by  the  knuckle  of 
the  hand,  when  directed  to  any  part  of  the 
body  ;  and  these  appeared  in  colour,  effect, 
crackling  noise,  and  general  luminous  cha¬ 
racter,  similar  to  that  which  we  are  all  ac¬ 
customed  to  observe  when  touching  a  charged 
Leyden  jar.  I  may  remark  the  coincidence, 
that  simultaneously  with  the  heat  of  the 
body  passing  ofl*|  the  electricity  was  evolved  ; 
and  I  am  therefore  led  to  ask  the  question — 
Are  not  the  heat,  electric,  and  galvanic  fluids. 
one  and  the  same  thing  ?  Does  not  the  fact 
of  the  passing  off  of  both  imponderable 
substances  at  one  and  the  same  time, 
strengthen  this  conclusion  ? 

Again,  are  not  the  whole  of  what  we  call 
vital  phenomena  produced  by  certain  modi¬ 
fications  of  the  electric  galvanic  magnetic 
matter  and  motions  ?  And  do  we  not  find 
that  these  vital  phenomena  are  continuously 
affected  by  the  relative  state  of  the  surround¬ 
ing  electric  medium  ?  To  what  can  we 
attribute  the  present  fluctuating  condition  of 
the  barometer,  if  not  to  it  ? 

We  know  what  a  powerful  decomposing 
action  galvanism  had  on  alkalies,  under  the 
hand  of  the  illustrious  Humphry  Davy,  but 
we  do  not  know ,  nor  have  we  any  concep¬ 
tion  in  the  present  state  of  knowledge,  of  the 
decomposing  action  of  electric  matter  of  the 
atmospheric  air  in  various  conditions,  on 
the  fluids  generally  of  the  animal  body. 
Chemistry  has  failed  in  pointing  out  any 
ponderable  material  as  the  exciting  cause  of 
epidemic  diseases. 

In  the  treatment  of  cholera,  all  are  agreed 
that  non- conducting  substances  on  the  sur¬ 
face  of  the  skin  aid  essentially  the  cure  ; 
and  during  the  disturbed  state  of  the  atmo¬ 
sphere,  for  the  purpose  of  retaining  the  elec¬ 
tricity  continually  eliminating  in  the  system, 
we  are  told  to  wear  woollen  bandages,  flannel, 
and  gutta-percha  soles,  so  as  to  insulate  the 
body  as  much  as  possible,  to  prevent  the 
heat,  the  electric  fluid,  from  passing  off.  I 
now  leave  this  important  subject  for  discus¬ 
sion,  and  for  those  who  have  studied  elec¬ 
tricity. — I  am,  sir, 

Your  obedient  servant, 

J.  C.  Atkinson. 

Hornsey  Terrace,  Westminster, 

Oct.  31st,  1848. 


CASE  OF  POISONING  BY  THE  SEEDS  OF  THE 
HELIANTHUS  OR  SUN-FLOWER. 

Sir, — 1  send  you  the  following  case  of 
poisoning  by  the  seeds  of  the  common 


helianthus,  or  sun  flower,  never  having  met 
with  any  similar  recorded  instance.  I  hope 
it  will  prove  interesting  to  your  readers. 

I  am,  sir. 

Your  obedient  servant, 

Norris  F.  Davey, 

Late  Surgeon  to  Millbank  Prison, 
London. 

4  p.m.,  Oct.  8,  1848. — I  was  called  to 
attend  Eliza  Hammond,  aet.  23,  an  inmate 
of  the  Romford  Union  House,  unmarried, 
with  an  infant  a  few  months  old.  1  found 
her  sitting  on  her  bed,  with  an  anxious 
countenance ;  eyes  suffused  ;  face  deeply 
flushed  ;  skin  generally  of  a  scarlet  redness, 
and  very  hot;  pulse  110,  full,  soft,  and 
compressible  ;  breathing  rather  difficult,  and 
hurried  ;  tongue  and  fauces  very  red,  and 
inclined  to  dryness;  voice  hoarse;  pupils 
natural  ;  mind  perfectly  clear.  She  com¬ 
plained  of  a  severe  burning  sensation  in  the 
fauces,  oesophagus,  and  epigastrium  ;  tin¬ 
gling  of  the  skin  ;  nausea  ;  headache  ;  thirst  ; 
stiffness  and  dryness  of  the  throat,  and  d  ffi- 
culty  in  articulating.  She  had  vomited 
freely  about  half  an  hour  before  my  visit; 
the  ejected  matters  not  preserved.  The 
bowels  had  acted  once  in  the  morning. 

I  found  that  at  10  a.m.  (being  then  in 
perfect  health)  she  had  eaten  a  quantity  of 
sun  flower  seeds  :  while  eating  them,  she 
remarked  that  they  had  an  unusually  hot 
taste,  and  immediately  afterwards  felt  a  sen¬ 
sation  of  glowing  in  the  throat  and  stomach. 
Shortly  after  this  she  became  very  sick  and 
ill,  and  her  symptoms  increased  in  severity 
until  the  vomiting  occurred  ;  she  taen  felt 
rather  better,  and  continued  to  amend  up  to 
the  time  of  my  visit.  She  could  not  say  how 
many  seeds  she  had  eaten,  but  she  thought 
more  than  100. 

As  she  had  vomited  freely,  I  gave  her  a 
brisk  aperient,  and  mucilaginous  drinks,  fol¬ 
lowed  by  salines ;  the  next  day  she  felt 
pretty  well,  and  complained  only  of  a  slight 
headache  and  some  stiffness  of  the  throat. 
The  child  continued  well  throughout,  and 
the  secretion  of  milk  was  uninfluenced.  Al¬ 
though  the  seeds  of  the  sun-flower  are  so 
commonly  eaten  with  impunity,  the  fore¬ 
going  case  shews  that  serious  results  may 
occasionally  ensue,  and  it  is  probable  that 
many  similar  instances  have  occurred,  but 
that,  from  the  generally-assumed  harmless¬ 
ness  of  the  seeds,  they  have  not  been  recog¬ 
nised  as  the  cause  of  the  symptoms.  Ham¬ 
mond  had  repeatedly  eaten  them  without  ill 
effect,  and  on  this  occasion  observed  a  de¬ 
cided  difference  in  taste  and  pungency; 
whence  we  must  conclude,  that  although 
usually  absent,  or  in  very  small  quantity,  an 
acrid  poison  may  be,  and  is  occasionally, 
developed  in  the  seeds  of  the  sun  flower. 

Romford,  Oct.  30,  1848. 


LONDON  COLLEGE  OF  PHYSICIANS — THE  PREVENTION  OF  CHOLERA.  815 


JMetucal  Ihudltgenre. 


THE  ROYAL  COLLEGE  OF  PHYSICIANS  OF 

LONDON  ON  THE  MEASURES  TO  BE 

ADOPTED  RESPECTING  THE  PREVENTION 

OF  ASIATIC  CHOLERA. 

The  Royal  College  of  Physicians  of  London, 
feeling  that  on  the  reappearance  of  Epidemic 
Cholera  in  England,  the  public  may  na¬ 
turally  look  to  them  for  advice  and  guidance, 
have  deemed  it  proper  to  appoint  a  Cholera 
Committee,  composed  of  physicians  who 
hold  important  offices  in  the  metropolitan 
hospitals,  or  who  had  extensive  experience 
of  the  disease  at  its  last  visitation,  to  con¬ 
sider  what  measures  it  is  expedient  to  adopt 
with  a  view  of  preventing  the  spread  of  the 
disease,  and  of  otherwise  mitigating  its 
evils. 

The  Committee  thus  formed,  have,  in 
compliance  with  the  wTish  of  the  College, 
drawn  up  the  following  remarks  and  instruc¬ 
tions,  for  the  information  of  the  public: — 

1st.  Cholera  appears  to  have  been  very 
rarely  communicated  by  personal  inter¬ 
course  ;  and  all  attempts  to  stay  its  progress 
by  cordons  or  quarantine  have  failed.  From 
these  circumstances,  the  Committee,  with¬ 
out  expressing  any  positive  opinion  with 
respect  to  its  contagious  or  non-contagious 
nature,  agree  in  drawing  this  practical  con¬ 
clusion  :  that  in  a  district  where  Cholera 
prevails,  no  appreciable  increase  of  danger 
is  incurred  by  ministering  to  persons  af¬ 
fected  with  it,  and  no  safety  afforded  to  the 
community  by  the  isolation  of  the  sick. 

2d.  The  disease  has  almost  invariably 
been  mcst  destructive  in  the  dampest  and 
filthiest  parts  of  the  towns  it  has  visited. 
The  Committee  would  therefore  urge  on  the 
public  authorities  the  propriety  of  taking 
immediate  steps  to  improve  the  state  of 
sewers  and  drains  ;  to  cover  those  which  are 
open  ;  and  to  remove  all  collections  of  de¬ 
caying  vegetable  and  animal  matter  from 
the  vicinity  of  dwellings.  They  would  also 
impress  on  individuals,  especially  of  the 
poorer  classes,  the  great  importance  of  well 
airing  their  rooms,  and  of  cleanliness  in  both 
their  dwellings  and  persons. 

3d.  A  state  of  debility  or  exhaustion, 
however  produced,  increases  the  liability  to 
Cholera.  The  Committee  therefore  recom¬ 
mend  all  persons  during  its  prevalence  to 
live  in  the  manner  they  have  hitherto  found 
most  conducive  to  their  health  ;  avoiding 
intemperance  of  all  kinds,  and  especially  the 
intemperate  use  of  ardent  spirits  and  other 
intoxicating  liquors.  A  sufficiency  of  nou¬ 
rishing  food  ;  warm  clothing,  and  speedy 
change  of  damp  garments ;  regular  and 
sufficient  sleep  ;  and  avoidance  of  excessive 


fatigue,  of  long  fasting,  and  of  exposure  to 
wet  and  cold,  more  particularly  at  night,  are 
important  means  of  promoting  or  main¬ 
taining  good  health,  and  thereby  afford  pro¬ 
tection  against  the  Cholera. 

The  Committee  do  not  recommend  that 
the  public  should  abstain  from  the  moderate 
use  of  well-cooked  green  vegetables,  and  of 
ripe  or  preserved  fruits.  A  certain  propor¬ 
tion  of  these  articles  of  diet  is,  with  most 
persons,  necessary  for  the  maintenance  of 
health  ;  and  there  is  reason  to  fear  that,  if 
they  be  generally  abstained  from,  now  that 
the  potato  crop  has  in  great  measure  failed, 
many  persons,  especially  amongst  the  poor 
in  large  towns,  will  fall  into  that  ill  condi¬ 
tion  which  in  its  highest  degree  is  known  as 
scurvy,  and  that  they  will  in  consequence 
be  the  readier  victims  of  Cholera.  The 
Committee  likewise  think  it  not  advisable 
to  prohibit  the  use  of  pork  or  bacon,  or  of 
salted,  dried,  or  smoked  meat  or  fish,  which 
have  not  been  proved  to  exert  any  direct 
influence  in  causing  this  disease.  Nothing 
promotes  the  spread  of  epidemic  diseases  so 
much  as  want  of  nourishment ;  and  the  poor 
will  necessarily  suffer  this  want,  if  they  are 
led  to  abstain  from  those  articles  of  food  on 
which,  from  tffiir  comparative  cheapness, 
they  mainly  depend  for  subsistence. 

On  the  whole,  the  Committee  advise  per¬ 
sons  living  in  districts  in  which  Cholera 
prevails  to  adhere  to  that  plan  of  diet  which 
they  have  generally  found  to  agree  with 
them  ;  avoiding  merely  such  articles  of  food 
as  experience  may  have  taught  them  to  be 
likely  to  disorder  the  stomach  and  bowels. 

4th.  The  Committee  are  unable  to  re¬ 
commend  an  uniform  plan  of  treatment  to 
be  adopted  by  the  public  in  all  cases  of 
looseness  of  the  bowels  supposed  to  be  pre¬ 
monitory  ot  Cholera.  It  is  doubtless  very  im¬ 
portant  that  such  ailments  should  be  promptly 
attended  to  ;  but  since  they  may  arise  from, 
various  causes,  of  which  a  medical  man  can 
alone  judge,  the  Committee  deem  it  safer 
that  persons  affected  with  them  should 
apply  at  once  for  medical  assistance,  than 
that  they  should  indiscriminately  use,  of 
their  own  accord,  or  on  the  suggestion  of 
unprofessional  persons,  powerful  medicines, 
in  large  and  frequently-repeated  doses. 
Should  the  looseness  of  the  bowels  be  at¬ 
tended  with  feelings  of  great  exhaustion  and 
chilliness,  the  person  should,  of  course,  be 
placed  in  a  warm  bed,  and  the  usual  means 
of  restoring  warmth  to  the  body  be  assi¬ 
duously  employed,  until  professional  advice 
can  be  obtained. 

5  th.  In  order  that  the  poor  may  have 
the  means  of  obtaining  such  assistance 
promptly,  the  Committee  recommend  that 
the  proper  authorities  should  at  once  esta¬ 
blish  Dispensaries  in  those  parts  of  the 
town  which  are  remote  from  the  existing 


816  SOGGESTIONS  ON  THE  TREATMENT  OF  CHOf.ERA  PATIENTS. 


medical  institutions ;  and  that  they  should 
also  take  steps  to  provide  distinct  Cholera 
Hospitals,  which  it  will  require  some  time 
to  organise,  and  which  they  believe  will 
be  found  to  be  absolutely  necessary,  should 
the  epidemic  prevail  in  this  metropolis  with 
a  severity  at  all  approaching  that  which  it 
manifested  on  its  first  appearance  in  Eng¬ 
land.  The  Committee  wish  it  to  be  clearly 
understood  that  they  do  not  recommend  the 
establishment  of  such  Cholera  Hospitals,  on 
the  ground  of  effecting  the  separation  of  the 
sick  from  the  healthy,  and  of  thus  prevent¬ 
ing  the  spread  of  the  disease ;  but  solely  in 
order  that,  should  the  epidemic  prove 
severe,  proper  attendance  and  prompt  treat¬ 
ment  may  be  ensured  for  the  sufferers  from 
Cholera  among  the  poorest  and  most  desti¬ 
tute  class.  The  existing  hospitals,  even  if 
the  authorities  should  consent  to  the  admis¬ 
sion  of  persons  ill  of  Cholera,  could  not 
furnish  the  requisite  accommodation,  unless 
they  were  shut  against  persons  labouring 
under  other  severe  diseases  :  a  measure 
which,  at  the  approach  of  winter  especially, 
would  add  much  to  the  distress  of  the  poor. 

6th.  In  conclusion,  the  Committee  would 
urge  on  the  rich,  who  have  comparatively 
little  to  fear  for  themselves,  the  great  duty 
of  generously  and  actively  ministering  to  the 
relief  of  the  poor,  while  the  epidemic  pre¬ 
vails  ;  bearing  in  mind  that  fuel,  warm 
clothing,  and  sufficient  nourishment,  are 
powerful  safeguards  against  the  disease. 

They  deem  it  most  desirable  that  the 
parish  authorities  should  at  once  improve 
the  diet,  and  increase  the  comforts,  of  the 
poor  under  their  charge ;  and  that  the 
wealthy  should  form  Societies  for  the  supply 
of  food,  clothing,  and  fuel,  to  those  who, 
though  not  paupers,  still  need  charitable 
assistance  in  the  present  emergency. 

Such  measures,  which  it  is  the  duty  of 
those  possessed  of  power  and  wealth  to 
adopt,  would,  the  Committee  believe,  if 
liberally  carried  out,  deprive  the  Cholera  of 
half  its  victims. 

Jonh  Ayrton  Paris, 
President. 

Francis  Hawkins, 

Registrar. 

College  of  Physicians, 

Oct.  28,  1848. 

SUGGESTIONS  ON  THE  TREATMENT  OF  CHO¬ 
LERA  PATIENTS,  ADDRESSED  TO  THE 
PAROCHIAL  BOARDS  JOINTLY  BY  A  COM¬ 
MITTEE  OF  THE  ROYAL  COLLEGE  OF 
PHYSICIANS  AND  THE  ROYAL  COLLEGE 
OF  SURGEONS  OF  EDINBURGH,  AND  DR. 
SUTHERLAND,  THE  COMMISSIONER  OF 
THE  GENERAL  BOARD  OF  HEALTH. 

I.  At  the  district  dispensaries  there  should 
be  kept,  not  only  the  medicines,  but  the  other 
materials  requisite  for  the  treatment  of  the 


disease,  in  the  houses  of  the  poor, — such  as 
straw-mattresses,  blankets,  vessels  for  healing 
sand  or  salt,  spirits  of  turpentine,  and  cloths 
for  applying  it,  mustard  for  cataplasms, 
coals  and  wood  for  firing  ;  but  these  are  to 
be  given  out  only  on  the  orders  of  medical 
men  who  have  seen  the  patients.  There 
should  also  be  the  necessary  messengers, 
materials  for  fumigation,  and  the  means  of 
conveyance  to  hospital. 

II.  On  an  application  to  one  of  these  dis¬ 
pensaries  from  a  patient  reported  to  have 
diarrhoea,  the  attendant  will  proceed  thus  : — 

1.  He  will  issue  directly  twelve  of  the 
pills  containing  opium,  hereinafter  specified, 
with  directions  to  give  two  immediately,  and 
repeat  them  every  three  hours  while  the 
diarrhoea  lasts  ;  but  if  there  be  along  with 
it  vomiting  or  cramps,  every  hour  while 
these  symptoms  last,  until  the  medical  man 
arrives  — 2.  He  will  give  directions  for  ap¬ 
plying  external  warmth  by  all  available 
means — blankets,  hot  bricks,  hot  sand  or 
salt,  turpentine,  or  mustard  poultices,  on  the 
abdomen  and  extremities,  bottles  of  hot 
water  laid  alongside  the  patient,  frictions 
with  hot.  flannels,  and  as  warm  covering  as 
possible. — 3.  He  will  direct  that  the  patient 
drink  nothing  for  a  quarter  of  an  hour  after 
each  dose  of  the  pills,  but  that  at  that  in¬ 
terval  after  each  dose,  he  take  a  table- spoon¬ 
ful  of  spirits  with  hot  water,  or  two  table¬ 
spoonfuls  of  spiced  wine  ;  and  if  his  skin  is 
felt  to  be  cold  and  damp,  repeat  this  every 
half-hour. 

N.B. — In  the  case  of  children  who  are 
from  10  to  14  years  of  age,  he  will  be  care¬ 
ful  to  direct  half  the  quantities  both  of 
opiates  and  spirits,  and  in  younger  children 
proportionally  smaller  doses. — 4.  He  will 
give  the  address  of  the  medical  man  attached 
to  the  district  where  the  patient  is, 
and  direct  that  he  be  immediately  in¬ 
formed  of  the  case,  and,  if  necessary,  send  a 
messenger  to  inform  him. 

The  following  pills  may  be  kept  constantly 
at  each  station,  and  the  medical  officers  may 
leave  general  directions  as  to  the  selection  of 
one  or  other  of  these  in  the  first  issues  to 
the  patients : — 

P  Acet.  Plumbi,  5ss. ;  Opii,  gr.  xij. ; 
Conserv.  Ros.,q.s.  Ft.  pilulse  xvi.  Sign. 
Lead  and  Opium  Pills. 

P  Tannini,  3ss. ;  Opii,  gr.  xij.;  Pulv. 
Capsici,  gr.  xvj.  ;  Conserv.  Ros.,  q.  s.  Ft. 
pilulse  xvi.  Sign.  Astringent  Pills  with 
Opium. 

P  Calomelanos,  3ss. ;  Opii.gr.  xij.  ;  Pulv. 
Capsici,  gr.  xvj.;  Conserv.  Ros.,  q.  s.  Ft. 
pilulse  xvi.  Sign.  Calomel  and  Opium 
Pills. 

The  doses  of  all  these  should  be  as  above 
directed.  Along  with  these,  in  the  early 
stage  of  the  disease,  and  when  the  skin  is 
cold  and  damp,  such  a  stimulating  mixture 


REMUNERATION  OF  MEDICAL  MEN - ATTENDANCE  ON  FEVER  CASES.  817 


as  the  following,  besides  the  wine  and  spirits, 
may  be  used  : — 

iEtheris  Sulph.  ;  Spirit.  Ammonise 
Aromal.  ana  ^ss.  ;  Tincturse  Cinnamon. 
Comp.  ^j.  ( Misce .)  Sign.  Two  tea¬ 
spoonfuls  to  be  taken  every  half-hour  or 
hour. 

III.  The  medical  officers  should  be  re¬ 
minded  of  the  paramount  importance  in  this 
disease  of  early  and  assiduous  treatment  and 
careful  watching  of  the  patients,  by  them¬ 
selves  or  trustworthy  assistants,  in  the  early 
stage  :  the  objects  being,  if  possible,  to  pre¬ 
vent  the  patient  falling  into  the  state  o.  col¬ 
lapse,  or  if  he  should,  to  bring  on  reaction  as 
speedily  as  possible. 

Concurrent  testimony  is  in  favour  of 
opium,  as  the  most  powerful  remedy,  pro¬ 
vided  it  be  given  in  full  and  repeated  doses 
within  the  first  12  hours — at  farthest  within 
the  first  24  hours  from  the  attack  — if  possi¬ 
ble  before  there  is  collapse,  certainly  before 
there  is  the  tendency  to  stupor,  which  is  to 
be  expected  after  the  collapse. 

When  reaction  has  taken  place,  and  the 
tendency  to  stupor  shewn  itself,  the  farther 
use  of  the  opium  and  astringents  requires 
much  caution,  and  the  case  must  be  treated 
as  one  of  febrile  disease,  particular  attention 
being  paid  to  the  quantity  and  quality  of 
urine  passed. 

IV.  When  removal  of  the  patient  to  hos¬ 
pital  is  thought  necessary,  it  should  be 
effected  in  the  recumbent  posture  ;  and  the 
litter  employed  should  be  so  constructed  and 
managed,  as  to  secure,  as  far  as  possible, 
protection  and  warmth  during  the  removal. 
Litters  of  this  kind  are  kept  at  the  cholera 
hospital,  Surgeon  Square,  and  at  the  Royal 
Infirmary. 

V.  When  the  first  patient  affected  in  a 
house  (particularly  if  crowded,  dirty,  and 
inhabited  by  destitute  people)  has  been  re¬ 
moved  or  has  died,  or  in  the  case  where  some 
of  the  members  of  the  family  are  of  no  use 
for  the  assistance  of  the  patient,  the  medical 
officer  will  consider  the  advantage  of  re¬ 
moving  the  remaining  or  less  useful  members 
of  the  family — and  when  the  locality  is  damp 
or  ill-aired,  or  the  cases  have  occurred  in 
rapid  succession,  some  of  the  neighbours — 
without  delay  into  one  of  the  houses  of 
refuge  prepared  for  their  reception  ;  expe¬ 
rience  having  shewn  that  when  this  measure 
has  been  promptly  adopted,  successions  of 
fatal  cases  in  the  same  family,  such  as  have 
already  occurred  in  at  least  eight  of  the 
places  where  the  disease  has  recently  ap¬ 
peared  in  Edinburgh,  have  very  generally 
been  averted.  If  this  measure  is  assented 
to  by  the  family,  he  will  give  immediate 
notice  to  the  officers  of  police  in  his  return 
of  the  case,  that  the  house  may  be  taken 
charge  of  by  the  police,  and  thoroughly 
cleansed.  Some  objection  to  this  measure 


on  the  part  of  the  affected  families  may  al¬ 
ways  be  expected  at  first,  but  a  little  ex¬ 
planation,  and  a  little  experience  of  its  effects, 
will  very  generally  surmount  the  difficulty. 

THE  DUBLIN  BOARD  OF  HEALTH  ON  THE 

REMUNERATION  OF  MEDICAL  MEN  FOR 

ATTENDANCE  ON  FEVER  CASES. 

The  Board  of  Health  have  had  under  consi¬ 
deration  those  provisions  of  the  amended 
Fever  Act,  12th  Viet. ,  c.  131,  which  have 
reference  to  the  Salaries  of  the  Medical 
Officers  at  the  Temporary  Fever  Hospitals, 
and  are  of  opinion  that  five  shillings  a  day, 
hitherto  allowed  to  medical  practitioners  for 
attendance  on  Temporary  Fever  Hospitals  or 
Dispensaries  witnin  their  own  districts,  is 
only  a  reasonable  remuneration  for  the  labour 
and  risk  incurred  in  such  attendance,  and 
that  it  should  not  be  departed  from. 

This  amount  of  remuneration  is  recom¬ 
mended  by  precedent,  as  it  appears  from 
Official  Returns  laid  before  the  Board,  that 
such  was  the  remuneration  generally  allowed 
to  medical  officers  appointed  to  similar 
duties  during  the  prevalence  of  former 
epidemics  of  fever,  viz.,  in  the  years  1816, 
’1 7,  and  ’18,  and  1826,  &c. ;  and  it  has 
received  the  approbation  of  the  Lords  of  the 
Treasury,  having  been  paid  with  their  sanc¬ 
tion  from  the  commencement  of  the  present 
epidemic  fever  in  1846,  up  to  the  passing  of 
the  amended  Fever  Act,  12th  Viet.,  c.  131, 
on  the  5th  September  last. 

Representations  have  been  laid  before  the 
Board  of  the  expediency  of  constructing  a 
scale  which  might  apportion  the  rate  of  re¬ 
muneration  to  the  relative  sizes  of  the  Tem¬ 
porary  Fever  Hospitals,  and  the  correspond¬ 
ing  amount  of  duty  to  be  performed.  The 
Board,  after  full  consideration,  are  con¬ 
vinced  that  it  would  be  hardly  practicable 
to  establish  any  such  scale.  The  numbers 
under  treatment  in  each  hospital  must 
necessarily  vary  from  week  to  week,  and  if 
the  numbers  in  hospital  were  permitted  to 
be  the  criterion  of  the  amount  of  salary,  the 
medical  officer  would  be  constantly  exposed 
to  the  imputation  of  retaining  a  greater 
number  of  patients  than  necessary,  in  order 
to  entitle  him  to  a  certain  amount  of  salary. 
Another  mode  of  lessening  the  expenditure 
for  medical  attendance  has  been  proposed 
for  the  consideration  of  the  Board,  viz.,  that 
the  attendance  of  the  Temporary  Fever 
Hospital  should  be  given  to  the  medical 
officer  already  holding  the  Workhonse 
Hospital,  or  some  other  appointment  or 
appointments  under  the  Board  of  Guardians, 
and  that  thus  by  giving  such  officer  two  or 
more  medical  appointments,  the  united 
salaries  would  amount  to  a  reasonable  sum, 
although  the  rate  allowed  for  any  one  might 
be  very  small. 

The  Board  of  Health  consider  that  such 


818  ON  THE  BEST  MEANS  OF  PRESERVING  HEALTH — THE  CHOLERA. 


an  arrangement  would  be  unjust  to  the 
medical  officer,  and  injurious  to  the  sick. 

If  attendance  on  a  Temporary  Fever 
Hospital  be  in  itself  worth  a  certain  rate  of 
remuneration,  that  amount  of  remuneration 
should  be  given  for  that  particular  duty, 
without  reference  to  any  other  appointment 
which  the  officer  may  hold — each  duty 
should  be  estimated  for,  and  paid  for  in 
respect  only  to  itself.  The  practice  of  im¬ 
posing  several  appointments  on  the  same 
medical  officer  on  the  ground  of  economy, 
is,  however,  open  to  another  and  more 
serious  objection  : — it  will  be  injurious  to 
the  sick  poor.  Every  practitiom  r  requires 
a  considerable  portion  of  each  day  for  pri¬ 
vate  practice,  which  is  generally  the  main 
source  of  his  income  ;  and  if  a  greater  amount 
of  hospital  duty  be  imposed  on  a  medical 
officer  than  he  can  perform  within  from  one  to 
three  hours  at  the  very  farthest,  the  sick  poor 
must  be  neglected  ; — no  extent  of  supervi¬ 
sion,  no  inspection,  how  often  soever  re¬ 
peated,  can  prevent  neglect  in  such  cases. 
It  appears,  by  a  return  before  the  Board, 
that  the  average  number  of  patients  in  each 
"Workhouse  Hospital  in  Ireland,  in  the  last 
week,  has  been  105.  If  such  cases  were 
like  the  ordinary  cases  in  a  Fever  Hospital, 
similar  in  kind  or  type,  the  time  required 
for  mere  attendance  would  not  be  so  great ; 
but  when  it  is  recollected  that  there  is  not 
only  this  large  average  number,  but  that  it 
includes  every  variety  of  medical  and  sur¬ 
gical  diseases,  requiring,  occasionally,  ope¬ 
rations  and  dressings,  it  is  evident  that  great 
care  should  be  taken  not  to  curtail,  on  the 
ground  of  economy,  the  time  required  for 
the  due  performance  of  such  laborious 
duties.  In  no  instance  in  Dublin  is  the 
duty  of  attending  100  patients,  in  a  general 
hospital,  imposed  upon  one  officer. 

In  England  the  practice  has  grown  up 
of  medical  officers  undertaking  a  greater 
amount  of  medical  attendance  than  they 
could  themselves  adequately  discharge,  and 
of  committing  the  care  of  the  sick  poor  to 
assistants  engaged  for  that  purpose.  The 
Board  most  strongly  disapprove  of  such  a 
system  ;  for  it  is  evident  that  there  can  be 
no  sufficient  security  for  the  professional 
knowledge  or  conduct  of  assistants  so  em¬ 
ployed.  Adequate  skill  and  attention  can 
only  be  afforded  and  secured  to  the  poor  by 
not  imposing  upon  any  medical  officer  any 
greater  extent  of  public  duty  than  he  can 
honestly  and  fairly  discharge  without 
trenching  on  his  private  practice,  and  by 
requiring  that  he  shall  personally  fulfil  the 
duties  of  any  medical  appointment  he  may 
undertake.  This  course  is  not  more  clearly 
pointed  out  by  justice  and  humanity,  than 
it  is  recommended  by  true  economy  ;  for 
neglect  or  bad  management  of  the  poor 
suffering  under  sickness  or  accident,  will 


render  them  or  their  families  a  lengthened 
charge  on  the  rates. — By  order  of  the 
Board, 

W.  H.  Hopper, 
Secretary. 

Central  Board  of  Health,  Dublin, 

11th  October,  1848. 

REPORT  OF  THE  PHYSICIANS  AND  SUR¬ 
GEONS  OK  SOUTHAMPTON  ON  THE  BEST 

MEANS  OF  PRESERVING  HEALTH  ON 

THE  REAPPEARANCE  OF  CHOLERA  IN 

ENGLAND. 

1.  Temperate  habits. — Intemperance  or 
any  excess,  late  hours,  and  every  habit 
which  weakens  the  body,  should  be  alto¬ 
gether  avoided.  Those  who  indulge  in  in¬ 
toxication  and  debauchery  are  most  liable 
to  be  attacked. 

2.  Diet. — Wholesome  and  nutritious  food 
in  moderation  prevents  disease  ;  and  those 
who  are  poor  should  rather  spend  their 
money  in  good  food  than  in  beer  and  spirits. 
Those  who  are  weak,  or  are  liable  to  bowel 
complaints,  should  abstain  from  fruit  and 
vegetables.  All  should  avoid  sour  beer, 
acid  drinks,  unripe  fruit,  and  fish  not  per¬ 
fectly  fresh,  especially  shell-fish. 

3.  Cleanliness. — The  skin  should  be  fre¬ 
quently  washed,  and  the  greatest  attention 
paid  to  personal  cleanliness. 

4.  Clothing. —  The  clothing  should  be 
such  as  to  keep  the  body  comfortably  warm. 
Flannel  should  be  worn  next  the  skin,  parti¬ 
cularly  around  the  bowels  and  loins.  No 
one  should  rest  in  wet  clothes  or  with  wet 
feet. 

5.  Ventilation. — The  windows  and  doors 
of  rooms  should  be  frequently  opened,  espe¬ 
cially  if  many  persons  are  working  together 
at  sedentary  occupations  in  the  same  apart¬ 
ment.  Bedroom  window's  and  doors  should 
be  freely  opened  during  the  day,  and  all 
fire-boards  or  obstructions  in  the  chimneys 
removed  at  night  as  well  as  by  day.  Bed¬ 
rooms  without  chimneys  should  have  a  ven¬ 
tilator  in  the  window,  or  the  door  should 
not  be  shut  at  night,  otherwise  they  are  very 
unwholesome.  The  beds  should  be  stripped 
early,  and  not  made  for  several  hours. 

6.  Drainage. — The  house  drains  should 
be  well  washed  down  every  evening,  as  ex¬ 
perience  has  shown  that  this  is  necessary 
even  where  the  drains  are  well  trapped.  If 
any  bad  smell  is  complained  of  in  the  house, 
iis  cause  should  be  discovered  and  removed. 
In  such  cases,  the  traps  of  the  drains  should 
be  examined.  No  filth  whatever  should  be 
allowed  to  accumulate  near  the  house.  All 
rooms  requiring  it  should  be  fresh  white¬ 
washed. 

7.  Improper  medicines.  —  Epsom  salts 
and  strong  purgatives  should  be  avoided. 

8.  Looseness  of  the  bowels. — Persons  at¬ 
tacked  with  looseness  of  the  bowels,  how¬ 
ever  slight,  should  immediately  apply  for 


AILEGED  UTILITY  OE  CAMPHOR  IN  THE  TREATMENT  OF  CHOLERA.  819 


medical  advice ;  for  looseness  is  the  first 
stage  of  cholera,  and,  if  neglected  for  a  few 
hours,  may  pass  into  fatal  cholera.  By  at¬ 
tending  to  this  precaution,  the  disease  was 
checked  in  many  places  in  1832.  and  in  the 
present  epidemic  in  Europe  it  has  been 
found  “  that  the  greatest  attention  must  be 
paid  to  the  Looseness  which  precedes  cho¬ 
lera.” 

9.  Protection  against  cholera. — In  con¬ 
clusion,  the  public  are  reminded  that  those 
who  are  temperate  in  all  things,  cheerful 
and  free  from  alarm,  by  confidently  trusting 
the  kind  providence  of  God,  active  and 
regular  in  their  habits,  early  in  their  hours, 
and  clean  in  their  persons  and  houses,  are 
the  least  liable  to  be  attacked  with  cholera. 

REJECTION  OF  THE  RECOMMENDATIONS  OF 

THE  NON  -MEDICAL  BOARD  OF  HEALTH 

BY  THE  PRACTITIONERS  OF  WORCESTER. 

At  a  Meeting  of  the  medical  practitioners 
of  Worcester,  held  October  19th,  1848,  at 
which  twenty-one  members  of  the  profession 
were  present,  Dr.  Hastings  in  the  chair,  it 
was  moved  and  seconded  :  — 

That  it  appears  to  this  meeting,  that  on 
the  late  occasion  of  the  prevalence  of  cho¬ 
lera  in  Worcester,  it  was  found  very  bene¬ 
ficial  to  have  a  separate  establishment  in  a 
healthy  locality,  for  the  treatment  of  cholera 
patients,  and  also  an  establishment  for  re¬ 
ceiving  the  inmates  of  houses  in  which  the 
disease  had  occurred,  and  wTho  had  not  been 
affected.  This  meeting  cannot  therefore 
concur  in  the  recommendation  of  the  Board 
of  Health,  that  cholera  patients  should  be 
received  into  the  General  Infirmary  or  at 
the  Dispensary. — The  resolution  was  carried 
with  two  dissentients. — Prov.  Journal. 

ALLEGED  UTILITY  OF  CAMPHOR  IN  THE 
TREATMENT  OF  CHOLERA. 

Letter  to  the  Right  Hon.  Lord  John 
Russell. 

My  Lord, — Some  time  since  I  had  the 
honour  of  directing  your  attention,  and 
that  of  Mr.  Chadwick,  to  my  Theory  of 
Cholera,  published  in  the  “  London  Medi¬ 
cal  Journal,”  1832.  I  there  showed,  that 
during  all  my  experiments  as  a  member  of 
the  Central  Board  of  Health,  the  origin, 
progress,  and  successful  treatment  of  cholera 
depended  on  circumstances,  the  exciting 
cause  of  which  consists  in  “  a  broken  balance 
of  animal  electricity ,  occasioned  by  a  w  ant 
of  equilibrium  between  that  of  the  atmo¬ 
sphere  and  the  magnetism  of  the  earth.” 

When  the  natural  galvanic  energy  of  man 
is  depressed,  or  disturbed  to  a  certain  de¬ 
gree,  chemical  changes  commence ;  vital 
action  is  prostrated,  and  animal  heat  de¬ 
pressed  ;  the  nerves  are  disturbed,  the 
bowels  deranged,  and  the  secretions  sup¬ 
pressed  or  vitiated. 


Referring  to  the  “  Lancet,”  of  September 
and  October  instant,  for  details,  I  beg  to 
assure  your  Lordship,  I  have  found  that 
camphor,  when  in  the  fluid  state,  has  the 
power,  in  large  doses,  of  creating  and  main¬ 
taining  a  more  natural  equilibrium  of  animal 
heat  and  electricity,  and  for  a  longer  time, 
than  any  other  internal  remedy.  Camphor 
in  the  solid  form,  or  in  mechanical  mixture, 
is  too  slow  of  digestion  when  the  stomach 
has  little  power,  as  in  cholera  ;  but  in  the 
fluid  state  it  acts  at  once,  arousing  electric 
energy ,  neutralising  negative  galvanism , 
maintaining  the  circulation,  preventing 
cramps  and  collapse,  promoting  perspira¬ 
tion,  and  procuring  sleep. 

I  have  now  the  pleasure  to  inform  your 
Lordship,  that  the  Fluid  Camphor,  which  I 
lately  submitted  to  the  profession,  through 
Mr.  William  Bailey,  of  Wolverhampton,  is 
by  far  the  best  and  most  speedy  agent  for 
restoring  the  electric  equilibrium  proper  to 
the  human  body.  I  therefore  request  your 
Lordship,  at  this  alarming  time,  to  appoint 
a  medical  commission  to  investigate  and  re¬ 
port  upon  this  important  subject. 

I  remain,  my  Lord, 

Your  most  obedient  servant, 

James  Murray,  M.D., 
T.C.D.  and  Edinburgh  :  Inspector 
of  Anatomy. 

Merrion  Square,  Dublin, 

17th  October,  1848. 

* 

DEATHS  IN  LONDON  DURING  THE  QUARTERS 


ENDING  SEPTEMBER, 

184/  8. 

Causes  of  Death. 

Quarters  endin 

g  Sept. 

1847. 

1848. 

All  Causes  . 

13187 

13503 

Specified  Causes  . 

13158 

13450 

Violence,  Privation,  Cold,  ) 
and  Intemperance  .  .  j 

464 

471 

Small  Pox 

320 

435 

Measles  . 

521 

154 

Scarlatina 

316 

1560 

Hooping  Cough 

238 

340 

Croup 

62 

63 

Thrush  . 

82 

77 

Diarrhoea 

1196 

1048 

Dysentery 

143 

171 

Cholera  .  . 

98 

153 

Typhus  . 

895 

882 

Phthisis  or  Consumption  . 

1581 

1534 

Hydrocephalus 

415 

351 

Apoplexy 

276 

282 

Convulsions 

521 

466 

Pericarditis 

20 

30 

Aneurism 

18 

19 

Disease  of  Heart 

331 

328 

Bronchitis 

330 

357 

Pleurisy 

35 

22 

Pneumonia 

409 

388 

Asihma 

96 

64 

Teething 

163 

117 

Childbirth 

91 

57 

820  THE  CHOLERA  AT  WOOLWICH  AND  HULL — EMIGRANT  SHIPS. 


THE  CHOLERA  AT  WOOLWICH. 

Woolwich ,  Nov.  6. — The  number  of  cases 
amongst  the  convicts  up  to  yesterday  at  12 
o’clock  were — 51  admitted,  17  deaths,  18 
discharged  as  recovered,  and  8  convalescent. 
There  has  been  no  change  of  any  kind  in  the 
report  up  to  12  o’clock  to-day.  When  the 
number  of  deaths,  recoveries,  and  conva¬ 
lescent,  does  not  amount  to  the  number  ad¬ 
mitted,  the  others,  of  which  there  is  a  differ¬ 
ence  of  8  to-day,  are  labouring  under  the 
disease,  and  appear  only  amongst  the  ad¬ 
mitted. 

THE  CHOLERA  AT  HULL. 

For  11  days  not  one  case  of  cholera  had 
occurred  in  Hull.  On  Sunday,  the  29th 
October,  however,  there  were  two  fatal  cases. 
One  was  that  of  a  young  sailor,  named  Henry 
Mallinson,  who  died  on  board  a  keel  in  the 
dock,  and  the  other  that  of  an  elderly  woman, 
named  Mary  Stubbs,  residing  in  Sewer- 
land.  The  medical  attendants  declare  both 
these  to  have  been  undoubted  cases  of  cho¬ 
lera. 

SANITARY  REGULATIONS  RESPECTING 
EMIGRANT  SHIPS. 

The  following  important  orders  regarding 
emigrant  ships  have  just  been  issued,  in 
pursuance  of  the  13th  section  of  the  act  11th 
Victoria,  chap.  6,  and  the  provisions  of  the 
Passengers’  Act : — 

No  vessel  proceeding  to  North  America  is 
to  carry  more  than  one  passenger  to  every 
two  tons  of  the  registered  tonnage  of  the 
ship  ;  nor;  whatever  be  the  tonnage,  more 
than  one  passenger  to  every  12  clear  super¬ 
ficial  feet  of  deck  on  which  the  passengers 
live,  and  one  passenger  for  every  30  super¬ 
ficial  feet  on  the  orlop  deck.  The  master 
is  liable  to  a  penalty  not  exceeding  for 
every  person  in  excess.  The  lower  deck  of 
the  ship  must  not  be  less  than  one  and  a 
half  inches  in  thickness,  and  properly  se¬ 
cured  to  the  hold  beams  ;  the  height  between 
decks  is  to  be  six  feet  at  least ;  there  must 
not  be  more  than  two  tiers  of  berths,  and 
the  bottom  of  the  lower  tier  must  be  six 
inches  above  the  deck.  The  berths  are  not 
to  be  less  than  six  feet  in  length  and  18 
inches  in  width  for  each  passenger.  All 
ships  carrying  100  or  more  passengers  are 
to  carry  a  duly  qualified  surgeon  ;  a  proper 
supply  of  medicines  is  to  be  provided  for 
the  voyage,  and  no  ship  is  to  proceed  until 
the  medicine  chest  and  passengers  have  been 
inspected  by  a  medical  practitioner.  All 
passengers  who  may  be  discovered  to  be 
affected  with  any  infectious  disease,  either 
at  the  original  port  of  embarcation,  or  at 
any  port  in  the  united  kingdom  into  which 
the  vessel  may  subsequently  put,  may  be  re¬ 
landed  with  those  members  of  their  families, 
if  any,  who  may  be  dependent  on  them  or 
unwilling  to  be  separated  from  them.  Ships 


that  after  sailing  may  put  into  any  port  of 
the  united  kingdom,  must  have  their  provi¬ 
sions  and  water  replenished  before  they  can 
be  allowed  again  to  sail,  under  a  penalty  not 
exceeding  ,£T00. 

LECTURES  ON  ANATOMY  IN  THE  UNIVER¬ 
SITY  OF  CAMBRIDGE. 

The  Professor  of  Anatomy  has  given  notice 
that  he  will  commence  his  Course  of  Lec¬ 
tures  on  the  Anatomy  and  Physiology  of  the 
Human  Body,  on  Tuesday,  November  14, 
at  1  o’clock,  in  the  Anatomical  School. 
The  Inspectors  of  the  Anatomical  Museum 
for  the  present  year  have  reported  to  the 
Senate,  that  they  have  examined  the  mu¬ 
seum,  and  have  found  the  collection  in  good 
order,  and  the  specimens  in  an  excellent 
state  of  preservation.  About  50  specimens 
hare  been  added  to  the  collection  since  the 
last  report. 


UNIVERSITY  OF  LONDON. 

B.M.  SECOND  EXAMINATION. 

PASS  EXAMINATION. - 1848. 

Monday,  Nov,  6. — Morning,  10  to  1. 

Physiology. 

Examiner,  Dr.  Carpenter. 

1.  What  are  the  sources  of  the  demand 
for  aliment  in  the  human  body  ;  and  what 
are  the  principal  conditions  by  which  that 
demand  is  regulated  ? 

2.  Enumerate  the  principal  classes  of  ali¬ 
mentary  materials ;  state  the  purposes  to 
which  they  are  severally  subservient  in  the 
economy  ;  mention  the  chief  proximate  com¬ 
ponents  of  bread,  meat,  potatoes,  milk,  rice, 
and  arrow-root ;  and  state  the  quantity  of 
food  ordinarily  requisite  to  maintain  the 
human  system  in  vigorous  action. 

3.  Describe  the  general  plan  of  the  cir¬ 
culation  of  the  blood  in  articulated  and 
molluscous  animals  ;  and  state  the  distinctive 
peculiarities  of  the  circulating  apparatus  in 
fishes,  reptiles,  birds,  and  mammals. 

4.  Describe  the  structure  of  the  liver  in 
insects  and  Crustacea,  and  point  out  the  re¬ 
lation  between  the  development  of  that  organ 
and  the  energy  of  the  respiratory  process ; 
describe  the  composition  of  bile ,  and  state 
w'hat  is  known  of  its  sources,  its  uses  in  the 
economy,  and  the  effects  of  its  accumulation 
in  the  blood. 

5.  Explain  the  dependence  of  the  respira¬ 
tory  movements  upon  the  nervous  system  ; 
describe  the  position  of  the  respiratory 
ganglia  in  articulata,  mollusca,  and  verte- 
brata  ;  give  the  rationale  of  the  ordinary  and 
extraordinary  movements  of  respiration  in 
man  ;  and  mention  what  nerves  are  con¬ 
cerned  in  each. 

6.  Describe  the  principal  stages  of  the 
development  of  the  nervous  centres  in  the 
human  foetus  ;  and  state  how  far  these  cor- 


EXAMINATIONS  AT  THE  UNIVERSITY  OF  LONDON 


respond  with  the  permanent  forms  of  those 
organs  in  the  lower  animals. 

Afternoon,  3  to  6. 

General  Pathology,  General  Therapeutics, 

and  Hygiene. 

CELSUS  DE  RE  MEDICA. 

Examiners,  Dr.  Billing  and  Dr.  Tweedie. 

1.  Mention  the  principal  predisposing 
causes  of  disease,  giving  a  few  examples  in 
illustration. 

2.  Explain  the  theory  of  the  operation  of 
cathartics.  Mention,  1.  the  diseases  in 
which  they  are  especially  indicated  ;  2.  the 
circumstances  by  which  their  selection  should 
be  regulated  ;  and  3.  those  which  render 
caution  necessary,  or  altogether  forbid  their 
employment. 

3.  Sketch  shortly  the  diseases  to  which 
artisans  are  liable  who  are  exposed  to  the 
noxious  effects  of  metals  in  their  occupation, 
with  the  hygienic  rules  to  be  adopted  for 
their  prevention. 

4.  Translate  the  following  passage  into 
English  : — 

Proximum  est,  ut  de  iis  dicam,  qui  partes 
aliquas  corporis  imbecillas  habent.  Cui 
caput  infirmum  est,  is  si  bene  concoxit, 
leniter  perfricare  id  mane  manibus  suis  de¬ 
bet  ;  nunquam  id,  si  fieri  potest,  veste 
velare ;  ad  cutem  tonderi :  utileque  lunam 
vitare,  maximeque  ante  ipsum  lunae  solisque 
concursum  ;  sed  nusquam  post  cibum  pro- 
gredi.  Si  cui  capilli  sunt,  eos  quotidie  pec- 
tere  ;  multum  ambulare,  sed,  si  licet,  neque 
sub  tecto,  neque  in  sole :  utique  autem 
vitare  solis  ardorem,  maximeque  post  cibum 
et  vinum  :  potius  ungi  quam  lavari ;  nun¬ 
quam  ad  flammam  ungi;  interdum  ad  pru- 
nam.  Si  in  balneum  venit,  sub  veste  pri- 
mum  paulum  in  tepidario  insudare ;  ibi 
ungi,  turn  transire  in  calidarium  :  ubi 
sudarit,  in  solium  non  descendere,  sed  multa 
calida  aqua  per  caput  se  totum  perfundere, 
turn  tepida,  deinde  frigida ;  diutiusque  ea 
caput  quam  caeteras  partes  perfundere; 
deinde  id  aliquamdiii  perfricare  ;  novissime 
detergere  et  ungere.  Capiti  nihil  aeque 
prodest  atque  aqua  frigida :  itaque  is  cui 
hoc  infirmum  est,  per  aestatem  id  bene  largo 
canali  quotidie  debet  aliquamdiii  subjicere. 
Semper  autem,  etiam  si  sine  balneo  unctus 
est,  neque  totum  corpus  refrigerare  sustinet, 
caput  tamen  aqua  frigida  perfundere:  sed 
quum  caeteras  partes  attingi  nolit,  demittere 
id,  ne  ad  cervices  aqua  descendat :  eamque, 
ne  quid  oculis  aliisve  partibus  noceat,  de- 
fluentem  subinde  manibus  ad  hoc  regerere. 
Huic  modicus  cibus  necessarius  est,  quem 
facile  concoquat ;  isque,  si  jejuno  caput 
laeditur,  assumendus  etiam  medio  die  est ; 
si  non  laeditur,  semel  potius.  Bibere  huic 
assidue  vinum  dilutum,  lene,  quam  aquam 
magis  expedit ;  ut  quum  caput  gravius  esse 


821 


coeperit,  sit  quo  confugiat:  eique  ex  toto 
neque  vinum  neque  aqua  semper  utilia  sunt ; 
medicamentum  utrumque  est,  quum  in 
vicem  assumitur.  Scribere,  legere,  voce 
contendere,  huic  opus  non  est,  utique  post 
coenam  :  post  quam  ne  cogitatio  quidem  ei 
satis  tuta  est :  maxime  tamen  vomitus  alienus 
est. — Celsus,  De  Re  Medica. 


BOOKS  &  PERIODICALS  RECEIVED 

DURING  THE  WEEK, 

With  those  not  given  in  our  last  number. 

Journal  of  Public  Health.  November  1848. 

The  Water-Cure  Journal.  Nov.  1848. 

Table  for  the  uniform  Medical  Registration 
of  Cases  of  Cholera. 

Pharmaceutical  Journal.  November. 

London  and  Edinburgh  Philosophical  Ma¬ 
gazine. 

Annales  d’ Hygiene  et  de  Medecine  Legale. 
Octobre  1848. 

Practical  Observations  on  Galvanism,  Elec¬ 
tricity,  and  Electro- Magnetism,  as  em¬ 
ployed  in  the  Cure  of  Disease.  By  John 
Palmer  Tylee. 

An  Introduction  to  Practical  Chemistry, 
including  Analysis.  By  John  E.  Bowman. 

Notes  on  the  Morbid  Anatomy  of  Chronic 
Rheumatic  Arthritis,  &c.  By  Edwin 
Canton,  F.R.C.S. 

The  Key  of  Cholera.  By  James  William 
Earle. 

Dr.  Leared  on  Asiatic  Cholera. 

The  Ethnological  Journal.  Edited  by  Luke 
Burke,  Esq.  No.  VI.  Nov.  1848. 

On  Turning  as  an  Alternative  for  Craniotomy 
and  the  Long  Forceps.  By  Robert  Col¬ 
lins,  M.D. 

Edinburgh  Monthly  Journal  of  Medical 
Science.  November. 

Transactions  of  the  Provincial  Medical  and 
Surgical  Association.  Vol.  XVI.  Part  1. 

The  American  Journal  and  Library  of  Den¬ 
tal  Science.  July  1848. 

The  Dublin  Medical  Press.  Nov.  8. 

Rose’s  Practical  Treatise  on  Chemical  Ana¬ 
lysis.  By  A.  Normandy.  Vol.  II. — 
Quantitative. 

Practical  Introduction  to  H.  Rose’s  Trea¬ 
tise  on  Chemical  Analysis.  By  A.  Nor¬ 
mandy. 

Reports  on  Asiatic  Cholera.  By  S.  Rogers. 

The  Philadelphia  Medical  Examiner.  June, 
July,  and  August,  1848. 

Observations  on  Malignant  Cholera.  By 
Andrew  Buchanan,  M.D. 

Tbe  Dublin  Quarterly  Journal  of  Medical 
Science.  November. 

Pathologia  Indica.  By  Allan  Webb,  B.M.S. 
2d  edition  :  Calcutta,  1848. 

Practical  Observations  on  the  prevailing 
Epidemic,  called  Cholera.  By  James 
Keir,  M.D.  Knt.  Part  1. 

Practical  Observations  on  a  successful  Me- 


822  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY,  ETC, 


thod  of  treating  Cholera.  By  Charles 
Patterson,  M.D. 

The  Treatment  of  Asiatic  Cholera.  By 
Archibald  Billing,  A.M.  M.D;  F.R.S. 
Remarks  on  the  Extension  of  Education  at 
the  University  of  Oxford.  By  H.  W. 
Acland,  M.D.  F.R.S.  &c.  Oxford. 
Casper’s  Woohenschrift  der  ges.  Heilkunde. 

Nos.  42,  43;  Oct.  14th  and  21st. 

Report  of  the  Edinburgh  Homoeopathic 
Dispensary  on  Asiatic  Cholera. 

METEOROLOGICAL  SUMMARY. 


Mean  Height  of  Barometer .  29'42 

“  “  Thermometer1  . .  4V9 

Self-registering  do. b  ....  max.  73'  min.  27-7 
“  in  the  Thames  water  —  49"2  —  43-5 

a  From  12  observations  daily.  b  Sun. 


Rain,  in  inches^  0-89 :  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteoroloqical. — The  mean  temperature  of  the 
week  was  about  2°  above  the  mean  of  the  month. 


BIRTHS  &  DEATHS  in  the  Metropolis 
Duriny  the  'week  ending  Saturday ,  Nov.  4. 


Births. 
Males....  734 
Females. .  727 

1461  ! 


Deaths 
Males....  565 
Females. .  550 

1115 


Av.  of  5  Ant. 
Males....  581 
Females. .  573 


1154 


Causes  of  Death. 


Specified  Causes . ... 

1.  .Zy/ttof/cforEpidemic, Endemic, 

Contagious)  Diseases.. 
Sporadic  Diseases,  viz. — 

2.  Dropsy,  Cancer,  &c.  ot  uncer¬ 

tain  seat  . 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  . 

4.  Lunars  and  other  Organs 

Respiration . 

5.  Heart  and  Bloodvessels  .. . 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion  . 

7.  Diseases  of  the  Kidneys,  &c.. . 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c . 

9.  Rhematisin,  Diseases  of  the 
Bones,  Joints,  &c . 

10.  Skin,  Cellular  Tissue,  &c . 

11.  Old  Age . 

12.  Violence,  Privation,  Cold,  and 

Intemperance . 


|  Av.  of 
5  Aut. 

11115 

1154 

1112 

1149 

423 

270 

44 

52 

108 

127 

125 

222 

42 

38 

59 

67 

6 

12 

12 

14 

11 

8 

2 

2 

33 

64 

29 

32 

The  following  is  a  selection  of  the  numbers  of 
Deaths  from  the  most  important  special  causes: 


Small-pox  .  36 

Measles  . .  11 

Scarlatina  . 135 

Hooping-cough..  27 

Diarrhoea  .  38 

Cholera  .  65 

Typhus  .  77 


Dropsy .  16 

Sudden  deaths  ..  16 

Hydrocephalus..  27 
Apoplexy .  25 


Paralysis .  15 

Convulsions  ....  37 

Bronchitis .  43 

Pneumonia.......  57 

Phthisis . 110 

Dis.  of  Lungs,  &c.  9 

Teething .  5 

Dis.  Stomach,  &c.  7 
Dis.  of  Liver,  &c.  11 

Childbirth .  7 

Dis.  of  Uterus,&c.  4 


Remarks. — The  total  number  of  deaths  was 
39  below  the  weekly  autumnal  average.  See 
page  801. 


NOTICES  to  CORRESPONDENTS. 

Dr.  Collins.— It  is  against  our  rule  to  insert  re¬ 
plies  to  communications  which  have  appeared 
in  other  journals.  The  insertion  of  the  letter 
would,  besides,  'e  d  to  a  controversy  of  which 
it  is  impossible  to  foresee  the  end. 

Dr.  Seaton. —  We  have  been  unavoidably  com¬ 
pelled  to  postpone  until  the  next  number  Dr. 
Seaton’s  letter,  and  the  plan  for  the  registra¬ 
tion  of  cases  of  cholera. 

The  communications  of  Drs.  C.  H.  Jones,  Snow, 
and  Mi Irov,  next  week. 

The  verses  on  St.  John  Long  are  good,  but  not 
fitted  for  publication  in  our  pages. 

Dr.  Jamieson’s  interesting  case  of  poisoning 
with  cantharides  is  not  forgotten.  It  will 
shortly  appear. 

“  J.”  Exeter.— The  paper  on  contagion  is  so  well 
written,  that  we  wish  to  have  our  correspon¬ 
dent’s  assent  to  the  proposition,  that  his  name 
should  be  attached  to  it.  The  writer  will  ob¬ 
serve  that  anonymous  controversial  attacks 
are  not  admitted  into  the  columns  of  the 
Medical  Gazette. 

Mr.  Christopher’s  paper  has  been  received,  and 
will  be  inserted  as  early  as  our  arrangements 
will  permit. 

“  A  Subscriber”  is  right  about  the  word  “  anaes¬ 
thetic,  ”  but  the  term  is  now  universally 
employed  under  a  w’ell-known  meaning. 

Dr.  J.  W.  Everitt,  Devizes. — We  shall  have  great 
pleasure  in  publishing  the  cases. 

Dr.  C.  Dawson  (54th  Regt.)-A  note  will  be  sent. 

Received.— Dr.  Snow  —  Dr.  J.  W.  Griffith  — 
Chirurgus. 


THE  GENERAL  INDEX. 


We  have  to  announce  to  our  Subscribers  that  a  General 
Index  to  the  first  40  Volumes  of  the  London  Medical  Gazette 
will,  it  is  calculated,  form  a  large  Yolume  of  about  700  pages. 
The  cost  of  the  Index  Yolume,  respecting  which  many  inquiries 
have  been  made,  will  be  Twenty-four  Shillings ;  and  it  is  proposed 
to  commence  it  so  soon  as  the  Names  of  Five  Hundred  Subscribers 
have  been  obtained. — The  printers,  Messrs.  Wilson  and  Ogilvy, 
57,  Skinner  Street,  will  receive  the  Names  of  Subscribers. 


ftontrou  chiral  ©alette. 

 Cm 


Scctures. 

LECTURES 

Off 

PRETERNATURAL  AND  COMPLEX 
PARTURITION. 

By  Edward  W.  Murphy,  A.M.  M.D. 

Professor  of  Midwifery,  University  College, 
London. 

Lecture  IV. 

COMPLEX  LABOURS. 

GENERAL  VIEW  OF  HAEMORRHAGES. 

Bichat’s  division  of  haemorrhage — by  ex¬ 
halation — by  rupture  of  a  blood-vessel. 
Principles  of  treatment  in  medical  and 
surgical  haemorrhages — Uterine  haemor¬ 
rhage  from,  the  unimpregnated  uterus — 
Haemorrhage  in  the  early  months  of 
gestation.  Flooding  at  the  time  of  deli - 
verg — arrangement  of  the  uterine  arteries 
and  veins.  The  circulation  in  the  pla¬ 
centa. 

Descriptions  of  the  Hunters,  Weber ,  Good- 
sir.  The  effect  of  partial  separation  of 
the  placenta — source  of  haemorrhage — 
The  effect  of  a  complete  separation — Ob¬ 
jections  considered —  Conclusion. 

Gentlemen, — The  last  division  of  la¬ 
bours  embraces  those  accidental  complica¬ 
tions  which  may  occur  in  the  progress  of 
parturition :  some  of  them  are  extremely 
dangerous,  even  fatal,  to  the  mother ;  the 
child  is  frequently  sacrificed,  and,  with  one 
exception,  the  aid  of  the  accoucheur  is  al¬ 
ways  demanded ;  they  form  the  last  excep¬ 
tion  to  Denman’s  definition  of  natural  la¬ 
bour,  and  their  study  is  of  the  highest 
importance  to  the  practitioner. 

Complex  parturition  includes  labours  at¬ 
tended  with  haemorrhages,  convulsions,  rup¬ 
tures  of  the  uterus,  inversion  of  the  uterus, 
prolapse  of  the  umbilical  cord,  twins,  &c. 
&c.  Of  these  complications,  the  first  that 
we  shall  consider  is  haemorrhage — the  first 
in  practical  importance — first,  because  the 
issues  of  life  and  death  are  so  much  in  the 
hands  of  the  practitioner.  The  best-di¬ 
rected  treatment  may  not  save  the  patient 
who  is  attacked  by  convulsions.  In  rup¬ 
tures  of  the  uterus  the  recovery  of  the 
patient  is  recorded  as  a  remarkable  excep¬ 
tion  to  the  general  rule  ;  but  when  haemor¬ 
rhage  takes  place,  her  safety  depends,  in  the 
majority  of  instances,  altogether  upon  the 
practical  experience  and  promptitude  of  the 
accoucheur.  This  alone  would  be  a  suffi¬ 
cient  reason  for  demanding  a  careful  exami¬ 
nation  of  the  subject ;  but  I  have  an  addi¬ 
tional,  and  equally  powerful  motive,  for 
asking  a  patient  and  impartial  attention  to 
it' — because  in  a  case  of  so  much  danger,  in 

XLII.— 1094.  Nov.  17,  1848. 


823 


which  it  is  desirable,  above  all  things,  to 
have  rules  of  practice  clear,  decided,  and 
intelligible,  we  find  them,  unfortunately,  so 
involved  in  controversial  intricacies  as  to 
render  them  obscure,  uncertain,  and  con¬ 
tradictory. 

In  order  to  understand  the  principles  of 
treatment  in  uterine  haemorrhage,  it  will  be 
advisable  to  review,  very  briefly,  the  manner 
in  which  haemorrhages  take  place  from  other 
parts  of  the  body,  and  to  point  out  the 
principles  upon  which  are  founded  the  dif¬ 
ferent  means  employed  to  arrest  them.  We 
may  compare  or  contrast  the  one  with  the 
other,  and  if  they  are  similar  there  can  be 
no  difficulty  in  applying  the  principles  of 
treatment  for  general  haemorrhages  to  flood¬ 
ings  from  the  uterus.  But  if,  as  it  appears 
to  me,  they  are  different,  and  in  some  de¬ 
gree  opposed,  it  is  of  the  utmost  importance 
to  observe  and  remember  the  essential  cha¬ 
racters  of  each,  so  as  to  avoid  the  very  com¬ 
mon  error  of  employing  treatment  quite 
applicable  to  haemorrhage  in  one  way,  pro¬ 
duced  for  the  purpose  of  arresting  haemor¬ 
rhage  caused  in  a  manner  altogether  dif¬ 
ferent. 

There  are  many  divisions  of  non-uterine 
haemorrhages  ;  that  adopted  by  Bichat  is 
the  simplest,  and  will  best  answer  the  pur¬ 
pose  we  have  in  view.  Haemorrhages  may 
arise  either  from  exhalation ,  or  from. 
rupture  of  a  blood  -  vessel.  The  first 
variety  includes  such  as  chiefly  fall  under 
the  notice  of  the  physician ;  the  second, 
those  haemorrhages  which  it  is  the  province 
of  the  surgeon  to  arrest.  Either  practi¬ 
tioner  may  meet  with  both  varieties,  but  the 
object  of  this  distinction  is  rather  to  direct 
your  attention  to  the  medical  and  surgical 
treatment  of  haemorrhages,  in  order  to  con¬ 
trast  them  with  the  management  of  floodings 
at  the  time  of  delivery. 

Haemorrhage  by  exhalation  is  most  fre¬ 
quently  observed  on  mucous  surfaces  ;  and 
whether  the  nostrils,  the  throat,  the  lungs, 
the  stomach,  the  intestines,  or  the  bladder 
be  its  seat,  in  all  these  instances  the  source 
of  haemorrhage  exists  in  the  minute  capil¬ 
lary  vessels,  which  admit  red  blood  to  exude 
through  them.  Why  they  do  so,  it  is  not 
my  province  to  inquire  ;  it  is  sufficient  for 
me  to  state,  that  vessels,  which  hitherto  re¬ 
sisted  its  escape,  now  permit  red  blood  to 
pass,  and  that  these  vessels  still  maintain 
themselves  unbroken.  Haemorrhages  of 
this  kind  may  be  active  or  passive ;  either 
the  result  of  local  congestion  in  the  part 
affected,  or  of  diminished  tone  in  the  vessels, 
accompanied,  perhaps,  with  an  altered,  a 
more  fluid  condition  of  the  blood  itself. 
The  former  variety  will  best  illustrate  the 
general  treatment.  Take  the  simplest  and 
most  common  example  of  active  haemorrhage 
by  exhalation — haemorrhage  from  the  pitui- 


824 


HAEMORRHAGE  NOT  DEPENDING  UPON  GESTATION. 


tary  membrane,  and  observe  the  symptoms. 
The  bleeding  is  preceded  by  symptoms  in¬ 
dicating  a  determination  of  the  circulation 
towards  the  part  affected — the  molimen 
hamorrhagicum  of  authors.  The  pulse  is 
full  and  bounding,  the  temporal  arteries 
throb,  there  may  be  giddiness  or  headache, 
a  disposition  to  sleep,  noises  in  the  ears,  &c. 
&c.  At  the  same  time  that  this  local  plethora 
exists,  the  circulation  of  the  general  surface 
and  lower  extremities  is  just  as  much  below, 
as  that  in  the  head  is  above,  the  standard ; 
the  patient  is  therefore  chilly,  and  complains 
of  cold.  When  haemorrhage  takes  place, 
the  circulation  is  relieved,  and  these  symp¬ 
toms  disappear;  but  if  it  continue  they  are 
again  renewed — there  is  an  effort  on  the 
part  of  the  circulation  to  supply  the  loss 
caused  by  the  haemorrhage — there  is  a  deter¬ 
mination  of  blood  towards  its  seat,  and  the 
symptoms  of  congestion  return.  What  are 
the  principles  of  treatment  ?  It  is  necessary 
to  direct  the  current  of  the  circulation  from 
the  seat  of  haemorrhage,  and  to  lessen  its 
force ;  hence  depletion,  cold  to  the  affected 
part,  and  other  such  means,  are  employed. 
It  is  also  requisite  to  cause  the  open  capilla¬ 
ries  to  contract,  and  to  promote  coagulation 
of  the  blood  ;  hence  astringents  are  indi¬ 
cated,  whether  applied  locally  or  conveyed 
through  the  circulation.  Everything  that 
would  excite  the  circulation  must  be  avoided  ; 
and  if  syncope  take  place  it  is  often  the  most 
efficient  means  of  arresting  the  discharge. 

Hemorrhage  by  rupture  of  a  blood¬ 
vessel  is  checked  in  a  manner  somewhat 
different,  which  is  best  observed  when  the 
arteries  of  the  surface  are  injured.  If  an 
artery  be  punctured,  divided,  or  lacerated, 
the  effort  of  Nature  in  the  first  instance  is 
to  coagulate  the  blood  in  the  injured  part. 
If  an  artery  be  divided,  the  two  internal 
coats  of  the  vessel  retract  themselves  within 
the  outer  sheath ;  the  fine  cellular  tissue 
drawn  out  by  this  retraction  entangles  the 
current  of  blood,  and  an  external  coagulum 
is  formed,  compressing  and  obstructing  the 
orifice.  A  conical  coagulum  is  also  formed 
within  the  artery,  and  thus  the  impetus  of 
the  blood  receives  a  check,  the  fibres  of  the 
middle  coat  of  the  artery  contract,  lymph  is 
effused  at  the  divided  extremity  of  the  vessel, 
and  ultimatelythe  breach  isclosed.  Such  is  the 
contrivance  of  Nature  for  this  purpose,  one 
which  would  always  be  successful  only  that 
the  current,  flowing  through  an  artery,  is 
so  strong  as  to  prevent  its  accomplishment 
in  the  majority  of  instances :  nevertheless, 
in  la  erated  arteries,  where,  from  the  kind 
of  injury,  a  more  efficient  means  of  coagula¬ 
tion  is  provided,  Nature  often  succeeds. 
The  great  object  of  art  is  therefore  to  con¬ 
trol  the  impetus  of  the  circulation,  and  to 
cause  the  blood  to  coagulate.  This  is  ac¬ 
complished  by  ligature  ;  but  if  this  cannot 


be  applied,  strong  compression  with  the 
tourniquet  is  used  on  the  main  trunk  of 
supply,  and  coagulation  is  induced  by  agaric 
and  styptics  locally  applied.  In  this  variety 
of  haemorrhage,  syncope  is  also  serviceable. 

In  this  brief  outline  of  general  haemor¬ 
rhages,  you  will  perceive  that  both  varieties 
agree  in  certain  common  principles  of  treat¬ 
ment.  First,  to  moderate  as  much  as  pos¬ 
sible  the  force  of  the  circulation.  Secondly, 
to  encourage  the  formation  of  coagula  in 
the  mouths  of  the  bleeding  vessels  until  they 
are  closed  by  lymph  and  the  inherent  con¬ 
tractile  power  of  their  coats.  Let  us  now 
examine  the  points  of  resemblance,  or  of 
distinction,  between  these  and  uterine  hae¬ 
morrhages. 

Uterine  haemorrhage  not  depending  upon 
gestation  may  be  considered  analogous  to 
haemorrhage  by  exhalation,  and  the  same 
principles  of  treatment  are  applicable  to  it. 
Uterine  haemorrhage  at  the  early  months  of 
gestation  arises  from  rupture  of  some  por¬ 
tion  of  the  vascular  net- work  that  ultimately 
forms  the  placenta ;  it  may,  therefore,  be 
included  under  the  second  division  of  hae¬ 
morrhages,  and  is  controlled  by  coagula,  as 
well  as  by  lessening  the  force  of  the  circula¬ 
tion,  in  order  that  these  vessels  may  more 
efficiently  contract  upon  themselves.  But 
when  flooding  occurs  at  the  time  of  delivery 
there  are  special  conditions  then  only  exist¬ 
ing,  connected  with  the  circulation,  which 
make  a  very  essential  difference  in  the  cha¬ 
racter  of  the  haemorrhage,  and  in  the  man¬ 
ner  in  which  it  is  arrested. 

Dr.  William  Hunter  observed,  that  “  there 
is  no  circumstance  in  which  the  gravid  uterus 
differs  more  from  the  unimpregnated  than 
in  the  size  and  termination  of  its  vessels.” 
The  uterus,  at  the  period  of  parturition,  is, 
therefore,  very  different  from  its  ordinary 
condition.  Let  us  briefly  consider  these 
peculiarities. 

1.  The  womb  is  enlarged  to  its  greatest 
extent — all  its  vessels  are  proportionately 
increased — the  arteries  in  connection  with 
the  placenta  are  especially  enlarged ;  and 
hence  vessels  carrying  red  blood  appear  to 
be  much  more  numerous  where  the  placenta 
is  attached. 

2.  The  arrangement  of  the  vessels  of  the 
uterus  is  different  from  that  of  the  arteries 
and  veins  in  other  parts  of  the  body  ;  conse¬ 
quently  the  manner  in  which  bleeding  from 
them  is  arrested  is  not  exactly  the  same. 

3.  The  circulation  going  forward  in  the 
placenta,  although  part  of  the  general  circu¬ 
lation,  must  be  considered  special,  at  least  in 
its  object.  The  quantity  of  blood  in  the 
uterus  at  this  time  is  far  beyond  what  is  re¬ 
quired  for  the  nutrition  of  that  organ.  It 
may  be  increased  or  diminished,  within 
certain  limits,  without  disturbing  the  general 
circulation.  The  contracted  uterus  may  b& 


ARRANGEMENT  OF  THE  UTERINE  ARTERIES  AND  VEINS.  825 


almost  emptied  of  its  blood  without  affect¬ 
ing  the  pulse ;  but,  if  haemorrhage  exceed 
this  point,  if  the  uterus  again  relax,  and  a 
new  demand  be  made  to  supply  the  defi¬ 
ciency,  then  the  circulation  is  at  once  re¬ 
duced  to  its  lowest  degree,  and  the  constitu¬ 
tion  receives  a  shock  proportionate  to  the 
magnitude  of  the  demand.  The  uterine 
vessels  are  precisely  adapted  to  meet  this 
condition.  When  they  are  completely  filled, 
a  very  large  quantity  of  blood  circulates 
through  them  for  the  nutrition  of  the  foetus, 
but  when  this  is  not  longer  required,  effi¬ 
cient  measures  are  provided  for  diminishing 
their  size,  and  so  interrupting  the  current  of 
blood  as  to  reduce  the  draught  on  the 
general  circulation  as  nearly  as  possible  to 
that  required  by  the  unimpregnated  uterus. 

The  arteries  of  the  gravid  uterus  are 
greatly  increased  in  size,  and  “  all  through 
the  substance  of  the  uterus  there  are  infinite 
numbers  of  anastomosing  arteries,  large  and 
small,  so  that  the  whole  arterial  system 
makes  a  general  net-work,  and  the  arteries 
are  convoluted  or  serpentine  in  their 
course.”*  A  quantity  of  blood  is  thus  con¬ 
veyed  to  and  contained  within  the  uterus, 
larger  than  could  be  effected  if  their  course 
were  more  direct :  these  vessels  can  adapt 
themselves  better  to  the  constantly  varying 
size  of  the  uterus,  when  in  the  act  of  expell¬ 
ing  its  contents,  and  the  current  of  blood  is 
more  efficiently  controlled  :  because,  when 
the  uterus  contracts,  the  spiral  coil  of  the 
artery  is  more  twisted  on  itself,  and  the  im¬ 
petus  of  the  blood  diminished.  It  is  pos¬ 
sible,  also,  that  the  surrounding  uterine  fibres 
may  so  compress  the  arteries  as  to  interrupt 
the  circulation  through  them  completely,  by 
rendering  the  points  of  reflection  in  the 
artery  more  angular,  so  as  to  give  it  rather 
a  zig-zag  than  a  spiral  direction.  You  per¬ 
ceive,  therefore,  that  by  this  mechanism  the 
agency  of  a  new  power  is  introduced  for  the 
purpose  of  suppressing  haemorrhage,  which 
is  not  employed  in  other  arteries. 

The  veins  of  the  uterus  are  still  more  re¬ 
markable  in  the  peculiarity  of  their  arrange¬ 
ments,  as  compared  with  other  veins.  Their 
relative  size  to  the  arteries  is  greater:  they 
<are  composed  of  a  number  of  large ,  short 
trunks ,  communicating  directly  with  each 
other,  and  forming  an  irregular  net-work  of 
vessels  like  capillaries  greatly  magnified : 
their  coats  are  single,  composed  only  of  the 
lining  membrane  of  the  veins  which  is  in¬ 
timately  adherent  to  the  fibrous  tissue  of  the 
.uterus.  They  have  no  valves ,  therefore 
when  the  veins  are  distended  an  uninter¬ 
rupted  current  of  blood  flows  through  them  ; 
but,  if  the  surrounding  fibres  contract, 
temporary  valves  are  formed,  which  break 

*  Dr.  W.  Hunter’s  Anatomical  Description, 
j&c.,  p.  17.  -  -  '  •  ' 


off  the  communication  between  these  short 
trunks.  Their  course  is  extremely  oblique 
nearly  parallel  to  the  surface  of  the  uterus, 
so  that  the  veins  may  be  described  as  form¬ 
ing  layers  or  planes  of  veins  freely  communi¬ 
cating  with  each  other. 

Mr.  Owen  has  made  a  careful  examina¬ 
tion  of  these  veins  in  a  portion  of  the  gravid 
uterus  furnished  him  by  Dr.  Lee.  He 
“commenced  the  dissection  from  the  out¬ 
side,  removing  successively,  and  with  great 
care,  the  layers  of  fibres,  and  tracing 
the  veins  as  they  passed  deeper  and 
deeper  in  the  substance  of  the  uterus,  in 
their  course  to  the  deciduous  membrane. 
Every  vein,  when  traced  to  the  inner  surface 
of  the  uterus,  appeared  to  terminate  in  an 
open  mouth  on  that  aspect  :  the  peripheral 
portion  of  the  coat  of  the  vein  or  that  next  the 
uterus  ending  in  a  well-defined  and  smooth 
semicicular  margin,  the  central  part  adhering 
to,  and  being  continuous  with,  the  decidua. 
In  the  course  of  the  dissection  I  (Mr.  Owen) 
observed,  that  where  the  veins  of  different 
planes  communicated  with  each  other,  in  the 
substance  of  the  walls  of  the  uterus,  the 
central  portion  of  the  parietes  of  the  super¬ 
ficial  vein  invariably  projected  into  the 
deeper-seated  one  ;  and  where  (as  was  fre¬ 
quently  the  case,  and  especially  at  the  point 
of  termination  on  the  inner  surface)  two  or 
even  three  of  these  wide  venous  channels 
communicated  with  a  deeper  sinus  at  the 
same  point,  the  semilunar  edges  decussated 
each  other,  so  as  to  allow  only  a  very  small 
portion  of  the  deep-seated  vein  to  be  seen. 
It  need  scarcely  be  observed,  how  admirably 
this  structure  is  adapted  to  ensure  the  arrest 
of  the  current  of  blood  through  these 
passages  upon  the  contraction  of  the  muscu¬ 
lar  fibres  with  which  they  are  every  where 
immediately  surrounded.”*  Professor  Good- 
sir  repeated  this  dissection,  and  observed 
the  same  appearances.f  Professor  Simpson 
also  made  a  similar  examination,  and  ob¬ 
served  that,  “  when  a  venous  tube  of  one 
plane  comes  to  communicate  with  a  venous 
tube  lying  in  the  plane  immediately  beneath, 
it,  the  foramen  between  them  is  not  in  the 
sides,  but  in  th e  floor  of  the  higher  and  more 
superficial  vein,  and  the  opening  itself  is  of  a 
peculiar  construction.  Looking  down  into 
into  it  from  above,  we  see  the  canal  of  the 
vein  below,  partially  covered  by  a  semilunar 
or  falciform  projection,  formed  by  the  lining 
membrane  of  the  two  venous  tubes,  as  they 
meet  together  by  a  very  acute  angle — the 
lower  tube  always  opening  very  obliquely 
into  the  upper.  In  the  folds  of  these  falci¬ 
form  projections  the  microscope  shows  the 


*  John  Hunter’s  Works,  by  Palmer,  vol.  iv.  p. 
68. 

t  Goodsir’s  Anatomical  and  Pathological 
Observations,  p.  61. 


826 


THE  CIRCULATION  IN  THE  PLACENTA. 


common  contractile  tissue  of  the  uterus.”* 
This  evidence  is  sufficient  to  prove  the  ar¬ 
rangement  of  the  uterine  veins,  and  the  in¬ 
fluence  of  this  new  agent  —  the  contractile 
fibres  of  the  uterus — in  controlling  any 
haemorrhage  that  may  flow  from  them. 
When  the  uterus  contracts,  these  semilunar 
edges  are  converted  into  valves,  and  where 
numerous  short  trunks  intersect  each  other 
the  decussation  of  these  valves  completely 
closes  the  communication  between  the  ves¬ 
sels  ;  but  when  the  uterus  is  relaxed,  there 
is  no  interruption  to  the  current  of  blood 
through  the  veins,  and  therefore  the  uterus 
in  this  state  may  be  compared  to  a  large 
sponge  filled  with  fluid,  while  the  same 
sponge  strongly  compressed  and  emptied  of 
the  fluid  will  illustrate  the  effect  of  uterine 
contraction.  The  oblique  direction  of  the 
veins  very  much  contributes  to  this  effect, 
because,  where  two  trunks  meet  at  a  very 
acute  angle,  it  requires  only  a  slight  con¬ 
traction  of  the  uterus  to  produce  a  valve  at 
the  point  of  junction,  and,  if  the  contraction 
be  great,  the  connection  is  broken  off. 

As  the  arteries  and  veins  are  much  more 
numerous  in  the  neighbourhood  of  the  pla¬ 
centa,  and  the  chief  cause  of  uterine  haemor¬ 
rhage  is  the  partial  separation  of  that  vascu¬ 
lar  mass  from  the  surface  of  the  uterus,  it 
will  be  necessary  to  examine  the  connection 
between  both,  in  order  to  understand  the 
manner  in  which  the  blood  circulates 
through  the  placenta,  and  how  this  haemor¬ 
rhage  occurs.  This  question  will  require 
your  especial  attention,  because  its  demon¬ 
stration  is  by  no  means  easy :  and  hence  it 
seems  to  be  the  rock  upon  which  more  than 
one  ingenious  theory  has  suffered  shipwreck. 

If  the  uterine  side  of  the  placenta  be  ex¬ 
amined,  you  perceive  a  lobulated  surface 
composed  of  an  immense  congeries  of  foetal 
vessels  compacted  together  into  cotyledons. 
This  surface  is  covered  by  a  delicate  mem¬ 
brane,  and  seems  to  be  so  applied  to  the 
walls  of  the  uterus  as  to  close  the  venous 
openings  on  its  surface,  without  having  any 
direct  connection  with  them.  The  placenta 
may  be  peeled  from  the  uterus  more  easily 
than  the  rind  from  an  orange  :  no  vessels 
seem  to  be  broken,  and  the  venous  openings 
are  freely  exposed  by  the  separation. 

The  natural  inference  from  these  facts 
would  be,  that  the  placenta  belongs  alto¬ 
gether  to  the  foetus — that  no  maternal  blood 
passes  into  it — and  that  any  interchange  be¬ 
tween  the  blood  of  the  child  and  the  mother 
takes  place  only  at  the  surface  of  the  uterus  to 
which  the  placenta  is  applied  like  a  cake  of 
unbaked  dough.  Such  had  been,  and  is  even 
still,  the  opinion  of  some  writers,  but  its  in¬ 
accuracy  has  been  clearly  proved. 

Many  years  ago,  the  Hunters  demon¬ 


strated  that  vessels  passed  from  the  uterus 
into  the  placenta,  and  the  beautiful  injec¬ 
tions  left  behind  them  still  remain  to  testify 
this  fact.  Since  then  several  attempts 
have  been  made  to  repeat  these  injections, 
but  without  success  ;  and  thus  incontrover¬ 
tible  evidence  seemed  to  be  afforded  in 
favour  of  the  opinion  that  the  placenta  was 
entirely  foetal.  The  injections  and  the  doc¬ 
trine  founded  upon  them  were  considered  to 
be  equally  fallacious.  Such  had  been  the 
opinion  of  Dr.  R.  Lee,  but  with  creditable 
candour  he  freely  admits  his  error,  and 
points  out  the  means  by  which  he  corrected  it. 

“  It  would  be  erroneous,”  he  observes, 
“  to  conclude,  as  I  did  ten  years  ago,  from 
similar  failures”  (in  injections)  “and  other 
circumstances,  that  the  maternal  blood  does 
not  enter  the  cavernous  structure  of  the  pla¬ 
centa  by  the  decidual  arteries,  and  flow  back 
by  the  decidual  veins  into  the  venous  system 
of  the  uterus,  as  first  demonstrated  by  John 
Hunter  .  .  .  The  repeated  examination  of 
the  uterus  and  placenta  in  their  natural  state, 
under  water,  and  when  the  uterine  vessels 
were  filled  with  injection,  having  led  to  no 
conclusive  and  satisfactory  results,  it  occurred 
to  me  soon  after  the  publication  of  my 
paper  in  the  Philosophical  Ttransactions,  in 
1832,  that  the  most  likely  means  of  dis¬ 
covering  the  real  connection  of  these  parts 
would  be  to  examine  the  placenta  when  the 
vessels  of  the  uterus  were  filled  with  their 

own  blood  and  coagulated . Dr. 

Lee  was  able  to  satisfy  himself ;  and  Mr. 
Lawrence,  who  was  present  at  the  examina¬ 
tion,  that  coagula  of  the  maternal  blood 
extended  from  some  of  the  openings  in  the 
lining  membrane  of  the  uterus  into  canals 
formed  by  the  deciduous  membrane  on  the 
margin  of  the  placenta.”* 

I  have  quoted  this  evidence  of  Dr.  Lee 
because  it  is  the  strongest  negative  on  the 
opinion  still  maintained  by  some  that  no 
maternal  blood  passes  through  the  placenta. 
Let  us  now  consider  the  manner  in  which  it 
circulates. 

John  Hunter  found  that  he  could  not 
trace  either  arteries  or  veins  distinctly  as 
vessels  beyond  the  surface  of  the  uterus, 
that  they  then  entered  into  a  structure  which 
he  compared  to  the  corpus  cavernosum  penis. 
Professor  Goodsir,  the  latest  observer,  finds 
the  same  appearances.  Making  a  dissection 
of  the  uterus  in  the  manner  of  Mr.  Owen, 
he  says — “  In  my  progress  I  occasionally 
found,  that  when  the  probe  was  pushed  along 
an  unopened  vein,  its  point  appeared  at  ano¬ 
ther  opening ;  and  as  I  approached  the 
internal  surface  of  the  wall  of  the  uterus, 
these  anastomoses  of  the  veins  became  more 
numerous,  the  spaces  which  they  inclosed 
presenting  the  appearance  of  narrow  flat 


♦Northern  Journal  of  Medicine,  January,  1846. 


*  Lee’s  Lectures,  pp.  135-136. 


THE  CIRCULATION  OF  THE  PLACENTA. 


827 


bands.  At  last,  in  introducing  the  probe 
under  the  falciform  edges  of  the  venous  ori¬ 
fices,  it  was  found  to  have  arrived  at  the 
placental  tufts,  which  could  be  seen  by  raising 
the  falciform  edges.  Having  passed  over  the 
falciform  edges,  the  venous  membrane  sud¬ 
denly  passed  on  each  side  to  the  great  cavity 
of  the  placenta.  The  flat  bands  which  I 
have  just  described  as  the  spaces  inclosed  by 
anastomosing  venous  sinuses  became  smaller, 
and  on  entering  the  cavity  itself,  the  bands 
were  seen  to  have  assumed  the  appearances 
of  threads,  which  passed  in  great  numbers 
from  the  vascular  edges  of  the  venous  open¬ 
ing,  and  from  the  walls  of  the  cavity  of  the 
placenta,  on  to  the  extremities  and  sides  of 
the  villi  and  tufts  of  the  placenta.  The 
whole  mass  of  spongy  substance,  that  is,  the 
whole  mass  of  tufts,  were  in  this  manner 
perceived  to  be  attached  by  innumerable 
threads  of  venous  membrane  to  that  surface 
of  the  parietal  decidua  of  the  placenta  which 
was  covered  by  the  venous  membrane.  On 
proceeding  deeper  into  the  substance  of  the 
placenta,  I  perceived  that,  throughout  its 
whole  extent,  villus  was  connected  to  villus, 
and  tuft  to  tuft,  by  similar  threads  of  venous 
membrane.  ”* 

These  reticulate  threads  form  the  Caver¬ 
nous  structure  of  John  Hunter  :  thus  you 
perceive  that  the  first  and  the  last  inquirer 
into  this  subject  are  nearly  agreed  in  their 
description.  Professor  Goodsir  has  used  a 
very  happy  expression,  “  the  great  cavity  of 
the  placenta” — a  cavity,  it  is  true, filled  up  by 
the  aggregated  tufts  of  foetal  vessels,  just  as 
the  great  cavity  of  the  peritoneum  is  filled 
up  with  viscera  and  intestines,  but  which 
cavity,  nevertheless,  exists.  Into  this  cavity 
the  maternal  blood  is  poured  by  the  curling 
uterine  arteries,  and  from  it  the  blood  returns 
into  the  uterine  veins;  no  foetal  blood  enters 
into  it.  But  to  place  the  relation  of  the 
maternal  and  foetal  vessels  in  a  clearer  light, 
I  shall  quoteWeber’s  description  of  their  ar¬ 
rangement.  He  says,  “  the  whole  placenta, 
and  therefore  every  individual  lobule  entering 
into  its  structure,  consists  of  two  distinct 
parts,  the  one  a  continuation  of  the  chorion 
and  vessels  of  the  embryo,  the  other  a  con¬ 
tinuation  of  the  membrana  decidua  and 
vessels  of  the  uterus.  From  the  chorion, 
for  instance,  dendritic  processes  or  elonga¬ 
tions  are  sent  out,  which  in  small  ova,  about 
a  month  old,  are  seen  so  small  and  simple, 
that  they  are  called  villi,  but  which  grow  by 
and  by  into  large  and  numerously  divided 
stems  and  branches.  Into  each  of  these 
dendritic  processes  of  the  chorion  there  pene¬ 
trates  a  branch  of  the  umbilical  artery  and 
a  branch  of  the  umbilical  vein.  Both  vessels 
divide  into  branches,  in  the  same  manner  as 
the  processes  of  the  chorion  in  which  they 

*  Goodsir,  op.  cit.  p.  61. 


run.  Each  particular  trunk,  with  its  divari¬ 
cations  of  the  shaggy  chorion,  form  a  lobe  or 
lobule  of  the  placenta,  which  is  covered  by 
the  tunica  decidua.  To  this  investment 
many  of  the  terminal  blanches  of  the  cho¬ 
rion  will  be  found  to  have  grown.  It  is  in 
the  spaces  between  the  divarications  of  the 
chorion  that  those  vessels  run  which  transmit 
the  blood  of  the  mother,  and  which  are  pro¬ 
longations  of  the  uterine  arteries  and  veins  : 
they  penetrate  in  this  way  even  to  the  most 
minute  lobule  of  the  chorion.  The  object  of 
this  structure  seems  to  be,  that  the  minute, 
convoluted,  greatly  elongated,  and  extremely 
thin-walled  capillaries  in  which  the  blood 
of  the  foetus  is  circulating,  may  be  brought 
into  the  most  intimate  contact  possible  with 
the  larger,  but  everywhere  excessively  thin- 
walled  canals,  in  which  the  blood  of  the 
mother  is  flowing,  that  the  two  currents, 
without  interfering  with  each  other’s  motion, 
may  pass  each  other  to  as  great  an  extent  as 
may  be,  with  nothing  interposed  but  the 
delicate  parietes  of  each  set  of  vessels.  The 
uterine  arteries  and  veins,  once  they  have 
entered  the  spongy  substance  of  the  placenta , 
do  not  farther  divide  into  branches  and 
twigs,  but  immediately  terminate  in  a  net- 
V)orh  of  vessels,  the  canals  of  which  are  of 
far  too  large  diameter  to  permit  them  to  be 
spoken  of  as  capillaries,  and  of  which  the 
parietes  are  so  thin,  that  they  cannot  be 
shewn  apart  by  the  most  careful  dissection. 
This  vascular  rete  which  connects  the  ute¬ 
rine  arteries  and  veins  with  each  other,  com¬ 
pletely  fills  the  spaces  between  the  branched 
divisions  of  the  chorion,  and  the  extremely 
thin  parietes  of  the  canals  of  which  it  is 
composed  insinuate  themselves  at  all  points 
into  the  most  intimate  contact  with  the 
branches  and  convoluted  masses  of  the  ca¬ 
pillaries  of  the  umbilical  system  of  vessels. 
This  net- work  of  vessels,  however,  with  re¬ 
ference  to  the  passage  of  the  uterine  arteries 
into  the  uterine  veins,  performs  the  same 
office  as  a  rete  of  true  capillaries,  so  that  it 
may  be  regarded  as  a  rete  of  colossal  capil¬ 
laries .* 

On  a  question  of  so  much  difficulty,  and 
one  which  has  been  so  much  misunderstood, 
I  have  preferred  giving  you  the  descriptions 
of  the  best  and  most  careful  observers,  rather 
than  my  own, — to  adopt  their  language  as 
being  the  least  likely  to  be  disputed.  These 
quotations  are  sufficient  to  prove  that  there 
is  a  portion  of  the  placenta  in  direct  com¬ 
munication  with  the  uterine  vessels,  which 
has  been  described  by  Weber  as  a  rete  of 
colossal  capillaries  ;  by  John  Hunter  as  a 
cavernous  structure ;  and  by  Goodsir  as  a 
great  cavity  everywhere  traversed  and  in¬ 
tersected  by  filamentous  prolongations  of  the 


*  Wagner’s  Elements  of  Physiology,  p.  201-202 
note. 


.‘828  the  circulation  in  the  placenta. 


lining  membrane  of  the  uterine  veins  ;  that 
the  maternal  blood  is  impelled  through  in- 
numerable  uterine  arteries  into  the  great 
cavernous  cavity  of  the  placenta,  and,  having 
supplied  the  necessary  nutriment  to  the  foetal 
blood,  flows  back  through  the  large  oblique 
canals  that  communicate  with,  or  are  part 


of,  the  uterine  veins ;  that  these  venous 
canals  and  the  cavernous  structure  is  com¬ 
posed  of  a  tissue  of  extreme  delicacy  ;  and 
lastly,  that  there  is  no  direct  communication 
between  this  maternal  circulation  of  the 
placenta  and  that  going  forward  in  the 
foetus.  What,  then,  would  be  the  effect  if 


Fig.  14. 


Diagram  sketch  to  represent  the  utero -placental  circulation. 

A.  Arterial  current  through  placenta.  B.  Venous  reflex  current  from  uterine  sinuses. 


this  vascular  connection  between  the  pla¬ 
centa  and  uterus  were  broken  through  ?  If 
the  placenta  were  separated  partially  from 
the  uterus  ?  From  the  nature  of  this  injury, 
the  torn  curling  arteries  might  not  pour  out 
much  blood.  Any  haemorrhage  must  arise 
chiefly  from  the  broken  veins,  and  not,  re¬ 
collect,  from  one,  but  from  both  of  the  di¬ 
vided  extremities.  There  are  thus  two 
sources  from  which  blood  escapes — 1st. 
From  the  openings  that  communicate  with 
the  rete  of  colossal  capillaries,  by  which  the 
cavernous  structure  is  emptied  of  maternal 
blood,  to  be  again  filled  by  the  uterine  ar¬ 
teries.  This  may  therefore  be  considered  as 
arterial  haemorrhage  of  the  uterus  through 
the  placenta — 2d.  From  the  venous  orifices 
on  the  surface  of  the  uterus.  The  maternal 
blood  flows  from  both  extremities  of  the 
divided  veins;  in  the  former  instance  in  a 
direct  current  from  the  uterine  arteries 
through  the  cavernous  structure :  in  the 
latter  by  regurgitation  from  the  veins  of  the 
uterus.  You  can  understand,  therefore,  not 
only  the  possibility  but  the  certainty  of  the 
fact  which  the  late  Dr.  Hamilton  stated 
many  years  ago, — which  Professor  Simpson 
has  since,  with  so  much  ability  confirmed, 
but  which  still  remains  an  enigma  to  perplex 


some  observers  who  have  written  on  the 
subject,  when  the  placenta  is  partially  de¬ 
tached  from  the  uterus, — you  can  under- 
derstand  why  blood  flows  from  its  denuded 
surface,  and  that  the  exposed  uterine  veins 
(or  sinuses,  as  they  are  called),  are  not  the 
only  sources  of  uterine  haemorrhage.  When 
that  viscus  is  completely  separated  from  the 
uterus,  and  its  connection  with  these  arteries 
broken  off,  you  can  also  perceive  that  blood 
will  no  longer  flow  from  the  surface,  and  the 
only  blood  t  at  can  then  be  expressed  from 
it,  is  the  residue  lodged  in  the  cavernous 
structure. 

Let  us  next  consider  the  natural  provisions 
to  check  haemorrhage  from  these  surfaces 
when  they  are  thus  exposed  by  a  partial 
separation  of  the  placenta.  The  arterial 
discharge  through  the  cavity  of  the  placenta 
can  only  be  controlled  by  coagulation  of 
blood  in  the  cells  of  its  cavernous  structure. 
This  is  greatly  promoted  by  the  nature  of 
this  structure,  as  well  as  by  the  slow  pro¬ 
gress  of  the  circulation  through  it.  The 
spiral  course  of  the  arteries  lessens  the  im¬ 
petus  of  the  circulation,  and  when  their  tor¬ 
tuosity  is  increased  by  the  contraction  of  the 
womb,  the  current  of  blood  is  arrested,  and 
coagulation  takes  place.  The  contraction 


EFFECT  OF  A  COMPLETE  SEPARATION  OF  THE  PLACENTA. 


829 


of  the  uterine  fibres  exerts  a  ‘  still  more  im-  | 
portant  influence  in  arresting  any  discharge 
from  the  exposed  veins,  because,  as  is  evi¬ 
dent  from  their  anatomical  relations,  the 
connection  between  the  veins  is  broken  off 
by  temporary  valves,  the  flattened  trunks 
are  compressed,  and  regurgitation  of  the 
blood  prevented.  The  importance,  nay  the 
necessity  of  this  new  agent,  to  prevent  hae- 
morrhage  from  the  uterus,  is,  I  trust,  suffi¬ 
ciently  obvious  to  you. 

Hitherto  I  have  directed  your  attention  to 
the  effect  of  a  partial  separation  of  the  pla¬ 
centa  from  the  uterus,  which  is  the  most 
common  cause  of  haemorrhage  before  the 
birth  of  the  child.  Let  us  now  observe  the 
results  of  its  complete  detachment,  such  as 
takes  place  after  the  birth  of  the  child,  whe¬ 
ther  it  be  retained  in  the  cavity  of  the  womb, 
or  is  expelled  from  it.  If  haemorrhage 
should  then  arise,  the  chief  source  of  the 
discharge  is  the  venous  openings  of  the 
uterus.  The  slender  lacerated  arteries  are 
not  likely  to  produce  the  violent  flooding 
sometimes  observed  ;  and  I  cannot  perceive, 
nor  can  I  direct  you  to,  any  other  means  of 
preventing  it  than  by  securing  an  efficient 
contraction  of  the  uterus.  But  it  has  been 
objected  to  this  principle  (and  the  difficulty 
occurred  to  the  acute  mind  of  Gooch*),  that 
you  may  have  relaxation  of  the  uterus  with¬ 
out  any  haemorrhage,  and  conversely  a  .pro¬ 
fuse  flooding  while  the  uterus  is  firmly  con¬ 
tracted.  It  is  necessary  to  consider  how 
this  may  be,  and  how  far  it  interferes  with 
what  has  been  laid  down.  It  appears  to  me, 
then,  that  haemorrhage  must  be  the  result  of 
a  complete  relaxation  of  the  uterus.  In  this 
I  am  happily  supported  by  the  opinion  of 
Prof.  Simpson,  who  remarks,  “  No  doubt 
the  occurrence  after  delivery  of  great  and 
decided  atony  in  the  whole  muscular  system 
of  the  uterus  does  assuredly  give  rise  to 
post-partem  haemorrhage. ”f  But  there  are 
many  reasons  why  haemorrhage  may  not 
occur  when  the  uterus  is  partially  relaxed , 
— a  very  common  condition  after  the  birth 
of  the  child.  For  instance,  you  will  fre¬ 
quently  meet  with  cases  where,  after  de¬ 
livery,  the  placenta  lies  loosely  in  the  cavity 
of  the  uterus,  which  may  be  large,  imper¬ 
fectly  conti acted,  in  that  state  most  com¬ 
monly  called  “  relaxed,”  and  yet  no  haemor¬ 
rhage  follows  from  it.  If  the  fundus  be 
firmly  compressed,  and  its  regular  and  effi¬ 
cient  contraction  be  secured,  the  placenta  is 
expelled  along  with  a  greater  or  less  quan¬ 
tity  of  coagulated  blood.  Why  does  not 
haemorrhage  take  place  ? 

First.  Because  the  uterus  is  not  perfectly 


*  Account  of  some  of  the  more  important 
Diseases  of  Women,  p.  832. 
t  Northern  Journal  of  Medicine,  January 

1846. 


relaxed.  A  slight  contraction  of  the  uterus 
is  sufficient  to  raise  the  falciform  valves,  and 
thus  partially,  but  not  completely,  close  the 
communication  between  the  different  venous 
trunks.  The  regurgitation  of  blood  is  at  least 
retarded,  although  not  altogether  prevented. 

Secondly.  The  current  of  the  uterine  cir¬ 
culation  is  altered,  both  in  its  direction  and 
force.  The  arterial  blood  is  no  longer 
drawn  towards  the  cavernous  structure  in 
the  placenta,  but  flows  into  the  inter¬ 
communicating  branches  in  the  parietes  of 
the  uterus.  The  current  of  the  venous 
blood  is  directed  much  more  rapidly  towards 
the  great  central  trunks  of  the  abdomen, 
because  these  vessels  are  now  relieved  from 
the  pressure  of  the  gravid  uterus,  and,  by 
their  expansion,  the  venous  blood  is  drawn 
more  strongly  from  the  terminal  branches 
towards  the  central  canals. 

Thirdly.  The  venous  openings  on  the 
surface  of  the  uterus  are  not  at  all  freely 
exposed :  on  the  contrary,  they  are  often 
filled  up  and  covered  by  fragments  of  the 
deciduous  membrane,  by  broken  tufts  of 
foetal  vessels,  and  by  small  coagula  resting 
within  them,  and  acting  as  plugs,  which,  it 
appears  to  me,  would  be  quite  adequate  to 
prevent  the  escape  of  blood  when  the  circu¬ 
lation  is  not  directed  strongly  towards  the 
uterine  surface. 

Haemorrhage  isnot,  therefore,  the  necessary 
consequence  of  this  partial  relaxation  of  the 
uterus  after  labour :  something  more  is  re¬ 
quired  to  cause  regurgitation  of  the  blood  to 
the  amount  of  serious  flooding.  We  know, 
from  the  coagula  expelled,  that  some  re¬ 
gurgitation  always  takes  place ;  but  so  long 
as  they  do  not  become  causes  of  irritation, 
they  are  not  accompanied  by  flooding. 

Let  us  now  examine  the  converse  pro¬ 
position.  It  sometimes  happens  that,  when 
the  uterus  is  strongly  contracted,  flooding 
takes  place.  I  confess  that  I  cannot  per¬ 
ceive  the  difficulty  which  this  fact  seems  to 
present.  Is  relaxation  of  the  uterus  the 
only  cause  of  haemorrhage  ?  or  are  there 
other  causes  which  may  produce  it  ?  I 
shall  mention  a  few :  there  may  be  more. 
Fragments  of  the  placenta  are  frequently 
left  behind  in  the  uterus,  which  afterwards 
separate  without  any  haemorrhage  occurring. 
But  this  does  not  always  happen.  One  of 
the  few  fatal  cases  of  uterine  haemorrhage 
that  have  fallen  under  my  notice  depended 
on  this  cause.  A  woman  had  been  safely 
delivered  ;  the  placenta  was  expelled  into 
the  vagina,  and  partly  protruded  through 
the  vulva ;  the  attending  midwife  removed 
it  too  forcibly ;  haemorrhage  followed. 
When  I  saw  the  patient,  the  placenta  was 
taken  away,  and  had  not  been  examined. 
The  uterus  was  firmly  contracted  to  its 
usual  size  after  delivery  :  nevertheless,  blood 
continued  to  drain  from  the  vagina,  and 


830  EFFECT  OF  A  COMPLETE  SEPARATION  OF  THE  PLACENTA. 


ultimately  to  increase  to  flooding.  In  spite 
of  every  means  that  was  used,  exhaustion 
and  death  took  place.  One  was,  how¬ 
ever,  omitted,  in  consequence  of  the  con¬ 
traction  of  the  uterus  :  the  hand  was  not 
passed  within  its  cavity,  which  the  sequel 
proved  to  have  been  an  unfortunate  omis¬ 
sion.  A  small  portion  of  the  placenta, 
about  the  size  of  a  crown,  was  attached  to 
the  back  of  the  uterus  near  the  cervix. 
Slight  lacerations  of  the  uterus  frequently 
occur,  and  these  sometimes  cause  haemor¬ 
rhage,  although  the  uterus  is  contracted. 
Dr.  Rigby  quotes  Naegele’s  experience  of 
this  source  of  flooding,  as  the  result  of  a 
practice  which  we  shall  have  again  to  con¬ 
sider.  “  Cases'’  (of  placenta  presentation) 
“  have  occurred  where  the  child  was  turned 
and  delivered  with  perfect  safety,  and  the 
uterus  contracted  into  a  hard  ball  :  in  fact, 
everything  seemed  to  have  passed  over  fa¬ 
vourably  ;  a  continued  dribbling  of  blood 
had  remained  after  labour,  which  resisted 
every  attempt  to  check  it :  friction  upon  the 
abdomen,  and  other  means  for  stopping 
haemorrhage  by  inducing  firm  contraction  of 
the  uterus,  were  of  no  use,  for  the  uterus 
was  already  hard  and  well  contracted :  the 
patient  had  gradually  become  exhausted, 
and  at  last  died.  On  examination  after 
death,  Professor  Naegele  has  invariably 
found  the  os  uteri  more  or  less  torn.”*  In 
the  case  quoted  by  Gooch,  there  was  an  un¬ 
usual  excitement  in  the  general  circulation 
previous  to  labour,  which  he  assigns  as  the 
cause  of  the  haemorrhage. 

Morbid  growths  also,  either  from  the  sur¬ 
face  or  in  the  parietes  of  the  uterus,  may 
maintain  haemorrhage  when  the  uterus  is 
contracted.  Of  this,  however,  I  can  give 
you  no  evidence ;  but,  I  would  ask,  are 
these  exceptions — and,  I  think,  rare  excep¬ 
tions — to  a  general  rule  to  be  considered 
sufficient  to  overturn  a  principle  that  has 
been  founded  on  such  clear  anatomical  evi¬ 
dence,  and  has  been  proved  by  daily,  almost 
hourly,  experience  ?  Are  we  to  say,  that 
because  haemorrhage  does  not  always  depend 
upon  relaxation  of  the  uterine  fibres,  their 
contraction  is  a  matter  of  no  importance  ? 
If  I  were  to  lay  down  such  a  proposition,  I 
would  lead  you  into  an  error  that  the  first 
case  of  haemorrhage  you  might  meet  with 
would  expose  ;  where  you  would  find  that 
flooding  continued  while  the  uterus  was  re¬ 
laxed,  and  that  it  ceased  the  moment  the 
hands  were  placed  firmly  on  the  fundus  to 
secure  its  uniform  and  firm  contraction. 

"We  have  stated  to  you  that  relaxation  of 
the  uterus  is  not  the  only  cause  of  hae¬ 
morrhage  ;  neither  is  haemorrhage  the  only 
cause  of  its  relaxation.  Atony  of  the  uterus 
may  arise  from  constitutional  debility,  pro¬ 


longed  labour,  and  other  causes  beside  hae¬ 
morrhage  ;  and,  therefore,  you  can  perceive 
why  in  such  instances  flooding  may  be  in¬ 
creased  by  this  weakened  condition  of  the 
uterus,  and  a  reciprocal  effect  produced ; 
want  of  tone  in  the  uterus  causing  haemor¬ 
rhage,  and  haemorrhage  increasing  the  atonic 
condition  of  the  womb. 

We  have  been  obliged  to  dwell  a  little 
longer  on  this  part  of  our  subject  than 
might  appear  necessary.  I  can  only  plead 
the  extreme  importance  of  a  clear  apprehen¬ 
sion  of  the  principles  that  must  govern  your 
practice  in  such  a  dangerous  complication  as 
haemorrhage,  and  the  probability  that  your 
minds  might  become  confused  by  the  in¬ 
genious  objections  that  have  been  raised 
against  those  we  have  placed  before  you. 
We  trust,  however,  that  we  have  succeeded 
in  proving — 

1.  That  the  anatomical  relations  of  the 
uterine  arteries  and  veins  to  the  contractile 
tissue  of  the  uterus  is  such  that  the  circu¬ 
lation  through  these  vessels  can  only  be 
controlled  by  the  contraction  of  its  fibres, 
and  that  every  provision  is  made  to  render 
even  slight  contractions  of  the  uterus  a 
means  of  moderating  the  force  of  the  uterine 
circulation,  and  preventing  a  regurgitation  of 
blood. 

2.  That  the  mode  of  controlling  and  ar¬ 
resting  uterine  haemorrhage  differs  in  this 
respect  from  that  employed  in  general  hae¬ 
morrhages,  because  bleeding  from  the  general 
circulation  is  controlled  by  a  power  inherent 
in  the  vessels  themselves,  and  independent 
of  the  surrounding  tissues  ;  in  uterine  hae¬ 
morrhage  it  is  the  reverse. 

3.  That  it  is  quite  possible  that  the  uterus 
may  expand  without  haemorrhage  taking 
place,  and  conversely  there  may  be  flooding 
when  the  uterus  is  contracted  ;  but  these 
exceptions  do  not  invalidate  the  general 
principle  that  contraction  of  the  uterine 
fibres  is  the  essential  means  of  arresting 
uterine  haemorrhages. 

We  have  still,  however,  to  consider  the 
influence  of  another  important  agent  over 
the  uterine  circulation,  which  must  be  taken 
in  connection  with  that  we  have  explained  to 
you,  in  order  to  understand  correctly  the 
principles  of  treatment. 


STAMMERING  PECULIAR  TO  THE  MALE  SEX. 

There  is  one  curious  fact  with  reference  to 
stammering,  which  I  do  not  think  has  been 
before  noticed — namely,  that  women  very 
rarely  stammer.  In  a  family  of  my  acquain¬ 
tance,  this  defect  of  the  speech  has  been 
hereditary  among  the  males  for  three  gene¬ 
rations,  but  the  females  have  in  no  single 
instance  been  so  affected. — Dr.  Graves’ 
Clinical  Lectures  on  the  Practice  of  Medi¬ 
cine ,  1848. 


*  Rigby’s  Midwifei-y>  p.  259. 


CASES  OF  PURPURA - ANALYSES  OF  THE  VENOUS  BLOOD.  83  L 


©rtgtnal  ©ommumcationg. 


TWO  CASES  OF 

PURPURA,  WITH  ANALYSES  OF 
THE  VENOUS  BLOOD. 

By  E.  A.  Parkes,  M.D. 

Assistant  Physician,  University  College  Hospital. 

[Concluded  from  p.  791.] 


Case  II. — Emma  Skinner,  set.  18: 
admitted  August  7th,  1848,  into  Uni¬ 
versity  College  Hospital,  under  Dr. 
Thomson.  A  stout,  very  healthy  look¬ 
ing,  young  unmarried  woman,  a  ser¬ 
vant.  She  stated  that  she  had  always 
enjoyed  excellent  health,  and  had 
never  had  any  serious  illness :  the 
catamenia  came  on  at  14  years  of  age; 
they  recurred  regularly  every  four 
weeks,  and  lasted  usually  seven  days; 
there  were  very  few  clots ;  she  had 
been  subject  for  six  years  to  epistaxis 
every  now  and  then,  and  at  times  she 
had  lost  as  much  as  four  ounces  of 
blood,  but  this  had  not  occurred  for 
some  time.  She  had  never  had  hae¬ 
moptysis  or  haematemesis.  Up  to  the 
three  months  before  admission  she  had 
lived  well;  since  then,  being  out  of 
lace,  she  had  fared  badly :  she  had 
ad  meat  two  or  three  times  a  week  ; 
potatoes  once  only  in  three  months, 
viz.  a  few  days  before  admission;  peas 
three  or  four  times  in  the  three  months  ; 
no  fresh  vegetables  of  other  kinds,  and 
no  fruit.  She  had  taken  daily  about 
a  quarter  of  a  pint  of  milk  and  half  a 
pint  of  porter  ;  she  had  had  as  much 
white  bread  as  she  liked,  a  little  cheese, 
and  about  half  a  pound  of  salt  butter, 
every  week.  She  had  not  been  accus¬ 
tomed  to  spirits  or  wine,  and  never  cared 
about  fresh  vegetables.  She  had  never 
had  rheumatism  or  palpitation  of  the 
heart.  She  stated  that  cuts  on  the 
finger  bled  a  long  time.  About  four¬ 
teen  days  before  her  admission  she  got 
her  feet  wet,  and  suffered  from  a 
feverish  cold  and  dry  cough ;  she  did 
not  think  much  of  this,  and  till  Au¬ 
gust  4th  she  considered  herself  in  per¬ 
fect  health.  At  this  time  she  observed 
a  little  redness  and  swelling  on  the 
right  instep;  this  was  succeeded,  in 
about  half  an  hour,  by  a  copious  erup- 


|  tion  of  purpuric  spots  :  about  an  hour 
afterwards  the  same  phenomena  oc¬ 
curred  on  the  anterior  surface  of  the 
left  knee,  and  in  a  few  hours  the  spots 
appeared  plentifully  over  the  whole  of 
both  legs  below  the  knees.  After  the 
spots  had  come  out  she  felt  a  little 
pain  in  the  loins,  but  this  soon  disap¬ 
peared.  On  the  8th  of  August  the 
eruption  presented  the  following  ap¬ 
pearance  :  over  the  whole  of  the  lower 
extremities,  but  principally  below  the 
knees,  were  numerous  true  purpuric 
spots,  varying  from  the  size  of  a  pin’s 
head  to  two,  three,  or  four  lines  in 
diameter :  the  spots  in  places  coalesced, 
and  formed  irregular  patches  of  a 
darkish  red  colour,  which  were  raised 
very  slightly  above  the  skin,  and  were 
not  altered  by  pressure;  in  some  parts 
of  their  peripheries  they  were  abruptly 
defined,  in  others  they  faded  gradually 
into  the  surrounding  skin,  and  conspi¬ 
cuous  red  vessels,  running  into  the 
haemorrhagic  spot,  formed  at  these 
points  little  prolongations:  the  spots 
were  not  connected  with  the  hairs,  and 
were  most  numerous  on  the  calves: 
there  were  also  ecchymoses  on  the  legs 
and  thighs.  The  skin  of  the  face,  the 
trunk,  and  the  upper  extremities,  was 
perfectly  normal.  On  the  previous 
day  there  had  been  a  little  pain  in  the 
hams,  but  that  had  disappeared.  The 
gums  were  pale  and  firm ;  the  tonsils 
and  soft  palate  healthy ;  the  lips 
were  healthfully  red ;  the  tongue  was 
rather  red  and  glazed  in  the  centre, 
and  the  papillte  at  the  tip  wTere  en¬ 
larged.  She  was  carefully  examined 
with  a  view  to  detect  any  latent  com¬ 
plication.  There  was  no  cough,  and 
the  thoracic  organs  seemed  perfectly 
healthy  :  the  chest  was  large  and  well 
formed  ;  the  respiratory  murmur  was 
every  where  normal ;  the  heart  was  in 
the  natural  position ;  the  sounds  were 
natural ;  the  liver  was  in  its  normal 
limits,  and  not  tender;  the  abdomen 
w7as  every  where  supple  and  painless; 
the  bowels  were  perfectly  regular,  and 
the  pulse  natural.  Up  to  this  date  she 
stated  that  the  urine  had  been  clear  : 
it  was  then,  however,  loaded  with 
pinkish  lithates,  which  were  perfectly 
soluble  by  heat ;  it  was  acid,  and  had 
a  specific  gravity  of  1020.  The  quan¬ 
tity  was  not  ascertained.  She  had 
taken  as  medicine  only  a  little  senna, 
and  a  few  doses  of  hydrochloric  acid. 
She  was  now  bled.  The  blood  was 


832  CASES  OF  PURPURA - ANALYSES  OF  THE  VENOUS  BLOOD. 


received  in  a  full  stream  into  three 
glasses.  The  contents  of  the  first  were 
beaten;  those  of  the  second  were  eva¬ 
porated  for  the  solid  constituents  of 
the  blood;  the  third  bottle  was  put 
aside  for  coagulation.  Coagulation 
commenced  in  the  usual  time:  after 
twenty-four  hours  the  separation  was 
complete;  the  clot  was  buffed  and 
cupped.  The  red  particles  were  ex¬ 
amined  under  the  microscope:  they 
appeared  natural ;  their  outlines  were 
defined  ;  they  were  not  serrated  ;  they 
ran  together  about  as  rapidly  and  as 
firmly  as  in  health  ;  they  subsided  also 
from  the  defibrinated  blood  in  the  usual 
way,  leaving  a  clear  serum.  The  se¬ 
rum  was  of  a  light  green  colour,  and 
distinctly  alkaline. 

Sp.  gr.  of  defibrinated  blood  .  10505 

Sp.  gr.  of  serum .  1028*6 

Temp.  65°.  Coagulating  point  of  the 
serum,  162°  Fah. 

Solids  of  the  blood  in  1000 

parts . 180*6 

Water . 8104 

The  fibrine  was  estimated  in  two 
ways ;  from  the  beaten  blood,  and  by 
washing  the  clot  of  the  third  bottle. 
After  boiling  in  alcohol  and  ether,  the 
amount  given  by  the  former  method 
was  5*21,  and  by  the  latter  method 
4*82,  in  the  1000  parts  ;  the  average 
of  the  two  was  5*015  (say  5)  in  the 
1000  parts. 

The  solids  in  the  serum  were  esti¬ 
mated  from  the  serum  of  the  third 
bottle.  The  organic  constituents  were 
80*22,  and  the  inorganic  7*3 1  in  the 
1000  parts.  The  organic  constituents 
of  the  serum  in  1000  of  blood  were, 
therefore,  75*31,  and  the  inorganic  6  63 
in  the  1000  of  blood. 

The  weights  of  the  fibrine,  and  the 
solid  constituents  of  the  serum  in  1000 
of  blood,  being  deducted  from  the 
solid  contents  of  the  blood,  leaves  93*66 
as  the  amount  of  the  corpuscles. 

The  inorganic  matters  were  deter¬ 
mined  in  the  same  way  as  in  the  pre¬ 
vious  analysis.  The  amount  of  the 
potash  was  estimated  both  from  the 
serum  and  from  the  dried  blood.  The 
proportion  of  double  salt,  obtained  by 
evaporating  the  salts  of  the  serum  with 
chloride  of  platinum,  was  3  56  in  the 
10Q0  parts  :  this  gives  *692  of  potash, 
a  proportion  slightly  over  the  norma 


amount.  In  the  second  experiment 
the  washings  of  the  incinerated  blood 
were  treated  in  the  same  way :  the 
chloride  of  platinum  and  potassium 
which  was  obtained  was  heated  to 
redness  in  a  platinum  crucible;  the. 
chloride  of  potassium  was  dissolved 
out,  evaporated,  and  weighed.  By  this 
means,  from  ten  grains  of  dried  blood 
*07  of  the  chloride  were  obtained  ;  this 
gives,  for  the  180*6  solids  in  the  1000 
grains,  about  1*26  of  chloride  of  potas¬ 
sium,  or  of  potash  about  *796.  The 
soluble  salts  in  the  incinerated  blood 
amounted  to  7*6  per  1000  of  blood, 
exceeding,  therefore,  the  soluble  and 
insoluble  salts  of  the  serum  in  1000  of 
blood  by  *97,  and  the  salts  in  1000  of 
serum  by  *021.  The  solution  of  the 
soluble  salts  was  distinctly  alkaline  ;  it 
contained  no  iron. 

The  chlorides  of  sodium  and  potas¬ 
sium  were  estimated  twice:  the  first 
experiment  gave  the  proportion  of 
2*5305,  and  the  second  of  2*4857,  in  the 
1000  parts.  The  tribasic  phosphate 
of  soda  was  determined  once  :  its  pro¬ 
portion  was  1*088  in  the  1000  parts. 
The  sulphates  were  not  noted. 

The  iron  was  determined  twice.  In 
the  first  experiment  the  residue  of  the 
incinerated  blood,  from  which  all  the 
charcoal  had  been  burnt  off  with  nitric 
acid,  was  treated  with  boiling  acetic 
acid;  the  portion  unacted  upon,  con¬ 
sisting  of  peroxide  and  phosphate  of 
iron,  existed  in  the  proportion  of  *602 
per  1000  of  blood.  In  the  second  ex¬ 
periment  the  iron  was  dissolved  in 
hydrochloric  acid,  precipitated  as  per¬ 
oxide,  washed,  dried,  and  heated  to 
redness:  the  quantity  of  the  peroxide 
was  *586  in  1000  parts  of  blood. 

The  lime  was  precipitated  both  as 
oxalate  and  as  sulphate;  but  want  of 
time  prevented  me  from  carrying  out 
this  delicate  analysis  with  sufficient 
accuracy :  the  lime  was  certainly  in 
small  quantity,  and  below  *08  in  the 
the  1000  parts. 

The  general  summary  of  this  analy¬ 
sis  may  be  given  as  follows  : — 


Fibrine .  5 

Organic  solids  of  serum  .  .  75*31 

Inorganic  solids  of  serum  .  .  6*63 

Red  particles . 93*66 

Water . 819*4 


1600*00 


CASES  OF  PURPURA - ANALYSES  OF  THE  VENOUS  BLOOD. 


833 


Chlorides  of  sodium  and  po¬ 
tassium  .  2*5305 

Phosphate  of  soda  ....  1*088 

Peroxide  and  phosphate  of 

iron . *602 

Lime  (uncertain,  but  below)  .  .08 

The  chief  point  of  interest  in  this 
analysis  appeared  at  first  to  be,  the 
great  increase  in  the  fibrine.  As  I  was 
almost  certain  that  there  was  no  latent 
inflammation,  and  as  there  were  no 
rheumatic  symptoms,  it  seemed  almost 
necessary  to  consider  it  attributable  to 
the  purpura ;  and  yet  1  could  not  con¬ 
ceive  that,  in  the  first  well-marked 
case,  the  increase  in  the  fibrine  should 
not  have  existed  if  it  was  an  essential 
part  of  the  disease.  The  difficulty 
was,  however,  completely  explained  by 
the  progress  of  the  case.  In  other  re¬ 
spects  this  analysis  agreed  with  the 
first ;  the  solid  contents  generally 
were  lowered.  Becquerel’s  average 
for  healthy  women  is  208*1  ;  and  al¬ 
though  the  normal  amount  is  not  very 
well  determined,  yet  in  this  case,  in  a 
particularly  strong  young  woman,  of 
sanguineo-lymphatic  temperament,  I 
should  have  anticipated  that  the  solid 
contents  would  have  been  at  least  195 
or  200  parts  in  the  1000,  instead  of  180. 
This  would  raise  the  corpuscles  to 
nearly  104  parts  per  1000,  which  is 
quite  within  the  limits  of  health.  The 
organic  contents  of  the  serum  are  also 
within  the  healthy  female  range,  as 
the  average  of  the  albumen  is  higher 
than  in  males.  The  organic  consti¬ 
tuents  in  this  case  as  in  the  former 
preserve  their  normal  relation  to  each 
other,  with  the  exception  of  the  fibrine. 

The  most  marked  change  in  the  in¬ 
organic  constituents  consisted,  as  in 
the  former  case,  of  an  increase  in  the 
quantity  of  iron.  With  only  95  of 
corpuscles,  the  iron  should  have 
been  reduced  to  about  *4,  whereas  it 
amounted  to  *602  in  the  1000  parts. 
The  increase,  however,  was  not  so 
great  as  in  the  analysis  of  the  male 
blood.  The  potash  was  in  normal 
quantity;  and,  as  the  patient  had  taken 
none  as  medicine,  it  may  be  considered 
certain  that  the  appearance  of  purpura 
is  not  coincident  with  deficiency  in 
potash.  The  salts,  taken  together,  are 
not  particularly  altered,  either  as  to 
increase  or  deficiency  ;  there  was,  how¬ 
ever,  still  the  difference  between  the 
quantity  of  the  salts  of  the  serum  and 


those  of  the  whole  blood.  The  amount 
of  the  soluble  phosphates  was  over 
that  of  the  first  analysis  ;  but  these 
seem  to  vary,  as  the  chlorides,  so  much 
with  the  season  of  the  year,  the  state 
of  the  system,  and  even  with  the  time 
of  the  day,  that  this  is  of  little  conse¬ 
quence  :  there  was  also  a  possible  in¬ 
accuracy  in  the  first  analysis. 

On  the  10th  of  August  the  purpuric 
spots  were  disappearing  in  the  usual 
way,  leaving  the  dirty  yellow  stains  of 
absorbed  blood.  The  urine  continued 
acid,  with  a  plentiful  deposit  of  pink 
lithates. 

On  the  14th  she  experienced  some 
rheumatic  pains.  On  the  15th  the 
eruption  had  disappeared  altogether, 
but  she  was  suffering  from  a  sharp, 
well-marked  attack  of  articular  rheu¬ 
matism,  for  which  Dr.  Thomson  found 
it  necessary  to  treat  her  actively. 
During  this  attack  the  urine  became 
intensely  acid,  and  ceased  to  deposit 
lithates.  Owing  to  particular  circum¬ 
stances,  it  was  not  analvsed. 

On  the  1 9th  the  rheumatism  had 
been  subdued,  and  she  began  to  take 
tonics.  During  convalescence,  the  de¬ 
posit  of  lithates  returned,  as  if  they 
had  again  lost  their  solvent.  A  week 
afterwards  she  left  the  hospital  per¬ 
fectly  well. 

I  do  not  think  there  can  be  a 
doubt  but  that  the  increase  in  this 
fibrine  was  connected  with  the  rheu¬ 
matic  diathesis.  The  existence  of  the 
diathesis  had  been,  in  fact,  already 
suspected,  partly  from  the  increase  in 
the  fibrine,  which  was  not  dependent 
on  inflammation,  and  partly  by  the 
copious  deposit  of  lithates,  which  is 
certainly  not  necessarily  a  part  of  pur¬ 
pura.  As  increase  in  the  fibrine  is  de¬ 
cidedly  a  part,  though  only  a  part,  of 
the  rheumatic  diathesis,  it  is  an  in¬ 
teresting  point  that  this  was  proved  to 
exist  for  more  than  a  week  before  the 
usual  and  more  obvious  symptoms  of 
the  disease  proclaimed  themselves.  It 
would  seem  to  indicate,  as  far  as  an 
isolated  fact  can  do  so,  that  the  hype- 
rinosis  is  even  a  more  important  ele¬ 
ment  in  the  production  of  rheumatism 
than  has  been  supposed  :  it  is  prior,  at 
any  rate,  to  the  local  affections. 

In  concluding  the  account  of  these 
two  cases  with  a  few  remarks,  I  am 
anxious  not  to  have  it  supposed  that  I 
wish  to  discuss  the  pathology  of  pur¬ 
pura:  our  knowledge  is  as  yet  insufli- 


834  CASES  OF  PURPURA - ANALYSES  OF  THE  VENOUS  BLOOD. 


cient  to  venture  on  such  a  problem.  I 
have  wished  merely  to  add  something 
to  the  information  already  collected 
respecting  a  single  point,  viz.  the  che¬ 
mistry  of  the  blood.  This,  however,  is 
only  a  small  portion  of  the  humoralism 
which,  with  its  inseparable  solidism, 
must  be  brought  to  bear  on  the  ques¬ 
tion  of  the  intimate  nature  of  the  dis¬ 
ease  ;  yet  there  are  some  points  in 
these  cases  which  possess  a  certain  im¬ 
portance,  and  which  may  be,  not  im¬ 
properly,  a  little  more  discussed. 

In  both  these  cases  the  patients  had 
been  badly  and  insufficiently  fed  ;  and 
although  it  is  by  no  means  proved  that 
purpura  is  dependent  on  errors  in  diet, 
yet  as  scurvy,  a  disease  usually  con¬ 
sidered  as  allied  to  it,  clearly  is  so, 
such  a  dependence  may  be  considered 
as  not  improbable;  but,  if  so,  the  first 
case  proves  that  the  deficiencies  of  diet 
must  be  very  different  from  those 
which  cause  scurvy,  as  the  patient  ap¬ 
peared  to  have  had  an  unusual  quan¬ 
tity  of  fruits,  and  had  not  been  insuffi¬ 
ciently  supplied  with  potatoes.  In  the 
second  case  there  had  been,  as  in  cases 
of  scurvy,  a  deficiency  in  fresh  vege¬ 
tables.  Certainly,  in  all  the  cases 
which  have  occurred  to  me  among  the 
out-patients  at  University  College  Hos¬ 
pital,  there  has  been  deficiency  in  the 
quantity,  and  want  of  variety,  in  the 
food.  At  the  same  time  I  cannot  but 
think  there  must  be  some  other  cause 
than  dietetic  errors  ;  as,  to  draw'  an 
example  from  my  own  limited  expe¬ 
rience,  I  have  witnessed  in  India 
several  cases  of  Morbus  Maculosus 
Werlhofii  (w’hich  has  not  yet  been 
distinguished  from  purpura  haemor- 
rhagica)  in  soldiers  wdio  had  been  well 
nourished,  and  who  w  ere  unavailingly 
treated  with  tonics,  generous  diet,  and 
fresh  vegetables,  but  were  cured  with 
tolerable  certainty  both  by  turpentine 
and  by  creosote  —  medicines  w'hich 
have,  I  presume,  no  nourishing  power. 

Although  the  pathology  of  the  dis¬ 
ease  is  not  now  under  discussion,  it 
may  be  permitted  to  inquire  into  the 
prob;  ble  changes  in  the  blood,  con¬ 
sidered  merely  as  symptoms  of  the  dis¬ 
ease.  It  appears  almost  certain,  from 
the  analyses  already  made  by  Routier, 
Garrod,  Frick,  &c.,  that  purpura  co¬ 
exists  both  with  increase  and  with 
diminution  of  the  fibrine;  and  that 
alteration  either  wray  is  not  essential  to 
the  disease,  but  generally  depends  on 


coincident  conditions,  as  in  my  second 
case  on  the  rheumatic  diathesis.  I  say 
generally,  because,  in  a  long-continued 
case,  I  can  quite  conceive  that  there 
might  be  diminution  or  increase,  with 
no  other  disease  except  purpura,  merely 
from  constitutional  changes  not  proper 
to  purpura,  though  induced  by  it.  The 
passage  of  the  red  particles  from  the 
vessels,  as  it  is  not  affected  by  changes 
in  the  fibrine,  seems  also  not  to  be 
attributable  to  alterations  in  the  albu¬ 
men,  or  in  the  other  constituents  of 
the  serum.  These  appear  altogether 
natural:  their  quantity  is  normal;  no 
change  in  properties  has  been  dis¬ 
covered;  and  in  other  diseases  in  w'hich 
there  are  great  changes  in  the  consti¬ 
tuents  of  the  serum,  the  red  corpuscles 
do  not  exude  from  the  vessels.  It  can 
also  hardly  be  supposed,  reasoning 
from  the  condition  in  other  diseases, 
that  the  mere  diminution  of  the  solids 
of  the  blood  should  be  the  cause  of  the 
haemorrhage,  though  it  may  be  an 
accessory  assisting  condition.  By  the 
principle  of  exclusion,  therefore,  we 
are  impelled  to  look  upon  that  part  of 
the  blood  w'hich  is  chiefly  poured  out, 
viz.  the  red  particles,  as  the  constituent 
w  hich  is  probably  most  diseased  ;  and 
possibly  this  accords  with  the  analyses, 
which  point  to  an  alteration  in  that 
ingredient  which  seems  to  be  essential 
to  the  structure  of  the  corpuscle.  In 
the  two  analyses  made  by  Frick,  he 
found  the  iron  considerably  increased, 
and  the  lime  diminished.  With  the 
first  observation  my  analyses  accord  j 
the  second  I  can  neither  confirm  nor 
disprove.  It  is  certainly  an  observa¬ 
tion  for  w'hich  no  analogy  had  pre¬ 
pared  us,  that  the  iron  should  be  in¬ 
creased  in  a  hsemorrhagic  disease  ;  and 
I  must  confess,  although  this  has  been 
found  to  be  the  case  in  four  analyses, 
I  should  be  glad  to  see  the  point  in¬ 
vestigated  by  other  observers.  It  re¬ 
mains  to  be  seen,  also,  whether  the 
excess  of  iron  is  really  combined  w'ith 
the  corpuscles :  this  point  I  have 
hitherto  assumed.  In  addition  to  this 
alteration  in  the  iron,  it  appears  as  if 
there  was  an  excess  of  salts  in  the 
fluids  of  the  corpuscles  over  those  of 
the  serum, — indicating,  it  may  be,  in 
this  particular  also,  changes  in  the  in¬ 
gredients  of  the  red  corpuscles.  But 
as  to  the  way  in  which  these  changes, 
supposing  them  correctly  indicated, 
act  in  causing  the  hsemorrhagic  spots, 


DR.  JONES  ON  THE  INTESTINAL  MUCOUS  MEMBRANE. 


835 


it  is  of  course  impossible  to  say.  If 
purpura  be  a  disease  produced  by  in¬ 
sufficient  food,  we  should  rather  expect 
some  ingredients  of  the  blood  to  be 
defective,  than  that  any  should  be  in¬ 
creased  in  amount.  Perhaps,  after  all, 
the  increase  of  the  iron  in  these  four 
cases  has  been  a  mere  coincidence, 
and  the  changes  in  the  blood  are  still 
to  be  determined.  But  I  am  indisposed 
to  push  farther,  speculations  so  desul¬ 
tory,  and  at  present  so  profitless.  I 
regard  them  as  of  little  value,  and  I 
have  wished  in  this  paper  simply  to 
contribute  something  towards  the  mass 
of  details  which  must  be  collected 
before  correct  generalizations  can  be 
made. 

3,  Upper  Seymour  St.,  Portman  Square, 

Sept.  23,  1848. 


SOME  OBSERVATIONS  ON  THE 

INTESTINAL  MUCOUS  MEMBRANE. 

By  C.  Handfield  Jones,  M.D. 

Physician  to  the  Chelsea  Dispensary,  &c. 

Since  the  appearance  of  Professor 
Goodsir’s  invaluable  memoir  on  the 
structure  and  functions  of  the  intes¬ 
tinal  villi,  several  observers  have 
followed  in  the  same  line  of  inquiry, 
but  no  important  addition  has  been 
made  to  our  knowledge  of  the  process  : 
the  chief  new  fact  is  that  ascertained 
by  Weber  and  Kuss,  that  the  shedding 
of  the  protective  epithelium  of  the 
villi  is  not  essential  to  the  performance 
of  their  absorbing  function.  Having 
lately  examined  the  intestinal  mucous 
membrane  carefully,  both  during  the 
time  when  absorption  is  proceeding 
and  when  it  has  ceased,  I  venture  to 
record  my  observations,  in  the  belief 
that  as  such  inquiries  are  multiplied, 
the  truth  will  become  more  and  more 
clearly  developed. 

I  would  in  the  first  place  ask  atten¬ 
tion  to  the  material,  which  forms  so 
large  a  part  of  the  substance  of  each 
villus,  filling  up  with  the  capillaries 
and  lacteals  the  whole  space  enclosed 
by  the  limitary  membrane.  This 
material  consists  of  granular  matter 
and  nuclear  corpuscles ;  these  latter 
seldom  attaining  the  perfection  of  ordi¬ 
nary  nuclei,  and  being  sometimes 
rather  indistinct.  In  the  quiescent 
state,  the  contents  of  the  villus  are 
semi-transparent,  and  there  is  never 


any  trace  of  complete  cells  being  found 
in  its  interior.  Now  this  granular 
basis,  which  is  so  conspicuous  in  the 
villi,  appears  to  belong  to  a  great  stra¬ 
tum  of  similar  material,  which  is  found 
underlying  the  basement  membrane  in 
the  whole  extent  of  the  intestinal  canal : 
this  has  not  been  before  described,  so 
far  as  I  know,  and  I  must  therefore 
dwell  for  a  moment  upon  it. 

Itisbest  seen  in  the  mucous  membrane 
of  the  large  intestine,  when  a  piece  of 
this  is  dissected  off,  moistened  with  ace¬ 
tic  acid,  and  viewed  with  its  free  surface 
uppermost.  The  orifices  of  the  Lieber- 
kuchnian  follicles  are  very  distinct ; 
and  if,  as  is  usually  the  case  in  the 
human  subject,  the  epithelium  has 
separated,  the  basement  tissue  will  be 
seen  sharply  defining  their  margins, 
and  marking  the  whole  space  interven¬ 
ing  between  contiguous  follicles.  In 
such  specimens  it  is  very  evident  that 
beneath  the  basement  membrane,  and 
immediately  in  contact  with  it,  there 
exists  a  layer  which  resembles  exactly 
in  its  constitution  that  contained  in  the 
interior  of  the  villi,  consisting,  there¬ 
fore,  of  nuclear  corpuscles  and  granular 
matter.  This  layer  may  be  named  the 
“  substratum ”  of  the  mucous  tissue.  In 
the  small  intestine  it  is  not  so  easily 
seen,  as  the  surface  is  so  thickly 
covered  with  villi,  but  by  a  careful  ex¬ 
amination  its  presence  may  be  satisfac¬ 
torily  ascertained.  I  have  never  seen 
any  trace  of  it  in  the  stomach;  the  tubes 
I  believe  lie  too  closely  packed  to¬ 
gether  to  leave  room  for  it  to  exist. 
This  substratum  is  the  seat  of  the  black 
discolouration,  which  is  so  common  in 
the  intestinal  mucous  membrane,  and 
which  is  sometimes  supposed  to  indi¬ 
cate  a  state  of  chronic  inflammation. 
In  several  examinations,  however, 
which  I  have  made,  I  have  found  it  to 
depend  simply  on  the  deposit  of  black 
granules  in  the  “  substratum,”  the  tissue 
retaining  all  its  healthy  characters.  The 
granular  basis  of  the  villi  is  often 
similarly  affected;  and  this  is  a  further 
proof  of  the  statement  I  have  made, 
that  the  contents  of  the  villi  are  con¬ 
tinuous  with,  and  form  part  of,  the 
“  substratum.”  The  thickening  of  the 
mucous  membrane  which  occurs  in 
dysenteric  inflammation  affects  princi 
pally  the  layer  we  are  now  considering : 
it  is  greatly  increased  by  infiltration 
with  a  plasma  passing  into  imperfect 
cellular  forms,  and,  the  basement  mem- 


DR.  JONES  ON  THE  INTESTINAL  MUCOUS  MEMBRANE. 


836 


brane  being  destroyed,  constitutes  of 
itself  almost  the  sole  representative  of 
the  mucous  tissue. 

Returning  now  to  the  examination 
of  the  villi,  it  may  be  remarked  that  in 
their  quiescent  state  they  are  semi¬ 
transparent,  so  that  their  structure  can 
be  readily  discerned.  During  the 
period,  however,  of  their  activity,  they 
become  more  or  less  opaque,  and  when 
a  number  of  them  are  examined  under 
the  microscope,  it  is  evident  that  the 
opacity  does  not  affect  only  the  bulbous 
extremity,  but  extends  in  the  majority 
throughout  the  greater  part  of  their 
length.  In  a  recent  inspection  of  the 
villi  of  a  dog,  killed  while  the  lacteals 
were  filled  with  milky  chyle,  I  observed 
distinctly  that  the  apex  in  some  was 
the  most  opaque  part :  in  others,  the 
apex  was  comparatively  clear,  and  the 
opaque  matter  was  diffused  throughout 
the  body  of  the  villus  ;  in  others,  again, 
the  whole  villus  from  base  to  apex  was 
almost  equally  opaque  in  every  part. 
From  these  facts,  therefore,  I  think  it 
must  be  concluded,  that  it  is  not  only 
the  extremity  of  a  villus  (which  is  by 
no  means  always  or  often  bulbous) 
which  exerts  the  power  of  active  ab¬ 
sorption,  but  that  the  whole,  or  nearly 
the  whole  of  these  processes, — that 
is,  so  much  of  their  length  as  can 
come  freely  into  contact  with  the 
chyme, — fulfils  a  similar  function. 
In  stating  this,  however,  it  may  be 
admitted  that  the  apex,  as  most  ex¬ 
posed  to  the  material  on  which  it  is  to 
act,  is  probably  the  seat  of  the  most 
active  absorption.  If,  now,  we  proceed 
to  examine  the  contents  of  a  villus 
during  its  period  of  activity,  we  shall 
find  the  above  conclusion  further  con¬ 
firmed  :  for  the  vesicles  which  Prof. 
Goodsir  describes  as  existing  at  the 
apex,  and  which  he  regards  as  inter¬ 
stitial  cells,  seem,  so  far  as  I  can  deter¬ 
mine,  to  be  nothing  more  than  large 
oil  drops,  and  present  no  appearance 
which  could  lead  one  to  consider  them 
as  actual  living  structures.  They  are 
often  very  small,  often  absent ;  they 
are  just  like  oil  drops  in  other  situa¬ 
tions,  and  they  resemble  exactly,  ex¬ 
cept  in  size,  the  larger  drops  which 
collect  occasionally  in  the  blind  ex¬ 
tremity  of  the  lacteal  canal  of  the 
villus.  The  opacity  of  an  actively 
absorbing  villus  seems  almost  entirely 
to  depend  on  the  quantity  of  oily 
matter,  in  a  state  of  minute  division, 


difFused  through  its  granular  basis; 
and  this  oily  matter,  so  far  as  I  can 
determine,  is  quite  in  a  free  state,  and 
is  not,  I  believe,  at  any  time  contained 
in  perfect  cells. 

I  have  given  much  attention  to  as¬ 
certain  this  point,  and  I  feel  quite 
assured  that  in  the  great  majority  of 
villi,  which  are  manifestly  actively 
absorbing,  no  cells  arc  to  be  discovered, 
either  at  the  apex  or  throughout  the 
entire  length  :  all  that  can  be  seen  is 
a  mixture  of  oily  and  granular  matter, 
which  obscures  very  greatly  the  nuclear 
corpuscles,  often  so  evident  in  the 
quiescent  condition  of  the  organ. 
Cells  do,  indeed,  occur  occasionally  in 
the  substance  of  the  villi,  but  they  are 
not  at  all  constantly  situated  at  the 
apex  :  they  are  never  more  than  two 
or  three  in  number;  they  are  but  sel¬ 
dom  present,  and  do  not  appear  to 
have  any  relation  to  the  absorbing 
process.  But  admitting  these  observa¬ 
tions  to  be  correct,  does  it  then  follow 
that  the  beautiful  leading  idea  of  Mr. 
Goodsir  is  to  be  given  up,  and  that,  we 
must  resort  to  our  former  complete 
ignorance  of  the  nature  of  chylific  ab¬ 
sorption?  Not  so,  surely  ; — it  is  well 
known  now  that  the  formation  of  per¬ 
fect  cells  is  by  no  means  to  be  regarded 
as  essential  to  the  exercise  of  the 
energy  of  nuclei,  those  fundamen¬ 
tal  and  efficient  parts  of  almost  all 
cell  formations;  it  is  also  known  that 
the  formation  of  perfect  cells  indicates 
a  certain  degree  of  permanence  in  the 
structures  so  formed,  and  that  their 
contents  are  destined  to  be  retained  for 
a  period  to  undergo  some  elaborating 
change,  not  to  be  immediately  yielded 
up;  while,  on  the  other  hand,  the 
non-completion  of  cells  indicates  that 
the  process  is  of  a  rapid  character,  and 
not  intended  to  produce  any  considera¬ 
ble  change  in  the  material  acted  on. 
Remembering  these  facts  (of  the  gene¬ 
ral  truth  of  which  there  cannot  be,  I 
think,  much  doubt),  it  will  be  admitted, 
perhaps,  as  highly  probable,  that  the 
nuclear  corpuscles  of  the  granular 
basis  of  the  villi  exert  an  attraction  on 
the  chyme  by  which  they  are  sur¬ 
rounded,  and  draw  it  continually  into 
the  substance  of  the  villus,  from  whence 
it  is  rapidly  conveyed  away  by  the 
efferent  lacteal.  The  function  of  the 
villi,  it  is  pretty  certain,  is  one  not  of 
elaborating  but  of  simply  absorbing; 
it  needs  not,  therefore,  that  perfect 


DR.  JONES  ON  THE  INTESTINAL  MUCOt'S  MEMBRANE. 


837 


cells  should  be  formed,  all  that  is  re¬ 
quired  is  that  the  nuclei  should  exert 
an  attractive  force,  which  there  is 
abundant  reason,  from  the  analogy  of 
their  behaviour  in  other  structures,  to 
believe  that  they  possess.  I  may 
adduce  here  an  observation  made  on  the 
mesenteric  gland  of  a  dog  killed  at  a 
time  when  chyle  was  traversing  its 
structure  abundantly. 

The  general  disposition  of  its  ele¬ 
ments  seemed  to  correspond  pretty 
closely  with  the  account  contained  in 
another  of  Mr.  Goodsir’s  well  known 
papers  ;  but  it  was  perfectly  evident 
that  though  a  few  complete  nucleated 
cells  were  occasionally  to  be  seen,  yet 
the  great  mass  of  the  gland  consisted 
of  mere  nuclei,  not  exhibiting  the  least 
tendency  to  undergo  development  into 
cells,  but  surrounded  by,  and  mingled 
with,  an  abundant  quantity  of  the 
molecular  base  of  the  chyle.  Now,  as 
we  have  good  reason  to  believe  that  the 
lymphatic  and  lacteal  glands  exert  an 
action  upon  the  fluids  which  are  con¬ 
veyed  to  them  by  the  afferent  vessels, 
the  ob-ervation  above  recorded  (which 
1  have  more  than  once  repeated)  seems 
to  prove  that  nuclei,  as  such ,  effect 
whatever  changes  are  produced  in  the 
chyle  during  its  passage  through  the 
gland;  while,  in  this  instance,  as  in 
the  prior  act  of  absorption  by  the  villi, 
the  brief  and  rapid  character  of  the 
process  seems  to  forbid  the  develop¬ 
ment  of  complete  cells. 

I  may  next  remark  that  my  observa¬ 
tion  leads  me  to  agree  with  Professor 
Weber  that  the  shedding  of  their  in¬ 
vesting  epithelium  is  not  necessary  to 
enable  the  villi  to  perform  their  func¬ 
tion.  I  have  certainly  seen  the  villi  clad 
with  their  epithelium  when  the  lacteals 
have  seemed  to  be  everywhere  filled 
with  chyle :  however,  I  think  there 
can  be  little  doubt  that,  when  the  ab¬ 
sorbing  process  is  most  actively  per¬ 
formed,  the  villus  does  throw  off  its 
protective  covering ;  certainly  this  is 
the  case  in  a  great  number  of  in¬ 
stances. 

I  have  observed  a  curious  circum¬ 
stance  in  the  condition  of  the  villi, 
which  has  been  before  described,  I  be 
lieve,  by  M.  Lacauchie:  this  is,  that 
they  are  capable  of  varying  very  con¬ 
siderably,  both  in  length  and  width, 
the  variation  in  the  two  directions 
taking  place  inversely.  In  some  I  re¬ 
cently  examined  during  their  period  of 


activity,  I  found  their  length  was  no 
more  than  from  l-24th  to  l-l Sth  of  an 
inch,  while  their  width  was  from 
1  1 12th  to  l-84th  of  an  inch  ;  their  mar¬ 
gins  were  wavy,  and  their  apices  often 
notched  :  in  fact,  they  gave  one  com¬ 
pletely  the  idea  of  being  contracted  in 
the  longitudinal  direction  :  the  piece- 
which  presented  this  condition  of  the 
villi  was  macerated  a  little  time  in 
water,  and  then,  by  gentle  stroking 
with  a  camel’s  hair  pencil,  the  villi 
were  made  to  elongate  themselves  very 
considerably,  at  the  same  time  dimi¬ 
nishing  in  width  to  one-tenth  their 
former  diameter.  In  another  part  of 
the  intestine  of  the  same  animal,  where 
there  wrere  numerous  taeniae,  the  villi 
were  all  in  the  state  of  elongation  ; 
and  recently,  in  another  dog,  the  villi 
of  the  small  intestine  near  the  ileo- 
caecal  valve,  which  the  chyme,  in  its 
progress,  had  not  yet  reached,  were  in 
the  same  state  ;  while  those  higher  up 
in  the  canal,  which  were  opaque  wdth 
absorbed  matters,  were  contracted. 
Howr  the  retraction  and  thickening  of 
the  villi  is  effected  l  can  form  no  idea: 
they  possess  no  contractile  tissue  as  an 
element  of  their  structure,  and  the  dis¬ 
tension  of  their  capillary  plexus  with 
blood  would  produce  rather  a  contrary 
effect.  Whatever  be  the  mode  in 
w7hich  this  remarkable  change  in  their 
form  is  produced,  I  can  scarcely  join 
M.  Lacauchie  in  believing  that  it  is  at 
all  concerned  in  aiding  the  propulsion 
of  chyle.  I  have  observed  the  curious 
circumstance  mentioned  by  Professors 
Weber  and  Goodsir,  respecting  the 
epithelial  particles  of  the  villi,  viz. 
their  becoming  filled  with  oily  mole¬ 
cules  while  chyme  is  traversing  the 
intestine :  this  may  occur  not  only 
when  they  are  shed,  but  even  while 
they  are  adhering  to  the  villi.  It  is 
also  worth  remarking  that  the  nuclei 
of  these  particles,  which  are  usually 
very  evident,  disappear  as  they  become 
filled  with  oily  matter;  so  that  it  does 
not  appear  as  if  the  particles  were 
passively  infiltrated,  but  exerted  some 
preparatory  action  on  the  chyme  before 
its  absorption  by  the  nuclear  corpuscles 
of  the  villi. 

I  may  next  offer  a  few  observations 
on  the  structure  of  the  solitary  and 
agminate  glands  of  the  intestine;  these 
I  have  studied  principally  in  the  hu¬ 
man  subject,  but  have  also  examined 
them  in  the  rabbit  and  dog.  The 


838 


DR.  JONES  ON  THE  INTESTINAL  MUCOUS  MEMBRANE. 


excellent  account  given  by  Dr.  Todd, 
in  his  Gulstonian  Lectures,  of  these 
glands,  contains  all  that  is  certainly 
known  respecting  them :  there  are, 
however,  a  few  points  regarding  their 
condition  in  the  human  subject,  and 
their  relations  to  the  constituent  parts 
of  the  mucous  tissue,  which  may  per¬ 
haps  be  further  elucidated.  In  the 
caecum  of  the  human  intestine,  the 
mucous  membrane,  when  dissected  off 
and  treated  with  acetic  acid,  exhibits 
a  number  of  small,  opaque,  whitish 
spots,  varying  somewhat  in  size  :  these 
are  the  solitary  follicles;  they  are 
most  numerous  in  the  vermiform  ap¬ 
pendix,  but  occur  throughout  the 
whole  of  the  large  intestine ;  their 
central  part  often  appears  more  trans¬ 
parent  than  their  peripheral,  giving 
the  idea  of  an  orifice  in  this  situation. 
If  a  vertical  section  be  made  through 
one  or  more  of  these  spots,  it  is  then 
clearly  seen  that  they  consist  of  masses 
of  nuclear  granules,  which  for  the 
most  part,  I  think,  are  solid,  not  in¬ 
cluding  a  distinct  cavity,  and  not  con¬ 
tained  in  any  definite  follicular  enve¬ 
lope  :  they  lie  at  various  depths;  the 
larger  are  in  contact  with  the  surface, 
the  mucous  membrane,  with  its  rows 
of  vertical  follicles,  having  disappeared 
above  them  ;  the  smaller  lie  unques¬ 
tionably  beneath  the  mucous  surface, 
and,  I  feel  quite  assured,  have  no  ori¬ 
fice  of  communication  by  which  their 
contents  might  escape  into  the  intes¬ 
tinal  cavity  ;  even  pretty  strong  pres¬ 
sure  does  not  evacuate  the  contents  of 
the  smaller  masses,  while  it  sometimes 
produces  this  effect  on  the  larger, 
which  more  closely  adjoin  the  surface. 
The  form  of  these  masses  varies  a  good 
deal ;  often  they  are  considerably 
flattened,  usually,  however,  more  or  less 
globular — their  upper  portion  being  al¬ 
ways  convex  and  tending  to  approach 
the  surface ;  when  it  reaches  this,  the 
mass  appears  to  become  more  or  less 
completely  evacuated,  and  ashallowde- 
pression  may  then  result;  this,  however, 
is  but  rarely  seen.  In  the  ceecumofthe 
dog  the  solitary  glands  are  more  or  less 
prominent  on  the  surface,  and  exhibit 
a  very  distinct  appearance  of  a  central 
orifice.  When  macerated  in  acetic 
acid,  they  appear  as  circular  spots 
about  the  size  of  a  large  pin’s  head, 
rather  flattened,  and  with  perfectly  de¬ 
fined  margins.  In  vertical  sections 
through  the  central  orifice  the  mucous 


membrane  is  seen  to  dip  down  and  be¬ 
come  gradually  thinner  ;  sometimes  it 
appears  to  be  perforated  at  the  bottom 
of  the  depression  ;  at  others,  is  con¬ 
tinued  plainly  across.  The  gland  itself 
consists  of  a  solid  mass  of  nuclear  cor¬ 
puscles,  with  a  little  granular  matter  : 
it  is  contained  in  a  kind  of  capsule, 
which  seems  to  belong  to  the  sub¬ 
mucous  tissue ;  at  the  bottom  of  the 
depression,  the  mass  comes  in  contact 
with  the  thinned  mucous  membrane, 
if  it  exists,  or  with  the  orifice  if  it  be 
absent,  but  can  rarely  be  made  to 
escape  even  by  strong  pressure.  It 
does  not  appear  that  these  glands  can 
be  regarded  as  true  follicles :  their 
capsule  is  not  continuous  with  the 
basement  membrane ;  their  contents 
are  not  epithelial  particles  lining  the 
wall,  but  a  solid  mass  of  nuclei ;  and, 
lastly,  the  existence  of  an  orifice  to 
them  does  not  seem  constant,  whether 
evidence  of  it  be  sought  for  by  minute 
examination  or  by  observing  the  effect 
of  pressure  upon  their  mass.  In  the 
rabbit  the  long  and  wide  appendix 
cseci  has  its  mucous  lining  greatly 
thickened  by  a  layer  of  masses  con¬ 
sisting  of  nuclear  granules:  these  are 
of  elongated  conical  form;  their  apices 
reach  to  the  surface,  and  lie  in  fossulse 
formed  by  septal  folds  of  mucous 
membrane ;  over  their  surface  a  ca¬ 
pillary  plexus  is  spread,  supplied  by 
long  vessels  which  run  up  from  below : 
they  appear  to  be  quite  solid,  and  their 
apex  is  certainly  not  perforated,  but  in 
some  instances  appears  to  be  invested 
by  a  distinct  homogeneous  membrane. 
In  all  these  cases  it  is  worthy  of  re¬ 
mark,  that  the  masses  of  nuclear  gra¬ 
nules  are  affected  in  a  peculiar  manner 
by  acetic  acid  ;  instead  of  rendering 
them  transparent,  it  makes  them  much 
more  opaque,  so  that  their  outlines 
become  extremely  distinct  even  to  the 
naked  eye  :  this  circumstance,  as  well 
as  the  marked  difference  between  their 
contents,  and  the  epithelium  of  any 
glands  or  follicles,  is  very  characteristic 
of  them,  and  tends  to  prove,  I  think, 
that  they  are  not  mere  follicular 
involutions  of  the  mucous  surface, 
but  superadded  structures  designed 
for  some  special  but  unknown  func¬ 
tion. 

The  Peyerian  patches  seem  to  be,  as 
usually  considered,  merely  aggrega¬ 
tions  of  solitary  glands  ;  this  appears 
not  only  from  their  structure,  but  also 


DR.  JONES  ON  THE  INTESTINAL  MUCOUS  MEMBRANE. 


839 


from  the  circumstance  that  in  the  ap¬ 
pendix  coeciof  the  rabbit  (a  part  which 
is  always  the  chosen  seat  of  solitary 
glands),  they  are  so  closely  set  as  to 
constitute  one  vast  patch  in  all  respects 
similar  to  the  patches  of  the  small 
intestine.  In  the  human  subject  they 
are  in  the  healthy  state,  but  moderately 
developed,  and  from  that  very  circum¬ 
stance  are  capable  of  being  examined 
more  satisfactorily.  When  undistended, 
the  margin  of  a  patch  is  very  slightly 
raised  ;  but  if  held  up  to  the  light,  the 
mucous  membrane  at  that  part  is  seen 
to  be  much  more  opaque  than  it  is  in 
the  parts  around.  The  surface  of  a 
patch  generally  presents  slight  depres¬ 
sions,  with  often  blackish  spots  or 
streaks  in  their  centre:  these  depressions 
are  not  open  mouths  of  follicles,  but 
seem  to  be  produced  by  the  absence  of 
the  villi  from  those  parts  of  the  mucous 
surface.  Occasionally  there  is  a  slight 
prominence  in  the  middle  of  each  de¬ 
pressed  spot,  but  this  never  reaches 
the  level  of  the  surrounding  villous 
surface,  so  that  the  appearance  of  a 
depression  still  remains.  In  vertical 
sections  I  have  repeatedly  seen  the 
aggregated  masses  of  nuclei  precisely 
similar  to  those  constituting  the  soli¬ 
tary  glands,  lying  in  the  “  substratum,” 
and  manifestly  subjacent  to  the  base¬ 
ment  tissue,  at  a  varying  depth  from 
the  surface.  Groups  of  villi  stand  up 
pretty  thickly  from  the  intervening 
portions  of  mucous  membrane,  while 
immediately  over  the  aggregated 
masses,  the  basement  membrane,  often 
beautifully  distinct,  passes  as  a  plane 
surface,  or  rises  into  a  few  low  ridges. 
The  examination  of  these  structures  is 
facilitated  by  treating  the  specimen 
with  acetic  acid,  which  renders  the 
masses  more  opaque,  and  thus  defines 
their  extent  and  situation  more  exactly: 
the  form  of  the  masses  varies  some¬ 
what  ;  often  it  is  rather  flattened,  more 
commonly,  however,  globular  or  conoid, 
the  apex  being  directed  towards  the 
surface.  Most  usually,  I  think,  the 
outline  is  ill  defined;  there  seems  to  be 
no  exact  limit  to  the  mass,  but  it  blends 
gradually  with  the  material  of  the 
“  substratum,”  in  which  it  lies,  and  of 
which  it  seems  to  form  a  part :  some¬ 
times  this  is  so  much  the  case  that  the 
mass  is  scarcely  distinguishable  as  an 
independent  part;  in  other  instances 
the  outline  is  better  preserved,  and 
there  is  some  trace  of  an  investing 


fibrous  capsule,  but  never  have  I  seen 
anything  to  indicate  that  the  masses 
were  contained  in  follicular  offsets  from 
the  mucous  surface.  The  aggregate 
masses  consist  of  the  peculiar  nuclear 
corpuscles  before  mentioned,  with  a 
small  quantity  of  granular  matter; 
black  matter  is  also  very  commonly 
present  in  them,  producing  the  blackish 
dotting  of  the  surface  of  the  patch 
before  alluded  to.  I  have  occasionally 
observed  some  trace  of  a  cavitv  in  the 
aggregate  masses,  but  am  inclined  to 
consider  them  for  the  most  part  as 
solid.  In  the  dog  the  patches  are  much 
more  thickly  covered  with  villi  than  in 
the  human  subject :  the  masses  have 
generally  a  well-marked  conical  form  ; 
some  are,  however,  rather  flattened, 
and  lie  manifestly  beneath  the  mucous 
surface,  not  having  yet  attained  their 
full  development.  There  does  not  ap¬ 
pear  to  be  any  trace  of  an  orifice  at  the 
apex  of  these  masses  ;  on  the  contrary, 
it  is  perfectly  even,  well-defined,  and 
not  unfrequently  invested  by  an  homo¬ 
geneous  membrane.  In  the  rabbit  the 
mucous  membrane  is  very  greatly 
thickened  in  the  situation  of  the 
glands,  the  conical  masses  are  very 
large,  and  lie  in  distinct  cavities,  en¬ 
closed  by  narrow  strips  of  mucous  mem¬ 
brane,  which  rise  into  beautiful  wavy 
folds.  The  apices  of  the  conical  masses 
are  well  defined ;  they  are  surrounded 
with  an  atmosphere  of  nuclear  granules 
(similar  to  those  of  which  they  them¬ 
selves  are  made  up),  which  nearly  fills 
up  the  cavities  in  which  they  lie  ;  and 
further,  in  injected  specimens  it  is  seen 
that  a  capillary  web  is  spread  over  their 
apices,  which  seems  to  indicate,  in-con¬ 
junction  with  other  facts,  that  the  con¬ 
tents  of  these  masses  are  not  intended 
to  be  discharged,  and  that  in  fact  they 
are  rather  of  the  nature  of  papillae  than 
follicles. 

I  cannot  offer  even  a  conjecture  as 
to  what  the  function  of  these  curious 
structures  may  be,  only  1  can  hardly 
think  that  they  are  destined  in  their 
natural  state  to  serve  as  excretory 
organs,  for  which  purpose  surely  their 
construction  is  but  little  adapted.  The 
changes  they  undergo  in  fever  are  just 
such  as  one  would  expect  from  a  con¬ 
sideration  of  the  details  now  given: 
consisting  almost  entirely  of  masses  of 
nuclei,  they  would  attract  the  matter  to 
be  eliminated  with  peculiar  energy, 
would  rapidly  enlarge,  by  development 


840  DR.  SNOW  ON  THE  ADMINISTRATION  OF  CHLOROFORM. 


of  theirnuclei,  intocellular  forms, reach 
the  surface,  and  burst,  forming  thereby 
the  ulcerations  so  frequently  met  with. 

54,  Sloane  Street,  Sept.  26,  1848. 

P.S.  In  the  foregoing  remarks,  I  have 
not  spoken  of  the  solitary  glands  as  ex¬ 
isting  in  the  small  intestine.  I  do  not 
mean  to  deny  their  existence,  but  it 
has  never  occurred  to  me  in  a  good 
many  examinations  to  discover  them  ; 
at  least,  such  as  are  to  be  seen  in  the 
large  intestine.  I  have,  however,  ex¬ 
amined  instances  of  what  are  com¬ 
monly  called  enlarged  solitary  glands, 
in  the  lower  part  of  the  ileum;  one  of 
which  I  may  mention.  A  man  died 
suddenly,  while  in  apparent  health, 
having  hypertrophy  and  dilatation 
of  the  heart,  with  diseased  aortic 
valves  :  the  lungs  were  free  from  tu¬ 
bercles  ;  the  mucous  lining  of  the 
lower  part  of  the  small  intestine  pre¬ 
sented  a  great  number  of  small  eleva¬ 
tions  of  varying  size,  much  resembling 
those  which  are  found  in  cases  of 
typhoid  fever;  these  by  microscopic 
examination  were  found  to  consist  of 
masses  of  nuclear  corpuscles  and 
granular  matter,  not  contained  in  defi¬ 
nite  capsules,  and  evidently  subjacent 
to  the  basement  membrane.  In  the 
smaller  ones,  the  nuclei  were  feebly 
formed,  rather  indistinct,  and  mingled 
with  a  good  deal  of  granulo  amorphous 
matter.  In  the  larger,  the  nuclei  were 
very  perfect  and  well  formed,  and  there 
was  but  little  granular  matter. 

Acetic  acid  affected  the  masses  just 
as  it  does  the  solitary  glands,  rendering 
them  more  conspicuous  by  their  opacity 
in  the  surrounding  transparent  tissue. 
It  seems  impossible  to  believe,  that  in 
this  and  several  instances  the  promi¬ 
nences  (“  boutons,”  as  they  are  called 
by  the  French)  are  developments  of 
naturally  existing  structures.  I  feel 
no  doubt  that  they  are  simply  deposits 
of  a  peculiar  material  in  the  substra¬ 
tum  of  the  mucous  tissue,  quite  analo¬ 
gous  to  pimples  or  pustules  of  the 
skin,  and  like  them,  capable  of  disap¬ 
pearing  by  absorption. 


MEDICAL.  STUDENTS  FROM  THE  MAURITIUS. 

Mr.  Jean  Felix  Pellegrin,  a  native  of 
Mauritius,  passed  his  examination  at  the 
Royal  College  of  Surgeons,  on  the  5th  inst., 
and  is  the  first  student  from  that  colony  who 
has  obtained  the  honour  of  an  English 
diploma. 


ON 

NARCOTISM  BY  THE  INHALATION 
OF  VAPOURS. 

By  John  Snow,  M.D. 

Vice-President  of  the  Westminster  Medical 
Society. 

[Continued  from  page  416.] 


Part  VII. 

On  the  administration  of  chloroform — 
Objections  to  giving  it  on  a  hand¬ 
kerchief —  Description  of  an  appa¬ 
ratus. 

The  conclusion  generally  arrived  at 
by  those  who  have  commented  on  the 
fatal  cases  of  inhalation  of  chloroform, 
is  one  in  which  I  do  not  agree.  It 
has  usually  been  concluded  that  there 
is  danger  necessarily  attending  the  use 
of  chloroform,  and  that  it  should  there¬ 
fore  be  confined  to  serious  operations. 
Now  a  great  part  of  the  advantage  at¬ 
tending  the  use  of  an  ansesthetic  con¬ 
sists  in  its  preventing  the  patient’s 
dread  of  the  operation  ;  but  if  the  im¬ 
munity  from  pain  could  only  be  ob¬ 
tained  by  incurring  a  danger  of  sudden 
loss  of  life,  there  would  be  a  new 
source  of  fear.  Many  patients,  again, 
have  been  readily  induced  to  submit  to 
a  necessary  operation,  through  the 
prospect  of  undergoing  it  without  pain, 
who,  otherwise,  would  have  withheld 
their  consent  either  altogether  or  till 
the  prospect  of  a  successful  issue  were 
much  diminished.  In  this  way,  there 
is  no  doubt,  many  lives  have  been 
saved.  But  if  the  patient  had  to 
choose  between  pain  and  a  risk,  how¬ 
ever  small,  of  sudden  death,  this  ready 
and  early  consent  could  not  be  ex¬ 
pected.  It  is  therefore  necessary,  for 
the  sake  of  patients  undergoing  capital 
operations,  to  inquire  whether  there  is 
any  means  of  preventing  the  pain, 
which  is  free  from  danger,  and  to  em¬ 
ploy  that  means  in  preference  to  ano¬ 
ther.  And  if  the  skilful  and  careful 
administration  of  chloroform  were 
really  attended  with  danger,  I  would 
recommend  that  it  should  not  be  re¬ 
sorted  to  in  any  case;  for  we  have  in 
ether  a  medicine  capable  of  affording 
all  the  benefits  that  can  be  derived 
from  chloroform,  and  which  never 
caused  accidents  of  the  kind  we  are 


OBJECTIONS  TO  GIVING  CHLOROFORM  ON  A  HANDKERCHIEF.  841 


considering,  although  it  was  the  first  |  to  the  Hotel  Dieu,  that  medical  men. 
used, — when  the  knowledge,  conse-  who  have  not  practised  anmstnesia 
quently,  of  producing  insensibility  was  should  first  study  it  from  the  action  of 


less.* 

There  is,  however,  no  reason  to 
doubt  that  chloroform  is,  when  ad¬ 
ministered  with  care  and  a  sufficient 
knowledge  of  its  properties,  unattended 
with  danger, — or,  at  all  events,  with  a 
degree  of  danger  so  small  that  it  cannot 
be  estimated; — not  greater,  for  in¬ 
stance,  than  attends  the  minor  opera¬ 
tions  of  surgery,  or  the  taking  of 
ordinary  doses  of  medicine.  When  the 
vapour  of  chloroform  is  well  diluted 
with  air,  it  is  as  safe  as  ether ;  and,  as 
it  possesses  some  minor  advantages 
over  it,— such  as  being  less  pungent, 
and  therefore  more  easily  inhaled, — 
not  leaving  its  odour  in  the  breath  for 
some  time  afterwards, — being  more 
portable,  on  account  of  the  smaller 
quantity  required,  and  producing  ex¬ 
citement  less  frequently  in  the  early 
stages  of  its  effects, — its  use,  by  all 
medical  men  who  are  perfectly  con¬ 
versant  with  its  effects  and  mode  of 
administration,  is  quite  allowable  in 
every  case  in  which  there  is  much  pain 
to  be  prevented. 

But,  without  proper  precautions,  the 
inhalation  of  chloroform  is  undoubtedly 
attended  with  danger,  on  account  of 
the  rapidity  of  its  action  when  not 
sufficiently  diluted  with  air,  and,  also, 
on  account  of  its  effects  accumulating 
for  about  twenty  seconds  after  it 
is  discontinued,  which  accumulation 
would  be  most  formidable,  if  the  air 
taken  into  the  lungs  just  before,  were 
highly  charged  with  vapour.  The  ex¬ 
hibition  of  ether  is  not  attended  with 
this  kind  of  danger,  even  if  but  little 
precaution  is  exercised,  and  the  symp¬ 
toms  caused  by  both  vapours  being 
the  same,  I  entirely  agree  in  the  re¬ 
commendation  of  M.  Yalleix,  physician 


*  I  am  aware  that  ether  was  thought  by  some 
to  have  caused  death  in  two  or  three  instances 
in  which  the  patients  did  not  recover  from  the 
operation,  but  died  tw  o  or  three  days  afterwards ; 
and  in  one  of  these  instances  a  coroner’s  jury 
returned  a  verdict  to  that  effect;  but  I  believe 
the  only  instance  on  record  in  which  the  inhala¬ 
tion  of  ether  was  fatal,  was  one  that  occurred  in 
France  (see  Gaz.  Mddicale,  4  Mars,  and  Med. 
Gaz.  p.  432,  last  vol.),  and  in  that  case  the  in¬ 
halation  was  continued  without  intermission  for 
ten  minutes,  although  alarming  symptoms  were 
present  nearly  all  the  time;  and  it  is  probable 
that  the  result  was  owing  as  much  to  some  de¬ 
fect  in  the  inhaler,  which  limited  the  supply  of 
air,  as  to  the  effect  of  ether. 


ether.*  This  advice  will,  perhaps, 
not  generally  be  followed  ;  but  if  prac¬ 
titioners  are  inclined  to  run  any  risk 
in  administering  chloroform  before 
they  are  well  prepared,  they  must  re¬ 
collect  that  they  are  not  doing  it  for 
the  sake  of  preventing  the  severe  pain 
and  shock  of  the  operation,  but  only  to> 
avoid  the  stronger  odour,  more  pungent 
flavour,  and  other  little  inconveniences 
of  ether. 

It  is  quite  obvious,  that  by  merely 
placing  the  chloroform  on  a  handker¬ 
chief  or  sponge,  and  getting  the  pa¬ 
tient  to  breathe  through  it,  we  can 
have  no  control  over  the  quantity  of 
vapour  in  the  air  breathed.  If  the 
handkerchief  be  not  applied  close  to 
the  face,  enough  vapour  will,  most 
likely,  not  be  taken  to  cause  insensi- 
bility ;  and,  if  applied  closely,  the  air 
breathed  will  probably  be  almost 
saturated,  and  that  at  a  rather  high 
temperature.  In  three  out  of  the  four 
fatal  cases  we  have  considered,  the 
chloroform  was  administered  on  a 
handkerchief ;  and  in  the  fourth  case 
— that  in  America— no  attention  was 
paid  to  the  proportions  of  vapour  and 
air :  the  only  endeavour  appeared  to 
be  to  make  the  patient  insensible  as 
quickly  as  possible.  The  handker¬ 
chief  is  advocated  by  some  practition¬ 
ers,  on  account  of  its  supposed  simpli¬ 
city  ;  but  whenever  I  have  had  occa¬ 
sion  to  give  chloroform  in  this  way,  I 
have  felt  it  to  be  a  very  complicated 
process,  on  account  of  the  difficulty  of 
getting  even  an  approximative  know¬ 
ledge  of  what  I  was  doing,  by  the  best 
calculation  I  could  make. 

Before  administering  chloroform,  the 
surgeon  should  have  as  clear  and  dis¬ 
tinct  an  idea  of  its  vapour  as  of  the 
blade  of  his  knife;  and  as  this  will  be 
read  by  students  as  well  as  practi¬ 
tioners,  I  shall  be  excused  lor  introduc¬ 
ing  a  brief  explanation  of  the  nature  of 
a  vapour.  In  a  popular  sense,  this, 
term  is  sometimes  applied  to  the 
minute  globules  of  liquid  suspended  in 
air,  which  result  from  the  condensa¬ 
tion  of  a  vapour  that  has  been  mixed 
with  it,  as  in  what  is  called  the  steam 
or  vapour  from  the  spout  of  a  tea- 


*  See  Med.  Gaz.  p.  305,  present  vol. 


842 


APPARATUS  FOR  THE  INHALATION  OF  CHLOROFORM. 


kettle.  But  chloroform  cannot  be 
taken  in  this  form  ;  if  it  were  attempted, 
spasm  of  the  glottis  would  ensue.  A 
vapour  is  a  dry  aeriform  condition  of 
a  substance  differing  from  a  gas  only 
in  the  circumstances  of  temperature 
and  pressure  under  which  it  takes  the 
liquid  form.  The  vapour  of  chloro¬ 
form  has  no  separate  existence  under 
natural  circumstances  of  pressure  and 
temperature,  or  in  any  form  of  inhaler. 
3STo  patient  ever  took  any  of  it  in  this 
way,  or  ever  will,  and  this  is  equally 
true  of  ether.*  Chloroform  requires  a 
temperature  of  140°  Fah.,  under  the 
ordinary  pressure  of  the  atmosphere, 
to  make  it  boil,  and  enable  it  to  exist  in 
the  state  of  undiluted  vapour ;  but 
mixed  with  air,  it  may  have  the  form 
of  vapour  at  inferior  temperatures  :  the 
quantity  that  may  exist  in  the  air  vary¬ 
ing  with  the  temperature  directly  as 
the  elastic  force  of  the  vapour.  The 
chloroform,  in  fact,  that  a  patient 
breathes,  is  dissolved  in  the  air,  just  as 
water  is  always  dissolved  in  it,  even  in 
the  driest  weather,  and  the  patient 
breathes  his  air  with  two  vapours  instead 
of  one — the  new  vapour  being,  to  be 
sure,  in  much  the  largest  quantity.  As 
a  proof  that  these  physical  considera¬ 
tions  are  worthy  our  notice,  1  may  state, 
that  if  chloroform  had  boiled  at  180° 
instead  of  140°,  its  solubility  and  other 
properties  remaining  the  same,  the 
four  fatal  cases  we  had  occasion  to  dis¬ 
cuss  w  ould  not  have  occurred. 

The  following  table  shews  the  result 
of  experiments  I  made  to  determine  the 
quantity  of  vapour  of  chloroform  that 
100  cubic  inches  of  air  will  take  up  at 
various  temperatures : — 


*  Many  practitioners,  judging  from  their 
Writings,  seem  to  have  very  incorrect  notions 
concerning  these  vapours.  For  instance,  M. 
Roux,  the  eminent  French  surgeon,  in  objecting 
to  the  use  of  the  handkerchief  in  the  Academy  of 
Sciences,  says — “  In  this  manner  the  patient  in¬ 
spires  the  chloroform  vapour  without  air.  (See 
Med.  Gaz.  present  vol.  p.  214).  Soon  after  the  in¬ 
halation  of  ether  was  introduced,  two  veterinary 
surgeons  in  London  endeavoured  to  try  its  effects 
on  a  horse  in  a  pure  state,  and  prevented  the  in¬ 
gress  of  air.  As  they  did  not  make  the  ether  boil, 
the  animal  could  get  no  vapour,  except  what  com¬ 
bined  with  the  little  air  that  might  get  in  through 
the  leakage  of  the  inhaler.  The  horse  in  fact 
was  burked.  The  efforts  at  respiration  were  pro¬ 
digious,— it  shortly  died, — and  the  heart  and  dia¬ 
phragm  were  found  to  be  ruptured.  (See  Lancet, 
April  10,  1847).  This  experiment  has  been  re¬ 
cently  quoted  in  a  pamphlet  opposed  to  chloro¬ 
form  in  midwifery,  as  a  proof  of  the  injurious 
effects  of  ether. 


Temperature. 

Cubic  inches. 

50°  .  . 

*  .  9 

55  .  . 

.  .  11 

60  .  . 

.  .  14 

65  .  . 

.  .  19 

70  .  . 

.  .  24 

75  .  . 

.  .  29 

80  .  . 

.  .  36 

85  .  . 

.  .  44 

90  .  . 

.  .  55 

The  most  perfect  way  of  giving  a  va¬ 
pour  to  animals  is  that  adopted  in  the 
experiments  I  have  related,  the  breath¬ 
ing  not  being  interfered  with,  and  the 
strength  of  the  vapour  being  accurately 
known.  This  method  is  not  applicable 
to  patients,  but  our  endeavour  should 
be  to  approach  to  it  as  nearly  as  we 
conveniently  can.  The  apparatus  I 
employ  is  delineated  in  the  subjoined 
engraving.*  (See  next  page). 

a.  Outer  case  containing  water  bath, 
screwed  on — A.  Cylindrical  vessel  into 
which  the  chloroform  is  put ;  it  is  lined 
with  a  coil  or  two  of  bibulous  paper  up 
to  the  point  c  d.  A  cylindrical  frame 
which  screws  into  b — it  has  apertures 
at  the  top  for  the  admission  of  air,  and 
its  lower  two-thirds  are  covered  with 
a  coil  or  two  of  bibulous  paper,  which 
touches  the  bottom  of  the  vessel  b,  ex¬ 
cept  where  the  notches  e  are  cut  in  it. 
f.  Elastic  tube.  g.  Expiratory  valve  of 
face  piece ;  the  dotted  lines  indicate 
the  position  of  this  valve  when  turned 
aside  for  the  admission  of  air  not 
charged  wTith  vapour.  A.  Inside  view 
of  face-piece,  pinched  together  at  the 
top  to  adapt  it  to  a  smaller  face.  i.  In¬ 
spiratory  valve. 

When  the  patient  inspires,  the  air 
enters  by  the  numerous  and  large 
apertures  in  the  top  of  the  inhaler, 
passes  between  the  two  cylinders  of 
bibulous  paper,  wet  with  chloroform, 
through  the  notches  in  the  bottom  of 
the  inner  one,  then  up  the  centre  of 
the  apparatus,  still  in  contact  with  the 
paper,  and  through  the  short  tube, 
which  is  three-quarters  of  an  inch 
wide  in  the  inside.  The  air  thus  gets 
charged  with  vapour,  whilst  it  meets 
with  no  obstruction  whatever  till  it 
arrives  at  the  inspiratory  valve  of  vul¬ 
canized  India-rubber,  which  weighs 
but  a  few  grains,  and  rises  at  the  be¬ 
ginning1  of  the  slightest  possible  inspi. 

*  It  is  made  according  to  my  directions,  by 
Mr.  Matthews,  10,  Portugal  Street,  Lincoln’s  Inn 
Fields. 


APPARATUS  FOR  THE  INHALATION  OF  CHLOROFORM. 


843 


ratory  movement.  The  cylinder  of 
thin  brass  in  which  the  chloroform  is 
placed  is  inclosed  in  a  larger  one  con¬ 
taining  water,  wdiich,  by  supplying  the 
caloric  that  is  removed  in  the  vapori¬ 
zation  of  the  medicine,  prevents  the 
temperature  from  being  lowered.  It 
also  prevents  it  from  being  raised  by 
the  wrarmth  of  the  hand,  and  thus 
keeps  the  process  steady.  If  the  tem¬ 
perature  of  the  water  be  60°,  each  100 
cubic  inches  of  air  passing  through  the 


apparatus  might,  according  to  the  table 
above,  take  up  14  cubic  inches,  and 
become  expanded  to  114  cubic  inches, 
when  it  would  contain  a  little  more 
than  twelve  per  cent,  by  measure. 
This  is  supposing  it  became  quite 
saturated,  which,  however,  it  does  not, 
and  ten  per  cent,  of  vapour,  or  eight 
minims  of  chloroform,  is  probably  as 
much  as  the  air  contains.  It  is  not 
desirable,  however,  to  give  it  to  the 
patient  even  of  this  strength,  and  the 


844 


DR.  GRIFFITH  ON  THE  COLOUR  OF  THE  HAIR. 


expiratory  valve  of  the  face-piece  *  is 
made  to  move  to  one  side,  so  as  to 
leave  uncovered  more  or  less  of  the 
aperture  over  which  it  is  placed,  and 
admit  pure  air  to  mix  with  and  dilute 
that  which  has  passed  through  the 
inhaler.  By  means  of  this  valve,  the 
vapour  may  be  diluted  to  any  extent, 
whilst,  at  the  same  time,  one  may  have 
a  knowledge  of  the  strength  of  the 
vapour  the  patient  is  breathing ;  not 
exact,  to  be  sure,  but  practically  of 
great  value.  The  valves  in  this  face- 
piece  act  properly,  and  close  of  them¬ 
selves,  in  every  position  in  which  a 
patient  can  be  placed,  except  on  his 
face,  and  even  ir>  this  posture  they  will 
act  if  the  head  be  turned  on  one  side. 

The  position  of  the  patient  and  in¬ 
haler  have  nothing  to  do  with  the 
specific  gravity  of  the  vapour,  as  some 
have  supposed.  If  what  the  patient 
breathes  were  as  heavy  as  the  pure 
vapour,  it  would  impose  no  appreciable 
labour  on  the  muscles  of  respiration  to 
raise  it  to  the  mouth  ;  and  although 
the  vapour  of  chloroform  is  four  times 
as  heavy  as  atmospheric  air,  it  does 
not  increase  the  specific  gravity  of  the 
air  the  patient  inhales  by  more  than 
one-fourth;  and,  indeed,  air  charged 
with  vapour  of  chloroform  is  not  so 
heavy  as  when  charged  with  vapour 
of  ether  at  the  same  temperature.  The 
most  convenient  position  of  the  patient 
taking  chloroform  is  lying  on  the  back 
or  side,  with  the  head  and  shoulders  a 
little  raised,  as  he  is  then  duly  sup¬ 
ported  in  the  state  of  insensibility,  and 
can  be  more  easily  controlled  if  he 
shall  struggle  whilst  becoming  insensi¬ 
ble.  But  there  is  no  objection  to  the 
sitting  posture,  when  that  is  most  con¬ 
venient  to  the  operator. 

In  the  next  paper,  I  shall  enter  on 
the  details  necessary  to  be  observed  in 
giving  chloroform  in  different  kinds  of 
surgical  operations. 

[To  be  continued.] 

*  It  is  the  same  face-piece  I  used  in  'riving' 
ether  for  three  or  four  months  before  Dr.  Simp¬ 
son  introduced  the  use  of  chloroform.  By  the 
removal  of  the  peculiar  expiratory  valve,  which 
is  its  most  important  part,  and  the  introduction 
of  a  sponge,  it  has  been  made  to  constitute  a 
chloroform  inhaler  by  more  than  one  practi¬ 
tioner.  These  inhalers  are,  undoubtedly,  better 
than  the  sponge  or  handkerchief;  but,  besides 
the  want  of  affording  due  command  over  the 
strength  of  the  vapour,  I  consider  that  they  are 
open  to  objection  from  the  chloroform  being  so 
near  to  the  mouth,  that  some  of  it  might  be  in¬ 
haled,  by  a  forcible  inspiration,  in  the  form  of 
minute  drops,  when  it  would  cause  temporary 
spasm  of  the  glottis. 


ON  THE 

COLOUR  OF  THE  HAIR. 

DECEPTIVE  APPEARANCE  UNDER  THE. 
MICROSCOPE. 

Bv  J.  W.  Griffith,  M.D.  &c. 


The  colour  of  hair  has,  I  believe,  been; 
long  considered  to  depend  upon  the 
presence  of  a  quantity  of  colouring 
matter  which  is  accumulated  into  little 
heaps,  and  contained  in  the  medullary 
portion  of  the  hair.  These  so-called 
accumulations  of  pigment  are,  as  it  is 
well  known,  very  beautifully  seen  in 
the  hair  of  many  kinds  of  animals,  as 
the  sable,  the  badger,  &c.,  where  they 
are  apparently  arranged  with  remarka¬ 
ble  regularity  and  beauty. 

The  object  of  the  present  note  is^ 
to  shew  that  the  above  appearances 
have  been  totally  misinterpreted,  and  it 
is  astonishing  how  such  misinterpre¬ 
tations  are  handed  down  from  author  to 
author,  and  even  how  they  are  made  by 
observer  after  observer. 

The  appearance  considered  as  the 
accumulation  of  pigment  into  little 
heaps,  arises  from  a  number  of  air  cavi¬ 
ties  existing  in  the  medullary  portion 
of  the  hair;  the  air  contained  within 
them  refracts  the  rays  of  light  beyond 
the  field  of  the  microscope,  and  thus 
they  appear  black  :  they  are,  however, 
rarely  perfectly  black,  there  being  ge¬ 
nerally  a  minute  white  spot  in  their 
centre. 

These  air  spaces  probably  arise  from 
the  evaporation  and  escape  of  the  fluid 
which  in  the  younger  hair  filled  the 
cells  of  the  medulla. 

That  they  contain  air,  and  that  the 
air  produces  the  pigment-like  appear¬ 
ance,  may  be  shewn  as  follows  : — 

1.  If  a  piece  be  cut  from  the  centre 
of  the  hair*  (by  transverse  cuts),  and 
this  be  digested  in  warm  water  or  alco¬ 
hol,  the  hair  becomes  very  transparent, 
and  by  this  method  all  the  air  cavities 
may  be  filled  with  the  water  or  spirit ; 
nay,  if  the  piece  of  hair  be  immersed 
in  the  oil  of  turpentine,  and  warmed, 
the  fluid  may  be  seen  under  the  micro¬ 
scape  to  enter  the  cells,  and  the  air  to 
escape  in  bubbles  at  the  ends.  All 
appearance  of  the  pigment  then  va¬ 
nishes,  but  traces  of  the  cell- wall  of  the 
medulla  are  still  faintly  seen,  they  not 
being  of  the  same  refractive  power  as 

*  That  of  the  sable,  or  some  other  animal  in 
which  the  cavities  are  large  and  distinct,  is  hest. 


845 


POISONING  BY  MISTAKE  IN  DISPENSING  MEDICINES. 


the  medium  in  which  they  are  im¬ 
mersed. 

2.  If  the  portion  of  hair  be  removed 
from  the  water,  spirit,  or  oil,  and  al¬ 
lowed  to  dry,  the  fluid  evaporates,  and 
the  air  may  be  seen  under  the  micro¬ 
scope  to  re-enter  and  restore  theoriginal 
appearance.  On  preserving  specimens 
of  hair  in  Canada  balsam,  the  cells  are 
frequently  completely  filled  in  parts 
with  the  balsam,  especially  at  the  ex¬ 
tremities. 

3.  If  the  hair  be  bruised  in  an  agate 
mortar,  it  becomes  flattened  out,  re¬ 
sembling  a  shred  of  membrane,  the 
pigment  appearance  being  completely 
destroyed. 

DR.  BUEL  ON  THE  RATE  OF  MORTALITY 

FROM  PRIMARY  AND  SECONDARY  AMPU¬ 
TATIONS. 

As  to  the  question  whether  primary  or  se¬ 
condary  amputation  is  preferable,  it  is  evi¬ 
dent  that  an  equal  number  of  similar  cases 
should  be  selected  from  each  class  in  order 
to  institute  anything  like  a  just  comparison. 
It  is  customary  at  the  New  York  Hospital, 
when  amputation  is  demanded  after  severe 
injuries,  to  operate  before  the  accession  of 
inflammatory  action.  So  that,  strictly  speak¬ 
ing,  the  occasions  for  secondary  amputations 
will  be  comparatively  rare. 

Of  the  whole  number  of  amputations, 
sixty-two  were  the  result  of  injuries,  and 
wTere  fatal  in  nineteen  cases,  making  the 
mortality  30  64  per  cent.  Of  these,  thirty- 
six  were  primary  amputations:  of  which 
there  were  of  the  hip-joint  one,  and  that 
fatal ;  of  the  thigh  seven,  of  which  four  were 
fatal  ;  of  the  leg  twelve,  of  which  five  were 
fatal ;  of  the  arm  seven,  and  of  the  forearm 
five,  of  which  none  were  fatal :  making  the 
mortality  27 ‘ 77.  The  remaining  twenty-six 
amputations  may  all  be  said  to  have  resulted 
from  injuries  of  a  more  or  less  severe  cha¬ 
racter ;  but,  as  will  be  seen,  they  were  per¬ 
formed  at  very  different  periods  after  the 
original  injury.  Of  this  number,  eleven 
were  amputations  of  the  thigh,  of  which 
three  were  fatal ;  at  the  knee-joint  one, 
which  was  fatal ;  of  the  leg  seven,  of  which 
one  was  fatal ;  at  the  shoulder-joint  five,  of 
which  three  were  fatal ;  of  the  arm  one,  and 
of  the  forearm  one,  of  which  neither  was 
fatal  :  making  the  mortality  30‘ 76  per  cent. 

The  number  of  operations  for  various 
chronic  affections  was  twenty-nine,  of  which 
six  were  fatal.  Of  the  thigh  there  were 
eighteen,  of  which  four  were  fatal ;  of  the 
leg  five,  of  which  none  were  fatal;  of  the 
arm  three,  of  which  none  were  fatal ;  of  the 
forearm  four,  of  which  two  were  fatal : 
making  the  mortality  ‘20'67  per  cent. — 
American  Journal  of  Med.  Sciences. 


MEDICAL  GAZETTE. 


FRIDAY,  NOVEMBER  17,  1848. 

There  is  a  form  of  poisoning  of  which 
we  have  had  of  late  several  lamenta¬ 
ble  instances  —  namely,  where  sub¬ 
stances  of  a  highly  poisonous  nature 
have  been  dispensed  by  mistake  for 
drugs  prescribed  medicinally.  It  is 
with  no  desire  to  add  to  the  sorrow  or 
legal  responsibility  of  those  who  have 
thus  been  unintentionally  the  means 
of  destroying  life,  that  we  advert  to 
this  subject;  but,  if  possible,  to  ex¬ 
tract  good  out  of  misfortune,  and  to 
impress  upon  those  who  dispense  me¬ 
dicines,  the  imperative  necessity  of 
keeping  all  active  poisons  apart  from 
drugs  which  are  required  for  daily 
use.  It  is  not  enough  to  have  them  on 
a  different  shelf,  but  they  should  be 
kept  in  a  distinct  part  of  the  dispensing 
establishment.  There  should  not  be 
the  least  risk  of  the  bottle  containing 
an  active  poison  being  left  by  accident 
on  the  same  counter — a  circumstance 
which  must  occasionally  happen  when 
poisons  are  retailed  and  drugs  dis"- 
pensed  in  one  shop.  Our  suggestion 
will  probably  be  met  by  the  statement 
that  no  line  of  distinction  can  be 
drawn  between  drugs  and  poisons ; 
that  many  medicinal  preparations  in 
constant  use  are  really  active  poisons  ; 
and  that  this  separation  of  pharma¬ 
ceutical  preparations  would  entail  so 
great  an  amount  of  trouble  and  ex¬ 
pense,  that  in  the  greater  number  of 
druggists’  shops  the  plan  could  not  be 
carried  out.  While  we  freely  admit 
the  inconvenience  and  additional  ex¬ 
pense  which  would  be  caused  by  such 
a  change,  we  are  bound  to  look  at  the 
consequences  to  the  public  under  the 
present  loose  plan  of  keeping  in  the 
same  shop  innocent  drugs  and  virulent 


846 


POISONING  BY  MISTAKE  IN  DISPENSING  MEDICINES - 


poisons.  W e  have  known  a  great  number 
of  instances  in  which  tincture  of  opium 
has  been  sent  out  for  tincture  of  rhu¬ 
barb  ;  and  in  several  of  these  cases  the 
poison  was  swallowed,  and  caused 
death.  Other  fatal  mistakes  are  re¬ 
corded  where  oil  of  tar  has  been  dis¬ 
pensed  for  black  draught ;  corrosive 
sublimate  for  calomel ;  salt  of  sorrel 
for  cream  of  tartar;  oxalic  acid  for 
Epsom  salts ;  cyanide  for  the  ferro- 
cyanide  of  potassium  ;  and  strychnia 
for  morphia  !  However  difficult  it  may 
be  to  draw  a  boundary  line  between  a 
poison  and  a  medicine,  no  person  can 
entertain  any  doubt,  with  respect  to 
the  substances  here  mentioned,  that 
they  admit  of  a  clear  separation,  and 
might  be  kept  in  a  part  of  the  dis¬ 
pensary  quite  distinct  from  that  in 
which  the  medicines  for  which  they 
have  so  often  been  fatally  mistaken,  are 
preserved.  But  we  must  go  a  step  fur¬ 
ther  than  this.  In  our  opinion,  such 
substances  should  be  dispensed  from  a 
different  counter,  with  different  scales 
and  measures,  and  under  the  super¬ 
intendence  of  an  assistant  to  whom 
this  duty  should  be  specially  assigned. 
If  this  plan  be  adopted  with  the  more 
active  poisons,  and  if  the  poisonous 
preparations  be  invariably  kept  in 
bottles  of  coloured  glass  ( e,g .  of  a  deep 
blue  colour),  we  are  satisfied  that  there 
will  be  no  danger  to  life  from  the  cir¬ 
cumstance  that  a  few  preparations  of 
a  doubtful  nature,  which  may  or  may 
not  be  regarded  as  poisons,  are  left  on 
the  shelves  of  the  dispensary. 

When  there  is  some  reason  to  sus¬ 
pect  that  a  fatal  mistake  has  been 
made,  and  the  druggist  is  questioned 
on  the  subject,  his  answer  is  com¬ 
monly  to  the  effect,  that  although  he 
has  the  poison  in  his  shop,  it  is  kept  on 
a  different  shelf,  at  some  distance  from 
the  drug  for  which  it  is  alleged  to 
have  been  mistaken,  and  that  an  as¬ 
sistant  could  not,  by  any  possibility, 


without  being  aware  of  it,  take  the  one 
bottle  for  the  other.  This  is  a  very 
plausible  statement,  and  being  given 
bond  fide,  carries  with  it  great  weight; 
but  the  misfortune  in  all  these  cases — 
the  very  essence  of  the  accident,  is, 
that  a  man  who  has  served  arsenic  for 
magnesia,  or  strychnia  for  morphia, 
under  such  circumstances,  is  not  aware 
of  his  fatal  error.  Powdered  arsenic 
would  not  be  kept  in  a  bottle  in  a  shop 
except  for  the  purpose  of  retailing  the 
poison  ;*  if  retailed,  this  bottle  may  by 
mere  accident  be  left  on  a  counter  for 
a  few  minutes,  with  other  bottles  con¬ 
taining  white  powders.  Owing  to  some 
momentary  inattention  (and  without 
this  no  accident  could  ever  occur),  the 
bottle  may  by  mistake  be  taken  up  by 
the  same  or  another  assistant,  and  a 
poison  supplied  for  an  innocent  medi¬ 
cine  !  The  patient  dies,  and  if,  unfor¬ 
tunately,  no  portion  of  the  poison  thus 
accidentally  supplied  for  medicine  be 
saved,  the  fact  that  there  has  been  a 
mistake  cannot  always  be  clearly  traced 
to  the  dispenser,  and  an  innocent  per¬ 
son  may  be  charged  with  the  administra¬ 
tion  of  poison.  The  assistant  is  fully  per¬ 
suaded  that  he  could  not  possibly  have 
made  such  a  serious  mistake — to  believe 
the  contrary  would  be  almost  equal  to 
supposing  that  he  dispensed  the  poison 
intentionally — and  the  master  calmly 
deposes,  before  a  coroner’s  jury,  that 
the  arsenic-bottle  is  of  a  different  size 
or  shape,  has  a  different  label  on  it, 
and  is  kept  on  a  high  shelf,  in  a  differ¬ 
ent  part  of  the  shop !  The  circum¬ 
stances  here  described  are  not  based  on 
fiction,  but  on  fact.  A  superintendent  of 
police,  in  endeavouring  to  trace  out  the 
sale  of  poison  in  reference  to  a  case  of 
murderwhichoccurred  some  yearssince, 
informed  us,  that  on  suddenly  entering 
the  shop  of  a  provincial  druggist,  on 


*  Many  druggists  wisely  keep  arsenic,  already 
weighed,  in  packets  and  properly  labelled.  To 
these,  of  course,  our  remarks  do  not  apply. 


SUGGESTIONS  FOR  THE  PREVENTION  OF  ACCIDENT. 


847 


a  market-day,  he  saw  on  the  counter  a 
bottle  of  powdered  arsenic,  near  several 
other  bottles  containing  white  powders, 
which  he  was  informed  were  of  a  me¬ 
dicinal  nature.  It  is  very  probable, 
that,  as  a  general  rule,  the  bottle  of 
arsenic  was  kept  at  a  distant  part  of 
the  shop,  on  a  high  shelf,  &c. ;  but  it 
must  be  remembered  that  these  fatal 
mistakes  could  never  arise  except  from 
the  non-observance  of  the  general  rules 
suggested  by  ordinary  prudence  and 
care.  A  mistake  of  this  kind  has  recently 
placed  in  the  greatest  jeopardy,  the 
lives  of  two  innocent  persons  in  this 
metropolis  ;  and  we  think  that  a 
Court  of  law  would  be  only  acting 
with  a  proper  degree  of  distrust, 
when  inquiring  into  the  probability 
of  the  occurrence,  if  it  rejected  all 
evidence  as  to  heights  of  shelves, 
shapes  and  sizes  of  bottles,  and  the  par¬ 
ticular  parts  of  the  shop  in  which  the 
medicine  and  poison  were  kept.  The 
questions  should  be — Is  the  poison 
kept  in  the  shop — is  it  retailed  from  the 
same  counter  as  ordinary  medicines — 
and  is  it  the  duty  of  one  person  to  retail 
the  poisons,  oris  this  performed  by  any 
individual  who  happens  to  be  in  the 
shop  ?  This  we  think  obvious,  that  a 
mistake  could  never  arise  except  from 
a  violation  of  some  of  those  rules,  w?hich 
reasonable  caution  would  suggest.  We 
hold  this  strong  opinion  on  the  irre¬ 
levancy  and  deceptive  character  of  evi¬ 
dence  of  this  kind,  not  merely  from  the 
repeated  occurrence  of  fatal  accidents 
from  mistakes  made  by  otherwise  care¬ 
ful  and  experienced  dispensers,  but  be¬ 
cause  no  man  can  be  answerable  for 
theconstant  exercise  of  caution  in  those 
who  are  under  him ;  no  man  who  re¬ 
tails  arsenic  kept  in  an  open  shop, 
could  sw:ear  that  in  his  absence,  his 
assistant  could  not  have  possibly  dis¬ 
pensed  this  poison  for  some  other  white 
powder,  or  have  sold  tincture  of 
opium  for  rhubarb  ;  and  in  the  event 


of  the  death  of  the  patient,  the  assistant 
could  not  admit  that  he  had  made  such 
a  serious  mistake  without  at  once  cri¬ 
minating  himself. 

In  general,  the  fact  of  poisoning 
under  these  circumstances  is  clear,  and 
the  extent  of  the  evil  is  then  known. 
The  life  of  the  unfortunate  patient  is 
sacrificed,  and  the  dispenser  is  put  on. 
his  trial  for  manslaughter.  In  our  last 
number  *  will  be  found  a  short  report 
of  a  case  of  poisoning  by  mistake, 
which  has  led  to  the  sudden  death  of  a 
lady  in  the  prime  of  life.  A  fatal  dose 
of  strychnine  wTas  dispensed  for  salicine , 
and  the  patient  died  in  less  than  two 
hours.  The  dispenser,  who  was  repre¬ 
sented  to  have  been  a  most  careful  and 
competent  person,  had  of  course  no  idea 
that  he  had  committed  such  a  serious 
mistake,  until  informed  of  the  death  of 
the  lady.  The  cause  of  the  accident  is 
alleged  to  have  been,  that  the  bottles 
containing  strychnine  and  salicine, 
were  kept  side  by  side,  and  one  was  in¬ 
advertently  taken  for  the  other!  On 
this  occasion,  the  mistake  was  clearly 
brought  home  to  the  dispenser,  1,  by 
the  sudden  death  of  the  lady  under  all 
the  symptoms  of  poisoning  by  strych¬ 
nine  ;  2,  by  the  absence  of  any  natural 
cause  of  death  on  an  inspection  of  the 
body;  and  lastly,  although  the  poison 
wras  not  detected  in  the  stomach,  by 
its  presence  in  part  of  the  mixture  dis¬ 
pensed.  Such  an  accident  might,  under 
some  circumstances,  have  occurred  to 
any  person,  however  cautious  he  may 
think  himself.  The  two  pow'ders  are 
very  similar  in  appearance ;  they  were 
probably  contained  in  similar  bottles, 
and  the  latter  half  of  the  name  on  the 
labels  is  the  same  in  each. 

We  are  indebted  to  Dr.  Snow  for  a 
short  report  of  another  case  of  poison¬ 
ing  by  mistake,  which  recently  occurred 
in  the  county  of  York.  The  parents  of  a 


*  Page  797. 


848 


THE  PROGRESS  OF  THE  CHOLERA  IN  THE  METRO 


child  sent  to  the  shop  of  a  druggist  for  a 
pennyworth  of  magnesia.  It  happened 
that  the  druggist  was  not  in  the  shop 
at  the  time,  and  the  youth  in  atten¬ 
dance  dispensed  arsenic  by  mistake, 
instead  of  magnesia.  The  poison  was 
given  to  the  child  :  the  usual  symp¬ 
toms  followed,  and  in  spite  of  all  reme¬ 
dial  treatment,  the  child  died.  The 
facts  of  this  case  were,  we  presume, 
too  clearly  indicative  of  a  mistake  to 
admit  of  a  doubt  of  the  allegation  that 
magnesia  had  been  really  dispensed, 
or  to  allow  of  the  suggestion  that  arse¬ 
nic  had  been  subsequently  substituted 
for  the  criminal  purpose  of  destroying 
the  child.  Admitting,  therefore,  that 
arsenic  was,  in  this  instance,  dispensed 
for  magnesia  by  a  youth  evidently 
ignorant  of  the  different  appearance  of 
the  two  substances,  and  probably  not 
used  to  dispensing,  it  remains  to  be 
considered  whether  any  sane  druggist 
would  keep  the  bottles  side  by  side  on 
the  same  shelf.  We  cannot  believe 
that  there  could  have  been  such  gross 
negligence  on  this  occasion,  and  we 
therefore  arrive  at  the  conclusion  that 
a  fatal  mistake  is  very  liable  to  happen 
even  when  such  a  precaution  is  ob¬ 
served. 

If  in  these  two  recent  cases  the 
poisons  had  been  kept  in  coloured 
bottles,  and  in  a  place  distinct  from 
the  shop  or  dispensary,  the  two  unfor¬ 
tunate  victims  would  probably  have 
been  now  living,  and  the  parties  making 
the  mistakes  would  not  have  had  to 
undergo  a  trial  for  manslaughter. 

The  most  serious  feature  which  these 
cases  presentremainsyet  tobedescribed. 
A  combination  of  circumstances  may 
lead  to  a  charge  of  murder  against, 
those  who  have  the  care  of  the 
deceased  ;  and  if  none  of  the  poison 
administered  for  medicine  can  be  pro¬ 
cured,  and  the  whole  of  the  facts  con¬ 
nected  with  the  death  be  not  accurately 
sifted,  the  discovery  of  arsenic  or  other 


poison  in  the  stomach,  may  actually 

he  taken  as  a  proof  of  guilt,  and  the 

accused  mav  incur  the  risk  of  be- 
•/ 

coming  the  victim  of  a  false  accusation. 
A  trial  took  place  at  the  Central 
Criminal  Court,  in  August  last,  the 
facts  of  which  will  serve  to  show  that 
a  mistake  in  dispensing  medicine  may 
not  only  affect  the  public,  by  causing 
the  death  of  a  parent  or  child,  but 
occasionally  by  aggravating  their  sor¬ 
row  in  leading  to  a  false  charge  of 
murder.  We  shall  reserve  our  analysis 
of  the  evidence  in  this  case  until  the 
next  number. 


The  weekly  return  of  the  Registrar- 
General  is  still  favourable  to  the 
healthy  condition  of  the  metropolis. 
The  deaths  are  represented  as  exceed¬ 
ing  the  autumnal  average  by  11  ;  but 
this  surplus  arises  not  from  an  in¬ 
creased  mortalitv,  but  from  the  intro- 
duction  of  a  number  of  deaths  from 
one  sub-district  which  should  have 
been  distributed  over  the  previous 
weeks.  The  mortality  from  zymotic 
diseases  is  actually  lower  than  in  the 
preceding  week  ;  the  registered  deaths 
from  diarrhoea,  cholera,  and  typhus, 
are  also  less  numerous. 

On  the  10th  inst.  there  were  in  the 
metropolis  six  cases  of  malignant  cho¬ 
lera,  and  one  death  ;  on  the  13th  inst. 
eighteen  cases,  and  thirteen  deaths ; 
on  the  14th  inst.  six  cases,  and  one 
death ;  and,  on  the  15ih  inst.  four 
cases,  and  three  deaths.  The  official 
report  up  to  this  date  gives  the  follow¬ 
ing  as  the  number  of  cases  and  deaths  : 

Cases.  Deaths. 

In  London  and  vicinity . .  327  171 

the  Provinces .  70  42 

Scotland . .  642  320 

Total .  1039  533 

The  deaths,  it  will  be  seen,  amount 
to  more  than  fifty  per  cent. ;  but  we 


ELEMENTS  OF  ANATOMY.  MEMORANDA  ON  POISONS. 


849 


are  inclined  to  doubt  whether  so  many 
cases  of  malignant  cholera  have  oc¬ 
curred  in  the  metropolis  as  the  above 
table  represents. 


Elements  of  Anatomy.  By  Jones 
Quain,  M.D.  Fifth  edition.  Edited 
by  Richard  Quain,  F  R.S.,  and 
William  Sharpey,  M.D.  F.R  S., 
Professor  of  Anatomy  and  Physio¬ 
logy  in  University  College,  London. 
Yoi.  2nd.,  8vo.  London:  Taylor 
and  Walton.  1848. 

As  the  volume  before  us  is  the  com¬ 
pletion  of  a  work  highly  prized  by 
students  of  anatomy  and  physiology, 
we  lose  no  time  in  announcing  its  pub¬ 
lication.  When  a  book  has  reached  its 
fifth  edition,  it  may  be  considered  as 
placed  beyond  the  necessity  of  a  formal 
review.  It  is,  however,  the  duty  of  a 
critic  to  see  that  there  is  no  retrogres¬ 
sion,  and, — acting  on  the  modern  rule 
non  progredi  est  reyvedi , —  that  the  work 
is  kept  up  to  that  level  which  students 
of  anatomy  have  in  the  present  day  a 
full  right  to  expect.  On  these  points 
it  is  a  pleasure  to  us  to  be  able  to  speak 
satisfactorily  of  the  labours  of  Mr. 
Quain  and  Dr.  Sharpey.  So  far  as  we 
have  examined  it,  the  work  is  im¬ 
proved  by  numerous  valuable  additions 
to  every  department.  In  General, 
Descriptive  and  Surgical  Anatomy,  it 
contains  all  the  information  which  a 
student  can  desire;  and  the  descrip¬ 
tions  are  rendered  intelligible,  by  the 
introduction  of  many  new  and  well-ex¬ 
ecuted  wood-engravings.  Either  to  the 
beginner  or  to  the  advanced  student, 
this  work  will  be  found  a  safe  and  useful 
guide. 

Popular  Lectures  on  the  prevailing 
Diseases  of  Towns  ;  their  Effects , 
Causes ,  and  the  means  of  Prevention. 
By  William  Kebbell,  M.D.,  Phy¬ 
sician  to  the  Brighton  Dispensary. 
Small  8vo.  pp.  196.  London: 
Whittaker.  1848. 

In  four  lectures,  Dr.  Kebbell  has  here 
endeavoured  to  enforce  the  necessity  of 
an  immediate  correction  of  those  evils 
which  are  dependent  on  the  deficiency 
of  drainage,  sewerage,  and  ventilation. 


in  large  and  populous  towns.  Admit¬ 
ting  that  no  remedy  can  be  applied, 
until  the  extent  and  effects  of  a  neglect 
of  sanitary  precautions  are  brought  in 
a  distinct  form  before  the  public,  much 
credit  is  due  to  professional  men,  who, 
like  Dr.  Kebbell,  devote  a  portion  of 
their  time  to  the  making  of  these  sub¬ 
jects  intelligible.  The  lectures,  al¬ 
though  written  for  a  local  purpose, 
have  a  general  application  ;  and  we, 
therefore,  recommend  this  little  volume 
to  those  of  our  readers  who  take  an 
interest  in  the  sanitary  movement,  not 
for  any  novelty  in  the  views  contained 
in  it,  but  for  a  compendious  arrange¬ 
ment  of  hygienic  facts. 

Memoranda  on  Poisons.  By  T.  H. 
Tanner,  M.D.  12mo.  pp.  61.  Lon¬ 
don  :  Renshaw.  1848. 

We  wish  we  could  speak  favourably  of 
these  memoranda,  but  a  glance  at  the 
book  has  satisfied  us  that  the  author  has 
not  had  sufficient  practical  experience 
of  the  subject  on  which  he  has  written. 
The  little  pocket  volume  is  on  the  same 
plan  as  Dr.  Rigby’s  Obstetric  Memo¬ 
randa,  but  far  inferior  in  execution. 
Dr.  Rigby  brings  us  well-digested  facts 
derived  from  long  experience  and  care¬ 
ful  observation.  Dr.  Tannerfurnishes 
us  with  an  abstract  of  toxicological 
facts  from  works  which  are  in  the  hands 
of  most  professional  men.  He  either 
does  not  understand  the  action  of  tests, 
or  has  a  very  unfortunate  way  of  ex¬ 
pressing  himself.  Thus  we  are  told,  in 
reference  to  the  tests  for  corrosive 
sublimate,  that  “  a  solution  of  iodide  of 
potassium,  added  to  a  small  quantity  of 
the  powder,  is  turned  of  a  bright  scar¬ 
let.”  Ttiere  are  some  other  equally 
strange  statements,  which  have  a  very 
questionable  claim  to  the  title  of  “  me¬ 
moranda.” 


OBITUARY. 

At  Newmarket,  ou  the  2nd  inst.,  Robert 
James  Peck,  Esq.,  surgeon,  aged  591 

On  Saturday,  the  11th  inst.,  at  Capecure, 
Boulogne-sur-Mer,  John  Hill,  Esq.,  M.D. 
in  the  70th  year  of  his  age. 

On  the  6th  inst.,  at  his  residence,  South¬ 
ampton,  highly  respected,  and  deeply 
lamented,  Mr.  John  Alfred  Stace,  surgeon, 
aged  29,  second  son  of  Joseph  Stace,  Esq., 
surgeon. 

On  the  15th  inst.,  aged  35,  William 
Twining,  Esq.,  M.D.,  youngest  son  of 
Richard  Twining,  Esq.,  of  13,  Bedford 
Place,  Russell  Square. 


850 


GOUTY  DEPOSIT  IN  THE  KNEE-JOINT. 


3PvocecDmg$  of  jcoriettess. 

PATHOLOGICAL  SOCIETY  OF 

LONDON. 

Monday,  Nov.  6,  1848. 

C.  Aston  Key,  Esa.,  in  the  Chair. 


Dr.  Handfield  Jones  exhibited  a 
Specimen  of  Gouty  deposit  in  the  Knee- 
joint, 

from  a  man  mt.  41,  admitted  August,  9  into 
St.  George’s  Hospital,  under  the  care  of  Dr. 
B.  Jones,  and  who  died  on  the  20th,  from 
continued  fever. 

Both  knee-joints  contained  deposits  of  the 
ordinary  white  chalky  matter  of  gout  in  the 
following  situations  : — (1)  Under  the  syno¬ 
vial  membrane  at  the  margin  of  the  cartilage. 
(2)  In  the  superficial  structure,  or  on  the 
surface  of  the  cartilage,  from  whence  it  could 
not  be  removed  by  gentle  washing  or  scrap¬ 
ing.  (3)  In  the  substance  of  the  cartilage 
at  some  depth.  (4)  In  the  cancelli  of  the 
subjacent  bone  (the  patella). 

The  gouty  matter  appeared  for  the  most 
part  as  aggregations  of  amorphous  masses, 
varying  in  size,  and  encrusted  over  fre¬ 
quently  with  minute  crystalline  spicula,  so 
as  to  present  an  appearance  somewhat  similar 
to  that  assumed  by  artificially. crystallized 
urate  of  soda. 

The  cartilage  was  remarkably  thickened, 
being  at  least  three  times  its  ordinary  dimen¬ 
sion.  Near  its  middle  it  was  much  more 
elevated  than  towards  its  margin,  and  very 
soft  and  yielding.  When  a  vertical  section 
was  made  of  it,  the  surface  exhibited  a 
marked  fibrous  structure,  quite  visible  to  the 
naked  eye;  the  fibres  being  arranged  verti- 
cally  to  the  surface,  and  being  much  more 
marked  in  the  deeper  than  in  the  superficial 
layers. 

The  microscope  showed  that  the  basis 
substance  was  considerably  increased,  the 
cells  being  in  much  scantier  proportion  than 
natural,  but  not  essentially  altered;  the 
fibres  were  not  isolated  from  each  other  ; 
in  fact,  the  basis  substance  had  not  yet  fairly 
broken  up  into  separate  fibres,  but  was  evi¬ 
dently  tending  so  to  divide.  The  fibres  or 
bands  were  of  some  considerable  width, 
separated  by  narrow  intervals  of  healthy 
structure.  It  was  worthy  of  notice  that, 
though  their  own  direction  was  manifestly 
vertical,  yet  they  were  striated  transversely 
in  a  very  marked  manner.  This,  as  well  as 
the  coarser  perpendicular  arrangement,  was 
scarcely  observable  in  the  parts  near  the 
surface. 


Dr.  Jones  also  made  the  following  re¬ 
marks  on  the  character  of  the 

Morbid  changes  in  Pulpy  Thickening  of  the 
Synovial  Membrane — a  specimen  of  the 
affection  was  exhibited. 

The  peculiar  and  remarkable  alteration 
which  the  synovial  membrane  undergoes  in 
the  disease  termed  “  pulpy  thickening,”  is, 

I  believe,  usually  conceived  to  depend  on 
the  exudation  of  lymph,  which  becomes 
organized  into  a  kind  of  false  membrane. 

This  statement  is  tolerably  correct,  but 
may  perhaps  admit  of  being  rendered  more 
full  and  precise  by  the  following  details  : — 

A  knee-joint  was  lately  removed  in  St. 
George’s  Hospital,  by  Mr.  Hawkins,  which 
was  affected  with  the  above-mentioned  dis¬ 
ease  ;  not,  however,  in  a  very  advanced 
stage.  The  synovial  membrane  was  con¬ 
nected  with  a  soft  greyish  structure,  which 
formed  prominent  fringes,  overlapping  and 
encroaching  considerably  on  the  surface  of 
the  articular  cartilage.  The  marginal  zone 
of  the  cartilage,  for  a  varying  extent,  was 
converted  into  a  kind  of  fibrous  tissue,  and 
blended  with  the  altered  synovial  membrane. 
More  internally,  the  cartilage  was  grooved 
on  the  surface,  and  overlapped  to  a  greater 
or  less  extent  by  the  fringe  of  the  newly- 
developed  structure.  The  fibrous  tissue 
into  which  the  cartilage  was  transformed, 
was  of  an  imperfect  kind,  not  divided  into 
distinct  fibres,  and  not  containing  any  of 
the  natural  cells  of  the  cartilage,  but  strewed 
over  with  numerous  oil  drops  and  yellowish 
molecules.  A  vertical  section  of  the  carti¬ 
lage,  carried  from  without  inwards,  pre¬ 
sented  to  the  naked  eye  the  following  ap¬ 
pearance  : — The  cartilage,  overlapped  above 
by  the  synovial  fringe,  was  obliquely  trun¬ 
cated  towards  its  outer  border,  and  passed 
by  actual  continuity  into  a  fibrous  tissue, 
which  blended  above  with  the  altered  syno¬ 
vial  membrane.  Up  to  its  truncated  edge, 
the  cartilage  to  the  naked  eye  appeared  not 
otherwise  than  healthy,  and  it  was  very  re¬ 
markable  to  observe  how  abruptly  the 
change  occurred  from  firm  cartilaginous 
into  soft  fibrous  structure.  On  a  microsco¬ 
pical  examination,  a  thin  vertical  section  of 
the  cartilage,  including  the  truncated  edge, 
displayed  some  interesting  changes  taking 
place  in  the  cartilage  itself.  At  a  certain  dis¬ 
tance  from  the  margin  where  the  change  was 
proceeding,  the  cells  of  the  cartilage  were 
quite  natural,  and  in  the  ordinary  propor¬ 
tion  to  the  basis  substance.  Nearer  the 
margin,  they  were  enlarged,  and  contained 
young  cells  in  their  interior  ;  while  close  to 
the  margin  itself  they  were  prodigiously  de¬ 
veloped,  crowded  with  young  cells,  and  had 
encroached  considerably  on  the  intervening 
basis  substance.  One  or  two  enlarged 
groups  projected  from  the  margin  into  the 


IMPERFECT  HYPERTROPHY  OF  THE  MAMMA. 


851 


fibrous  tissue,  and  there  were  debris  of 
several  others  strewed  throughout  the 
neighbourhood.  The  cells  formed  by  endo¬ 
genous  growth  within  the  original  cell,  con¬ 
tained  generally  each  a  small  oil  drop,  but 
were  principally  filled  with  a  transparent 
matter  :  the  quantity  of  oil  contained  in 
them  was  so  small  that  it  was  quite  clear 
that  fatty  degeneration  was  not  the  essence 
of  the  morbid  change.  The  intervening 
basis  substance  had  a  finely  granular  aspect, 
and  was  not  perceptibly  altered  from  its 
healthy  state,  save  that  it  was  greatly  en¬ 
croached  on,  and  diminished  by,  the  absorb¬ 
ing  action  of  the  unnaturally-developed 
cells.  One  of  the  enlarged  cellular  groups, 
near  the  margin,  had  a  long  diameter  of 
inch,  and  a  short  diameter  of  inch. 

The  peculiar  synovial  structure,  under 
whose  influence  these  changes  seem  to  have 
been  wrought,  was  found  to  possess  a  low,  but 
definite  and  significant  type  of  organization. 
It  consisted  principally  of  well-formed  nuclei 
of  the  ordinary  appearance,  and  granular 
matter,  with  which  were  mingled  a  few  fusi¬ 
form  and  circular  cells.  These  elements 
were  contained  in  an  exterior  enveloping 
membrane,  very  thin,  of  whitish  aspect,  and 
nearly  of  homogeneous  texture.  There  was 
scarcely  any  appearance  of  stromal  fibres 
throughout  the  contained  mass,  except  that 
there  existed  a  good  many  large  vesicles  or 
loculi  from  1  -56  to  1  -  3  7  of  an  inch  in  diameter, 
which  had  nearly  homogeneous  envelopes, 
and  were  filled  with  material  similar  to  that 
which  surrounded  them.  Bloodvessels  with 
delicate  walls  ramified  through  the  mass,  but 
not  in  great  numbers. 

It  is  evident,  from  the  above  description, 
that  this  peculiarly-developed  synovial  tissue 
is  much  more  than  mere  exudation  of  lymph  ; 
no  false  membrane  could  assume  such  a 
form  and  arrangement  :  it  is  not,  therefore, 
a  product  of  a  chronic  inflammatory  process, 
but  a  special  growth.  It  does  not  appear  to 
be  of  malignant  character,  as  it  shews  no 
tendency  to  infiltrate  the  adjacent  parts,  or 
to  contaminate  the  constitution  or  glands. 
It  remains,  then,  to  inquire  what  is  its  real 
nature  and  function.  If  we  call  to  mind  the 
observations  of  Mr.  Key  and  Professor 
Goodsir,  as  to  the  mode  in  which  ulceration 
of  articular  cartilage  takes  place,  we  shall 
find  in  the  account  above  given  of  the  con¬ 
dition  of  the  cartilage  and  synovial  structure, 
much  reason  to  believe  that  the  process  in 
the  instance  we  are  now  considering  is  but  a 
variety  of  that  which  occurs  in  other  cases 
of  ulceration  of  cartilage.  For  the  peculiar 
thickening  of  the  synovial  membrane  is  pro¬ 
bably  only  a  higher  development  of  the 
vascular  fringes  of  the  same  tissue  by  means 
of  which  Mr.  Key  describes  the  erosion  and 
removal  of  the  cartilage  to  be  effected.  And 
again,  we  observe  in  the  cartilage  itself  the 


very  same  changes  to  be  going  on  as  were 
first  described  by  Mr.  Goodsir  in  his  well 
known  paper.  It  may  further  be  remarked, 
that  the  structural  condition  of  the  altered 
synovial  membrane  is  just  that  which  is  best 
adapted  for  the  function  it  may  be  supposed 
to  discharge — viz.  absorbing  into  its  sub¬ 
stance  the  cartilaginous  tissue,  either  im¬ 
mediately  or  after  it  has  been  disintegrated 
by  the  action  of  its  own  cells :  this  appears 
probable,  from  the  circumstance  that  it  is 
not  made  up  of  complete  cells,  but  of 
myriads  of  mere  nuclei,  whose  attractive 
energy  seems  generally  to  be  more  power¬ 
fully  exerted  when  they  do  not  proceed  to 
the  stage  of  cell  development. 

It  is  an  interesting  inquiry,  though  diffi¬ 
cult  to  determine  what  is  the  cause,  which 
induces  the  cartilage  itself  to  take  on  so  re¬ 
markable  an  action,  resulting  in  its  own  de¬ 
struction.  Can  it  be  the  proximity  of  the 
absorbing  synovial  tissue  ?  or  are  the  deve¬ 
lopment  of  this  tissue,  and  the  change  in 
the  cartilage,  but  two  concurrent  results  of 
one  common  cause,  exercising  a  morbid  in¬ 
fluence  on  the  nutrition  of  the  tissues  com¬ 
posing  the  joint  ? 

Mr.  Birkett  exhibited  a  specimen  of 

Imperfect  Hypertrophy  of  the  Mamma. 

E.  R.,  set.  34,  a  married  lady,  without 
children,  of  a  very  nervous  temperament, 
but  general  good  health,  upon  the  19th 
October,  1840,  presented  to  Sir  A.  Cooper 
a  swelling,  the  size  of  a  large  orange,  in  her 
right  breast.  She  had  suffered  occasionally 
from  darting  pains  in  her  left  breast ;  and 
one  day,  after  experiencing  some  uneasiness 
in  the  part,  she  suddenly  felt  soreness  and 
tenderness  on  the  opposite  side.  Upon 
examining  the  right  breast  she  discovered  a 
swelling,  the  size  of  a  pigeon’s  egg,  situated 
upon  the  upper  and  inner  part  of  the  nipple. 
Becoming  alarmed,  and  living  at  Holyhead, 
she  went  to  Dublin,  and  consulted  Messrs. 
Colies  and  Carmichael,  who  both  pronounced 
the  tumor  to  be  constitutional  cancer. 
After  her  return  home,  and  using  the  reme¬ 
dies  suggested  without  any  benefit,  she 
came  to  London  and  consulted  Sir  A. 
Cooper.  The  disease  had  been  gradually 
growing  for  fourteen  months,  and  was  of 
the  size  of  a  large  orange.  The  catamenia 
had  always  been  quite  regular.  She  had 
never  borne  a  child.  During  the  increase 
of  the  swelling,  and  until  its  removal,  it  was 
unattended  with  pain. 

The  tumor  was  removed  on  the  28th 
October,  1840  ;  and  when  minutely  exa¬ 
mined  the  diseased  tissue  was  pronounced 
by  Sir  A.  Cooper  to  be  an  enlargement  of 
several  lobes  of  the  mammary  gland.  In 
its  centre  were  a  number  of  cysts,  contain¬ 
ing  a  transparent  fluid,  and  he  was  of 
opinion  that  it  was  not  malignant,  having 


852 


DISEASE  OF  THE  THYROID  GLAND. 


been,  however,  of  a  contrary  opinion  before 
the  operation.  The  wound  healed  quickly. 

From  October  1840,  until  March  of  this 
present  year,  being  seven  years  and  six 
months,  she  frequently  experienced  an  occa¬ 
sional  pain  in  the  part ;  but  as  she  was  of  a 
nervous  temperament  it  was  always  attributed 
to  some  irritation  of  the  divided  nerves.  At 
the  commencement  of  this  present  year  she 
complained  of  pricking  sensations  in  the  cica¬ 
trix,  with  some  little  hardness,  and  a  change 
of  colour  of  the  part.  The  functions  of  the 
uterus  were  correct.  She  took  the  various 
preparations  of  iron  and  iodine,  and  at  the 
suggestion  of  Sir  B.  Brodie,  Liq.  Potass, 
in  small  beer,  and  at  the  same  time  Ext. 
Conii.  Great  benefit  was  derived  from  this 
last  treatment,  so  much  so  that  the  chronic 
enlargement  of  the  breast  almost  disappeared , 
and  the  patient  thought  herself  cured.  This 
was,  however,  only  temporary,  for  the  breast, 
without  any  apparent  cause,  again  grew 
large. 

On  the  10th  March,  1848,  she  complained 
of  more  pain  in  the  part,  and  from  this  period 
the  disease  rapidly  increased  ;  more  parti¬ 
cularly  after  an  attack  of  urticaria,  which 
was  so  severe  as  to  blind  her  for  twenty- 
four  hours. 

She  came  latterly  under  the  care  of  Mr. 
Key,  when  the  tumor  appeared  moveable, 
uniform  on  the  surface,  pulpy  to  the  feel, 
and  giving  every  appearance  of  an  encysted 
fungoid  tumor.  Owing  to  its  rapid  growth, 
having  increased  in  the  space  of  a  week  to  a 
sixth  of  its  original  volume,  and  the  skin 
over  it  appearing  as  though  it  would  ulce¬ 
rate,  the  tumor  was  removed. 

The  tumor  weighed  one  pound  and  a 
quarter,  was  soft  and  elastic  to  the  touch, 
had  a  portion  of  the  integuments  and  of  the 
pectoral  muscle  adherent  to  it,  and  was  sur¬ 
rounded  by  adipose  tissue.  Upon  the  in¬ 
teguments  were  traces  of  a  cicatrix,  and  of 
the  bites  of  leeches.  There  was  no  evidence 
of  the  disease  having  attacked  the  cutis, 
although  it  was  close  beneath  it.  The  ex¬ 
terior  of  the  tumor  was  deeply  and  minutely 
lobulated,  and  invested  by  a  kind  of  delicate 
fascia  of  fibro-cellular  tissue. 

A  section  was  made  of  it,  and  the  surface 
exhibited  one  uniform  pinkish  tint.  No 
opake  fluid  could  be  expressed,  but  a  glary 
blood-coloured  fluid  might  be  scraped  off. 
The  whole  mass  was  made  up  of  minute 
lobuli  not  larger  than  one- eighth  of  an  inch 
in  diameter,  and  the  lobed  character  of  the 
exterior  did  not  penetrate  the  substance  of 
the  mass. 

Minute  examination. — The  fluid  which 
was  scraped  off  presented  oil  globules  and 
nucleated  bodies,  which  were  of  two  kinds, 
and  both  differing  frum  those  usually  found 
in  carcinoma. 

The  thin  section,  under  the  microscope, 


presented  the  acini  or  terminal  vesicles  of 
gland  tissue,  very  large  and  distended  with 
epithelium.  They  did  not  present  ducts,  and 
were  even  often  isolated.  A  very  imperfectly- 
formed  uniting  tissue  could  be  distinguished 
between  these  acini.  The  epithelium  of  the 
acini  resembled  that  of  mammary  gland. 
The  large  nucleated  bodies  those  that  are 
seen  in  young  tissues  in  the  process  of  deve¬ 
lopment. 

Mr.  Birkett  concluded  that  the  tumor 
consisted  of  imperfectly-developed  gland 
tissue. 

Dr.  Hughes  exhibited  a  specimen  of 

Disease  of  the  Thyroid  Gland,  and  En¬ 
largement  of  the  Internal  Jugular  Vein 

and  Collateral  Branches,  which  during 

life  had  given  rise  to  a  large  cervical 

tumor  of  very  doubtful  character. 

John  W.  presented  himself  among  the 
out-patients  at  Guy’s  Hospital,  March  31st, 
1848,  but  was  so  feeble  and  emaciated  as 
to  require  to  be  taken  in  immediately.  He 
was  a  carpenter,  and  had  recently  been  under 
the  care  of  Dr.  Haycraft,  of  Greenwich,  for 
vomiting,  pain  of  the  stomach,  and  general 
symptoms  of  dyspepsia,  though  he  had  not, 
to  his  own  knowledge,  passed  any  blood  by 
the  bowels  or  otherwise.  He  complained 
of  pain  and  tenderness  in  the  epigastrium, 
in  which  existed  considerable  aortic  pulsa¬ 
tion,  distinguishable  by  both  hand  and  ear. 
The  rhythm  of  the  heart  was  strikingly 
abnormal.  There  existed  a  very  distinct 
and  obvious  triple  sound.  The  third  sound 
occupied  the  interval,  and  the  three  sounds 
were  thus  composed  of  one  long  and  two 
short  sounds.  A  singular  tumor  in  the  neck 
was  observed,  the  very  existence  of  which 
was  unknown  to  the  patient.  A  soft 
roundish  mass,  about  the  shape  and  size  of 
a  Norfolk  biffin,  existed  under  the  right 
sterno-cleido-mastoid,  slightly  moveable, 
and  indistinctly  connected  with  the  larynx, 
but  not  sensibly  affected  by  the  act  of  swal¬ 
lowing,  or  the  movement  of  that  organ. 
Independently  of  this  tumor,  which  was 
constant,  upon  coughing,  or  upon  other 
violent  forced  expiration,  great  lateral  dis¬ 
tension  of  the  right  side  of  the  neck  became 
apparent.  The  temporary  additional  dis¬ 
tension  was  apparently  caused  by  some  fluid, 
and,  as  far  as  could  be  ascertained,  did  not 
afford  any  resonance  on  percussion  ;  while 
the  permanent  tumor  seemed  to  be  partially 
composed  of  solid  materials.  The  tempo¬ 
rary  enlargement  was  very  considerable,  and 
of  an  elongated  form,  and  appeared  to  pass 
in  the  course  of  the  jugular  vein,  but  at  the 
same  time  was  broad  and  flat,  and  occupied 
the  greater  part  of  the  neck  upon  the  affected 
side.  There  existed  a  little  enlargement  of 
the  thyroid,  but  no  venous  distension  was 
apparent  upon  the  left  side.  The  temporary 


MALIGNANT  DISEASE  OF  BOTH  OVARIES. 


853 


swelling  could  he  prevented  by  pressing  the 
finger  firmly  behind  the  clavicle,  but  it  was 
not  materially  influenced  by  pressure  in  the 
upper  pait  of  the  neck.  A  great  variety  of 
opinions  were  given  as  to  the  nature  of  this 
swelling  :  abscess  connected  with  the  cervical 
vertebrae,  a  serous  cyst,  malignant  disease  of 
the  anterior  mediastinum,  hernia  of  the  lung, 
a  permanent  tumor,  with  pressure  upon  the 
brachio-cephalic  vein,  and  enlarged  bronchial 
glands,  were  among  the  number. 

His  tongue  and  his  skin,  excepting  the 
extreme  pallor,  were  not  morbid ;  nor,  ex¬ 
cepting  feebleness,  was  his  pulse.  In  a  few 
days  he  began  to  complain  of  pain  in  swal¬ 
lowing,  and  of  hoarseness,  with  sore  throat ; 
and  soon  after,  his  general  emaciation  led  to 
an  exploration  of  his  chest,  when  it  was 
discovered  that,  in  addition  to  his  other 
ailments,  he  had  decided  tubercular  disease 
of  the  lung.  The  phthisis  assumed  an  acute 
form,  and  he  rapidly  sank.  A  few  days 
before  his  death  the  triple  beat  disappeared. 
His  bowels  became  relaxed,  and  aphthse 
appeared  on  the  tongue  on  the  15th  June, 
and  he  died  on  June  24th. 

Inspection  five  hours  after  death. — The 
diaphragm  extended  up  to  the  fifth  rib. 
Bosh  pleurae  were  adherent,  and  both  lungs 
abundantly  disseminated  with  tubercles,  ac¬ 
companied  with  old,  grey,  and  recent  red 
pneumonic  consolidation.  The  pericardium 
was  slightly  adherent  by  a  very  delicate 
membrane  to  the  pleura  of  the  left  lung, 
and  internally  a  delicate  web  of  fibrine  con¬ 
nected  the  aorta  with  the  superior  cava. 
The  right  auricle  now  opened  was  found  to 
contain  a  colourless  clot,  extending  far  into 
the  large  veins.  A  tube  was  now'  introduced, 
and  by  inflation  the  jugular  vein  was  dis¬ 
tended  to  a  size  considerably  larger  than  an 
adult  thumb,  and  the  lateral  branches  to  a 
proportionable  extent,  displaying  the  cause 
of  the  temporary  tumor,  which  was,  pro¬ 
bably,  itself  induced  by  the  enlargement  of 
several  enlarged  bronchial  glands  in  the 
vicinity  of  the  great  vessels.  The  thyroid 
gland  was  generally  enlarged,  but  on  the 
right  side  formed  a  process  with  a  narrow 
neck,  of  the  size  and  shape  of  a  dried  pear, 
which  contained  a  little  serous  fluid  in  an 
irregular  cavity,  with  a  brilliantly-lustrous 
lining,  like  the  belly  of  a  mackerel.  The 
tricuspid,  pulmonary,  and  aortic  valves 
were  healthy  ;  the  mitral  was  thick,  opaque, 
and  corrugated  at  the  edges,  but  quite  flexi¬ 
ble,  and  probably  efficient  as  a  valve.  A 
patch  of  white  deposit,  the  result  of  an  old 
inflammatory  process,  existed  on  the  endo¬ 
cardium  below  the  valve,  and  the  aorta  con¬ 
tained  a  few  atheromatous  patches.  The 
stomach  was  small  and  natural.  At  the 
low'er  part  of  the  jejunum  was  an  old  ulcer, 
nearly  an  inch  long,  but  evidently  in  the 
process  of  healing.  No  other  disease  was 


noticed  in  the  intestines.  The  liver  was 
rather  large,  and  somewhat  oedematous  ;  the 
kidneys  were  not  unhealthy.  Mr.  Birkett 
had  examined  the  substance  lining  the  cyst 
of  the  thyroid,  and  had  found  it  composed  of 
a  densely- packed  layer  of  cholesterine. 

Dr.  Johnson  exhibited,  for  Mr.  H. 
Smith,  a  specimen  of 

Malignant  Disease  of  loth  Ovaries. 

A  female,  aged  40,  had  suffered  for  the 
last  four  months  from  constant  vomiting 
whenever  she  took  food  of  any  description 
except  diluents.  She  complained  also  of 
great  pain  in  the  region  of  the  epigastrium 
and  abdomen,  which  prevented  her  from  as¬ 
suming  the  recumbent  posture.  Latterly 
ascites  came  on,  and  she  rapidly  wasted 
aw'ay,  and  died  six  months  after  her  illness 
first  commenced. 

On  post-mortem  examination,  the  abdo¬ 
men  was  found  quite  full  of  fluid.  On  dis¬ 
charging  this,  the  great  omentum  was  dis¬ 
covered  to  be  changed  into  a  mass  of  disease, 
composed  of  cancerous  tumors  about  the 
size  of  a  nut.  The  interior  of  the  stomach 
was  quite  healthy.  The  peritoneum  cover¬ 
ing  the  diaphragm  and  the  large  and  small 
intestines  was  studded  with  small  cancerous 
tumors.  The  uterus  was  perfectly  healthy, 
and  of  the  normal  size ;  but  in  place  of 
the  ovaries  there  was  on  each  side  a  rounded 
mass  about  the  size  of  an  orange,  consisting 
of  the  same  structure  as  the  tumors  ob¬ 
served  in  the  omentum. 

The  case  was  interesting,  inasmuch  as  the 
constant  vomiting  immediately  after  eating 
had  led  to  the  diagnosis  of  the  extensive 
disease  of  the  cardiac  orifice  of  the  stomach. 

Dr.  Brinton  exhibited  a 

Tumor  of  the  Fifth  Nerve  in  a  Lamb 
aged  about  Six  Months. 

The  specimen  had  been  forwarded  to  him 
by  Mr.  Lawson. 

The  only  symptoms  which  the  farm- 
servant  could  afford  were,  that  the  animal 
frequently  turned  or  “  spun’'  round  towards 
the  right  side;  and,  after  falling  on  this 
side,  could  not  raise  itself.  It  did  not 
appear  to  suffer  any  pain.  Gradually,  how¬ 
ever,  marasmus  came  on ;  and,  after  pro¬ 
ceeding  for  some  time,  the  disease  was  cured 
by  the  animal  being  killed. 

The  origin  of  the  fifth  nerve  on  the  right 
side  was  occupied  by  a  tumor  dilating  the 
pons  Varolii,  and  in  three  or  four  places 
reaching  the  surface,  and  forming  small, 
round,  and  apparently  isolated  tumors,  of 
about  the  size  of  a  millet  seed  or  barleycorn. 
The  fibres  of  the  nerve  were  stretched  oyer 
the  tumor  ;  others  mingled  with  its  struc¬ 
ture.  Both  portions  of  the  nerve  appeared 
to  be  involved,  but  perhaps  the  motor  part 
chiefly.  The  tumors,  where  they  projected 


854 


MR.  BAKER  ON  THE  USE  OF  EMETICS  IN  CHOLERA. 


from  the  surface,  had  a  glistening  white  ap¬ 
pearance,  and  their  texture  was  firm,  and 
almost  cartilaginous ;  nevertheless,  the  mi¬ 
croscope  shewed  them  to  be  composed  of 
fat-cells,  with  a  few  nerve-tubules  in  the 
interstices  of  the  adipose  masses,  and  a  very- 
small  quantity  of  fibrous  tissue. 

Dr.  Ogier  Ward  read  the  following 
particulars  of 

Impaction  of  a  Halfpenny  in  the  Pharynx 
for  Eight  Months. 

A  boy,  set.  1  year  and  8  months,  came 
under  Dr.  Ward’s  care,  June  23d,  when  his 
breathing  was  so  loud  and  stridulous  that  it 
resounded  through  the  hall  in  which  he  was 
waiting.  As  soon  as  he  saw  him ,  the  child  be¬ 
gan  to  cry  so  convulsively,  and  was  seized  with 
such  violent  coughing,  that  a  close  examina¬ 
tion  of  his  throat  was  impossible.  He  was 
pale  and  emaciated,  and  seemed  decidedly 
phthisical.  The  glands  of  the  neck  were 
somewhat  enlarged,  and  the  chest  sounded 
well  on  percussion.  His  mother  observed 
that  he  was  quite  well  and  hearty  till 
March  3d,  when  she  supposed  he  swallowed 
a  halfpenny  with  which  he  was  playing,  as 
he  began  to  choke  immediately,  and  the 
coin  could  not  be  found  afterwards,  and 
from  that  moment  his  breath  had  become 
stridulous.  She  was  then  in  Coventry  bar¬ 
racks,  and  she  took  him  to  the  regimental 
surgeon,  who,  thinking  it  an  attack  of  irri¬ 
tation  from  teething,  merely  gave  him  some 
castor  oil.  At  this  time,  besides  the  dysp¬ 
noea,  he  was  constantly  dribbling  a  thick 
mucus,  and  he  could  only  suck  one  mouth¬ 
ful  of  milk  at  a  time,  being  forced  to  with¬ 
draw  from  the  breast  with  each  effort  of 
swallowing.  The  mucus  was  so  profuse  as 
almost  to  choke  him  ;  and  these  symptoms, 
with  an  increasing  cough,  continued  for 
three  months,  till  a  short  time  before  he 
came  under  Dr.  Ward’s  care,  when  the 
dribbling  had  almost  ceased.  The  mother 
next  took  him  to  the  Coventry  Hospital, 
where  the  case  was  again  considered  to  be 
laryngismus  from  teething,  and  was  treated 
accordingly.  Dr.  Ward  concluded  that  the 
bronchial  glands  were  affected  with  tuber¬ 
culosis,  as  well  as  those  of  the  neck,  and, 
pressing  on  the  recurrent  nerves,  were 
causing  the  stridulous  breathing.  He  there¬ 
fore  prescribed  an  iodine  liniment,  and  the 
syrup  of  iodide  of  iron.  Under  this  treat¬ 
ment  the  child  rapidly  improved,  with  occa¬ 
sional  relapses,  and  thus  seemed  to  confirm 
his  diagnosis,  when,  on  Oct.  25th,  his  mother 
brought  him,  looking  comparatively  well, 
and  produced  the  halfpenny,  which,  she 
said,  he  had  taken  out  of  his  mouth  and  put 
into  his  father’s  hand,  after  a  severe  fit  of 
coughing,  the  day  before.  There  is  now, 
however,  considerable  hoarseness  when  he 
cries  or  coughs,  the  latter  symptom  not 


having  ceased  with  the  removal  of  the  cause’ 
The  halfpenny  was  very  much  worn  or  cor¬ 
roded,  and  covered  with  a  thick  coating  of 
dried  mucus  or  masticated  food.  — - 

From  this  time  the  patient  has  gradually 
improved,  and  may  now  be  considered  con¬ 
valescent. 

Dr.  Ward  also  related  another  case  in 
which  a  halfpenny  had  been  impacted  three 
days,  and  in  which  the  symptoms  were 
similar,  particularly  "the  dribbling  |of  the 
saliva  and  mucus. 

The  meeting  adjourned  to  Monday,  Nov. 
20,  1848. 


MEDICAL  SOCIETY  OF  LONDON. 

Monday,  November  6,  1848. 

Mr.  Hancock,  President. 

Emetics  in  cholera. 

Mr.  T.  E.  Baker  (Bengal  Establish¬ 
ment)  said — It  is  now  thirty  years  since  I 
first  saw  the  disorder.  The  treatment  then 
strongly  recommended  was,  scruple  doses  of 
calomel,  with  half  a  drachm  or  a  drachm  of 
laudanum ,  in  peppermint  water.  This  treat¬ 
ment  was  often  successful  when  the  disease 
had  assumed  a  milder  form,  but  was  very  far 
from  succeeding  when  it  first  broke  out,  and 
the  patients  would  die  in  the  course  of  two, 
three,  or  four  hours.  We  were  not  confident 
in  any  mode  of  treatment,  but  I  think  the 
most  successful  was  an  emetic  in  the  first  in¬ 
stance,  which  induced  full  vomiting,  quite 
different  from  the  spasmodic  action  caused 
by  the  disorder  ;  afterwards,  five-grain  doses 
of  antimony,  with  or  without  calomel ;  bleed¬ 
ing  ;  mild  purgatives ;  flannel  rollers  to  the 
extremities  ;  lemonade,  tea,  plain  water,  or 
soda-water.  Full  vomiting  by  emetics  will 
often  excite  reaction,  which  seems  the  chief 
indication  in  our  treatment.  Bleeding  di¬ 
minishes  the  blood  in  the  veins,  and  we  find 
the  venae  cavae  gorged  with  blood  ;  the  heart 
beats  quick,  weak,  and  indistinct ;  the  breath 
is  quite  cold,  for  the  blood  does  not  circulate 
in  the  lungs.  The  tight  flannel  rollers  re¬ 
lieve  the  painful  spasms ;  they  do  not  stop 
the  circulation  in  the  arteries,  but  may  retard 
the  flow  of  blood  to  the  venae  cavae,  which 
we  always  find  gorged.  I  much  question  the 
use  of  stimulants  at  any  period  of  the  dis¬ 
order,  though  I  have  seldom  seen  marks  of 
inflammation  in  the  stomach  where  they  have 
been  given.  There  are  often  ecchymoses  near 
the  pylorus,  which  I  considered  to  be  the 
effect  of  spasmodic  vomiting.  We  find  the 
duodenum  red  and  inflamed,  and  the  inflam¬ 
mation  appears  to  extend  in  proportion  to 
the  duration  of  the  disease.  The  disorder 
appears  to  be  the  highest  stage  of  congestive 
fever,  and  if  we  can  succeed  in  making  the 
blood  circulate  through  the  lungs,  and  con- 


EMETICS  IN  CHOLERA.  MR.  BROWN  ON  SCARLATINA. 


855 


sequently  through  the  whole  system,  we  have 
found  a  remedy  for  the  disease.  Though 
there  are  some  symptoms  similar  to  the  cold 
stage  of  an  ague,  I  do  not  remember  to  have 
noticed  any  tremor  or  shivering.  In  18 1 7,  a 
medical  friend  of  mine  (Mr.  Curling)  found 
bleeding  to  be  very  beneficial,  but  in  1828, 
Dr.  Mouat,  Surgeon,  Her  Majesty's  14th 
regiment,  found  it  injurious,  or  at  least  of 
doubtful  benefit.  He  also  stated  that  some 
severe  cases  of  cholera  occurred  in  a  native 
regiment,  in  which  eleven  men  died  out  of 
the  twelve  attacked.  In  these  cases,  there 
was  purging  without  any  vomiting,  and  to 
the  best  of  his  recollection  (the  patients  not 
being  under  his  care)  there  was  a  total  ab¬ 
sence  of  spasm. 

Mr.  Hird  considered  that  emetics  were 
useful  in  bring  on  reaction.  He  referred  to 
the  plan  of  treating  the  disease  by  calomel 
and  opium,  as  extensively  tried  in  1832. 
That  plan  had  been  found  wanting.  The 
experience  of  Dr.  Graves  confirmed  this. 
He  (Mr.  Hird)  had  found  no  benefit  from 
large  doses  of  calomel  or  opium.  The  ace¬ 
tate  of  lead  appeared  to  him  to  have  the 
most  effect  in  stopping  the  profuse  alvine 
discharge.  This  medicine  was  given  in 
doses  of  two  grains  with  an  eighth  to  a 
twentieth  of  a  grain  of  opium  every  half 
hour,  according  to  the  severity  of  the  symp¬ 
toms.  He  should  be  fearful  of  giving  the 
vapour  of  chloroform  in  cholera.  The  pa¬ 
tient  was  already  nearly  asphyxiated,  and 
this  process  would  increase  that  condition. 

Dr.  Clutterbuck  considered  that  we 
knew  little  or  nothing  of  the  pathology  of 
cholera.  He  was  convinced  of  the  utility  of 
the  chloroform,  which  was  uniformly  of  ser¬ 
vice. 

Dr.  Gavin  Milroy  entered  at  some 
length  into  his  views  with  respect  to  the 
value  of  emetics  in  cholera.  He  regarded 
this  disease  as  consisting  essentially  of  con¬ 
gestion  in  the  viscera.  Vomiting,  when 
produced  by  medicine — in  contra-distinction 
to  that  emptying  of  the  stomach  by  pump¬ 
ing  on  its  contents,  which  obtained  in  cho¬ 
lera — had  a  tendency  to  remove  this  conges¬ 
tion.  This,  with  the  application  of  strong 
stimulants  to  the  stomach  extensively,  was 
a  most  successful  plan  of  treatment.  Opium, 
he  thought,  had  done  harm. 

Dr.  Bennett  inquired  if,  in  the  case 
treated  by  chloroform,  any  secondary  fever 
had  followed.  He  related  a  case  which  had 
occurred  in  St.  Thomas’s  Hospital,  in  which 
the  patient  died  from  secondary  fever. 

Dr.  Clutterbuck  said  that  in  all  cases 
which  had  recovered,  secondary  fever  oc¬ 
curred. 

Mr.  Dendy  reiterated  his  opinions  re¬ 
specting  the  diseased  condition  of  the  blood 
in  cholera. 

Mr.  Headland  made  some  observations 


on  the  directions  respecting  cholera  which 
had  been  promulgated  by  the  Board  of 
Health.  He  regarded  these  as  reflecting 
highly  on  the  medical  profession.  He 
thought  we  should  do  more  good  by  treating 
this  disease  on  some  recognised  principle, 
than  by  looking  merely  at  the  symptoms. 
Some  of  these  symptoms,  as,  for  instance, 
vomiting,  was  but  an  effort  of  Nature  to  get 
rid  of  the  poison.  Opium  he  regarded  as 
generally  useless  or  injurious.  Calomel,  in 
small  and  often-repeated  doses,  and  emetics, 
with  attention  to  the  surface  of  the  body, 
he  regarded  as  the  best  plan  of  treatment. 

WESTMINSTER  MEDICAL 
SOCIETY. 

November  4,  1848. 

J.  Webster,  M.D.,  F.R.S.,  President. 

Mr.  I.  B.  Brown  read  a  paper  on 
Scarlatina. 

He  considers  that  this  disease  is  not  a 
plethoric  inflammatory  affection,  but  is  one 
of  an  asthenic  form  of  inflammation,  belong¬ 
ing  to  that  class  produced  by  the  wonderful 
action  of  morbid  poison  upon  the  system ; 
that  any  cases  not  of  this  nature  are  excep¬ 
tions  to  the  general  rule ;  that  the  disease  is 
one  of  low  type,  requiring  the  early  admini¬ 
stration  of  stimulants  and  nutriment.  Mr. 
Brown  applied,  at  the  commencement, 
caustic  to  the  tonsils  and  fauces,  gave  calo¬ 
mel  and  castor  oil,  and  followed  them  up  by 
dilute  acetic  acid,  being  convinced  that  this 
acid  acts  as  a  powerful  stimulant  by  the  kid¬ 
neys  and  skin,  so  as  to  excite  them  to  their 
proper  functions.  He  was  not  prepared  at 
present  to  state  fully  the  peculiar  state  of  the 
blood  and  of  the  urine  under  the  influence  of 
this  acid,  but  he  trusted  shortly  to  lay  the 
result  of  some  careful  analyses  before  the 
Society.  He  believed  that  death  was  caused 
either  from  depression  of  the  nervous  sys¬ 
tem,  from  disease  of  the  throat,  or  from  the 
rtinoculation  of  the  virus  into  the  system  by 
the  external  air  passing  into  the  lungs,  over 
the  viscid  secretion  of  the  tonsils  and  fauces, 
carrying  into  the  blood  the  poison,  and  thus 
preventing  any  chance  of  the  disease  being 
eliminated.  Mr.  Brown  than  alluded  to 
dropsy,  which  he  had  never  seen  follow  the 
plan  of  treatment  he  advocated.  In  re¬ 
ference  to  this  subject,  Mr.  Brown  laid 
great  stress  on  the  importance  of  keeping 
the  patient  in  bed  during  the  stage  of  des¬ 
quamation  ;  he  dwelt  on  the  necessity  of  a 
careful  inspection  of  the  quantity  and  quality 
of  the  urine,  and  mentioned  his  preference 
for  the  microscope,  in  the  examination  of  it, 
to  chemical  processes.  He  related  two  cases 
of  very  severe  malignant  disease  successfully 
treated.  Mr.  Brown  thought  that  the  action 


856 


ON  SCARLATINA.  DEATH  FROM  A  PISTOL-SHOT. 


of  the  acetic  acid  was  that  of  a  specific 
stimulant  to  the  cutaneous  vessels ,  for  as 
alcohol,  ether,  chloroform,  and  all  other 
compounds  allied  to  acetic  acid  in  their 
chemical  constitution,  had  peculiar  and 
marked  influence  on  the  nervous  system,  he 
did  not  see  why  acetic  acid  might  not  have 
its  peculiar  influence  on  some  parts  of  the 
organism. 

Mr.  Hird  could  not  regard  all  the  good 
effects  in  the  cases  alluded  to  as  due  to  the 
acetic  acid.  Scarlet  fever  was  sometimes 
so  mild  that  it  would  get  well  without  any 
treatment,  whilst  in  other  cases  it  killed 
before  any  medicine  could  exert  its  influence. 
He  thought  we  should  be  safe  in  treating 
the  disease  on  general  grinciples. 

Dr.  Snow  considered  that  the  kidney  was 
liable,  as  well  as  the  skin  and  tonsils,  to 
partake  of  the  primary  affection  of  scarlet 
fever,  and  this  was  apt  to  be  followed  by 
secondary  effects  at  the  end  of  two  or  three 
weeks,  probably  analogous  to  the  desqua¬ 
mation  of  the  cuticle,  which  led  to  conges¬ 
tion  of  its  vessels,  and  obstruction  to  its 
secreting  functions.  This  diseased  state  of 
the  kidneys  caused  dropsy,  and  often  inflam¬ 
mation  of  the  serous  membranes,  and  some¬ 
times  renal  convulsions.  Dropsy,  if  con¬ 
fined  to  the  cellular  tissue,  or  to  this  and 
the  peritonaeum,  was  not  so  serious  as  the 
other  results  of  the  renal  affection,  and  was 
amenable  to  treatment.  He  had  seen  no 
case  of  dropsy  after  scarlet  fever,  except 
where  there  was  evidence  of  interrupted 
function  of  the  kidney,  and  the  renal  affec¬ 
tion  preceded  the  anasarca.  It  was  then 
only  seventeen  days  since  the  commence¬ 
ment  of  one  of  the  cases  Mr.  Brown  had 
related,  and  the  most  frequent  time  for  the 
appearance  of  dropsy  was  about  twenty-one 
days  from  the  beginning  of  the  fever  ;  there¬ 
fore  it  yet  remained  to  be  seen  whether  this 
patient  was  out  of  danger,  and  Mr.  Brown 
might  have  dismissed  other  cases  who  might 
subsequently  have  had  renal  affections. 

Dr.  Rogers  had  used  the  acetic  acid, 
freely  and  fully  combined  with  bark,  in  a 
family  of  eleven,  all  affected  with  scarlet 
fever.  Three  of  these  suffered  from  dropsy 
afterwards. 

Dr.  Willshire  said  that  the  present 
epidemic  on  the  Surrey  side  of  the  water  did 
not  in  general  at  all  approach  to  the  malig¬ 
nant  form  of  the  disease,  and  was  followed 
almost  certainly  by  some  form  of  dropsy.  It 
appeared  sometimes  without  eruption,  some¬ 
times  without  sore-throat,  and  in  sixteen  or 
twenty  cases  under  his  care,  neither  eruption 
nor  sore  throat  presented  themselves,  yet 
dropsy  followed.  The  present  epidemic  was 
peculiarly  disposed  to  be  followed  by  rheu- 
matoidal  affections.  He  had  never  used  the 
acetic  acid,  but  had  found  the  chlorate  of 
potash  of  most  service. 


Dr.  Ogier  Ward  referred  to  the  disease 
as  epidemic  in  Kensington  and  Fulham.  He 
traced  its  prevalence  to  bad  drainage.  On 
improving  this,  the  disease  was  mitigated, 
and  then  disappeared. 

Dr.  Lankester  did  not  think  that  the 
acetic  acid  in  Mr.  Brown’s  case  had  had 
much  efficacy  in  curing  the  disease.  It 
must  not  be  forgotten  that  scarlet  fever  was 
a  malady  that  would  frequently  terminate 
favourably  without  any  treatment  at  all. 
Sometimes  he  believed  the  worst  symptoms 
which  presented  themselves  were  caused  by 
the  treatment ;  for  his  own  part  he  did  not 
feel  justified  in  trying  the  acetic  acid,  for  he 
could  not  understand  upon  what  principle  it 
could  effect  benefit.  Hydrochloric  acid  and 
chlorate  of  potash  he  had  found  most  bene¬ 
ficial,  and  when  in  a  low  state,  ammonia. 

The  discussion  was  adjourned. 

In  the  course  of  the  evening  Dr.  Will¬ 
shire  exhibited  a  handkerchief  belonging  to 
a  phthisical  patient,  which  was  full  of  holes. 
He  had  noticed  this  in  two  or  three  other 
cases,  and  could  not  explain  the  reason. 
Many  causes  had  been  suggested,  such  as 
the  tenacity  of  the  dried  sputa  tearing  the 
linen  when  it  was  washed,  the  use  of  mineral 
acids  in  the  medicine,  &c.  ;  but  none  of 
these  seemed  to  answer  in  the  cases  to 
which  he  referred. 

Dr.  Lankester  said  the  holes  resembled 
those  which  he  had  seen  produced  by  fungi 
on  linen. 

Mr.  Brown  had  noticed  the  same  effect 
in  a  case  of  phthisis  under  his  own  care, 

Mr.  Marshall  recollected  a  paper  which 
was  inserted  some  years  since  in  the  Edin¬ 
burgh  Medical  and  Surgical  Journal,  in 
which  it  was  stated  that  the  napkins  of  a 
child  went  into  holes  in  consequence  of  its 
mother  having  taken  diluted  sulphuric  acid 
in  her  medicine. 

Death  from  a  pistol-shot. 

Mr.  Wade  related  the  case  of  a  man  who 
placed  a  pistol  loaded  only  with  powder  into 
his  mouth,  and  discharged  it.  The  clieeks 
were  literally  torn  into  ribbons,  and  the 
lower  jaw  was  fractured  ;  the  mucous  mem¬ 
brane  of  the  mouth  wras  black.  Proper  ap¬ 
plications  were  made  to  the  parts  ;  he  ap¬ 
peared  to  be  doing  well  for  a  day  or  two, 
but  died  suddenly,  as  Mr.  Wade  believes, 
from  spasm  of  the  glottis,  consequent  upon 
removal  to  a  hospital. 

Saturday,  November  II,  1848. 

Mr.  Hird,  President. 

Case  of  Albuminuria — The  Urine  of  very 

low  specific  gravity,  without  Dropsy — 

Ulceration  of  the  Gall  Bladder. 

The  patient  was  a  female,  aged  38,  who 
had  been  subject,  for  many  years,  to  disorder 


CASE  OF  ALBUMINURIA. 


of  the  digestive  organs.  In  March  last,  she 
suffered  very  severely  from  headache  and  sick¬ 
ness,  but  her  health  improved  greatly  during  a 
subsequent  residence  in  the  country.  Early 
in  September,  soon  after  her  return  to  Lon¬ 
don,  she  was  seized  with  a  violent  attack  of 
epistaxis,  which  was  with  difficulty  con¬ 
trolled,  and  from  which  she  never  fairly 
rallied.  I  saw  her  first  on  October  3d,  and 
found  her  very  pale,  greatly  emaciated,  and 
suffering  from  obstinate  vomiting,  and  ex¬ 
treme  tenderness  in  the  left  hypochondriac 
region.  The  urine  was  pale,  clear,  and  acid  ; 
it  deposited  an  abundance  of  albumen  on  the 
application  of  heat,  and  was  of  specific  gra¬ 
vity  1008.  The  vomiting  and  tenderness 
were  soon  relieved,  but  a  convulsive  attack 
took  place  shortly  afterwards  ;  the  sensorium 
became,  affected  ;  the  countenance  assumed 
a  peculiarly  wild  and  anxious  look,  though, 
on  the  attention  being  roused,  she  was  able 
to  understand  and  answer  questions.  About 
ten  days  before  death,  the  conjunctive  of 
both  eyes  became  injected  with  blood  ;  there 
was  a  return  of  epistaxis,  pale  coloured 
blood  continuing  to  ooze  from  the  nose  for 
some  hours  ;  and  there  was  beematemesis. 
The  convulsions  recurred  at  frequent  inter¬ 
vals,  and  after  lingering  for  a  longer  period 
than  I  ever  remember  to  have  seen  a  patient 
do,  under  similar  circumstances,  death,  pre¬ 
ceded  by  coma,  took  place  on  October  ‘29th. 
The  urine  was  usually  not  deficient  in  quan¬ 
tity,  though,  on  two  or  three  occasions,  none 
was  voided  for  nearly  twenty  hours  ;  it  be¬ 
came  neutral,  or  even  alkaline,  but  conti¬ 
nued  to  deposit  albumen  on  the  addition  of 
nitric  acid  ;  and  the  last  time  I  examined 
the  specific  gravity,  about  a  fortnight  before 
death,  it  had  fallen  to  1005.  On  examina¬ 
tion  after  death,  the  kidneys  were  found  to 
be  smaller  than  natural,  pale,  and  flabby  ; 
the  left  was  smaller  than  the  right.  The 
emulgent  artery,  where  it  enters  the  kidney, 
was  of  cartilaginous  hardness,  and  the  vein 
was  partially  blocked  up  by  a  firm  mass  of 
fibrine.  The  divided  arteries  of  the  mesen¬ 
tery  were  rigid  and  gaping.  The  liver  ap¬ 
peared  natural  in  structure.  The  gall-bladder 
was  of  a  deep  purple  hue,  and  firm  and  flesh¬ 
like  to  the  touch ;  on  slitting  it  open,  it  was 
found  to  be  filled  with  a  firm  coagulum  of 
blood,  partially  adherent,  the  source  of  which 
was  extensive  ulceration  of  the  mucous 
membrane  of  the  fundus  and  body  of  the 
organ.  The  other  viscera  of  the  abdomen 
presented  no  unnatural  appearance,  and  un¬ 
fortunately  time  did  not  permit  me  to  exa¬ 
mine  tho;  e  of  the  chest  and  the  brain.  On 
reviewing  the  case,  there  could,  he  thought, 
be  no  doubt  that  the  disease  of  the  kidneys 
was  of  long  standing.  Whether  it  was  oc¬ 
casioned  by  the  condition  which  appeared  to 
prevail  in  the  arterial  system,  or  whether 
both  were  the  common  result  of  faulty  nu¬ 


PLACENTA  PR.® VTA.  857 


trition,  it  is  not  easy  to  decide ;  but  to  my 
mind  the  latter  is  the  most  probable  expla¬ 
nation.  The  haemorrhagic  tendency  which 
prevailed  during  the  last  two  months  of  the 
patient’s  life  is  very  remarkable. 

Placenta  Prcevia. 

Mr.  Dunn  related  a  case  of  placenta 
praevia,  in  which  haemorrhage  prevailed  for 
some  time,  but  was  arrested  by  plugging 
the  vagina  with  a  sponge  dipped  in  vinegar. 
The  child  was  delivered  by  turning.  It 
was  to  the  condition  of  the  placenta,  which 
he  now  exhib  ted,  that  Mr  Dunn  wished  to 
direct  the  attention  of  the  Society.  The 
contrast  between  the  detached  and  the  un¬ 
detached  portions  was  most  striking.  While 
the  latter  was  blanched,  and  more  pale  than 
natural,  the  former  would  be  seen  to  be 
gorged  with  blood.  The  source  of  the  hae¬ 
morrhage,  in  such  cases,  was  the  great  point 
of  practical  importance.  In  reference  to 
this  point  he  brought  the  placenta  for  in¬ 
spection. 

The  adjourned  discussion  on  scarlatina 
was  resumed.  The  speakers  were,  Mr. 
Clarke,  Mr.  Wing,  Mr.  Wade,  Mr.  Hard¬ 
ing,  Dr.  Webster,  and  Dr.  A.  T.  Thomson. 
The  speakers,  without  exception,  spoke  of 
the  fallacy  of  attributing  to  a  medicine  like 
acetic  acid  any  peculiar  property  in  curing 
scarlet  fever.  The  disease  was  one  assum¬ 
ing,  under  various  circumstances,  and  in 
the  various  epidemics,  characters  so  different, 
that  at  one  time  they  w7ere  totally  opposed 
to  those  at  another.  The  disease,  to  be 
treated  successfully,  must  be  handled  on  the 
known  principles  of  pathology  and  physi¬ 
ology.  To  seek  for  a  particular  remedy 
under  such  circumstances,  as  applicable  in 
all  cases,  was  to  seek  for  that  which  did  not 
exist.  No  one  speaker  could  believe  that 
the  acetic  acid  had  rendered  any  peculiar 
service  in  any  of  the  cases,  but  all  regarded 
it  as  an  adjunct  to  more  suitable  medicines, 
at  best,,  but  of  doubtful  utility. 

At  the  next  meeting,  Dr.  Garrod  will 
read  a  paper  on  some  points  connected  with 
gout  and  phthisis  pulmonalis. 


PARIS  ACADEMY  OF  SCIENCES. 

Sitting  of  November  6,  1848. 

MM.  Andral,  Flourens,  and  Velpeau 
made  a  report  on  two  communications  which 
had  been  presented  on  the  same  subject :  the 
one  by  M.  Miguel,  of  Amboise,  the  other  by 
M.  Stein,  of  the  Hague,  on  a  method  of  plug¬ 
ging  ( tamponnement )  the  genital  passages 
in  the  case  of  uterine  haemorrhage  in  preg¬ 
nant  females.  The  first  was  ordered  to  be 
inserted  in  the  Recueil  des  Savants  etr an¬ 
gers. 

X 


858 


PLAN  FOR  THE  REGISTRATION  OF  CASES  OF  CHOLERA. 


M.  Fourcault  read  a  paper  on  the  pro¬ 
gress  of  the  cholera. 

M.  Dumas  exhibited  a  simple  and  con¬ 
venient  apparatus,  constructed  by  M.  Blan- 
qui,  for  liquefying  the  gaseous  protoxide  of 
nitrogen. 

M.  E.  BECQUERELcommunicated,  through 
M.  Biot,  his  further  researches  on  the 
method  of  taking  a  photographic  impres¬ 
sion  of  the  spectrum,  with  its  colours. 
Last  February,  M.  Becquerel  announced 
this  discovery  to  the  Academy,  which  he 
accomplished  by  means  of  a  layer  of  sub¬ 
chloride  of  silver  formed  on  a  silvered 
copper  plate  by  the  action  of  chlorine. 
Subsequently,  M.  Becquerel  found  that  im¬ 
mersion  of  the  plate  in  solutions  of  the  chlo¬ 
rides  of  iron,  copper,  &c.,  and  of  the  hypo¬ 
chlorites  of  soda,  lime,  &c.,  produced  the 
same  result :  he  now  finds  that  still  better 
results  are  obtained  by  placing  the  metallic 
plate  in  connection  with  the  positive  end  of 
a  voltaic  battery,  and  immersed  in  water 
acidulated  with  hydrochloric  acid,  so  that 
the  chlorine  disengaged  may,  in  its  nascent 
state,  act  upon  the  entire  surface  of  the 
plate.  At  present  the  paintings  by  nature 
thus  obtained  can  only  be  kept  in  the  dark  : 
exposure  to  light  produces  instant  decompo¬ 
sition  of  the  chloride  of  silver,  and  the 
colours  disappear. 

The  permanency  of  the  colours  produced 
still  remains  therefore  a  desideratum  in  the 
science  of  photography. 


(£om&ponUence. 


PLAN  FOR  THE  REGISTRATION  OF  CASES 
OF  CHOLERA. 

Sir, — I  forward  for  publication  in  the 
London  Medical  Gazette,  the  Plan  for 
Uniformly  Reporting  Cases  of  Cholera, 
drawn  up  by  the  Committee  of  the  Western 
Medical  and  Surgical  Society  appointed  to 
carry  out  the  Society’s  Resolutions  of  the 
13th  instant.  It  is  intended  that,  in  the 
course  of  this,  or  early  in  next  week,  copies 
of  this  plan  shall  be  in  the  hands  of  every 
practitioner  in  the  district  to  which  the 
Society  intends  to  limit  its  operations.  It 
is  known  that  a  great  number — it  is  hoped 
and  believed  that  all — to  whom  the  forms 
are  distributed  will  take  the  trouble  of  filling 
them  up  with  the  details  of  any  case  which 
may  occur,  and  of  returning  them  to  the 
Society.  It  will  be  the  business  of  the 
Committee  hereafter  to  tabulate  and  analyse 
the  returns  thus  obtained,  and  to  make 
public  the  results. 

Of  the  merits  of  the  plan  itself  for  elicit¬ 
ing  the  information  required,  it  would  not 


become  its  authors  to  speak.  I  can  only 
say,  on  their  behalf,  that  it  has  been  drawn 
up  and  revised  with  the  greatest  deliberation, 
and  with  an  anxious  desire  to  omit  nothing 
important,  nor  to  introduce  anything  which 
might  complicate  the  appearance  of  the 
table,  or  give  unnecessary  trouble  to  the 
observer.  Yet  the  Committee  are  deeply 
sensible  that  it  is  but  an  imperfect  perfor¬ 
mance;  and  while  they  claim  for  it  the 
indulgence  due  to  a  first  attempt  (for  they 
can  find  no  record  of  any  attempt  to  carry 
out  an  inquiry  in  detail  in  the  manner  pro¬ 
posed,  either  in  any  department  of  the 
public  service,  or  in  the  proceedings  of  any 
society),  they  anxiously  look  for  sugges¬ 
tions  from  the  profession  which  may  enable 
them  to  render  it  more  complete,  and  more 
fit  for  its  purpose. 

Besides  an  accurate  report  of  cases  of 
cholera,  it  is  felt  by  the  Committee  to  be 
highly  necessary  to  obtain  information  as  to 
the  nature  and  peculiarities  of  the  diseases 
now,  and  for  some  time  past,  prevalent  in 
the  district — information  which  may  throw 
light  on  what  is  termed  the  “  epidemic  con¬ 
stitution  ”  of  the  period  ;  and  especially  to 
have  some  return  of  cases  of  severe  diar¬ 
rhoea,  and  other  disorders,  always  more  or 
less  prevalent  during  an  epidemic  of  cholera, 
and  which  may  fairly  be  regarded  as  mani¬ 
festations  of  the  peculiar  virus  short  of  its 
full  effect,  the  perfect  development  of  the 
disease.  To  arrive  at  this,  and  also  at  in¬ 
formation  on  various  points  respecting 
cholera  itself,  to  which  it  is  difficult  to  call 
attention  in  a  table,  a  circular  letter  will 
be  drawn  up,  and  will  follow,  as  early  as 
possible,  the  distribution  of  the  forms. 

I  trust  that  the  plan  now  set  on  foot  by 
our  Society  will  be  taken  up  by  other 
societies  and  associations  throughout  the 
kingdom.  No  time  is  to  be  lost :  already, 
in  England  alone,  nearly  200  cases  have 
occurred,  of  many,  perhaps  of  most,  of 
which  no  record  is  preserved ;  and  fresh 
cases  are  occurring  every  day.  1  hope,  sir, 
to  have  your  powerful  aid  in  stirring  up  the 
profession  to  the  requisite  exertion. 

I  have  only  to  add,  that  to  the  secretary 
of  any  society  or  association  who  will  apply 
to  me,  by  letter  or  personally,  I  shall  have 
great  pleasure  in  giving  every  explanation 
in  my  power,  both  as  to  manner  of  working 
the  scheme,  and  as  to  the  expense,  &c. 
necessarily  attending  it. 

I  have  the  honour  to  be,  sir, 

Your  faithful  servant, 
Edward  Cator  Seaton,  M.D. 

Hon.  Sec.  to  the  Western  Med. 
and  Sur.  Society. 

77,  Sloane  Street,  Oct.  1848. 

Number  of  Case — Date — Name  and  Oc¬ 
cupation — Sex — Age — Habits  and  Previous 
Health— Residence — Nature  of  Locality.  ^ 


PROPOSED  MONUMENT  TO  HARVEY.  THE  CHOLERA. 


859 


History  of  the  Case  up  to  the  Appear¬ 
ance  of  the  Characteristic  Symptoms. — 
Day  and  hour  of  seizure?  Supposed  excit¬ 
ing  cause  of  the  attack  ?  Diet  within  the 
preceding  24  hours  ?  State  of  Stomach  ? 
Bowels  ?  Other  ailments  ?  Medicine  already 
taken  ? 

Characteristic  Symptoms. — Hour  of  first 
appearance?  Countenance,  expression  of ? 
Appearance  of  the  Eves  ?  State  of  the 
Pupils  ?  Tongue — Appearance  and  condi¬ 
tion  of  ?  Temperature  of  ?  Skin,  gene¬ 
rally  or  locally — Appearance  of  ?  Condition 
of  (as  to  secretion)  ?  Temperatare  of  ? 
Pulse — Volume  and  character  of?  Number 
of,  whether  felt  at  the  wrist  ?  in  the  Axilla  ? 
in  the  Carotids  ?  Heart — Stethoscopic  ex¬ 
amination  of  ?  Voice — As  to  tone  and 
power  ?  Respiration — Frequency  of  ?  Free 
or  laborious  ?  Relative  duration  of  inspira¬ 
tion  and  expiration  ?  Breath — Temperature 
of  ?  Vomiting — Its  character  and  frequency  ? 
Stools  —  Their  quantity  and  frequency  ? 
Their  character,  colour,  and  consistence  ? 
Cramps — Nature,  frequency,  and  parts  af¬ 
fected  ?  Thirst — Urgent  or  tolerable  ?  Uri¬ 
nary  Secretions — as  to  heat  and  cold  ?  as  to 
pain  ?  Nervous  System — Affections  of  ? 
Degree  of  Consciousness?  Deafness?  Noises 
in  the  Head  ?  Loss  of  Vision  ?  Convul¬ 
sions  ?  Termination  of  the  Case — in  gradual 
or  sudden  recovery — in  consecutive  fever — 
or  in  death  ? 

Post-mortem  Examination  —  hours  after 
Death. — External  Appearance  of  the  Body 
— Colour  ?  Temperature  ?  Rigidity  ?  Any 
muscular  Twitching  after  Death  ?  its  dura¬ 
tion  ?  Encephalon — Degree  of  congestion  ? 
Effusion — its  nature  and  seat  ?  Other  le¬ 
sions  ?  Thorax — Pericardium  ?  Heart — De¬ 
gree  of  rigidity  and  flaccidity  of  each  ventri¬ 
cle  ?  Contents  of  each  ventricle  as  to 
quantity  ?  Condition  of  Blood  as  to  fluidity 
and  colour  ?  If  fluid,  does  it  coagulate  on 
exposure  ?  Lungs — General  condition  and 
appearance  of?  Abdomen — State  of  the 
Peritoneum,  and  of  the  Abdominal  Cavity  ? 
Liver — Condition  and  appearance  of  ?  Gall 
Bladder — Nature  and  quantity  of  its  con¬ 
tents  ?  Gall  Ducts — Condition  of?  Sto¬ 
mach,  Duodenum,  Small  Intestine,  Caecum, 
Colon,  and  Rectum — Contents  of,  respec¬ 
tively  ?  are  they  acid  or  alkaline  ?  Condi¬ 
tion  of  the  Mucous  Membrane  of,  re¬ 
spectively?  Spleen?  Kidneys?  Urinary 
Bladder — as  to  contents  and  degree  of  con¬ 
traction  ? 


PROPOSED  MONUMENT  TO  HARVEY. 

Sir, — A  Committee  has  recently  been 
formed  here,  whose  object  it  is  to  raise 
funds  for  the  erection  of  a  monument  to  the 
commemoration  of  Harvey  in  his  native 
town. 


It  is  considered  that  an  application  to  the 
medical  profession,  through  your  columns, 
will  have  the  effect  of  making  the  subject 
generally  known  amongst  its  members,  and 
of  stimulating  each  and  all  to  exert  their  in¬ 
fluence  with  their  friends  and  patients 
towards  the  fulfilment  of  this  undertaking. 

The  Committee  therefore  request  the 
favour  of  your  kind  co-operation  and  assist¬ 
ance,  feeling  convinced  that  it  is  only  by 
such  means  that  success  can  be  expected  to 
result. 

The  Earl  of  Radnor  has  kindly  granted 
the  most  eligible  site  of  ground  on  his 
Folkstone  estate,  and  the  subscriptions  for 
this  town  at  present  amount  to  about 
twenty-five  pounds. 

The  Committee  is  composed  of  the  mayor, 
the  magistrates,  and  the  medical  men  of  the 
town ;  and  the  manager  of  the  National 
Provincial  Bank,  Folkstone,  is  the  treasurer. 

I  am,  sir, 

Your  very  obedient  servant, 

Michael  Minter, 

Folkstone,  Hon.  Sec. 

Oct.  29,  1848. 


JWelucal  Intelligence. 


THE  CHOLERA  AT  ROTTERDAM. 

A  letter  from  Rotterdam  of  the  6th  inst. 
states  that  the  cholera,  which  appeared  there 
on  the  1st  inst.,  has  raged  with  great  vio¬ 
lence.  On  the  preceding  day  41  new  cases 
were  declared,  and  29  deaths,  whilst  there 
were  but  seven  recoveries.  During  the  pre¬ 
vious  five  days  there  had  been  298  cases, 
157  died,  121  recoveries,  and  16  remained 
under  cure. 

THE  CHOLERA  IN  HAMBURGH  AND 
DANTZIC. 

Only  16  cases  of  cholera  had  occurred  in 
Hamburgh  since  the  first  of  the  month, 
making  the  total  number  of  cases  3,362,  of 
which  1,671  have  been  fatal.  A  letter 
dated  Dantzic,  the  3d  inst.,  states  that  the 
cholera  is  raging  in  thac  city  with  intense 
violence.  There  were  no  fewer  that  62  new 
cases  in  one  day.  388  individuals  had 
already  been  attacked,  of  whom  185  died, 
34  had  recovered,  and  179  were  under  cure. 
In  the  small  town  of  Gartz,  in  the  district 
of  Stettin,  the  cholera  has  carried  off  102 
persons  out  of  a  population  of  700. 

ALLEGED  APPEARANCE  OF  CHOLERA  IN 
FRANCE. 

It  is  stated  in  a  letter  from  Calais  that  two 
cases  of  cholera  have  occurred  there,  but 
that  the  character  of  the  disease  is  much, 
less  violent  than  that  which  carried  off  so 
many  persons  16  years  since. 


860  THE  CHOLERA.  DEATH  FROM  CHLOROFORM. 


THE  CHOLERA  AT  GLASGOW. 

Two  fatal  cases  of  cholera  have  occurred  in 
this  city.  On  Saturday  afternoon  a  work¬ 
ing  gardener,  named  Gordon,  was  seized  ;  he 
did  not  get  medical  assistance  till  the  follow¬ 
ing  morning,  but  died  in  the  course  of  the 
day.  The  man’s  residence  was  at  Burnbank, 
a  most  filthy  locality  in  the  western  part  of 
the  city.  Yesterday  afternoon  medical  as¬ 
sistance  was  called  in  the  case  of  a  man 
named  Morton,  a  calenderer,  residing  in 
Greame-street,  a  low-lying,  filthy  locality, 
surrounded  by  tanpits,  &c.  It  was  a  de¬ 
cided  case  of  cholera,  and  he  died  at  4 
o’clock  this  morning.  This  man  had  been 
ill  since  the  preceding  Friday,  and  had  not 
asked  for  medical  aid  till  yesterday.  The 
two  cases  have  occurred  two  or  three  miles 
apart.  As  yet  no  other  well-authenticated 
cases  have  been  reported. 

THE  CHOLERA  IN  SOUTHWARK — APPOINT¬ 
MENT  OF  ADDITIONAL  MEDICAL  OFFI¬ 
CERS. 

In  consequence  of  the  apprehensions  enter¬ 
tained  of  the  spread  of  cholera  in  the  close 
and  crowded  streets  of  St.  Mary,  Newing¬ 
ton,  a  special  meeting  of  the  governors  and 
guardians  of  the  poor  wras  held  at  the  work- 
house  on  Tuesday  evening,  with  the  view  of 
determining  the  measures  to  be  adopted  to 
insure  immediate  and  efficient  medical  atten¬ 
dance  upon  any  of  the  poorer  classes  when 
attacked  by  the  epidemic.  After  some  dis¬ 
cussion,  it  was  determined  to  elect  ten  me¬ 
dical  officers  in  addition  to  those  already 
appointed,  one  for  each  particular  locality, 
but  each  gentleman  being  required  to  act  in 
any  part  of  the  parish  should  it  become 
necessary.  The  fee  was  fixed  at  10s.  6d. 
each  case.  The  following  gentlemen  were 
accordingly  appointed: — Mr.  Boddy,  12, 
Saville  Row,  Walworth  ;  Mr.  Marshall,  9, 
Marlborough  Place  ;  Mr.  Nolan,  11,  Church 
Row,  Newington;  Mr.  Hicks,  4,  High 
Street;  Mr.  Mason,  High  Street;  Mr. 
Howitt,  5,  Apollo  Buildings,  Walworth; 
Mr.  Darville,  Dean’s  Row,  Walworth ;  Mr. 
Crisp,  Charlotte  Row;  Mr.  Townsend, 
Newington  Causeway  ;  Mr.  Lewis,  4,  Brigh¬ 
ton  Place,  New  Kent  Road;  Mr.  Rathbone, 
Webb’s  County  Terrace ;  and  Mr.  Hawkins, 
Great  Dover  Street. 

ANOTHER  CASE  OF  DEATH  FROM  THE  IN¬ 
CAUTIOUS  USE  OF  CHLOROFORM  VAPOUR. 

On  Tuesday  last,  Mr.  Carruthers,  a  gentle¬ 
man  of  fortune,  residing  at  Dormount, 
Annan,  lost  his  life  from  the  incautious  ap¬ 
plication  of  chloroform.  It  appears  that 
the  deceased  was  afflicted  with  asthma,  and 
having  found  relief  from  inhaling  the  subtle 
vapour,  had  frequent  recourse  to  it.  Being 
an  expert  angler,  and  extremely  fond  of 
piscatorial  recreation,  he  sometimes  em¬ 


ployed  himself  rather  late  in  adjusting  his 
hooks,  and  making  artificial  flies.  On 
Tuesday  morning  he  was  found  sitting  at  the 
table  apparently  following  this  occupation, 
in  the  position  in  which  his  servant  had  left 
him  on  the  preceding  night,  but  it  was  soon 
discovered  that  the  unfortunate  gentleman 
was  quite  dead,  and  to  all  appearance  life 
had  been  extinct  for  some  hours.  On  the 
table  was  the  evidence  of  the  fatal  occur¬ 
rence — the  handkerchief  which  he  had  used 
in  applying  the  chloroform  to  his  mouth. 
His  death  forms  another  melancholy  in¬ 
stance  of  the  folly  of  employing  such 
dangerous  agents  for  the  purpose  of  obtain¬ 
ing  a  temporary  relief  from  pain.  —  Carlisle 
Patriot. 

ORDER  RESPECTING  THE  NON-APPEAR¬ 
ANCE  OF  CANDIDATESFOR  EXAMINATION 
AT  THE  ROYAL  COLLEGE  OF  SURGEONS 
AND  APOTHECARIES’  HALL. 

We  are  informed,  that  in  consequence  of 
the  disappointment  to  which  the  Court  of 
Examiners  of  the  College  of  Surgeons,  and 
of  the  Apothecaries’  Society,  have  been  sub¬ 
jected  by  the  non-attendance  of  candidates 
on  the  day  appointed  for  their  examination 
for  the  diploma,  the  Courts  have  come  to  the 
following  resolution  : — “  That  in  future, 
when  a  candidate  for  the  diploma  shall  fail 
to  attend  for  the  purpose  of  examination,  on 
the  day  for  which  he  shall  have  entered  his 
name,  and  received  a  card  of  admission,  his 
name,  as  heretofore,  shall  be  placed  at  the 
bottom  of  the  list  of  candidates  for  the 
diploma,  and  he  shall,  further,  not  be  ad¬ 
mitted  to  examination  within  the  period  of 
one  month  from  the  date  of  his  so  failing  to 
attend.” 


UNIVERSITY  OF  LONDON. 

B.M.  SECOND  EXAMINATION. 

PASS  EXAMINATION. - 1848. 

Tuesday,  November  7.— Morning,  10  to  1. 

Surgery. 

Examiners ,  Sir  Stephen  Hammick  and 
Mr.  Caesar  Hawkins. 

1.  What  are  the  appearances  and  altered 
conditions  of  the  Leg,  when  in  a  state  of 
common  inflammation  ?  Give  the  various 
terminations  of  inflammation  ;  describe  the 
symptoms  of  each  termination  respectively, 
with  the  mode  of  treatment,  both  local  and 
general,  through  the  different  stages  of  the 
disease  of  this  part,  up  to  a  favourable  or 
fatal  issue. 

2.  Describe  the  system  and  treatment, 
both  locally  and  generally,  of  a  wound  of 
the  Abdomen  of  moderate  size,  accordingly 
as  there  is  merely  a  wound  of  the  parietes 
opening  the  peritoneal  cavity ;  or  a  wound 


861 


DEFECTIVE  SIGNS  OF  THE 


of  the  abdominal  walls  with  protrusion  or 
uninjured  intestine,  or  omentum,  or  both; 
or  such  protrusion  of  small  intestine  with  a 
slight  wound  of  its  coats,  or  with  a  large 
wound,  or  with  entire  transverse  division  of 
the  canal. 

3.  What  are  the  symptoms  and  effects  of 
Gonorrhoea  in  the  male  sex,  in  mild,  or  irri¬ 
table,  or  acute  cases  ?  Give  the  treatment 
which  should  be  adopted  under  these  several 
circumstances  for  their  different  stages  and 
symptoms  of  the  complaint. 

Afternoon,  3  to  6. 

Medicine. 

Examiners,  Dr.  Billing  and  Dr. 

Tweedie. 

1.  Describe  the  anatomical  characters  and 
progressive  changes  in  the  cerebral  tissue  in 
cerebritis. 

2.  Sketch  shortly  the  functional  diseases 
of  the  stomach,  with  their  diagnostic  symp¬ 
toms  and  treatment. 

3.  Give  the  differential  diagnosis  of 
pleurisy  and  pneumonia. 

4.  Describe  the  various  forms  of  insanity, 
with  the  treatment,  moral,  remedial  and 
dietetic. 

5.  Give  the  symptoms,  anatomical  cha¬ 
racters  and  treatment  of  pericarditis. 

6.  Sketch  the  principal  forms  of  cuta¬ 
neous  affections  of  the  scalp,  with  the  treat¬ 
ment  applicable  to  each. 

Wednesday,  Novembers. — Morning  10  to  1. 

Midwifery. 

Examiner ,  Dr.  Rigby. 

1.  What  are  the  symptoms  approaching 
miscarriage  ? 

2.  What  are  the  symptoms  of  approach¬ 
ing  labour,  and  those  which  simulate  it  ? 

3.  What  is  the  diagnosis,  prognosis,  and 
management  of  a  nates  presentation  ? 

4.  Describe  the  forms,  symptoms,  and 
treatment  of  placenta  praevia. 

Afternoon,  3  to  6. 

Forensic  Medicine. 

Examiners,  Prof.  Brande,  Dr.  Pereira, 
and  Dr.  Rigby. 

1.  What  is  the  nature  of  the  noxious 
emanations  from  sewers  and  cesspools  ? 
What  are  the  means  of  preventing  their 
production ;  and,  when  produced,  how  is 
their  influence  u[>on  the  sanitary  condition 
of  the  neighbourhood  most  effectually 
guarded  against  ? 

2.  Enumerate  the  principal  inorganic 
poisons ;  annex  to  them  their  chemical 
symbols  ;  state  by  what  tests  they  are  most 
unequivocally  recognised,  and  what  are  their 
respective  antidotes. 

3.  What  are  the  symptoms  and  post¬ 


POS1TION  OF  THE  HEART. 


mortem  appearances  of  slow  arsenical  poi¬ 
soning  ?  What  are  the  maladies  with  which 
the  arsenical  disease  is  liable  to  be  con¬ 
founded  ;  and  what  are  the  circumstances 
calculated  to  aid  you  in  your  diagnosis  ? 

4.  The  body  of  a  person  suspected  to 
have  been  poisoned  by  arsenic  having  been 
exhumed,  and  the  stomach  and  intestines 
being  found  wanting  (having  been  removed 
prior  to  interment),  you  are  required  to  state 
how  you  would  proceed  in  order  to  deter¬ 
mine  whether  the  suspicion  is  or  is  not  well- 
founded. 

5.  A  woman  recently  married  becomes 
pregnant ;  suspicions  are  excited  that  it  is 
not  her  first  pregnancy  :  how  will  you  decide 
the  question  ? 

6.  What  are  the  evidences  of  recent  de¬ 
livery  ? 


Selections  from  ^journal*. 


PATHOLOGY. 

A  CASE  IN  WHICH  THE  PHYSICAL  SIGNS 

OK  THE  POSITION  OF  THE  HEART  WERE 

DECEPTIVE.  BY  DR.  P1CKFORD. 

L.  L.,  a  labourer,  set.  55  years,  had  recently 
suffered  from  a  severe  attack  of  sciatica,  but 
was  otherwise  a  strong  and  healthy  man. 
According  to  his  account,  for  some  time 
past  he  had  experienced  distressing  pa¬ 
roxysms  of  dyspnoea.  On  the  night  of  26th 
August,  1845,  these  became  greatly  aggra¬ 
vated. 

When  seen  by  Dr.  Pickford,  he  was  in 
bed,  in  a  half-sitting  posture,  leaning  to¬ 
wards  the  left  side,  breathing  laboriously ; 
the  countenance  livid  and  bloated,  expressing 
intense  anguish  ;  his  skin  bedewed  with 
perspiration  ;  his  pulse  frequent  and  small ; 
the  lower  extremities,  as  high  as  the  knees, 
oedematous.  Closer  inspection  furnished  the 
following  information  : — The  left  side  of  the 
chest  was  not  moved  in  breathing — it  was 
inclined  forward ;  the  left  hypochondrium 
remarkably  full,  not  manifesting  the  slightest 
fremitus;  percussion  gave  an  entirely  dull 
sound  from  the  clavicle  down  to  the  last  rib, 
except  that  under  the  clavicle  there  was  a 
faint  trace  of  resonance,  and  some  very  in¬ 
distinct  and  doubtful  breathing  ;  otherwise 
no  respiratory  murmur  detectible.  The 
right  side  was  sonorous — in  the  lower  part 
behind  even  somewhat  tympanitic ;  in  the 
upper  part  there  was  a  loud  respiratory 
murmur  ;  in  the  lower  part,  here  and  there 
some  mucous  rattle  corresponding  with  a 
difficult  cough,  attended  with  a  scanty,  thin, 
mucous  expectoration. 

Between  the  cartilages  of  the  third  and 
fourth  ribs,  to  the  right  of  the  sternum, 


862 


DEFECTIVE  SIGNS  OF  THE  POSITION  OF  THE  HEART. 


could  be  felt  a  somewhat  feeble  impulse  of 
the  heart  equal  to  the  force  of  the  pulse  ;  in 
the  same  spot  the  heart’s  sounds  could  be 
heard,  as  at  its  apex :  hence,  also,  in  a 
triangular  space  bounded  by  the  clavicle 
above  the  sternum  internally,  and  outwardly 
by  a  line  drawn  from  the  middle  of  the 
clavicle,  percussion  gave  but  little  sound  : 
none  at  all,  indeed,  in  the  middle  and  lower 
part  of  this  space.  Hence  it  was  concluded 
that  the  heart  had  been  forced  to  this  spot 
out  of  its  proper  situation  by  extensive 
empyema  of  the  left  side. 

The  patient,  from  the  painful  urgency  of 
the  sense  of  suffocation,  requested  to  be 
relieved  by  any  means  whatever.  More 
than  mere  relief  one  could  not  expect  from 
the  patient’s  condition  :  expansion  of  the 
lung,  if  even  paracentesis  were  performed, 
could  scarcely  be  hoped  for,  since  the  dis¬ 
ease,  from  June  last,  had  been  subjected 
only  to  a  mere  symptomatic  treatment,  for 
no  other  name  can  be  given  to  a  treatment 
which,  began  by  an  emetic,  was  varied  with 
an  occasional  purgative,  some  morphia,  and 
a  little  compound  camphor  liniment  rubbed 
on  the  chest. 

The  poor  fellow  dreaded  a  return  of  his 
former  anguish,  and  urged  the  performance 
of  the  operation,  which  at  least  afforded  him 
a  chance  of  at  all  events  temporary  relief ; 
it  was  therefore  performed  the  next  morn¬ 
ing,  in  the  fifth  intercostal  space,  about  an 
inch  and  a  half  from  the  left  nipple.  Six 
pints  of  thickish,  yellowish,  albuminous 
fluid,  containing  fibrinous  clots,  were  eva¬ 
cuated.  By  permitting  a  gradual  flow  the 
patient  bore  it  well,  and  felt  relieved ;  the 
diaphragm  rose  to  its  proper  position,  but 
the  heart’s  impulse  continued  to  be  felt  as 
before. 

The  relief  lasted  only  until  night ;  the 
patient  sank,  and  died  at  8  o’clock  the  next 
morning. 

On  examining  the  chest,  about  five  pints 
of  fluid  and  coagulated  fibrin  were  found 
on  the  left  side  of  the  chest.  The  lung  was 
bound  down  to  the  spine  by  a  tough  mem¬ 
brane  ;  the  upper  sixth  was  entirely  free 
from  air,  being  covered  and  held  down  by 
the  thick  pseudo- membrane.  But  there 
were  other  more  remarkable  changes  :  in 
the  triangular  space,  where  diagnosis  had 
pointed  out  the  position  of  the  heart,  was 
seen  a  body  which  seemed  to  be  a  very  thin 
expansion  of  the  pericardium,  but  which,  on 
further  investigation,  proved  to  be  nothing 
more  than  a  membranous  enlargement  of 
the  left  lobe  of  the  thyroid  gland,  ex¬ 
tending  downwards  and  outwards  beneath 
the  clavicle,  containing  colloid  matter. 
Closely  attached  to  this  tumor  was  the 
pericardium  metamorphosed  into  a  dense 
felt-like  substance,  three  lines  in  thick¬ 
ness.  The  right  side  of  the  heart  was 


somewhat  dilated  ;  the  heart  itself  soft  and 
pale,  its  parietes  not  hypertrophied ;  the 
valves  were  healthy,  but  bound  down  by 
adhesion.  It  was  necessary  to  peel  off  the 
pericardium  from  the  surface  of  the  heart ; 
it  was  also  attached  behind  and  to  the  left  to 
the  compressed  lung  ;  forwards  and  to  the 
right  it  adhered  to  the  thyroid  tumor,  and 
by  this  adhesion  the  apex  of  the  heart  had 
been  dragged  forwards,  so  that  its  impulse 
and  sounds  were  transmitted  to  this  part. 
The  lungs  were  free  from  tubercle;  the  right 
was  loaded  with  blood,  and  oedematous. 

This  examination,  therefore,  demonstrates 
that  such  an  unusual  combination  of  cir¬ 
cumstances  may  occur  as  shall  altogether 
deceive  us  as  to  the  physical  signs  of  the 
situation  of  the  heart  ;  it  also  divulges  the 
results  of  a  neglected  pericarditis  and  pleu- 
ritis. — Dr.  Pickford ,  in  Henle’s  Zeitschrift. 

X 

ON  THE  SIGNS  OF  DISEASED  HEART  AF¬ 
FORDED  TO  THE  HAND  LAID  OVER  THE 
PR^ECORDIUM.  BY  PROF.  JAKSCH. 

The  purring  tremor  ( fremissement  cataire ) 
perceived  in  certain  affections  of  the  heart, 
is  felt  most  distinctly  when  the  flat  hand  is 
laid  over  the  part  of  the  prsecordium  cor¬ 
responding  to  the  point  of  the  heart’s  im¬ 
pulse.  When  this  peculiar  tremor  is 
dependent  upon  narrowing  of  the  left  auri- 
culo-ventricular  opening,  it  is  perceived  at 
the  period  corresponding  to  the  diastole  of 
the  heart.  Dr.  Jaksch,  however,  states  that 
he  has  observed  it  in  cases  of  insufficiency  of 
the  aortic  valves.  For  determining  to  which 
of  these  morbid  conditions  the  tremor  during 
the  diastole  is  in  any  case  due,  he  points 
out  the  following  diagnostic  signs  : — If  it 
occurs  when  the  impulse  is  feeble,  the  heart 
broad  (as  indicated  by  increased  lateral  dul- 
ness  on  percussion),  and  the  second  sound 
increased,  it  is  dependent  on  narrowing  of 
the  left  auriculo-ventricular  opening  :  if,  on 
the  other  hand,  it  coincides  with  an  increased 
ifnpulse,  an  hypertrophied  left  ventricle  (as 
indicated  by  a  tremulous  impulse  and  in¬ 
creased  dulness,  in  the  longitudinal  direction, 
on  percussion),  and  with  absence  of  the 
second  sound  of  the  heart,  it  may  be  consi¬ 
dered  as  most  probably  dependent  upon 
imperfection  of  the  aortic  valves.  In  cases 
in  which  a  contracted  left  auriculo-ventri¬ 
cular  opening  coincides  with  imperfect  aortic 
valves,  a  purring  tremor  accompanying  the 
diastole  of  the  heart  is  sometimes  observed 
coincidently  with  an  increased  impulse.  The 
diagnosis  of  such  cases  is  rendered  suffi¬ 
ciently  easy  by  the  increased  second  sound 
audible  in  the  pulmonary  artery,  the  en¬ 
largement  of  the  heart  in  its  longitudinal 
and  transverse  direction,  and  the  absence  of 
the  second  sound  from  the  aorta  and  the 
carotid  arteries. 


FATAL  CASE  OF  INFANTILE  PNEUMONIA. 


863 


It  is  not  uncommon,  especially  after  peri¬ 
carditis,  that  peculiar  tremors  or  vibrations 
are  produced  within  the  pericardium,  and 
may  give  to  the  hand  laid  over  the  region  of 
the  heart  a  sensation  of  grating,  scraping, 
creaking,  or  even  buzzing.  The  existence 
of  previous  pericarditis,  the  absence  of 
change  of  form  of  the  heart,  the  want  of 
rhythm,  and  the  variableness  of  the  morbid 
sound,  preclude  much  risk  of  error  in  the 
diagnosis. 

By  means  of  the  hand  laid  over  the  prse- 
cordium,  Professor  Jaksch  has  perceived 
vibrations  synchronous  with  the  systole  of 
the  heart.  1.  In  cases  of  narrowing  of  the 
aorta  from  rigid  semilunar  valves.  2.  In 
cases  of  dilatation,  thinning  and  relaxation 
of  the  portion  of  the  aorta  immediately 
above  the  semilunar  valve.  3.  In  aneuris- 
mal  dilatation  of  the  ascending  aorta,  ac¬ 
companied  by  roughness  of  the  internal  sur¬ 
face  of  the  vessel.  4.  In  some  cases  of  true 
aneurism  of  the  ascending  aorta,  with  rough¬ 
ness  of  the  orifice  or  internal  surface  of  the 
same.  5.  In  a  case  in  which  numerous 
tendinous  bands  were  stretched  across  the 
left  ventricle  near  the  orifice  of  the  aorta.  6. 
In  a  case  of  perforation  of  the  inner  division 
of  the  bicuspid  valve.  7.  In  inefficiency  of 
the  bicuspid  valve,  in  consequence  of  rup¬ 
ture  of  some  of  the  tendinous  cords.  8.  In 
narrowing  of  the  ascending  aorta.  The 
sounds  dependent  upon  disease  of  the  aorta 
are  perceived  most  distinctly  when  the  hand 
is  placed  in  the  middle  of  the  sternum,  and 
is  thence  carried  upwards  and  to  the  right, 
in  the  direction  of  the  aorta. — Oesterrei- 
chische  Medcciniscke  Wochenschrift.  A 

FATAL  CASE  OF  INFANTILE  PNEUMONIA. 

The  following  case  may  serve  as  a  good 
illustration  of  the  peculiar  features  of  pneu¬ 
monia  as  it  occurs  in  infants,  and  the  differ¬ 
ence  both  in  its  symptoms  and  its  morbid 
anatomy  from  that  of  adults. 

An  infant,  aged  four  months,  was  with  its 
mother  admitted  into  the  Necker  Hospital. 
The  child  was  labouring  under  measles,  and 
for  some  time  past  it  had  had  occasional 
slight  fits  of  hooping  cough.  The  measles 
went  through  their  course  without  any 
unusual  occurrence,  except  that  on  the 
eighth  day  of  the  disease,  and  before  the 
eruption  had  entirely  declined,  violent  fever, 
accompanied  with  profuse  diarrhoea,  super¬ 
vened.  The  respiration  became  frequent, 
and  slightly  embarrassed  ;  the  pulse  strong  ; 
skin  warm  ;  cough  diminished.  Pneumonia 
was  at  first  apprehended,  but  there  were  no 
physical  indications  thereof  to  be  detected  ; 
and  as  the  diarrhoea  continued  profuse,  it 
was  considered  that  the  fever  was  sympto¬ 
matic  of  enteritis. 

On  the  next  day  the  oppression  in  the 
breathing  had  greatly  increased  ;  the  disten¬ 


sion  of  the  nostrils  great ;  pneumonic  costo- 
abdominal  furrows  very  distinct ;  fever  more 
acute,  and  diarrhoea  decreased.  It  was  now 
impossible  to  misinterpret  these  general 
symptoms,  though  physical  signs  were  still 
wanting,  beyond  the  slightest  mucous  rale, 
not  always  audible ;  and  the  respiratory 
murmur  was  somewhat  indistinct :  there  was 
no  dulness  on  percussion. 

The  infant  died  on  the  seventh  day  after 
the  access  of  the  preceding  symptoms, 
without  any  auscultatory  signs  having  been 
manifested. 

Examination  of  the  body,  made,  twenty- 
four  hours  after  death,  showed  inflammatory 
congestion  of  the  bronchial  glands.  Several 
distinct  patches  of  pneumonia,  advanced  to 
the  second  stage,  in  the  upper  lobes  of  both 
lungs ;  in  the  middle  lobe  the  inflammation 
was  marginal,  in  the  inferior  lobes  general 
lobular  pneumonia,  in  the  granular  stage  ;  no 
depositions  of  pus.  The  lungs  were  free 
from  tubercle  throughout.  The  inflamed 
portions  sank  when  immersed  in  water. 

In  the  preceding  case  we  see,  as  in  in¬ 
fants  generally,  that  the  pneumonia  is  seated 
in  lobules,  not  in  lobes,  as  with  adults  ;  and, 
as  often  occurs,  the  inflammation  proceeds 
without  other  than  general  symptoms,  aus¬ 
cultatory  signs  being  entirely  absent. — Bul¬ 
letin  General  de  Therapeutique. 

***  We  apprehend  that  the  absence  of 
physical  signs  is  not  so  rare  as  the  pre¬ 
ceding  remarks  would  warrant ;  the  pre¬ 
sence  of  pneumonia  in  infants  is  very 
frequently  indicated  by  mere  increase  of 
intensity  in  the  respiratory  murmur,  arising 
out  of  the  fact  of  its  lobular  seat  causing  a 
compensating  activity  of  respiration  in  the 
adjoining  lobules.  We  have  seen  this  occur 
to  the  extent  of  producing  emphysema  of 
the  upper  lobes  in  the  course  of  a  very  few 
days.  In  one  case  it  was  found  on  post¬ 
mortem  examination  that  rupture  of  the  air 
cells  on  the  surface  had  occurred  during 
coughing,  and  the  air  escaping  at' the  root 
of  the  lung  into  the  mediastinum,  quickly 
permeated  the  subcutaneous  cellular  tissue, 
producing  emphysema  of  the  whole  integu¬ 
ments  of  the  head  and  the  upper  half  of  the 
body.  Increased  dyspnoea  followed,  and  the 
child  died  in  the  course  of  twelve  hours,  x 

ON  THE  PREVENTION  OF  BED-SORES. 

BY  DR.  BERNARD. 

It  is  well  known  to  every  practitioner,  that 
although  the  most  timely  precautions  may 
be  adopted,  and  the  most  skilful  means 
directed  towards  their  prevention,  yet  they 
will  (in  opposition  to  every  exertion)  make 
their  appearance.  We  may  succeed  often 
by  stimulating  applications  and  other  auxili¬ 
aries  to  interrupt  their  progress  ;  yet  so  low 
are  the  powers  of  life  in  some  cases,  and  so 
great  the  loss  of  nervous  energy,  that  the 


864 


POTASH  ESSENTIAL  TO  AN  ANTI-SCORBUTIC  DIET. 


parts  subjected  to  pressure  quickly  fall  into 
a  state  of  sphacelus.  To  such  an  extent  was 
this  tendency  manifested  in  one  case  which 
I  had  lately  under  my  care,  that  not  only 
the  integuments  and  subjacent  cellular  tissue 
over  the  sacrum,  spinal  processes,  and  hips, 
sloughed,  but  even  those  parts  of  the  body 
which  come  occasionally  in  contact  (as  the 
knees,  &c.)  were  affected  in  like  manner. 
To  avert  so  great  a  calamity,  we  must  call 
to  our  assistance  every  available  remedy. 
As  a  matter  of  the  first  importance,  we 
should  be  satisfied  that  the  nurse  in  attend¬ 
ance  on  our  patient  has  sufficient  expe¬ 
rience  ;  as,  without  proper  attention  on  her 
part,  and  implicit  obedience  to  the  phy¬ 
sician’s  directions,  his  best  efforts  will  be 
frustrated.  In  protracted  fevers  the  phy¬ 
sician  should  not  even  depend  on  the  nurse’s 
watchfulness :  he  should  make  it  a  rule  to 
examine  daily  those  parts  subjected  to  pres¬ 
sure. 

When  the  first  blush  of  unhealthy  inflam¬ 
mation  makes  its  appearance  (which  is  in¬ 
dicated  by  a  livid  colour  in  the  integuments) 
we  should  take  care  that  all  pressure  from 
the  parts  be  immediately  removed.  This 
can  be  done  either  by  the  patient’s  position 
being  changed,  or  by  the  aid  of  bolsters  or 
air-cushions  ;  and  if  the  case  is  one  likely 
to  be  protracted,  the  hydrostatic  bed  of 
Arnott  should  be  at  once  procured.  The 
simple  plan  recommended  by  M.  Purefoi 
(as  lately  described  in  the  Gazette  Medicate) 
is  well  worthy  of  the  attention  of  the  pro¬ 
fession.  He  uses  a  cow’s  bladder,  softened 
in  warm  water  :  this,  being  oiled  and  par¬ 
tially  inflated,  is  placed  under  the  part 
suffiring  from  continued  pressure.  The 
effect  of  this  support  (in  a  case  of  fractured 
leg)  exceeded  his  expectations.  He  says — 
Ai  From  the  moment  the  patient  experienced 
the  change,  he  cried  out  that  he  was  in 
heaven,  and  to  the  end  of  the  fracture  he 
felt  no  more  pain,  nor  was  the  bladder 
changed  bnt  once  during  the  month  this  was 
effecting.  Another  patient,  who  had  gan¬ 
grene  from  infiltration  of  urine,  had  to  rest 
almost  entirely  on  the  sacrum  for  two 
months,  and  was  saved  any  pain  or  ulcera¬ 
tions  of  the  part  by  having  placed  under  it 
a  bladder,  prepared  as  above,  and  wrapped 
in  a  towel.”  What  renders  this  contrivance 
valuable  is  its  simplicity  and  cheapness ;  it 
forms  a  very  manageable  substitute  for  the 
hydrostatic  bed  of  Arnott,  and  will,  I  am 
convinced,  add  more  to  the  comfort  of  our 
patients  than  a  more  costly  article. 

In  addition  to  these  preventives,  others 
to  stimulate  the  surface,  and  excite  the 
dormant  capillaries  to  a  more  healthy  action, 
should  be  diligently  used.  The  lotion  re¬ 
commended  by  Sir  B.  Brodie  is  admirable 
for  this  purpose.  It  consists  of  two  grains 
of  bichloride  of  mercury  to  an  ounce  of 


proof  spirit.  These  two  contrivances,  if 
used  at  the  same  time,  will  be  found  in¬ 
valuable  in  the  prevention  of  bed-sores. 
The  lotion  of  Sir  B  Brodie,  by  its  stimulat¬ 
ing  properties,  will  serve  to  thicken  the 
cuticle  and  render  it  more  efficient  to  resist 
injury  ;  whilst  the  inflated  bladder  of  M. 
Purefoi,  by  its  softness  and  elasticity,  will 
preserve  a  uniform  pressure  on  the  sur¬ 
rounding  parts,  and  allow  the  free  circula¬ 
tion  of  olcod  through  the  capillaries  at  the 
surface  o'  *he  body. — Dub.  Med.  Press,  1 848. 

POTASH  ESSENTIAL  TO  AN  ANTI-SCORBUTIC 
DIET. 

All  fruits  contain  potash  in  abundance,  as 
oranges,  lemons,  limes,  grapes,  gooseberries. 
&c.,  and  these  are  all  highly  anti-scorbutic, 
Potatoes,  also,  which  perhaps  are  the  most 
valuable  as  an  addition  to  a  dietary  for  the 
purpose  of  preventing  scurvy,  and  owing  to  the 
scarcity  of  which  article  this  disease  has  been, 
so  prevalent  within  the  last  two  years, 
contain,  as  analyses  proves,  a  very  large 
amount  of  potash,  and  when  boiled  (not  too 
much,  and  unpeeled),  still  retain  most  of 
that  ingredient :  this  also  accords  with  the 
fact  that  potatoes,  when  cooked  in  the  ordi¬ 
nary  way,  are  anti-scorbutic,  and  at  the 
same  time  explains  why  the  hard  core  of 
that  tuber,  which  is  so  much  liked  by  the 
Irishman,  is  most  powerful  in  preventing 
the  occurrence  of  scurvy  (see  Dr.  Lonsdale, 
in  Edinburgh  Monthly  Journal  for  August). 
Milk,  which  is  undoubtedly  a  good  anti-scor¬ 
butic,  and  upon  which  the  young  of  animals 
are  for  some  time  sustained,  contains  a  very 
large  proportion  of  potash  salts  compared 
with  those  of  soda,  being  an  exception  to 
the  relation  between  these  two  classes  of 
salts  which  is  found  in  the  other  animal 
fluids — a  pint  of  milk  (London)  which  had 
a  sp.  gr.  of  1‘021,  contained  6180  grains. 
This  was  probably  considerably  diluted,  as 
the  usual  sp.  gr.  is  from  1*026  to  1*030. 
Berzelius’s  analysis  gives  about  9  grains  ; 
but  the  sp.  gr.  of  the  milk  which  he  ana¬ 
lysed  was  about  one-third  greater.  Fresh 
meat  also  contains  potash  in  rather  large 
proportion ;  and  there  is  no  doubt  that 
animals,  such  as  the  carnivora,  living  entirely 
on  this  substance  in  its  uncooked  state, 
take  an  amount  of  potash  quite  sufficient 
for  the  wants  of  the  system.  When  we  exa¬ 
mine  other  articles  noted  for  preventing  or 
curing  the  disease  in  question,  we  find  that 
potash  enters  into  the  composition  ot  all  in 
considerable  quantities :  this  is  true  with 
regard  to  cabbages,  turnips,  onions,  garlic, 
leeks ;  and  hence  their  efficacy,  and  also  of 
pickles  and  sour-krout  made  from  them. 
The  same  is  the  case  with  the  young  tops  of 
plants,  as  of  the  Pinus  sylvestris,  &c.,  when 
a  decoction  is  made.  Potash  is  also  found 
in  spruce  beer,  wort,  malt  liquors,  wines, 


RESTRAINT  AND  NON-RESTRAINT  IN  INSANITY. 


especially  the  lighter  description,  which 
contain  this  substance  in  the  form  of  a  bi¬ 
tartrate,  but  which  becomes  deposited  in  the 
stronger  varieties. — Dr.  Garrod,  Edinburgh 
Monthly  Journal ,  1848. 

RESTRAINT  AND  NON-RESTRAINT  IN  IN¬ 
SANITY. 

The  debate  upon  the  comparative  merits  of 
the  restraint  and  non-restraint  systems  of 
practice  of  the  present  day,  about  which  so 
much  time  and  talent  have  been  expended, 
we  cannot  but  regard  as  a  mere  quibble, 
which  has  been  agitated,  exaggerated,  and 
caricatured  by  over-sensitive  benevolence, 
and  refined  and  timid  prejudice.  What  is 
the  restraint  system  of  the  present  day  as 
practised  in  all  the  continental  asylums,  and 
in  most  of  the  leading  asylums  of  our  own 
land?  It  may  be  stated  in  the  following 
terms  :  that,  inasmuch  as  lunatics  do  occa¬ 
sionally  present  the  awful  spectacle  of  the 
consentaneous  supremacy  of  destructive  im¬ 
pulses  with  abeyance  of  moral  liberty  or 
control  over  the  actions,  forcible  means  must 
be  resorted  to,  in  order  to  prevent  the  grati¬ 
fication  of  the  impulse  in  question  ;  and  inas¬ 
much  as  the  judicious  use  of  ingenious 
mechanical  contrivances  is  more  humane, 
certain,  constant,  and  less  painful  in  its 
operation  than  the  hands,  vigilance,  and 
forcible  control  of  attendants,  the  treatment 
by  mechanical  restraint  is  to  be  preferred  to 
the  living  restraint  of  attendants.  And  surely 
there  is  nothing  in  such  a  proposition  to  call 
up  so  much  cavil  and  warm  animadversion 
as  the  advocates  of  the  opposite  view  have 
been  in  the  habit  of  putting  forth.  More¬ 
over,  in  discussing  the  question,  they  have 
constantly  identified  the  modified,  the 
enlightened,  the  kind  and  necessary  restraint 
of  the  present  day,  with  the  dreadful  details 
of  mismanagement  of  the  days  when  Pinel 
and  Esquirol  began  their  labours  of  love  and 
pity.  And  the  public,  thus  misled,  have 
learned  to  associate  the  word  restraint  with 
every  species  of  suffering  and  barbarity,  and 
to  see  an  approach  to  Utopia  in  the  doctrine 
of  non -restraint ;  little  thinking  that  in 
avoiding  Scylla  they  are  rushing  upon 
Charybdis. — Dublin  Quarterly  Journal. 

MORTALITY  OF  THE  POPULATION  OF  PHI¬ 
LADELPHIA  AT  DIFFERENT  AGES. 

It  appears  that,  in  1840,  when  the  census 
was  taken  by  the  general  government,  the 
mortality  under  the  10th  year,  compared 
with  the  population  of  and  under  that  age, 
was  3’7  per  cent.,  or  1  death  to  about  27  of 
the  population  at  the  age  designated.  The 
deaths  between  10  and  20  were  only  1  in 
about  260  of  the  inhabitants  of  that  period 
of  life  !  Those  between  the  20th  and  30th 
years  of  age,  were  1  in  about  102  ;  between 
the  30th  and  50th  years,  1  in  about  57; 
between  the  50th  and  100th  years,  1  in  22  ; 


865 


whilst  those  of  and  over  100  were  1  in  6  o^ 
the  inhabitants. 

The  mortality  in  the  first  year  of  life  was 
5,171,  which  is  about  47  per  cent,  of  the 
whole  mortality  under  the  20th  year  (10,979), 
and  about  27  per  cent,  of  the  mortality  at 
all  ages.  The  deaths  under  the  5th  year 
amounted  to  9,394,  constituting  about  86 
per  cent,  of  the  whole  mortality  under  the 
20th  year,  and  leaving  but  16  per  cent,  for 
the  succeeding  15  years  of  life.  Compared 
with  the  total  mortality  at  all  ages,  that 
under  the  5th  year  comprises  49  per  cent., 
and  that  under  the  20th  year,  56  per  cent. — 
American  Journal  of  Med.  Sciences,  July. 

BOOKS  &  PERIODICALS  RECEIVED 

DURING  THE  WEEK. 

Elements  of  Anatomy.  By  Jones  Quain, 
M.D.  5th  Edition.  Edited  by  Richard 
Quain,  F.R.S.  ;  and  William  Sharpey, 
M.D.  F.R.S.  In  2  vols.  Vol.  II. 
Physiological,  Anatomical,  and  Pathological 
Researches.  By  John  Reid,  M.D.  Pro¬ 
fessor  of  Anatomy,  Sec.  in  the  University 
of  St.  Andrews. 

Dr.  Tanner’s  Memoranda  on  Poisons. 
Medical  Jurisprudence.  By  Dr.  Alfred 
Taylor.  3d  Edition. 

Surgical  Anatomy.  By  Joseph  Maclise, 
Surgeon.  Fasciculus  1. 

British  Record  of  Obstetric  Medicine,  &c. 

Edited  by  Dr.  Clay.  No.  22,. Nov.  15. 
Report  on  the  Edinburgh  Royal  Matern  ty 
Hospital,  from  1844  to  1846.  By  J.  Y. 
Simpson,  M.D. 

Reflections  on  Organization,  or  Suggestions 
for  the  Construction  of  an  Organic  Atomic 
Theory.  By  Henry  Freke,  A.B.  M.B. 
Clinical  Lectures,  delivered  at  Mercer’s 
Hospital,  Dublin.  By  James  F.  Duncan, 
M.D.  &c. 

Journal  de  Chirr, ie  Medicale.  Nov.  1848. 

AMERICAN  WORKS. 

The  Transactions  of  the  American  Medical 
Association.  Instituted  1847.  Vol.  1. 
The  American  Journal  of  the  Medical 
Sciences.  No.  32,  Oct.  1848. 

Medical  Lexicon.  By  Robley  Dunglison, 
M.D.  &c.  7th  edition.  Philadelphia, 
Lea  and  Blanchard. 

An  Analytical  Compendium  of  the  various 
branches  of  Medical  Science,  for  the  Use 
and  Examination  of  Medical  Students. 
By  John  Neill,  M.D.  &c. ;  and  Francis 
Gurney  Smith,  M.D.  &c.  Ibid. 

On  Bandaging,  and  other  Operations  of 
Minor  Surgery.  By  F.  W.  Sargent, 
M.D.  Ibid. 

Medical  Chemistry,  for  the  Use  of  Students, 
&c.  By  D.  P.  Gardiner,  M.D.  Ibid. 
An  Inquiry  into  the  Degree  of  Certainty 
in  Medicine,  &c.  By  Elisha  Bartlett, 
M.D.  Ibid. 


866  BIRTHS  AND  DEATHS,  METEOROLOGICAL  SUMMARY,  ETC 


METEOROLOGICAL  SUMMARY. 


Mean  Height  of  Barometer .  29’87 

«  “  Thermometer1  .  40'3 

Self-registering  do.b - max.  56  6  min.  24- 

“  in  the  Thames  water  —  44*8  —  38'8 


a  From  12  observations  daily.  b  Sun. 

Rain,  in  inches,  0T1 :  sum  of  the  daily  obser¬ 
vations  taken  at  9  o’clock. 

Meteorological. — The  mean  temperature  of  the 
week  was  20,6  below  the  mean  of  the  month. 


BIRTHS  &  DEATHS  in  the  Metropolis 


During  the  weetc  ending  Saturday ,  Nov.  11. 


Births. 
Males ....  673 
Females..  694 


Deaths. 
Males....  586 
Females. .  579 


Av.  of  5  Aut. 
Males....  581 
Females..  573 


1367 


1165 


1154 


Causes  of  Death. 

All  Causes . 

Specified  Causes . 

1 .  Zymotic(orEy\demic, Endemic, 

Contagious)  Diseases . . 
Sporadic  Diseases,  viz. — 

2.  Dropsy,  Cancer,  &c.  of  uncer¬ 

tain  seat  . 

3.  Brain,  Spinal  Marrow,  Nerves, 

and  Senses  . 

4.  Lungs  and  other  Organs  of 

Respiration . 

5.  Heart  and  Bloodvessels . 

6.  Stomach,  Liver,  and  other 

Organs  of  Digestion  . 

7.  Diseases  of  the  Kidneys,  &c.. . 

8.  Childbirth,  Diseases  of  the 

Uterus,  &c . 

9.  Rhematism,  Diseases  of  the 
Bones,  Joints,  &c . 

10.  Skin,  Cellular  Tissue,  &c . 

11.  Old  Age . 

12.  Violence,  Privation,  Cold,  and 

Intemperance . 


Av.  of 
5  Aut. 

1165 

1154 

1149 

1149 

414 

270 

37 

52 

131 

127 

147 

222 

45 

38 

71 

67 

12 

12 

5 

14 

14 

8 

2 

2 

37 

64 

21 

32 

The  following  is  a  selection  of  the  numbers  of 
Deaths  from  the  most  important  special  causes : 


Small-pox  .  34 

Measles  ...v...  17 

Scarlatina  . 135 

Hooping-cough..  27 

Diarrhoea  .  26 

Cholera  .  62 

Typhus  .  65 

Dropsy .  15 

Sudden  deaths  . .  7 

Hydrocephalus..  22 
Apoplexy . .  30 


Paralysis .  21 

Convulsions  ....  51 

Bronchitis .  58 

Pneumonia .  63 

Phthisis . 127 

Dis.  of  Lungs,  & c.  7 

Teething .  7 

Dis.  Stomach,  &c.  11 
Dis.  of  Liver,  &c.  14 

Childbirth .  2 

Dis.  of  Uterus, &c.  2 


Remarks. — The  total  number  of  deaths  was 
11  above  the  weekly  autumnal  average.  See 
page  841. 


NOTICES  to  CORRESPONDENTS. 

The  communications  of  Dr.  Jamieson,  Sir  Chas. 
Scudamore,  Mr.  Swan,  Mr.  Hanks,  and  Chi- 
rurgus,  will  be  inserted  in  the  following  No. 

The  two  caffes  of  Cholera  referred  to  by  Mr. 
Owen,  in  the  report  of  the  South  London  Me¬ 
dical  Society  (page  804),  occurred  in  the  prac¬ 
tice  of  Mr.  Unwin,  of  Brixton  Road.  Their 
duration  was  respectively  eighteen  and  thirty- 
six  hours. — Our  correspondent’s  wish  respect¬ 
ing  his  paper  shall  be  attended  to. 

We  have  been  unavoidably  compelled  to  post¬ 
pone  Dr.  Milroy’s  continuation  paper  on 
Cholera  until  next  week. 

Dr.  Gavin. — The  proposed  exchange  shall  be 
commenced  with  the  new  volume  of  the 
Medical  Gazette.  A  note  will  be  sent. 

We  shall  have  much  pleasure  in  giving  insertion 
to  Dr.  James  Arnott’s  remarks  on  Congelation 
as  a  remedy  for  disease.  Several  communica¬ 
tions  from  other  correspondents  are  in  type, 
and  as  soon  as  these  have  been  published,  it 
shall  appear.  A  proof  will  be  sent. 

Insurance  Offices  and  Medical  Fees. — A  corres¬ 
pondent  informs  us  that,  in  addition  to  the 
Westminster,  the  following  Offices  are  in  the 
habit  of  remunerating  Medical  Referees: — 

The  Medical  Invalid  Office,  15,  Pall  Mall. — 
The  Britannia,  Princes  Street,  Bank. — The 
Commercial  and  General  Assurance  Associa¬ 
tion,  112,  Cheapside. 

It  is  suggested  that,  in  the  new  edition  of  the 
Medical  Directory,  those  Offices  which 
thus  act  with  justice  to  the  profession  should 
be  placed  in  a  separate  list,  with  a  special  an¬ 
nouncement  to  this  effect. 

Corrected  formula  for  Pills  prescribed  by  the 
Edinburgh  Colleges  (see  page  816.)  Formula, 
No.  2  :  —  R.  Tannini,  dr.  ss. ;  Opii,  gr.  xij. ; 
Pulv.  Capsici,  gr.  xvj. ;  Spirit.  Rectif.  gtt.  v. ; 
Conserv.  Ros.  gr.  x.  Ft.  pilulae  xvi.  Sign. 
Astringent  Pills  with  Opium. 

Dr.  Mackenzie  (Archangel). — The  report  on  the 
Cholera  in  Russia  has  been  received. 

The  reports  of  cases  forwarded  by  Mr.  Balman 
of  Liverpool,  and  Dr.  Hill  of  Peckham,  shall 
have  early  insertion. 

Received. — Mr.  James.— Dr.  Merryweather. — 
Mr.  Durden. —  Mr.  Moffatt.  —  M.  P. — Philo- 
medicus. 


THE  GENERAL  INDEX. 

We  have  to  announce  to  onr  Subscribers  that  a  General 
Index  to  the  first  40  Volumes  of  the  London  Medical  Gazette 
will,  it  is  calculated,  form  a  large  Yolume  of  about  700  pages. 
The  cost  of  the  Index  Yolume,  respecting  which  many  inquiries 
have  been  made,  will  be  Twenty-four  Shillings ;  and  it  is  proposed 
to  commence  it  so  soon  as  the  Names  of  Five  Hundred  Subscribers 
have  been  obtained. — The  printers,  Messrs.  Wilson  and  Ogilvy, 
57,  Skinner  Street,  will  receive  the  Names  of  Subscribers. 


867 


Utmtion  iiJtfi  ral  ®a?ctte. 


Xecturcs. 

COURSE  OF  SURGERY, 
Delivered  in  the  years  1846  and  1847, 

By  Bransby  B.  Cooper,  F.R.S. 

Surgeon,  and  Lecturer  on  Surgery  at  Guy’s 
Hospital. 


Lecture  XLIII. 

Genito-urinary  Organs  (continued). — 
Stricture  of  the  urethra — Definition — 
Spasmodic  stricture — JJrethra  not  mus¬ 
cular — Spasmodic  more  properly  termed 
irritable  stricture — Often  constitutional 
— Treatment  —  Gonorrhoea  a  frequent 
cause  —  Diagnosis  —  Treatment — Mixed 
stricture —  Treatment —  Suppository  — 
Gentle  use  of  bougie — Permanent  stric¬ 
ture — Definition —  Causes  —  Bulb  of  the 
urethra  most  liable  to  stricture — Does 
not  occur  in  membranous  part — Diffi¬ 
culty  in  passing  urine — Neglect  of  pa¬ 
tients  in  seeking  medical  advice — The 
probable  consequences  of  delay — Symp¬ 
toms  of  stricture — Examination  by  the 
bougie — Retention  of  urine — Means  of 
overcoming  the  obstruction — Dilatation 
by  the  bougie — by  the  injection  of  water 
— Application  of  caustic — Precautions — 
Introduction  of  cathetei — Use  of  cutting 
instruments —  Puncturing  the  bladder , 
per  rectum,  above  the  pubes — Case  — 
Cutting  through  the  perineum — Advan¬ 
tages  of  this  operation — Case — Obstruc¬ 
tions  in  the  urethra  from  calculi — Mode 
of  removal —  Cases. 

Stricture  of  the  urethra. — A  stricture  of 
the  urethra  is  an  abnormal  contraction  in 
any  part  of  the  course  of  its  canal :  this 
contraction  is  caused  by  a  morbid  deposition 
of  adhesive  matter  in  the  submucous  cellular 
tissue,  in  which  case  the  stricture  is  perma¬ 
nent;  or  by  a  sudden  congestion  in  the 
corpus  spongiosum,  when  it  is  merely  tem¬ 
porary. 

Strictures  have  been  divided  into  two 
classes,  according  as  they  are  permanent  or 
spasmodic.  Some  authors  have,  indeed, 
added  a  third  class,  which  they  have  termed 
“  mixed  stricture.”  I  believe,  myself,  that 
the  doctrine  of  the  existence  of  spasmodic 
stricture  has  arisen  upon  the  supposition 
that  the  urethra  is,  through  the  whole  of  its 
length,  partially  composed  of  muscular 
fibres :  of  this  there  does  not,  however, 
appear  to  be  any  proof  whatever.  Mr. 
Howship  considers  that  he  has  proved  the 
existence  of  muscular  fibre  in  the  urethra  by 
the  power  which  hat  canal  possesses  to 

xlii.— 1095.  Nov.  24,  1848. 


expel  spontaneously  a  moderately  -  size^ 
bougie.  This  action  he  attributes  to  muscle, 
while  it  in  fact  results  from  the  excitement 
produced  in  the  erectile  tissue  of  the  urethra, 
the  consequence  being  an  increased  flow  of 
blood  to  the  part,  which  causes  a  contrac¬ 
tion  in  the  calibre  of  the  urethra,  of  which 
the  expulsion  of  the  bougie  is  the  effect. 
In  the  same  manner,  spasmodic  stricture  is 
produced,  when,  from  some  morbid  cause, 
a  sudden  distension  of  the  erectile  tissue 
occurs.  The  idea  that  these  obstructions 
are  true  spasmodic  contractions  has  doubt¬ 
less  been  strengthened  by  the  circumstance 
that  they  are  relieved  by  precisely  the  same 
remedies  as  those  that  overcome  muscular 
irritability — viz.  bleeding,  purging,  nau¬ 
seating  medicines,  and  hot  bath,  which 
exercise,  in  fact,  an  equal  influence  over  the 
circulating  and  muscular  systems.  When 
these  contractions  occur,  however,  in  the 
bulb  or  membranous  portion  of  the  urethra, 
muscular  fibre  may  be  secondarily  affected, 
as  both  those  parts  are  under  the  influence 
of  muscle,  although  muscular  fibre  does  not 
enter  into  the  composition  of  the  urethra 
itself. 

The  kind  of  obstruction  generally  termed 
spasmodic  stricture,  independent  of  mus¬ 
cular  action,  may  perhaps  be  with  more 
propriety  called  ‘‘irritable  stricture,” — an 
affection  frequently  induced  by  a  general 
state  of  irritability  of  the  constitution.  This 
requires,  as  I  shall  presently  shew,  to  be 
treated  by  sedatives  administered  to  the 
system  generally,  and  by  soothing  local 
applications;  such  strictures  may,  however, 
result  from  disease  in  neighbouring  organs, 
as  the  prostate  gland,  bladder,  or  rectum, 
although  it  is  much  more  generally  the 
effect  of  some  morbid  action  commencing  in 
the  urethra  itself ;  and  perhaps  gonorrhoeal 
inflammation  is  one  of  the  most  frequent  of 
its  causes. 

Any  circumstance  that  produces  irritation, 
and  consequent  extraordinary  influx  of  blood 
to  the  urethra,  will  have  a  corresponding 
tendency  to  dimmish  for  the  time  the  size  of 
that  canal.  This  is  the  case  during  the 
natural  excitement  of  the  organ  ;  as  when  it 
is  in  a  state  of  priapism  the  urine  can 
scarcely  be  expelled  even  in  the  minutest 
quantity.  A  partial  determination  of  blood 
to  the  part  leads,  therefore,  to  a  certain 
amount  of  obstruction,  and  constitutes  what 
I  consider  spasmodic  or  irritable  stricture. 
This  condition  may  be  readily  distinguished 
from  permanent  stricture  by  the  suddenness 
with  which  the  patient  is  attacked  by  diffi¬ 
culty  in  passing  the  urine,  unattended  by 
any  other  premonitory  symptoms  than  those 
of  the  mere  cause  of  irritability — as  pro¬ 
tracted  retention  of  the  urine,  haemorrhoids, 
or  excessive  venereal  excitement.  In  the 
treatment  of  this  affection,  the  catheter 


868 


PERMANENT  STRICTURE — DEFINITION - CAUSES. 


should  not  be  employed  at  first,  but  a  dose 
of  opium  with  tartarized  antimony  given, 
together  with  the  application  of  hot  bath 
and  a  warm  purgative  enema  ;  and  these 
measures  will  generally  he  found  sufficient 
to  remove  the  complaint  without  any  instru¬ 
ment  being  had  recourse  to.  If  the  catheter 
he  passed  without  the  sedatives  being  first 
employed,  even  should  it  effect  its  intended 
result,  viz.  relief  from  retention  of  urine,  it 
would  tend  to  increase  the  cause  of  the 
obstruction  by  irritating  the  urethra :  it 
would  also  probably  cause  considerable 
bleeding,  and  perhaps  lacerate  the  interior 
of  the  canal  itself.  I  do  not,  however, 
mean  to  say  that  constitutional  remedies 
alone  will  always  cause  the  removal  of  the 
disease ;  for  the  congestion  of  the  vessels  of 
the  irritated  part,  or  perhaps  some  sub¬ 
cutaneous  effusion,  may  have  led  to  perma¬ 
nent  obstruction  ;  and  if  that  were  the  case, 
and  local  irritation  present  at  the  same 
time,  the  mixed  kind  of  stricture  already 
alluded  to  would  be  established.  In  obsti¬ 
nate  cases  of  this  mixed  stricture,  cupping 
in  the  perineum  will  often  be  found  of  great 
advantage  :  two  grains  of  calomel  and  a 
grain  of  opium  may  be  taken  at  bed-time, 
and  also  small  doses  of  the  sesquicliloride  of 
iron,  and  the  bougie  may  at  the  same  time 
be  employed  in  a  very  gentle  manner ;  but 
if  it  should  produce  pain  and  bleeding, 
caustic  should  be  applied  to  the  stricture : 
and  this  I  believe  to  be  an  almost  infallible 
means  of  subduing  the  irritability  in  some 
cases  ;  and  the  following  suppository  at  bed¬ 
time  will  be  found  to  produce  a  very  bene¬ 
ficial  effect : — Pulv.  Opii,  gr.  iss. ;  Ext. 
Hyos.  gr.  v.  ;  Sapon.  Hispan.  q.  s.  ft.  sup- 
positorum. 

But  ordering  the  suppository,  gentlemen, 
is  not  sufficient :  you  must  also  see  it  pro¬ 
perly  introduced  into  the  rectum,  otherwise 
it  will  increase,  instead  of  diminish,  the 
suffering  of  the  patient.  If,  for  example,  it 
be  only  placed  within  the  anus,  under  the 
influence  of  the  sphincter  muscle,  it  will 
produce  an  aggravation  of  all  the  symptoms  ; 
while,  if  it  be  passed  into  the  bowel  above 
the  sphincter,  it  will  speedily  produce  the 
desired  soothing  effect.  After  all  the  symp¬ 
toms  of  irritation  are  relieved,  there  may 
still  remain  slight  permanent  obstruction, 
requiring  the  continued  use  either  of  the 
catheter  or  bougie  to  re-establish  the  natural 
calibre  of  the  urethra  :  the  size  of  the  instru¬ 
ment  may  be  fairly  judged  of  by  that  of  the 
stream  of  water  passed  in  micturition  ;  but 
whatever  the  instrument  may  be,  gentleness 
in  its  use  is  the  great  point  to  which  atten¬ 
tion  should  be  directed. 

Permanent  stricture. — This  consists  in  a 
contraction  of  some  part  of  the  urethral 
canal  from  the  formation  of  an  adventitious 


deposit.  It  does  not,  however,  exist  in  the 
urethra  itself,  but  in  the  cellular  tissue  be¬ 
tween  the  mucous  membrane  and  corpus 
spongiosum,  the  mucous  membrane  being 
pressed  inwards  by  it  so  as  to  reduce  the 
size  of  the  canal  at  the  point  at  which  the 
deposit  is  produced.  This  deposition  of 
matter,  and  consequent  morbid  contraction 
of  the  urethra,  may  result  from  various 
causes,  which,  either  in  an  acute  or  chronic 
form,  may  give  rise  to  the  stricture.  Pro¬ 
tracted  gonorrhoea  is,  as  I  have  already 
stated,  the  most  frequent  cause  ;  but  ex¬ 
ternal  injury,  an  acrid  state  of  the  urine,  or 
anything  that  could  produce  an  irritable 
stricture,  may  also  be  the  means  of  esta¬ 
blishing  a  permanent  one.  The  bulb  is  the 
part  of  the  urethra  most  liable  to  stricture, 
as  it  is  not  only  the  most  vascular,  but  com¬ 
posed  also  of  a  large  quantity  of  cellular  tis¬ 
sue  :  it  likewise,  from  the  close  vicinity  of  the 
ducts  of  Cowper’s  glands,  is  very  subject  to 
become  implicated  in  the  diseases  that  attack 
them.  Many  surgeons  state  that  the  mem¬ 
branous  part  of  the  urethra  is  often  the 
seat  of  stricture  ;  but  such  is  not  the  case  ; 
and  you,  as  anatomists,  gentlemen,  will 
readily  see  why  it  should  not  be  so,  owing 
to  the  small  quantity  of  cellular  tissue 
which  surrounds  it,  and  the  absence  of 
corpus  spongiosum  :  it  may,  however,  be 
subject  to  temporary  constriction  from  the 
contraction  of  Wilson’s  muscles,  which  com¬ 
pletely  encompass  it. 

The  result  of  stricture  is  necessarily  a 
difficulty  in  passing  the  urine  ;  and,  there¬ 
fore,  increased  muscular  action  is  required 
in  the  bladder  and  abdominal  parietes  to 
force  the  fluid  through  the  contracted 
urethra.  The  violence  with  which  the  urine 
is  propelled  against  the  stricture  tends  to 
excite  further  irritation :  the  obstruction 
consequently  becomes  increased  ;  and  if,  at 
the  same  time,  the  subject  of  the  disease 
pays  no  attention  to  dietetic  rules,  and  ex¬ 
poses  himself  to  vicissitudes  of  temperature, 
the  difficulty  of  micturition  increases,  and 
every  symptom  is  aggravated :  still,  it  is 
surprising  to  remark  to  what  extent  patients 
will  allow  the  disease  to  proceed  before  they 
consult  a  surgeon.  Nothing  can  be  more 
unwise  than  such  procrastination  ;  for  during 
the  delay  the  bladder  becomes  thickened, 
its  capacity  correspondingly  reduced,  the 
ureters  enlarged,  the  pelvis  of  the  kidney 
distended,  its  secreting  portion  compressed, 
and  the  secretion  of  urine  diminished, — all 
which  effects  are  more  or  less  the  conse¬ 
quence  of  not  early  seeking  medical  advice  ; 
the  result  being,  that,  in  addition  to  these 
symptoms  of  the  disease  itself,  the  general 
health  of  the  patient  is  liable  to  become 
seriously  affected.  The  delay  on  the  part  of 
individuals  suffering  from  this  complaint, 
can,  indeed,  only  be  accounted  for  by  the 


PERMANENT  STRICTURE — EXAMINATION  BY  THE  BOUGIE.  869 


insi<6i°us  manner  in  which  the  symptoms 
follow  each  other;  and  I  have  known  per- 
S0,4C  '.ubmit  so  long  to  the  difficulty  in  pass¬ 
ing  the  urine,  that  the  urethra  has  at  length 
given  way  behind  the  stricture,  and  extrava¬ 
sation  of  urine  into  the  perineum  had  oc- 
{- r^xred  before  any  medical  assistance  had 
«•  been  sought. 

The  first  complaint  of  a  patient  in  this 
disease  is  generally  that  he  experiences  a 
d/;.iculty  in  passing  his  water,  which  reciuires 
a  much  longer  time  than  is  natural,  and  after 
he  believes  that  the  bladder  is  emptied,  the 
necessity  for  its  further  evacuation  imme¬ 
diately  returns,  and  an  additional  portion, 
equal  in  quantity  to  the  first,  is  voided,  the 
stream  in  which  it  escapes  from  the  urethra 
being  remarkably  small  and  tortuous.  The 
frequent  desire  to  make  water  is  almost  in¬ 
variably  an  early  symptom  of  stricture,  and 
sometimes  an  involuntary  dribbling  comes 
on,  which  causes  great  inconvenience  and 
annoyance.  These  symptoms  vary  very  much 
in  degree,  and  are  increased  by  any  kind  of 
intemperance,  and  by  exposure  to  wet  and 
cold  :  abstinence  and  quietude  are,  however, 
sure  to  afford  relief ;  it  is  this  fluctuating 
character,  and  the  occasional  cessation  of  the 
symptoms,  that  probably  induce  the  patient 
to  defer  so  long  any  application  for  medical 
assistance.  When  you  are  consulted  under 
such  circumstances,  your  first  step  will  ba  to 
make  an  examination  of  the  urethra,  by 
passing  a  bougie ;  this  is  generally  done 
while  the  patient  is  standing  with  his  back 
against  a  wall,  but  I  think  this  a  bad  plan, 
forpatients  are  very  liable  to  faint  upon  the  in¬ 
troduction  of  the  instrument,  even  although 
they  do  not  experience  pain.  I  therefore 
consider  it  better  that  the  individual  should 
be  placed  in  the  recumbent  posture  on  a 
sofa. 

Having  placed  your  patient  in  the  proper 
position,  you  will  oil  a  bougie  or  silver  ca¬ 
theter  (No.  6),  and,  raising  the  penis  to  an 
angle  of  about  4015  from  the  abdomen,  pass 
the  instrument  gently  down  to  the  stricture, 
against  which  you  press  it  slightly,  and 
equably,  for  the  space  of  a  minute,  or  perhaps 
rather  more,  according  to  the  degree  of  pain 
the  patient  experiences.  It  may  happen  that 
the  instrument  soon  passes  the  obstruction  ; 
if  that  be  the  case  I  do  not  advocate  its  fur¬ 
ther  introduction,  so  that  it  may  enter  the 
bladder,  but  think  it  better  to  be  satisfied 
with  the  progress  already  made.  After  the 
employment  of  the  bougie,  the  patient 
should  be  kept  extremely  quiet  during  the 
remainder  of  the  day,  should  live  abste¬ 
miously,  and  at  bed-time  take  the  following 
.draught: — ]£>  Liq.  Potass,  gtts.  xx.  ;  Tree. 
Opii,  gtts.  x. ;  Mist.  Camphorae,  3>ss.  Ft. 
haustus.  An  aperient  should  likewise  be 
taken  the  next  morning.  The  instrument 
should  be  again  passed  about  forty- eight 


hours  after  the  first  examination,  and  it 
may  now  be  passed  into  the  bladder,  and  left 
there  for  ten  minutes  or  a  quarter  of  an  hour, 
unless  it  causes  great  irritation,  for  I  have 
always  found  the  cure  to  be  greatly  expedited 
by  the  continued  pressure  which  the  bougie 
thus  keeps  up.  I  have  recommended  No. 
6  as  the  size  of  the  instrument  first  employed, 
as  I  consider  it  less  likely  to  produce  irrita¬ 
tion  than  the  one  of  smaller  size,  for  the 
latter  is  not  only  likely  to  catch  in  the  lacu¬ 
nae,  but  may  also  make  a  false  passage  by 
penetrating  the  sides  of  the  urethra.  If, 
however,  No.  6  be  found  too  large  to  pass 
through  the  stricture,  smaller  instruments 
must  necessarily  be  used  ;  but  it  should  be 
borne  in  mind  that  they  require  a  degree  of 
caution  in  their  introduction  proportionate 
to  the  smallness  of  their  size.  If  the  in¬ 
strument  cannot  be  passed  through  the  stric¬ 
ture  into  the  bladder,  a  question  naturally 
arises  as  to  what  other  means  are  to  be 
adopted  for  the  relief  of  the  patient.  This 
depends  entirely  upon  the  urgency  of  the 
symptoms,  especially  in  reference  to  the  dis¬ 
tension  of  the  bladder  from  the  retained 
urine  :  the  judgment  cannot  here  be  much 
guided  by  the  expressions  of  the  patient  as 
to  the  amount  of  his  suffering,  for  the  pain 
which  in  one  patient  may  be  described  as  little 
more  than  mere  inconvenience,  may  be  com¬ 
plained  of  by  another  as  excruciating  agony. 
Therefore,  the  first  thing  to  be  done  is  to 
examine  the  state  of  the  bladder  per  anum, 
and  also  through  the  parietes  of  the  abdo¬ 
men.  If  the  bladder  be  felt  pressing  on  the 
rectum,  you  may  be  assured  that  the  disten¬ 
sion  is  extreme,  for  it  is  in  the  posterior 
direction  that  the  organ  projects  lastly  under 
the  influence  of  the  internal  pressure  of  the 
urine.  I  have  but  very  rarely  met  with  a  case 
that  did  not  admit  of  sufficient  delay  to  allow 
of  the  trial  of  medicinal  means  before  pro¬ 
ceeding  to  puncture  the  bladder,  although 
no  doubt  such  cases  occur.  The  plan  I 
adopt  is  to  place  the  patient  in  a  hot  bath, 
give  a  large  dose  of  opium  (gr.  iss.  to  gr.  ij.) 
and  employ  a  purgative  enema.  As  soon  as 
the  bowels  are  open  I  order  a  suppository 
composed  of  opium,  and  a  fourth  of  a  grain 
of  belladonna,  to  be  inserted  into  the  rectum  : 
these  means  rarely  fail  to  produce  a  flow  of 
urine,  which,  even  if  it  takes  place  but  slowly, 
relieves  the  urgency  of  the  symptoms,  and 
gives  time  for  the  adoption  of  further  means 
for  the  removal  of  the  obstruction.  This 
may  be  effected  by  four  different  methods— 
dilatation,  caustic,  puncture,  and  incision. 

Dilatation  should  be  first  tried ;  it  is 
effected  by  the  catheter  or  bougie,  or 
by  injecting  the  urethra  with  water.  In 
speaking,  however,  of  this  treatment  of 
stricture,  I  wish  to  impress  on  your  minds 
that  something  more  is  to  be  done  beyond 
the  mere  mechanical  removal  of  the  impe- 


870  PERMANENT  STRICTURE - EXAMINATION  BY  THE  BOUGIE. 


1 


diment  to  the  passage  of  the  urine,  and  that 
the  use  of  local  remedial  means  should  be 
judiciously  combined  with  constitutional 
treatment;  the  latter  consisting  chiefly  in 
the  strictest  observance  of  dietetic  rules  to 
the  state  of  the  bowels,  and  in  the  employ¬ 
ment  of  such  medicines  as  tend  to  diminish 
arterial  action ;  such  as  blue  pill,  with  tar- 
tarized  antimony,  followed  by  slight  ape¬ 
rients.  Recent  strictures  may  almost  always 
be  cured  by  this  system  of  treatment,  assisted 
by  the  gentle  introduction  of  the  bougie 
every  other  clay,  and  even  when  the  stricture 
has  reached  its  more  permanent  form,  its 
cure  may  generally  be  effected  by  following 
out  this  plan,  and  in  passing  the  instruments 
without  violence,  as  the  object  is  not  to  force 
a  passage  through  the  stricture,  but  by  gentle 
pressure  produce  a  slight  inflammatory  ac¬ 
tion,  in  consequence  of  which,  disintegration 
and  absorption  are  likely  to  be  induced.  This 
plan  was  strongly  recommended  by  Dupuy- 
tren,  and  I  have  followed  it  with  very  great 
success.  The  indication  that  the  treatment  is 
producing  the  desired  effect  upon  the  stricture 
is  found  in  the  appearance  of  a  slight  puru¬ 
lent  discharge,  and  soon  after  this  effect  is 
fii’st  seen,  the  catheter  will  generally  soon 
pass  the  obstruction.  During  the  progress  of 
the  treatment  the  permanent  stricture  often 
becomes  irritable, — just  as  irritable  stricture 
is  convertible  into  permanent :  this  is  shewn 
by  its  tendency  to  bleed  on  attempting  to 
pass  a  catheter,  and  by  the  pain  which  the 
slightest  touch  of  the  instrument  produces  : 
in  such  cases  you  will  also  find  that  if  you 
succeed  in  passing  the  stricture,  there  will 
be  considerable  difficulty  in  withdrawing  it, 
and  it  will  generally  be  attended  by  bleed¬ 
ing.  With  these  symptoms  recourse  must 
be  had  to  sedatives,  and  also  to  the  caustic 
bougie,  which  seldom  fails  to  diminish  the 
irritability,  probably  by  destroying  the 
sentient  extremities  of  the  nerves  which  had 
become  exposed  by  the  ulcerative  changes 
the  substance  of  the  stricture  had  undergone. 
Some  surgeons  recommend  the  use  of  potassa 
fusa  as  the  escharotic,  instead  of  nitrate  of 
silver.  I  believe  it  unsafe,  however,  on  ac¬ 
count  of  its  deliquescence,  which  renders  it 
much  less  manageable.  In  cases  in  which 
the  stricture  resists  the  gentle  application  of 
bougies,  I  have  rendered  the  obstruction  per¬ 
meable  by  injecting  tepid  water  into  the  ure¬ 
thra  by  means  of  a  syringe  furnished  with  a 
long  canula.  By  repeating  this  operation  the 
opening  becomes  dilated, — a  condition  soon 
made  evident  by  the  greater  freedom  with 
which  the  water  enters  :  a  bougie  may  after¬ 
wards  again  be  had  recourse  to.  It  is  some¬ 
what  remarkable,  that  after  the  introduction 
of  the  bougie,  although  no  evident  mechanical 
effect  has  been  produced  by  it,  the  patient 
finds  that  he  can  pass  his  water  much  more 
freely ,  and  yet  perhaps  the  instrument  may  not 


penetrate  the  stricture  until  some  days  differ. 
Caustic  is  sometimes  employed  as  a  di  rect 
means  of  overcoming  a  stricture,  the  flty 
of  which  is  so  great  as  to  prevent  its  being  • 
acted  on  by  simple  pressure.  The  applica¬ 
tion  of  the  escharotic  produces  a  siight  slough 
on  the  surface,  and  tends  to  soften  the 
of  adventitious  matter,  so  as  to  renderit  betted 
fitted  for  absorption.  Some  precaution  is 
necessary  in  using  the  caustic  bougie, .  ind 
contact  with  any  portion  of  the  urethra  ^  3- 
sides  the  stricture  must  be  carefully  avoiu{'l. 
To  secure  this,  a  larger  instrument  should  be 
passed  first,  to  clear  the  way,  as  it  were,  for 
the  cauterising  bougie.  Although  I  have 
attached  great  importance  to  the  observance 
of  extreme  gentleness  in  the  introduction  of 
the  bougie,  circumstances  may  occur  in 
which  it  may  be  necessary  to  employ 
force  to  effect  its  entrance  into  the  bladder ; 
for  it  may  happen  that  the  symptoms  of  re¬ 
tention  of  urine  may  be  so  urgent,  that  im¬ 
mediate  relief  is  imperatively  required,  and 
under  such  circumstances  the  forcible  intro¬ 
duction  of  the  catheter  becomes  not  only 
justifiable,  but  may  be  an  advisable  measure. 

If,  in  the  attempt  to  introduce  the  instru¬ 
ment,  it  is  found  that  it  can  be  brought  to  a 
right  angle  with  the  body  in  its  recumbent 
position,  it  will  prove  that  the  stricture  is 
situated  just  at  the  junction  of  the  bulb  with 
the  membranous  part  of  the  urethra,  and 
then,  in  order  to  effect  the  introduction  of 
the  catheter  into  the  bladder,  the  fore-finger 
of  the  left  hand  should  be  passed  into  the 
rectum  ;  and  when  the  point  of  the  instru¬ 
ment  is  felt,  as  it  may  easily  be,  the  handle 
must  be  depressed  with  moderate  force,  and 
the  point  may  then  be  directed  at  once  into 
the  bladder.  Some  surgeons  recommend 
that  in  such  strictures  the  catheter  should  be 
thrust  in  with  sufficient  force  to  overcome 
the  obstruction  at  all  risks :  but  I  am  per¬ 
suaded  that  this  is  bad  practice,  as  the  lace¬ 
ration  of  the  canal,  perforation  of  the  pros¬ 
tate  gland  or  rectum,  are  accidents  very 
likely  to  occur  :  it  is,  therefore,  better  to 
puncture  the  bladder  than  to  have  recourse 
to  such  violence. 

In  cases  where  the  catheter  cannot  be 
passed  through  the  stricture,  instruments 
have  been  employed  for  the  purpose  of  cut¬ 
ting  a  passage  :  the  instrument  is  composed 
of  a  kind  of  catheter  with  a  concealed  lancet, 
which  is  projected  from  its  canula  the 
moment  it  touches  the  stricture.  But  it  is  so 
perfectly  impossible  to  direct  a  sharp  cutting 
instrument  merely  through  the  obstruction, 
without  wounding  the  urethra  itself,  that  I 
totally  repudiate  its  employment,  unless  it 
be  for  the  purpose  of  dividing  a  stricture 
placed  anterior  to  the  bulb,  and  consequently 
in  the  straight  part  of  the  canal.  If  the 
nature  of  the  stricture  does  not,  however, 
admit  of  the  use  of  the  instrument,  and 


PUNCTURE  OF  THE  BLADDER  ABOVE  THE  PUBES. 


871 


the  attempts  at  dilatation,  by  the  gentle 
introduction  of  the  catheter  or  bougie,  in¬ 
jection  of  water,  or  application  of  caustic, 
have  failed,  and  the  patient  be  still  suffering 
from  retention  of  urine,  or  be  in  consequence 
of  the  straining  threatened  with  ulceration 
of  the  urethra  behind  the  stricture,  punc¬ 
turing  the  bladder  must  necessarily  be  re¬ 
sorted  to.  The  operation  may  be  performed 
either  by  making  the  puncture  into  the  blad¬ 
der  through  the  rectum  above  the  pubes,  or 
by  making  an  incision  into  the  perineum.  I 
have  always  had  an  objection  to  the  opera¬ 
tion  per  rectum ;  for,  although  it  is  per¬ 
formed  with  great  facility,  still  you  are  inter¬ 
fering  with  the  functions  of  an  important 
organ,  in  addition  to  those  implicated  in  the 
disease,  and,  moreover,  you  are  only  reliev¬ 
ing  the  patient  from  the  retention,  without 
removing  the  cause  of  that  evil.  Some  sur¬ 
geons  maintain  that  the  stricture  is  much 
more  readily  cured  when  the  urine  is  made 
to  pass  off  by  another  channel,  as  it  is  then 
relieved,  owing  to  its  being  no  longer  sub¬ 
jected  to  the  pressure  of  the  urine,  or  the 
irritating  influence  of  constant  attempts  at 
micturition.  My  experience  does  not, 
however,  lead  me  to  this  opinion,  as  it  still 
requires  much  time  to  remove  the  obstruc¬ 
tion  ;  and  during  this  period  a  canula  or 
bougie,  sufficiently  long  to  protrude  from 
the  anus,  must  be  left  in  the  opening  be¬ 
tween  the  bladder  and  rectum  ;  and  as  this 
instrument  must  irritate  the  rectum  by  its 
presence,  it  would  tend  to  produce  a  liability 
to  permanent  fistula.  My  colleague,  Mr. 
Cock,  has  frequently  performed  the  above 
operation  in  cases  where  immediate  relief 
was  necessary  from  the  urgency  of  the  symp¬ 
toms  of  retention  of  urine  ;  and  the  circum¬ 
stance  of  his  having  repeated  it,  is,  in  my 
opinion,  a  sufficient  guarantee  for  its  ex¬ 
pediency  in  certain  cases.  In  the  operation, 
the  patient  should  be  placed  in  the  same  posi¬ 
tion  as  in  the  operation  for  lithotomy  :  the 
fore-finger  of  the  left  hand  must  be  passed 
up  the  rectum  beyond  the  prostate  gland, 
and  upon  the  patient’s  coughing,  the  inferior 
region  of  the  bladder  may  be  felt  pressing  on 
the  rectum.  The  middle  finger  should  now 
be  introduced,  and  a  long  curved  canula 
passed  on  the  fingers  and  pressed  against  the 
bladder,  being  at  the  same  time  held  in  such 
a  direction  that  the  extremity  points  towards 
the  umbilicus.  The  trocar  is  next  passed 
along  the  canula,  and  plunged  into  the 
bladder  ;  on  withdrawing  which,  the  urine 
immediately  follows. 

In  cases  of  enlarged  prostate  this  opera¬ 
tion  should  certainly  never  be  had  recourse 
to,  as  there  is  danger  of  wounding  its  third 
lobe.  And,  moreover,  before  this  operation 
is  decided  on,  it  should  be  ascertained 
that  the  bladder  is  really  distended  by  urine, 
and  not  thickened  by  hypertrophy,  in  which 


case  the  urine  may  be  contained  in  abnor¬ 
mally  distended  ureters,  and  in  the  pelvis  of 
the  kidney,  and  not  in  the  bladder.  In 
such  cases,  the  stricture  itself  should  be  ope¬ 
rated  on,  and  not  the  bladder  merely  punc¬ 
tured. 

Puncture  of  the  bladder  above  the  pubes 
is  sometimes  had  recourse  to  for  the  purpose 
of  relieving  insuperable  retention  of  urine, 
but  the  same  objection  exists  to  this  as  to 
the  puncture  of  the  bladder  per  rectum — 
viz.  that  it  is  merely  relieving  i*etention,  with¬ 
out  at  the  same  time  removing  the  stricture, 
which  is  the  cause  of  obstruction  to  the 
passage  of  the  water  through  the  urethra. 
This  operation,  considered  only  as  a  ready 
mode  of  drawing  off  the  water,  certainly 
offers  considerable  facilities,  but  the  subse¬ 
quent  danger  from  the  great  liability  of  in¬ 
filtration  of  urine,  offers  a  great  objection  to 
its  adoption. 

The  manner  in  which  the  operation  when 
determined  on  is  to  be  performed,  is  by 
making  an  incision  an  inch  and  a  half  long 
through  the  skin  in  the  median  line  imme¬ 
diately  above  the  pubes,  and  having  laid 
bear  the  linea  alba,  divide  it  also  to  the 
same  extent.  The  anterior  region  of  the 
bladder,  uncovered  by  peritoneum,  will  now 
be  exposed,  and  a  trochar  and  canula  are  to 
be  plunged  into  the  bladder,  and  the  water 
drawn  off.  Care  should  be  taken  that  the 
canula  is  sufficiently  long  to  permit  its  being 
retained  in  the  bladder  when  that  viscus  re¬ 
cedes  as  the  water  is  evacuated,  otherwise 
extravasation  would  immediately  take  place, 
and  to  prevent  the  subsequent  occurrence  of 
this,  means  must  be  employed  to  retain  the 
canula,  and  to  keep  the  patient  in  such  a 
position  as  would  guard  against  such  an  ac¬ 
cident.  The  same  difficulty,  however,  oc¬ 
curs  as  in  the  operation  per  rectum,  as  to 
the  period  at  which  the  canula  may  be 
withdrawn,  for  the  permeable  condition  of 
the  urethra  has  yet  to  be  restored. 

I  knew  a  farmer  at  Chipping  Ongar,  who 
for  the  last  twelve  years  of  his  life  was  con¬ 
stantly  obliged  to  wear  the  instrument, 
proving  that  the  operation  had  only  relieved 
the  retention,  without  effecting  the  removal 
of  its  cause.  It  may  be  considered  that 
puncturing  the  bladder  by  either  of  the  de¬ 
scribed  methods  ought  only  to  be  had  re¬ 
course  to  when  there  is  danger  to  life  arising 
from  a  protracted  retention — a  condition 
which  can  only  arise  either  from  the  delay 
and  neglect  of  the  patient,  or  from  the  in¬ 
judicious  treatment  adopted  for  the  cure  of 
the  obstruction.  When,  therefore,  a  patient 
applies  to  you,  who  is  the  subject  of  diffi¬ 
culty  in  passing  water,  and  of  frequent  at¬ 
tacks  of  partial  retention,  and  you  find  it 
impossible  to  pass  an  instrument  into  the 
bladder,  and  that  the  symptoms  are  not  re¬ 
lieved  by  warm-bath,  opium,  and  such  other 


872 


OPERATION  OF  DIVIDING  THE  STRICTURE  IN  PERINEO. 


remedies  as  have  already  been  mentioned, 
and  also  that  the  stricture  does  not  yield  to 
the  means  employed  for  its  dilatation,  nor 
to  the  action  of  caustic,  I  believe  the  most 
advisable  operation  to  be  cutting  through  the 
stricture  in  perineo,  as  by  this  mode  of 
procedure  you  not  only  radically  over¬ 
come  the  obstruction,  but  at  the  same 
time  relieve  the  retention  of  urine.  It 
is  true  that  this  operation  is  more  difficult 
than  the  others,  but  that  in  itself  offers  no 
reasonable  objection  to  its  adoption,  if  it 
actually  affords  more  benefit  to  the  patient. 
The  cause  of  its  frequent  failure  arises  from 
the  delay,  which  is  allowed  to  produce  great 
constitutional  disturbance  before  the  opera¬ 
tion  is  had  recourse  to  as  a  rational  means 
of  cure. 

The  operation  of  dividing  the  stricture  in 
perineo  is  performed  with  the  patient  in  the 
same  position  as  in  lithotomy  :  an  instrument 
is  passed  down  to  the  stricture,  the  grooved 
stall  being  perhaps  the  most  appropriate  to 
the  purpose.  An  incision  is  next  made  in  the 
perineum,  commencing  at  the  point  where  the 
end  of  the  instrument  can  be  felt  resting  on 
the  stricture  ;  the  groove  is  then  to  be  cut 
into,  and  the  knife  carried  downwards  with 
great  caution,  cutting  the  way  for  the  point 
of  the  staff,  which  should  be  made  to  follow 
it  as  it  gradually  divides  the  stricture,  and  the 
staff,  being  pushed  on,  passes  into  the  bladder. 
The  staff  should  then  be  withdrawn,  and  an 
elastic  gum  catheter  put  in  its  place,  and  re¬ 
tained  there  for  several  days.  I  have  gene¬ 
rally  adopted  another  plan  for  performing  this 
operation,  in  consequence  in  most  of  the  cases 
of  fistulous  opening  in  the  perineum  being 
concomitant  with  the  stricture.  Having- 
made  the  incision  into  the  perineum,  instead 
of  opening  the  urethra  at  the  groove  of  the 
staff  as  before  described,  I  have  first  opened 
the  membranous  parts  of  the  urethra  behind 
the  stricture,  and  then  passed  a  female 
catheter  into  the  bladder,  and  drawn  off  the 
urine  ;  thus  relieving  the  patient  of  the  re¬ 
tention,  but  having  still  to  divide  the  stric¬ 
ture  :  this  is  effected  by  feeling  within  the 
wound  for  the  point  of  the  grooved  staff 
above  the  stricture  ;  and,  proceeding  to  cut 
through  the  obstruction,  carrying  forward 
the  staff  as  before  described, — first,  how¬ 
ever,  having  withdrawn  the  female  catheter, — 
the  staff  enters  the  bladder  through  the 
opening  originally  made  for  that  instru¬ 
ment.  The  staff  should  then  be  with¬ 
drawn,  and  an  elastic  gum  catheter  inserted 
in  its  stead :  this  should  be  left  in  for  a 
week,  when  it  must  be  removed,  and 
substituted  by  a  new  one.  At  first,  some 
urine  will  escape  by  the  wound  through  the 
perineum,  as  in  the  operation  for  lithotomy  ; 
but  generally  in  the  course  of  a  week  or  ten 
days  it  passes  entirely  through  the  catheter. 
About  a  fortnight  after  it  has  entirely  ceased 


to  flow  from  the  perineum,  the  catheter 
should  be  removed,  but  still  for  some  time 
the  patient  should  regularly  have  the  water 
drawn  off,  and  this,  if  performed  with  gen¬ 
tleness,  produces  much  less  irritation  than 
would  be  excited  by  the  constant  presence 
of  an  instrument  in  the  bladder.  I  have,  at 
the  present  time,  a  gentleman  under  my  care, 
and  ten  days  have  elapsed  since  the  above 
operation  was  performed,  and  the  urine  has 
ceased  to  flow  from  the  perineum  ;  but  he 
continues  to  employ  the  catheter  to  evacuate 
the  bladder.  I  have  performed  this  opera¬ 
tion  many  times,  both  in  public  and  private 
practice,  and  am  convinced  that  if  resorted 
to  in  an  early  stage  of  the  disease,  or  at 
least  immediately  after  the  appearance  of 
urgent  symptoms,  there  are  few  cases  in 
which  it  would  not  prove  successful ;  but,  on 
the  other  hand,  in  protracted  cases,  suc¬ 
cess  is  very  doubtful.  When  a  permanent 
stricture  occurs  in  the  urethra  anterior  to 
the  bulb,  and  especially  in  that  part  of  the 
canal  covered  by  scrotum,  it  is  not  ad¬ 
visable  to  cut  down  upon  the  stricture  from 
without,  owing  to  the  liability  to  infil¬ 
tration  of  urine  if  the  incision  be  made 
through  the  scrotum,  and  of  the  difficulty 
of  healing  the  wound  when  the  opening  is 
made  anterior  to  it.  The  cure  of  such 
strictures  must,  therefore,  be  assiduously 
attempted  by  the  use  of  bougies  or  caustic, 
or,  should  they  resist  this  treatment,  per¬ 
haps  the  instrument,  furnished  with  a  cut¬ 
ting  stelitte,  employed  by  Mr.  Stafford, 
may  be  used :  as  this  part  of  the  urethra 
may  be  rendered  straight,  the  instrument 
may  be  directed  with  much  more  certainty 
than  when  the  stricture  is  seated  in  the  curved 
portion  of  the  canal.  I  should  myself, 
however,  prefer  opening  the  urethra  behind 
the  stricture,  if  retention  demanded  it, 
rather  than  to  puncture  the  stricture  itself. 

Obstructions  in  the  urethra  sometimes 
occur  from  the  lodgment  of  a  small  calculus 
in  the  passage,  and  this  may  lead  to  reten¬ 
tion  of  urine,  even  without  any  premonitory 
symptoms  leading  either  the  patient  or  the 
surgeon  to  suspect  the  cause  of  the  obstruc¬ 
tion.  The  patient,  however,  may  have 
experienced  pain  in  the  loins,  nausea,  and 
retraction  of  the  testicle ;  and  a  sudden 
cessation  of  these  symptoms,  probably  from 
the  use  of  a  warm  bath,  or  a  dose  of 
opium,  would  lead  you  at  once  to  suspect 
the  cause  of  the  retention,  and  would  ne¬ 
cessarily  preclude  the  propriety  of  passing 
an  instrument,  as  you  would  be  liable  to 
push  the  stone  back  again  into  the  blad¬ 
der;  and  this  would  lead  to  the  necessity 
for  some  future  serious  operation  for  its 
removal.  Should,  however,  the  foreign 
body  in  the  urethra  produce  decided  reten¬ 
tion,  it  must  be  removed,  either  by  a  pair 
of  forceps  passed  down  the  urethra  for  the 


POISONING  BY  CANTH ABIDES - RECOVERY. 


873 


purpose  of  crushing  it,  or  by  cutting  down 
upon  it,  and  removing  it  whole  ;  in  the  latter 
case,  the  patient  should  not  he  allowed  to 
pass  his  water  without  the  use  of  an  instru¬ 
ment,  or  a  permanent  fistulous  opening  is 
almost  certain  to  be  the  result :  in  these 
cases,  however,  the  wound  heals  much  more 
readily  than  in  cases  of  stricture,  which  fact 
is  easily  explicable,  as  in  the  former  case 
the  urethra  is  healthy,  while  in  the  latter 
its  diseased  condition  prevents  the  ready  re¬ 
union  of  the  divided  parts.  I  have  fre¬ 
quently  treated  cases  both  where  the  pre¬ 
sence  of  the  stone  was  manifest,  and  where 
its  existence  was  merely  suspected  from 
the  suddenness  with  which  the  obstruction 
occurred.  I  was  once  sent  for  to  a  gentle¬ 
man  at  Mould’s  Hotel,  who  had  been 
seized  with  retention  of  urine,  to  which, 
indeed,  he  told  me  he  had  been  subject  upon 
several  occasions.  With  some  considerable 
difficulty  I  at  length  succeeded  in  passing 
an  instrument  and  drawing  off  his  water  :  he 
remained  under  rr.y  care  for  about  ten  days, 
during  which  period  I  had  occasion  to  use 
the  catheter  three  or  four  times,  and  never 
detected  the  presence  of  a  stone  ;  one  day, 
however,  shortly  after  I  had  left  him,  a 
calculus  of  considerable  size  passed  from 
the  urethra,  and  he  has  remained  perfectly 
well  ever  since.  The  anomaly  in  this  case  is, 
how  the  catheter  could  pass  the  stone  with¬ 
out  giving  evidence  of  its  presence  ;  but  1 
suspect  that  it  had  lodged  in  the  bulb, 
where  it  had  perhaps  formed  a  kind  of 
pouch,  and  I  also  believe  that  its  formation 
had  taken  place  in  the  prostate  gland,  as 
its  constituents  proved  to  be  phosphate  of 
lime ;  and  this  would  account  for  the  ab¬ 
sence  of  symptoms  of  the  passage  of  the 
stone  from  the  kidney  into  the  bladder. 

I  was  sent  for  to  a  patient  who  had  sud¬ 
denly  become  the  subject  of  insuperable 
retention  of  urine,  unattended  by  any  pre¬ 
monitory  symptoms  :  the  patient  describing 
he  had  never  been  the  subject  of  stricture  or 
any  other  disturbance  to  the  passage  of  his 
urine.  Upon  attempting  to  pass  a  catheter, 
I  found  the  meatus  of  the  urethra  so  con¬ 
tracted  that  No.  6  could  not  be  introduced. 
I  was  therefore  obliged  to  substitute  a 
smaller  instrument,  which,  although  it  en¬ 
tered  the  passage,  was  immediately  stopped 
by  some  foreign  substance  :  with  a  probe- 
pointed  bistoury  I  enlarged  the  mouth  of  the 
urethra,  and  with  a  pair  of  small  “  dressing 
forceps”  easily  removed  a  calculus,  which  I 
found  to  have  been  the  only  cause  of  the 
obstruction  to  the  passage  of  the  urine. 


Original  ©cmmumcation*. 

POISONING  BY  CANTHARIDES. 
RECOVERY. 

By  Robert  Jamieson,  M.D.  Edin. 

Lecturer  on  Medical  Jurisprudence,  University 
and  King’s  College,  Aberdeen. 


Cantharides  is  not  a  poison  often 
employed  with  a  homicidal  purpose  ; 
its  injurious  effects  have  been  usually 
seen  in  cases  of  attempted  foeticide,  and 
have  unexpectedly  resulted  when  the 
drug  has  been  intentionally  and  fool¬ 
ishly  taken,  or  secretly  and  basely  ad¬ 
ministered,  with  the  view  of  exciting 
the  sexual  propensity.  Though,  as 
has  been  written,  nulliis  amor  est  me - 
dicabilis  herbis,  the  vulgar  belief  was 
once  strong  that  the  opposed  states  of 
apathy  or  aversion  were  quite  within 
the  management  of  drugs.  As  much 
powder  of  Spanish  flies  as  would  lie 
upon  a  silver  threepence,  administered 
at  the  height  of  the  moon,  or  at  some 
other  equally  favourable  astrological 
season,  was  formerly  a  reputed  pre¬ 
scription  for  what  was  termed  love 
powder.  The  occasional  administra¬ 
tion  of  the  pulvis  lyttse  to  cattle  has 
tended  to  make  the  nature  of  its  effects 
more  generally  known  than  might  he 
expected  amongst  such  persons  as  the 
criminal  in  the  following  case,  who 
being  better  acquainted  with  the  cha¬ 
racter  than  the  danger  of  its  action,  are 
liable  to  employ  it  mischievously,  in 
effecting  a  verv  coarse  and  hazardous 
practical  joke.  This  species  of  trick  is 
rather  an  old  one.  “  In  the  year  1691, 
October  25,”  says  Dr.  Greenfield  (Trea¬ 
tise  of  Cantharides,  translated  by  Mar¬ 
ten),  “  five  young  men  went  into  a 
tavern,  and  being  a  little  merry  with 
drinking  of  wine,  had  a  mind  to  try  the 
effects  of  cantharides,  having  some 
ready  powdered  by  them.  Some  time 
after,  a  friend  coming  in,  not  knowing 
anything  of  the  design,  after  some 
glasses  going  round,  they  gave  him 
one  with  a  large  dose  of  cantharides  ; 
in  a  few  hours  after  he  feels  great  itch¬ 
ing  and  pricking,  at  length  very  great 
heat  of  urine,  and  a  most  violent  stran¬ 
gury  ;  towards  the  evening,  Mr.  Foss- 
chet,  the  surgeon,  is  sent  for  (all  the 
while  his  sociates  are  privately  laugh- 


874 


POISONING  BY  CANTHARIDES - RECOVERY. 


ing  among  themselves);  the  surgeon 
examines  the  symptoms,  and  imme¬ 
diately  lets  him  blood,  and  prescribes 
emulsions  ;  but  the  patient  finding  no 
manner  of  ease  by  all  this,  mightily 
exclaims  at  his  sociates  ;  at  length  they 
confess  what  they  gave  him  to  drink ; 
then  the  surgeon  prepares  injections 
of  emollients  and  anodynes,  and  gives 
opiates,  but  all  to  no  manner  of  pur¬ 
pose  ;  after  five  days,  by  meer  ac¬ 
cident,  the  surgeon  meets  me,  tells  me 
the  story,  and  asks  my  advice,  which  I 
freely  gave  him,  and  prescribed  cam¬ 
phor  £)ij.  to  be  made  into  2  boluses, 
one  to  be  taken  presently,  the  other  in 
six  hours  after  ;  the  first  dose  gave  him 
great  ease,  the  last  quite  removes  all 
pain.  This  patient’s  master  was  one 
Mr.Bennet,an  honest  man,  well  known 
in  Wapping,  who,  upon  this  so  sudden 
and  good  success,  asks  the  surgeon  how 
he  came  by  such  a  remedy  ?  The  sur¬ 
geon  tells  him  the  whole  story  ;  I  am 
sent  for,  and  Mr.  Bennet  gives  me 
many  thanks,  and  discharges  me  with 
great  honour  and  civility.” 

On  Saturday  night,  the  13th  of  last 
May,  Robert  Petrie,  a  robust  country 
labourer,  about  23  years  of  age,  acci¬ 
dentally  encountered  in  the  village  of 
Banchory,  a  person  unknown,  whose 
acquaintance  he  had  made  some  months 
before,  in  working  together  on  a  rail¬ 
way  line.  Though  his  knowledge  of 
the  individual  was  so  slight  that  he  was 
ignorant  both  of  his  name  and  his  re¬ 
sidence,  it  was  quite  sufficient  to 
warrant  his  acceptance  of  a  share  of  a 
bottle  of  porter,  of  which  he  was  ge¬ 
nerously  made  the  offer,  and  which 
they  accordingly  sat  down  to  discuss 
together  in  a  neighbouring  inn.  While 
they  were  thus  pleasantly  engaged,  his 
friend  mentioned  to  him  that  he  was  in 
present  want  of  threepence  worth  of 
Spanish  flies  to  make  a  blister,  and  re¬ 
quested  him  to  go  out  and  make  the 
purchase,  as  he  would  know  better  than 
the  stranger  wrhere  such  a  thing  was  to 
be  got  good.  Petrie  had  no  objection 
to  show  himself  obliging,  and  went  out 
to  a  neighbouring  merchant’s,  where  he 
procured  aquarterofanounce  of  cantha- 
rides.  On  returning,  he  found  that  ano¬ 
ther  bottle  of  porter  had  been  called 
for,  and  was  already  equally  divided  in 
two  tumblers.  It  was  somewhere  at 
this  stage  of  the  transaction  that  the 
drink  was  hocussed  ;  but  whether 
during  Petrie’s  absence,  or  by  dexte¬ 


rous  juggling  when  he  was  present, 
cannot  be  determined.  •  They  finished 
their  porter  at  a  draught,  and  the 
friends  separated — Petrie  to  go  to  his 
home,  about  four  miles  distant,  and  the 
unknown  to  some  place  which  is  still 
as  unknown  as  himself.  Nothing  par¬ 
ticular  was  remarked  in  the  liquor 
when  it  was  swallowed,  and  the  vessels 
were  carried  off  and  cleaned  by  the 
inn-servant,  without  anything  being 
observed  about  them  to  attract  unusual 
attention. 

The  patient  had  not  proceeded  far  on 
his  way,  when  he  began  to  feel  a 
strange  heat  in  his  mouth.  He  got 
very  sick,  and  vomited  several  times 
on  the  road ;  he  had  pain  in  making 
water,  and  became,  in  his  own  phrase, 
so  “  senseless,”  that  he  had  great  diffi¬ 
culty  in  reaching  home. 

Next  day,  Dr.  Thom,  of  Banchory, 
was  sent  for,  and  found  him  in  bed, 
with  cold  extremities,  anxious  counte¬ 
nance,  pain  and  heat  in  the  stomach, 
profuse  salivation,  indistinct  articula¬ 
tion,  difficulty  in  swallowing,  stran¬ 
gury,  and  bloody  urine.  He  under¬ 
stood  that  the  patient  believed  himself 
to  be  poisoned  by  something  which 
had  been  mixed  in  the  porter ;  and, 
from  the  history  and  symptoms,  he  had 
little  doubt  but  that  he  had  had  can- 
tharides  given  to  him.  On  examining 
his  mouth,  the  tongue  and  fauces  were 
found  swollen  and  inflamed  ;  the  mu¬ 
cous  membrane  was  elevated  here  and 
there  in  vesications,  and  small  particles 
of  the  poison  suspected  were  found 
sticking  between  the  teeth.  Vomiting 
having  already  taken  place  freely,  the 
patient  was  directed  to  drink  plenti¬ 
fully  of  milk,  gruel,  and  barley-water, 
from  the  employment  of  which  much 
relief  was  experienced.  In  the  even¬ 
ing  a  full  opiate  was  prescribed,  and 
the  diluents  ordered  to  be  continued. 

15th. — The  patient  had  slept  well, 
but  the  pain  in  the  abdomen  and  loins 
was  very  considerable,  and  the  irrita¬ 
tion  of  the  urinary  organs  greater. 
Pulse  90,  sharp. 

Blood  was  taken  from  the  arm  until 
the  approach  of  faintness;  fomenta¬ 
tions  were  ordered  to  the  abdomen  ; 
the  demulcents  to  be  continued  ;  three 
grains  of  Pulv.  Ipecac,  every  three 
hours  ;  and  castor  oil,  if  required. 

16th. — Painful  symptoms  considera¬ 
bly  relieved.  Had  passed  a  greenish 
stool  mixed  with  mucus  and  blood. 


POISONING  BY  CANTHARIDES — RECOVERY 


875 


Urine  still  bloody  and  scanty.  Ap¬ 
pearance  agitated  and  confused.  Pulse 
95,  softer.  Head  to  be  shaved. 

17th. — Much  the  same.  Half  an 
ounce  of  castor  oil. 

I  visited  on  the  evening  of  the  next 
day,  along  with  Dr.  Thom,  and  found 
the  patient  perfectly  collected,  and  evi¬ 
dently  beginning  to  recover.  The  calls 
to  make  water  were  still  frequent,  and 
the  secretion  was  scanty,  and  dis¬ 
coloured  by  some  worm-shaped  coagula 
of  blood.  There  was  no  pain  in  the 
head  ;  the  pain  in  the  back  was  gone, 
and  there  was  neither  tenseness  nor 
tenderness  of  the  abdomen.  There 
was  no  inflammation  nor  swelling 
about  the  genital  organs,  and  priapism 
had  not  been  a  prominent  symptom. 
He  complained  much  of  the  tenderness 
in  his  mouth,  arising  from  the  raw 
patches  on  the  tongue,  inside  of  the 
lips  and  velum,  and  ptyalism  was  still 
rather  profuse.  The  castor  oil  had 
brought  off  three  feculent  stools  of  a 
natural  colour,  in  which  were  several 
discoloured  coagula  of  a  small  size,  but 
no  trace  of  cantharides  particles  dis¬ 
coverable  by  an  ordinary  examination. 
The  pulse  was  84,  and  soft ;  the  skin 
warm  and  moist,  and  the  expression 
of  countenance  natural. 

The  improvement  was  steadily  pro¬ 
gressive  ;  and  some  days  afterwards  I 
understood  from  Dr.  Thom  that  the 
patient  had  entirely  recovered. 

In  this  case  all  the  usual  phenomena 
of  poisoning  by  this  agent  were  pre¬ 
sent,  with  the  exception  of  diarrhcea, 
priapism,  and  inflammation  of  the 
generative  organs.  The  dose  taken 
was  probably  two  drachms,  which  was 
the  quantity  purchased ;  but  on  this 
point  there  is  room  for  uncertainty. 
The  active  principle  of  the  cantharides 
being  dissolved  in  the  porter,  the  re¬ 
mote  action  of  the  poison  on  the  system 
was  manifested  nearly  as  speedily  as 
its  local  irritation  on  the  stomach. 
Symptoms  of  urinary  irritation  had 
begun  before  the  patient  reached 
home.  The  violence  of  its  acrid  effect 
seems  to  have  been  mainly  confined  to 
the  mouth,  gullet,  and  stomach ;  and, 
from  the  absence  of  diarrhoea  and 
bloody  stools,  it  might  be  inferred  that 
the  powder  had  been  almost  entirely 
ejected  by  vomiting,  and  that  but  a 
small  quantity  had  found  its  way  into  j 
the  intestinal  tube. 

Independent  of  the  proof  afforded  by 


the  detection  of  particles  of  the  pow¬ 
der  in  the  interstices  of  the  teeth,  the 
history  of  this  case  would  have  been 
sufficiently  conclusive  of  the  poison 
which  had  been  taken.  Highly  cha¬ 
racteristic,  and  in  many  points  pecu¬ 
liar,  as  the  symptoms  produced  by 
cantharides  are,  they  cannot  be  held 
to  be  sufficiently  diagnostic  of  them¬ 
selves,  since  the  publication  by  Dr. 
Hastings,  of  Worcester,  of  a  remarka¬ 
ble  instance — one,  so  far  as  I  am 
aware,  which  is  unique — of  natural 
death,  in  which  every  prominent  fea¬ 
ture  during  life,  and  the  appearances 
in  the  body  after  death,  would,  in  the 
absence  of  known  evidence  to  the  con¬ 
trary,  have  been  held  conclusive  of  the 
administration  of  this  agent.  (Trans, 
of  Prov.  Med.  Assoc,  i.  402).  During 
life  the  indications  were,  the  sudden 
and  unaccountable  occurrence  of  vo¬ 
miting  ;  pain  in  the  stomach  and 
loins;  strangury;  heematuria ;  and 
painful  tumidity  about  the  generative 
organs ;  and  after  death,  the  kidneys, 
ureters,  ovaries,  and  Fallopian  tubes, 
were  found  inflamed  ;  the  bladder  con¬ 
tained  blood,  and  the  villous  coat  of 
the  stomach  presented  appearances 
such  as  are  produced  by  the  irritant 
poisons,  and  are  rarely  occasioned  by 
any  other  cause. 

Symptoms  of  combined  gastric  and 
genito-urinary  irritation,  even  when  of 
sudden  occurrence,  and  under  circum¬ 
stances  of  a  suspicious  nature,  cannot 
therefore  amount  to  proof  of  the  agency 
of  this  poisonous  article,  if  no  traces 
of  the  substance  itself,  or  its  active 
principle,  be  discovered  in  the  vomited 
matters,  the  dejections,  or,  after  de¬ 
cease,  in  some  part  of  the  stomach  and 
intestines.  The  loosening  of  the  mu¬ 
cous  membrane  of  the  mouth  by  vesi¬ 
cation — a  result  observed  in  the  pre¬ 
sent  instance,  but  not  a  constant 
phenomenon  —  would,  when  it  does 
exist,  be  a  very  important  means  of 
discriminating  the  effects  of  cantharides 
from  those  of  any  morbid  condition 
such  as  that  recorded  by  Dr.  Hastings, 
in  those  instances  in  which  circum¬ 
stantial  and  necroscopical  proof  was 
deficient.  No  other  acrid  poison  occa¬ 
sions  a  similar  train  of  symptoms.  The 
muriated  tincture  of  iron  might  give 
I  rise  to  a  considerable  amount  of 
|  urinary  disorder ;  but,  when  given  in 
j  doses  to  prove  poisonous,  it  kills,  from 
the  amount  of  muriatic  acid  which  it 


876 


ON  THE  TREATMENT  OF  PHTHISIS  PULMONALIS — 


contains,  by  the  mode  of  corrosive 
irritation. 

Several  remedies  have  been  recom¬ 
mended  in  this  form  of  poisoning,  after 
the  efficient  emptying  of  the  stomach — 
amongst  which  may  be  enumerated 
diluents,  camphor,  bark,  stimulants, 
and  narcotics:  in  other  words,  the 
treatment  must,  as  in  the  case  of  most 
poisons,  be  upon  no  specific  plan,  but 
regulated  entirely  by  the  aspect  of  the 
danger  in  each  particular  case.  When 
the  symptoms  are  merely  those  of 
strangury,  camphor  emulsion  with 
mucilaginous  diluents  will  be  suffi¬ 
cient;  but  where  the  case  is  compli¬ 
cated  with  gastric  inflammation,  vene¬ 
section  may  be  required,  and  advan¬ 
tageously  employed,  if  emesis  have 
been  complete.  In  those  instances  in 
which  the  poisonous  influence  on  the 
nervous  system  forms  an  early  and  a 
threatening  feature,  much  good  seems 
to  have  resulted  from  the  employment 
of  stimulants.  In  such  cases,  can- 
tharides,  while  it  occasions  its  charac¬ 
teristic  effects  on  the  urinary  organs, 
depresses  the  action  of  the  heart,  and, 
unless  alcoholic  stimulants  and  opiates 
be  freely  administered,  will  occasion 
death  by  syncope.  Either  of  the  pre¬ 
ceding  modes  of  treatment  pursued 
from  a  mistaken  view  of  the  nature  of 
the  irritant  action,  would,  under  such 
circumstances,  prove  fatal :  the  one  by 
its  inertness  ;  the  other  by  its  activity. 

Aberdeen,  Oct.  14,  1848. 


SOME  REMARKS  ON  THE 

TREATMENT  OF  PHTHISIS  PUL¬ 
MONALIS; 

AND  ESPECIALLY  ON  THE  USE  OF  COD- 
LIVER  OIL  IN  THAT  DISEASE. 

By  Sir  Charles  Scudamore. 


In  my  publication  on  Tubercular 
Phthisis  and  Bronchitis,  I  have  repre¬ 
sented  myself  to  have  had  a  con¬ 
siderable  share  of  success  in  my  com¬ 
bined  mode  of  treatment,  by  the  use  of 
inhalation ,  alteratives,  and  tonics  ;  fur¬ 
ther  assisted  by  ablutions,  local  com¬ 
presses,  and  occasional  counter- irrita¬ 
tion,  with  very  supporting  diet,  and 
that  attention  to  climate,  good  air, 
proper  ventilation,  and  general  regi¬ 
men,  which  no  class  of  invalids  more 
require  than  the  consumptive. 


I  may  be  considered  to  have  drawn 
too  flattering  a  picture  of  the  medica- 
bility  of  phthisis,  and  of  the  remedial 
influence  of  the  inhalation  of  iodine 
with  conium  towards  the  absorption  of 
early  tubercles,  and  the  healing  of 
small  cavities  when  tubercles  have 
softened.  In  extremely  bad  cases,  I 
have,  in  common  with  my  medical 
brethren,  to  lament  the  usual  failure 
of  the  treatment.  But  I  contend,  that 
even  when  success  is  not  possible,  the 
symptoms  may,  by  the  combined  means 
to  which  I  have  alluded,  be  greatly 
mitigated,  and  life  be  prolonged.*  It 
must  be  kept  in  view,  that  chronic 
bronchitis  forms  a  large  part  of  the 
disease  in  tubercular  phthisis;  and 
those  who  deny  the  benefit  to  be 
afforded  to  the  morbid  conditions  of 
the  bronchial  membrane  by  inhala¬ 
tion,  cannot,  I  affirm,  have  made  fair 
trial  of  the  treatment. 

But  it  is  not  my  present  object  to 
expatiate  on  this  particular  point;  and 
I  take  up  my  pen  to  offer  a  few  re¬ 
marks  on  the  use  of  cod-iiver  oil — a  re¬ 
medy  which  is  daily  exciting  increased 
attention  for  the  relief  of  the  consump¬ 
tive. 

In  my  Treatise  on  Rheumatism, 
published  in  1827,  I  adverted  to  this 
remedy,  as  first,  I  believe,  recom¬ 
mended  by  Dr.  Percival,f  and  favour¬ 
ably  mentioned  by  the  late  Dr.  Bards- 
ley  in  his  Reports.  The  exceeding 
nauseousness  of  the  article  has  always 
been  a  great  hindrance  to  its  use ;  and 
I,  not  standing  alone  in  this  respect, 
choosing  to  look  to  the  patient’s  com¬ 
fort  rather  than  urge  him  to  revolting 
measures,  have  been  slow  to  advise  the 
use  of  this  oil.  Yet  I  have  not  omitted 
to  prescribe  it  in  consumptive  cases; 
confessing,  however,  that  I  have  not 
met  with  many  instances  in  which  a 
perseverance  in  the  taking  of  the  oil 
lias  appeared  possible  :  the  recusants 
having  declared  that  they  would  accept 
any  alternative  to  the  misery  of  a  fre¬ 
quent  swallowing  of  this  nauseous 
fluid.  There  may,  however,  be  found, 
many  accommodating  stomachs  that 
will  not  rebel ;  and  there  are  some  in- 

*  1  have  had  a  few  eases  in  which  a  cavity  of 
very  considerable  size,  being1  in  one  lung  onlv, 
has  so  far  yielded  to  treatment,  that  seeming  re¬ 
covery  has  taken  place,  and  life  has  been  much 
prolonged- in  one  remarkable  instance,  three 
years.  Nature  sometimes  makes  surprising  efforts 
towards  cui'e  in  consumption  :  it  is  not  too  much 
to  say,  that  she  may  be  materially  assisted. 

t  Died  1804,  eet.  64. 


AND  ON  THE  USE  OF  COD-LIVER  OIL  IN  THAT  DISEASE. 


877 


dividuals  who  even  contract  a  liking  to 
it,  as  do  the  Russians  to  the  train  oil. 

It  becomes  a  question  of  some  im¬ 
portance  to  examine  further  into  the 
merits  of  cod-liver  oil,  and  ascertain 
the  fittest  pharmaceutical  state  in 
which  it  can  be  prescribed. 

In  the  Medical  Gazette  for  1843, 
Nos.  839,  840,  Mr.  Chalk  has  given 
valuable  papers  “  On  the  effects  of  the 
cod-liver  oil*  upon  strumous  anu  other 
diseases” — the  results  of  his  practice  in 
the  Margate  Infirmary.  Till  of  late  this 
oil  has  been  almost  a  disregarded  me¬ 
dicine.  Neither  in  Hooper’s  Medical 
Dictionary  (1825) ;  nor  in  Thomson’s 
Elements  of  Materia  Medica  and  The¬ 
rapeutics  (1835),  is  it  at  all  mentioned. 

In  Good’s  Study  of  Medicine,  (vol. 
ii.  1825)  I  find  the  following  state¬ 
ment: — “This  offensive  material  is 
procured  by  the  process  of  putrefaction, 
and  appears  to  derive  its  stimulant 
power  at  least  as  much  from  rancidity 
as  from  any  natural  quality. 

“  Dr.  Percival  tried  it  upon  a  large 
scale  in  the  Manchester  Infirmary,  and 
with  so  much  success,  that,  nauseous  as 
it  is  to  the  taste,  rheumatic  patients, 
from  being  eye-witnesses  of  its  benefit, 
were  in  the  habit  of  applying  to  him 
for  a  course  of  it. 

“  Dr.  Bardsley  has  since  spoken  of  it 
in  terms  of  equal  recommendation  ;  and 
Dr.  Parr  asserts  that  he  thinks  he  has 
seen  chronic  rheumatism  yield  to  a  con¬ 
stant  use  of  this  oil,  which  had  resisted 
every  other  remedy.  Dr.  Bardslev’s 
dose  was  from  one  to  three  table¬ 
spoonfuls  in  the  course  of  the  day.” 

I  may  here  observe,  that  I  have  not 
found  it  an  eligible  remedy  in  chronic 
rheumatism. 

The  decided  good  name  now  accorded 
to  this  oil  in  pulmonary  consump¬ 
tion  and  marasmus,  has  caused  it 
to  be  a  subject  of  particular  atten¬ 
tion  with  the  pharmaceutical  chemist. 
None  can  claim  exclusive  credit  for 
keeping  that  which  is  genuine  ;  but  I 
believe  that  no  one  has  paid  more  at¬ 
tention  to  its  preparation  than  Mr. 
Bell,  of  Oxford  Street.  I  have  not 
seen  any  so  beautifully  transparent, 
light  in  colour,  and  so  little  disagreeable 
in  odour  and  taste,  as  his  first  quality 
oil,  which  is  the  first  spontaneous  flow 

*  He  gives  a  quotation,  stating  that  the  liver 
of  the  melter  cod  yields  the  strongest  oil,  and 
darker  in  colour  than  that  of  the  spawner.  I  do 
not  give  any  credit  to  the  truth  of  this  account. 


ofit  from  the  application  of  steam  heat.* 
That  which  comes  off  afterwards  is  of 
darker  colour,  and,  though  rendered 
perfectly  clear  by  filtration,  is  less 
acceptable  to  the  palate.  Some  me¬ 
dical  men  with  whom  I  have  conversed 
prefer  the  darker  sort,  asserting  it  to 
be  more  efficacious,  but,  l  think,  pro¬ 
bably  not  with  good  reason.  It  cer¬ 
tainly  contains  a  larger  portion  of 
stearine  (solid  fatty  matter),  but  it  has 
the  serious  disadvantage  of  being  the 
most  nauseous ;  and  it  seems  fair  to 
presume  that  the  lighter  and  more 
transparent  sort — the  first  flowing 
from  the  liver — which  contains  less 
stearine  and  more  liquid  oil  (oleine),  is 
really  as  conducive  to  nutrition  from 
its  oil,  as  the  dark  from  its  surplus  of 
stearine,  and  far  more  palateable. 

Assuredly  such  oil  as  is  procured 
from  the  putrefactive  state  of  the  liver, 
under  exposure  to  the  sun’s  rays, 
should  be  rejected  as  unfit  for  use. 
The  cod  furnishes  this  species  of  oil 
more  abundantly  than  any  other  fish. 
The  livers  should  be  well  chosen,  and 
none  but  steam  heat  be  employed. 

Vegetable  oils  have  been  tried  in 
comparison  of  effect  with  this  animal 
one;  and  it  is  found  that  they  are  less 
nutritious,  and  not  so  easily  digested. 

Mr.  Chalk  informs  me  that,  after 
much  trial,  he  found  small  or  medium 
doses  succeed  the  best.  1  am  convinced 
that  it  is  right  to  begin  with  a  dose  of 
from  5i.  to  5ih>  and,  as  a  general 
statement,  not  to  go  beyond  half  an 
ounce,  three  times  a  day.  If  it  cannot 
be  digested,  as  shown  in  the  perma¬ 
nent  nausea  which  it  may  produce,  or 
if  it  run  off  by  the  bowels,  the  remedy 
fails.  The  mode  of  taking  it  must  be 
studied.  It  may  be  allowed  to  float  on 
extremely  dilute  brandy  and  water,  or 


*  In  a  book  on  the  Natural  History  of  Fishes, 
I  find  the  following  statement,  as  quoted  from  a 
work  of  Sir  A.  Capel  de  Brooke,  who  speaks  of 
the  method  used  on  the  North  Coast  of  Norway 
for  obtaining  the  cod-liver  oil : — “The  livers  are 
taken  home  in  barrels,  which  are  allowed  to 
stand  as  long  as  possible  to  produce  the  clearer 
kind  of  oil.  This,  which  is  called  blank  trail,  or 
white  oil,  exudes  from  the  liver  by  its  own  pres¬ 
sure,  and  is  the  most  valuable;  the  livers  are 
afterwards  boiled  up  in  large  cauldrons,  kept 
constantly  stirring,  and  the  oil,  as  it  rises,  is 
skimmed  off  and  barrelled. 

The  oil  thus  obtained  is  called  brnnn  tran,  brown 
oil,  and  does  not  fetch  in  general  so  good  a  price 
as  the  former.  500  cod  livers  are  reckoned  to 
make  a  barrel  of  36  gallons  ;  30,000  barrels  are 
annually  exported  from  Norway. 

This  oil  is  principally  sent  to  Holland,  where  it 
is  used  in  the  currying  ot  leather. 


878 


ON  THE  TREATMENT  OF  PHTHISIS  PULMONALIS. 


tepid  milk,  or  lime  water,  but  I  think 
that  most  persons  will  prefer  plain 
water,  making  a  determined  swallow, 
and  washing  the  mouth,  and  taking 
something  agreeable  to  conciliate  the 
palate  and  throat,  before  the  recovery 
of  the  breath. 

When  the  patient  is  in  a  state  of 
great  debility,  it  may  be  useful,  and 
perfectly  consistent,  to  ally  with  the 
oil,  at  other  periods  of  taking  it,  the 
use  of  a  tonic  or  alterative  tonic,  as 
quinine,  or  sulphate  of  iron,  in  a  pill ; 
or  the  iodide  of  iron,  or  other  forms  of 
iron,  in  solution.  But  I  am  disposed 
to  say,  that  when  the  persevering  use 
of  the  oil  seems  to  fulfil  all  purposes, 
it  should  be  used  alone,  with  the  ex¬ 
ception  that  it  may  be  right  to  conjoin 
the  inhalation  of  iodine  and  conium. 
All  juvantia  are,  of  course,  to  be  em¬ 
ployed;  all  Icedentia  avoided. 

Whence  the  modus  operandi  of  this 
oil?  We  should  never  reject  a  suc¬ 
cessful  medicine  because  we  cannot 
explain  its  useful  properties  ;  but  it 
is  extremely  pleasing  when  the  indica¬ 
tions  of  science  are  fulfilled  by  the 
results  of  experience.  Chemistry  is  a 
beautiful  hand-maid  to  medicine,  yet 
must  not  always  be  worshipped  too 
closely. 

Mr.  Phillips,  in  his  very  able  work 
on  Scrofula,  alluding  to  the  opinion  at 
one  time  entertained  that  the  virtues 
of  cod-liver  oil  were  due  to  iodine  and 
bromine,  remarks  that,  according  to 
Falker,  when  iodine  has  been  found, 
(and  this  rarely,  rather  than  uniformly) 
it  did  not  amount  to  more  than 
ToWo  Pal’t  5  and,  according  to  Wacken- 
roder,  0*162  per  cent. 

I  learn  that  Dr.  Ure  has  not  suc¬ 
ceeded  in  his  endeavours  to  find  iodine 
in  this  oil.  Mr.  Phillips  expresses  his 
belief  that,  when  good  is  derived  in 
scrofula  from  the  cod-liver  oil,  it  is  to 
be  referred  to  its  effect  in  improving 
digestion  and  nutrition.  He  does  not 
appear  to  rate  its  powers  highly. 

1  have  shown  by  numerous  experi¬ 
ments,  as  related  in  my  Treatise  on 
Tubercular  Phthisis,  that  in  this  dis¬ 
ease  the  animal  heat  is  higher,  and 
often  very  remarkably  so,  than  in  any 
other  chronic  disease ;  indeed,  I  con¬ 
sider  it  to  be  one  of  the  diagnostic 
signs  of  tubercles. 

Notwithstanding  that  there  is  a  great 
abridgment  of  acting  lung,  and  this 
sometimes  to  a  wonderful  extent,  we 


find  that,  such  is  the  increased  activity 
of  aeration,  the  animal  heat  is  in  mor¬ 
bid  excess,  even  when  there  is  no 
feverish  condition  shewn.  In  acute 
consumption,  I  have  sometimes  found 
it  105°  (the  mean  normal  point  being 
96^),  and  then  the  hectic  fever  has 
been  in  proportion,  the  emaciation 
rapid  —  a  state  emphatically  called 
“  galloping  consumption.” 

Is  the  wasting  of  the  body, — one  of 
the  strongest  signs  of  pulmonary  con¬ 
sumption, — to  be  accounted  for  from 
the  rapid  absorption  of  the  tissues,  de¬ 
manded,  as  it  were,  by  this  increased 
rate  of  aeration  ;  and  does  the  admi¬ 
nistration  of  the  cod-liver  oil,  such  a 
highly  carbonaceous  principle,  serve  to 
check  the  loss  of  flesh  and  strength, 
in  being  a  pabulum  to  the  oxygen, 
and,  in  great  measure,  elected  by  the 
oxygen  for  combustion  (to  use  the 
chemical  phrase),  instead  of  the  tis¬ 
sues  of  the  body  ?  I  have  submit¬ 
ted  these  views  to  my  friend  Dr. 
Garrod,  who,  to  the  good  physician, 
unites  the  accomplished  chemist,  and 
he  thinks  them  reasonable.  Happily 
we  find  instances  in  which  consump¬ 
tive  patients  do  take  this  oil  success¬ 
fully,  finding  their  appetite  to  improve 
instead  of  decreasing,  and  that  they 
gain  flesh  and  strength.  Hence  we  see 
a  reason  for  administering  as  full  doses 
as  can  be  found  perfectly  to  agree. 

In  concluding  my  subject,  I  am 
induced  to  offer  a  few  further  reflec¬ 
tions. 

Looking  at  the  condition  of  the  con¬ 
sumptive  patient,  we  find,  too  often,  a 
state  of  total  emaciation  :  not  merely  a 
loss  of  fat,  but  also  of  the  gelatinous 
and  albuminous  tissues.  Whatever  im¬ 
portance  we  may  attach  to  the  adminis¬ 
tration  of  this  oil,  as  a  contribution  to 
the  oleaginous  principle  in  the  animal 
economy,  we  must  also  consider  it  ne¬ 
cessary  to  direct  a  generous  diet,  con¬ 
sisting  of  various  articles  of  nutriment, 
suited  to  the  inclination  of  the  patient, 
to  his  powers  of  digestion,  and  in  har¬ 
mony  with  the  proper  treatment  of  his 
symptoms. 

The  theory  of  digestion  and  assimi¬ 
lation  which  might  be  founded  alone  on 
chemical  views,  would  very  insuffi¬ 
ciently  explain  the  ultimate  acts  of  the 
nutritive  process,  in  a  large  degree  de¬ 
pending  on  vital  function — the  play  of 
the  vital  principle. 

In  No.  81  of  the  Monthly  Journal  of 


=2K 


DR.  MILROY  ON  THE  USE  OF  EMETICS  IN  CHOLERA. 


879 


Medical  Science,  will  be  found  a  very 
ingenious  paper  by  Dr.  John  Hughes 
Bennett,  “  On  the  structural  relation  of 
oil  and  albumen  in  the  animal  economy, 
and  on  certain  physical  laws  connected 
with  the  origin  and  development  of 
cells.”  The  inquiry  relates  to  the  man¬ 
ner  in  which  the  daily  waste  of  the 
body  is  repaired. 

After  adverting  to  the  known  fact, 
that  albumen  constitutes  the  basis  of 
the  tissues,  and  that  oil  furnishes  the 
elements  of  respiration  and  of  animal 
heat,  the  author  remarks  as  follows  : — 
“This ingenious  theory, however  it  may 
account  for  the  tear  and  wear  of  the 
animal  machine,  in  no  way  explains 
the  origin  and  maintenance  of  cell 
growth,  which  anatomists  and  phy¬ 
siologists,  by  another  series  of  re¬ 
searches  equally  exact,  have  shewn  to 
be  essential  to  the  vital  functions.  By 
not  paying  attention  to  structure,  also, 
the  chemist  has  overlooked  the  fact 
that  oil  is  not  merely  a  material  for 
combustion,  but  is  as  essential  to  the 
formation  of  the  tissues  as  albumen ; 
for,  as  we  shall  subsequently  see,  there 
is  no  elementary  cell  with  which  both 
oil  and  albumen  do  notenter  as  consti¬ 
tuent  parts.  It  would  be  foreign  to  my 
present  object  to  pursue  a  scientific 
digression ;  but  it  will  be  allowed  to 
me,  I  hope,  to  enter  so  far  into  theory 
as  I  have  done  in  this  practical  paper. 

It  is  desirable  that  medical  practi¬ 
tioners  should  report  their  experience 
with  this  newly  revived  therapeutic 
agent,  in  the  journals,  from  time  to 
time. 

Wimpole  Street,  Oct.  30,  1848. 


ON  THE 

USE  of  EMETICS  in  CHOLERA. 

By  Gavin  Milroy,  M.D. 

Member  of  the  Royal  College  of  Physicians,  &c. 


No.  II. 

In  my  former  paper*,  I  endeavoured  to 
point  out  the  good  effects  of  emetics  in 
the  treatment  of  the  common  cholera 
of  this  country  ;  and  not  only  in  mild 
cases  of  the  disease,  but  also  when  the 
symptoms  are  very  severe,  and  there 
seems  danger  of  the  attack  running  on 
to  something  like  one  of  the  Asiatic 
pestilence.  The  modus  operandi  of 


artificial  vomiting  in  such  cases  was 
suggested  to  be  threefold  : — 1st,  the  dis- 
lodgment  of  offending  matters  irritating 
the  stomach  and  duodenum,  and  which 
the  efforts  of  nature  are  unable  per¬ 
fectly  to  effect ;  2d,  the  suspension  of 
these  ineffectual  efforts,  and  the  conse¬ 
quent  arrest  of  the  excited  irritability 
of  the  affected  organs  ;  and  lastly,  the 
cessation  of  the  exaggerated  detrusive 
action  of  the  lower  part  of  the  intesti¬ 
nal  tube  downwards,  by  the  forcibly- 
inverted  action  of  its  upper  extremity, 
as  we  often  see  to  be  signally  exem¬ 
plified  in  the  treatment  by  emetics  of 
diarrhoea  and  dysentery.  There  are 
other  cotemporaneous  or  subsequent 
efforts  of  vomiting,  such  as  the  relaxa¬ 
tion  of  spasm  every  where,  and  the 
copious  diaphoresis  on  the  skin,  which 
are  not  without  their  advantage  :  but 
as  these  results  are  more  directly  salu¬ 
tary  in  such  diseases  as  jaundice  and 
fevers,  than  in  cholera,  it  is  not  neces¬ 
sary  here  to  do  more  than  merely 
mention  them  in  passing.  But  I  wish, 
before  proceeding,  to  invite  the  reader’s 
attention  for  a  few  moments  to  the 
second  effect  attributed  above  to  emetics, 
viz.  that  of  allaying  the  excited  irrita¬ 
bility  of  the  stomach ;  and  the  more 
so,  as  I  fear  that  medical  men  are  often 
too  timid  in  the  use  of  the  remedy  in 
question,  from  fear  of  aggravating  this 
very  symptom.  I  believe  this  to  be, 
in  many  instances,  a  great  mistake; 
provided,  always,  there  be  no  reason  to 
suspect  the  existence  of  incipient  cere¬ 
bral  mischief  (as  is  not  unfrequently 
the  case  in  young  children  when  obsti¬ 
nate  vomiting  occurs),  or  of  inflamma¬ 
tion,  or  any  organic  lesion  of  the 
stomach.  Certain  it  is,  that  sponta¬ 
neous  vomiting,  even  when  it  has 
existed  for  a  length  of  time,  or  been  of 
frequent  occurrence,  will  often  yield 
more  promptly,  and  withal  much  more 
satisfactorily  as  respects  after  conse¬ 
quences,  to  the  exhibition  of  a  mild, 
but  efficient,  emetic,  than  to  the  in¬ 
ternal  use  of  sedative  or  repressive 
means.  The  vomiting  which  occurs 
in  the  early  months  of  pregnancy  may 
frequently  be  much  relieved  by  a 
draught  of  chamomile  tea,  taken  every 
morning  for  a  week  or  a  fortnight : 
the  expulsive  efforts  are  rendered  at 
first  more  easy  and  less  straining,  and 
subsequently  they  become  less  frequent 
and  severe.  Still  more  decided  is  the 
benefit  from  encouraging  the  vomiting 


*  Med.  Gaz.  Oct.  27. 


8*0 


DR.  MILROY  ON  THE  USE  OF  EMETICS  IN  CHOLERA. 


that  is  not  an  uncommon  attendant  of 
dysmenoirhoea  and  hysteralgia :  it 
should,  almost  always,  be  promoted  for 
a  short  time  before  recourse  is  had  to 
opiates  or  other  similar  remedies.  The 
same  remark  may  be  made  as  to  the 
vomiting  that  generally  occurs  at  the 
outset  of  small-pox,  and,  indeed,  of 
most  other  fevers,*  as  well  as  in  ne¬ 
phritic  and  nephralgic  attacks,  in 
painters’  colic,  during  labour,  and  so 
forth.  In  all  these  cases,  it  is,  where 
not  unusually  protracted  or  violent,  a 
purely  sanative  and  salutary  act,  that 
should  not  be  rudely  or  untimeously 
checked.  But  even  when  this  cannot 
be  affirmed  of  the  symptom,  the  phy¬ 
sician  will  sometimes  obtain  good  re¬ 
sults  from  a  practice  which  some  may 
be  disposed  to  savour  of  homoeopathic 
principles.  Take  the  following  case 
for  example : — 

Mrs.  W.,  set.  29,  of  a  slender  and 
delicate  habit  of  body,  stated  that  for 
the  last  three  or  four  years,  ar.d  more 
especially  during  the  spring  months, 
she  had  been  subject  to  frequent 
attacks  of  vomiting  almost  imme¬ 
diately  after  taking  food :  she  first 
experienced  a  sense  of  painful  uneasi¬ 
ness  in  the  left  hypochondrium,  and, 
very  soon  afterwards,  whatever  she  had 
swallowed  was  rejected  from  the  sto¬ 
mach.  In  this  manner  she  sometimes 
vomitedsixand  seven  times  in  the  course 
of  the  twenty-four  hours;  the  annoy¬ 
ance  had  been  quite  as  frequent  as  this 
for  several  days  before  she  applied  to 


*  The  utility  of  promoting  this  symptom,  even 
in  the  more  advanced  stage  of  typhus,  is  ex¬ 
pressly  mentioned  by  Dr.  Lalor,  in  his  interest¬ 
ing  account  of  the  epidemic  fever  at  Kilkenny 
last  year.  He  says:— “The  irritability  of  sto¬ 
mach,  and  especially  the  green  vomit  so  pre¬ 
valent,  often  baffled  treatment  from  the  first. 
The  best  and  safest  general  remedy,  at  all  periods 
of  this  affection,  was  the  application  of  external 
stimulants,  as  sinapisms  or  blisters,  over  the 
stomach.  After  the  first  twenty-four  hours,  in¬ 
ternal  remedies  had  a  fairer  chance;  and,  of 
these,  effervescing  draughts,  opium,  and  creosote 
were  the  best.  Stimulating  emetics  sometimes 
produced  a  good  effect  very  rapidly,  in  cases 
where  extreme  collapse  was  produced  by  constant 
small  vomitings  or  nausea .  The  principal  emetic 
I  used  was  mustard ;  and  in  the  above  cases 
reaction  often  speedily  followed,  and  the  nausea 
or  vomiting  was  quieted  after  the  action  of  the 
emetic.  Emetics  should  be  avoided  when  drowsi¬ 
ness,  or  any  decided  symptoms  of  head  engorge¬ 
ment,  exist.  Mustard  emetics  had  an  extraordi¬ 
narily  good  effect  in  cases  which  were  admitted  in 
a  state  of  great  collapse,  with  copious  bronchial 
effusion;  and  emetics  of  ipecacuan  were  very 
serviceable  in  many  cases  of  jaundice,  when  the 
constitutional  powers  were  not  sunk  so  low  as  to 
torbid  their  use.” — Dublin  Quarterly  Journal, 
Feb.  1848. 


me.  She  was  not  pregnant,  nor  were 
there  any  signs  of  existing  organic 
mischief  anywhere.  I  advised  her  to 
take  an  ipecacuan  emetic  in  the  even¬ 
ing,  and  a  draught,  containing  a  few 
drops  of  liquor  opii  and  acid,  hy¬ 
drocyan.  dil .,  at  bed-time.  Next  day, 

I  found  that  she  had  rejected  her  food 
only  once  after  the  action  of  the  emetic 
had  ceased,  and  that  she  felt  much  more 
comfortable,  although  no  offensive 
matter  had  been  evacuated,  either 
upwards  or  downwards.  She  was  then 
recommended  to  try  a  sinapism  over 
the  region  of  the  stomach,  every,  or 
every  second,  night.  The  improve¬ 
ment  continued  for  several  days,  and 
then  I  lost  sight  of  the  patient. 

I  find  among  my  memoranda  the 
notes  of  another  case,  where  the 
vomiting  had  continued  for  fourteen 
days:  everything,  whether  in  the  way 
of  physic  or  food,  had  been,  during 
this  lime,  rejected  as  soon  as  taken. 
The  patient  was  a  healthy-looking 
middle-aged  man,  who  could  not  ac¬ 
count  for  his  very  troublesome  annoy¬ 
ance  :  there  were  no  symptoms  of 
embarras  (jastrique  present,  nor  yet 
any  feverishness  or  disturbance  of  the 
system,  with  the  exception  of  a  slight 
diarrhoea.  He  was  ordered  an  emetic 
of  ipecacuan,  and  ten  small  doses  of 
magnesia  in  mint  water,  to  be  taken 
frequently.  Nothing  but  the  water 
which  he  drank,  and  a  little  mucus, 
was  rejected  from  the  stomach ;  the 
spontaneous  vomiting,  however,  ceased, 
and  the  amendment  continued  as  long 
as  he  was  under  my  care,  which  was 
for  a  week  or  so. 

But  I  have  now  to  speak  of  seme 
other,  and  still  more  important  (at  least, 
in  certain  morbid  conditions  of  the  sys¬ 
tem),  effects  of  artificial  vomiting,  be¬ 
sides  those  which  have  been  hitherto 
mentioned.  For  the  better  illustration 
of  mv  subject,  it  will  be  of  use  that  I 
should  first  briefly  consider  the  phy¬ 
siology  of  this  process  in  ordinary  cir¬ 
cumstances.  The  reader  is  probably 
aware  that  there  has  been  considerable 
discordancy  of  opinion  among  medical 
writers  as  to  the  organs  that  are 
thought  to  be  most  immediately  con¬ 
cerned  in  producing  the  act  of  vomit¬ 
ing,  as  well  as  to  the  mode  in  which 
these  organs  are  affected.  Some,  as 
M.  Chirac  in  former,  and  M.  Magendie 
in  more  recent  times,  have  supposed 
that  the  stomach  itself  is  nearly,  if  not 


DR.  MILROY  ON  THE  USE  OF  EMETICS  IN  CHOLERA. 


881 


altogether,  inoperative  during  the  pro¬ 
cess  ;  and  who  has  not  heard  of  the 
hideous  and  revolting  experiment  per¬ 
formed  by  the  latter,  of  excising  this 
organ  in  a  dog,  and  substituting  a 
bladder  in  its  place  ?  And  then  we 
are  told  (what  rational  man  believes 
it  ?)  that,  when  a  solution  of  tartarized 
antimony  was  injected  into  the  veins 
of  the  writhing  animal,  vomiting  ac¬ 
tually  took  place  from  the  forcible 
pressure  of  the  diaphragm  and  abdo¬ 
minal  muscles  upon  the  lifeless  bag! 
But  Nature’s  experiments  (if  we  may 
so  call  congenital  and  pathological  de¬ 
viations  as  respect  the  structure  and 
situation  of  organs)  are  a  thousandfold 
more  instructive  than  the  mutilating 
butcheries  of  the  vivisector  can  ever 
be.  The  case  related  by  Drs.  Graves 
and  Stokes  in  the  Dublin  Hospital 
Reports— and  there  are  several  similar 
on  record,  1  believe, — where  vomiting 
took  place  in  a  patient  in  whom  the 
stomach  was  found,  on  dissection,  to 
be  fairly  within  the  thoracic  cavity,  a 
large  opening  existing  through  the 
diaphragm,  will  naturally  be  regarded 
by  most  sensible  men  as  affording  a 
very  strong  presumption  that  the  organ 
does  really  aid,  by  its  contractions,  to 
expel  the  contents  from  its  cavity.  It 
is  probably,  however,  by  the  energetic 
contractions  of  the  abdominal  muscles, 
and,  indeed,  of  all  those  that  are  en¬ 
gaged  in  forced  expiration — the  dia¬ 
phragm  being  at  the  same  time  fixed, 
and  the  cardiac  orifice  of  the  stomach 
relaxed  and  open, — that  the  act  of  vo¬ 
miting  is  mainly  effected.  But,  how¬ 
ever  we  interpret  the  physiology  of  the 
process,  the  consequence  of  it  is,  that 
all  the  abdominal  and  thoracic  viscera 
are  powerfully  compressed — squeezed, 
to  use  Haller’s  phrase,  as  in  a  press,— 
and  their  contents  forcibly  expelled 
through  the  openings  with  which  they 
communicate.  That  such  is  the  case 
with  the  liver  and  gall-bladder,  is 
obvious  by  the  quantity  of  bile  that  is 
often  ejected  upwards,  especially  if  the 
strainings  be  unusually  severe,  or  very 
frequently  renewed.  The  urinary 
bladder,  too,  is  forced  to  part  with  its 
contents ;  and  if  there  be  much  faecal 
matter  in  the  intestines,  it  is  propelled 
downward,  and  is  very  generally  eva¬ 
cuated,  if  not  simultaneously  with  the 
vomiting,  very  soon  after  this  has 
ceased.  ‘  That  the  lungs  also  experience 
the  general  compression  of  the  viscera, 


appears  from  the  large  quantities  of 
mucus  that  are  thrown  off  in  cases  of 
catarrh,  and  the  consequent  relief  that 
is  often  derived  in  this  way.  But  it  is 
less  to  these  results  than  to  the  effects 
of  constrained  and  forcible  vomiting 
on  the  circulatory  apparatus,  that  I 
wish  now  more  especially  to  direct  the 
reader’s  attention.  Each  act  of  heav¬ 
ing  and  expulsive  straining,  that  takes 
place  during  the  operation,  being,  in 
short,  a  strong  expiratory  effort  (as 
Dr.  Marshall  Hall  has,  with  his  ac¬ 
customed  ingenuity,  so  satisfactorily 
shewn),  is,  of  course,  immediately  fol¬ 
lowed  by  a  rapid  and  powerful  inspira¬ 
tion  ;  and,  indeed,  just,  before  the  first 
act  of  heaving  takes  place,  a  quantity 
of  air  appears  to  be  drawn  into  the 
chest,  and  some  writers  say  into  the 
stomach  also.  Now  what,  pray,  are 
the  effects  of  these  forced  respiratory 
movements  on  the  circulation  of  the 
blood  ?  I  cannot  answer  this  question 
better  than  by  quoting  the  description 
given  by  Mr.  Wardrop,  in  his  most 
interesting  work  on  the  Physiology 
and  Diseases  of  the  Heart,  now  in 
the  course  of  publication  : — 

“  By  whatever  powers  the  venous 
blood  reaches  the  two  vense  cavse,  in¬ 
spiration ,  or  that  movement  which 
draws  the  air  into  the  chest,  assists  in 
bringing  the  venous  blood  into  the  right 
heart.  Inspiration  also  assists  the  cir¬ 
culation  of  the  blood  in  the  pulmonary 
arteries,  the  expansion  of  the  lungs 
facilitating  the  ingress  of  the  venous 
blood  into  the  pulmonary  arteries,  and 
also  permitting  the  arterialised  blood 
to  flow  readily  through  the  pulmonary 
veins. 

“  Whilst  the  entrance  both  of  the  air 
and  of  the  venous  blood  into  the  chest 
takes  place  during  inspiration,  so,  in 
like  manner,  is  the  air  expelled,  and  an 
additional  impulse  given  to  the  stream 
of  the  arterial  blood  during  expiration. 
The  diminution  in  the  capacity  of  the 
lungs,  and  the  subsidence  of  the  parietes 
of  the  chest  and  abdomen,  which  take 
place  during  expiration,  aid  by  their 
pressure  the  transmission  of  the  arte- 
rialized  blood  from  the  lungs  into  the 
left  heart,  along  the  large  arteries ; 
whilst,  at  the  same  time,  they  impede 
the  current  of  blood  coming  from  the 
right  one  into  the  pulmonary  artery. 
Inspiration  may  be  therefore  considered 
as  accessary  to  the  venous ,  and  expira¬ 
tion  to  the  arterial  circulation,  the  one 


882 


DR.  MILROY  ON  THE  USE  OF  EMETICS  IN  CPIOLERA. 


aiding  the  heart  like  a  sucking,  and  the 
other  like  a  forcing  pump.”  pp.  58-9. 
This  view  of  the  relations  between  the 
respiratory  and  circulatory  movements, 
in  strict  accordance  with  what  Haller 
has  taught  in  his  Physiology,  received 
considerable  confirmation  some  years 
ago,  from  the  experiments  of  the  late 
Sir  David  Barry ;  for  he  found,  upon  in¬ 
troducing  one  extremity  of  a  tube  into 
the  jugular  vein  of  a  horse,  and  the 
other  into  water,  that  there  was  an  al¬ 
ternate  elevation  and  depression  of  the 
water  with  the  acts  of  inspiration  and 
expiration.  Dr.Carpenter,  after  quoting 
this  experiment,  remarks  : — “  It  is  evi¬ 
dent  that  the  suction  of  the  blood  into 
the  chest  will  aid  the  flow  through  the 
veins,  by  removing  the  obstacle  to  it 
in  front,  although  it  does  not  exercise 
any  more  direct  influence  over  the  cur¬ 
rent  at  a  distance.  On  the  other  hand, 
the  expiratory  movement,  while  it 
directly  causes  accumulation  in  the 
veins,  will  assist  the  heart  in  propelling 
the  blood  into  the  arteries ;  and  by  the 
combined  action  of  these  two  causes,  is 
produced,  among  other  effects,  the  rising 
and  sinking  of  the  brain,  synchronously 
with  expiration  and  inspiration,  which 
are  observed  when  a  portion  of  the 
cranium  is  removed.”* 

Now,  if  such  be  the  influence  of  the 
alternate  expansion  and  contraction  of 
the  thoracic  cavity  on  the  movement  of 
the  circulating  mass  during  ordinary 
breathing,  how  greatly  must  it  be  in¬ 
creased  when  these  acts  are  performed 
with  almost  convulsive  vehemence  ! 

There  is  probably  no  part  of  the  circu¬ 
latory  apparatus  that  experiences  these 
effects  more  than  the  vessels  of  the  por¬ 
tal  system.  The  powerful  compression 
to  which  they  are  directly  exposed, 
along  with  the  viscera  which  they  supply 
during  the  expulsive effortsof  vomiting, 
must  obviously  tend  to  force  on  the 
movement  of  the  blood,  not  only  from 
the  larger  into  the  smaller  arteries,  but 
also  along  the  splenic  and  mesenteric 
veins  towards  the  sinus  of  the  liver; 
while  the  close  proximity  of  the  orifices 
of  the  large  hepatic  veins  to  the  right 
auricle  of  the  heart  naturally  suggests 
the  idea  that  they  will  feel  the  full 
degree  of  the  sucking  action  that  has 
been  described  above.  Certain  it  is, 
that  we  know  of  no  means  so  effectual 
in  quickening  and  exciting  a  torpid 


circulation  through  all  the  abdominal 
viscera,  as  the  operation  of  forcible  vo¬ 
miting.  And  is  not  this  just  what  we 
might  expect,  when  we  consider  the  ra¬ 
tionale  of  the  process  ?  Every  medical 
practitioner  must  have  had  occasion  to 
witness  the  marked  and  very  prompt  re¬ 
lief  that  is  often  obtained  in  this  way  in 
many  disorders  of  these  organs,  in 
which  this  morbid  condition  is  believed 
to  be  present;  and  the  surgeon  finds 
that,  in  distended  and  painful  haemor¬ 
rhoids,  there  is  no  remedy  so  quickly 
efficacious  as  an  emetic.  Whenever, 
in  short,  there  is  congestion  in  the 
portal  system  of  vessels,  a  vomit  may 
be  usefully  had  recourse  to ;  unless,  in¬ 
deed,  there  be  some  contra-indicating 
circumstance  in  the  case,  such  as  the 
existenceof  cardiac  disease,  or  tendency 
to  encephalic  plethora.  It  is  on  this 
principle  of  relieving  the  internal  con¬ 
gestion,  and  of  equalising  the  distri¬ 
bution  of  the  blood  all  over  the  sys¬ 
tem,  that  the  action  of  vomiting  is  so 
very  serviceable  in  the  cold  stage  of 
fevers,  when  there  is  reason  to  believe 
that  nature  may  be  incapable  by  her¬ 
self  of  bringing  on  the  hot  one  in  due 
time  ;  for  such  is  the  overwhelming  op¬ 
pression,  resulting  from  the  stagnant 
accumulation  of  blood  in  the  visceral 
veins,  in  the  malignant  remittents  of 
hot  climates,  that  the  patient,  if  not 
relieved,  dies  in  a  few  hours  after  being 
seized.  And  here  it  is  worthy  of  no¬ 
tice  that  the  symptoms  of  such  an 
attack  often  bear  a  striking  resem¬ 
blance  to  those  of  Asiatic  cholera.  Take, 
for  example,  the  description  of  a  case 
given  by  Torti,  of  the  pernicious  fever 
of  Italy,  more  than  a  century  ago 
“  When  I  reached  the  patient,  he  had 
been  several  hours  labouring  under  the 
disease.  I  found  him  universally  cold 
as  marble,  with  the  pulse  altogether,  if 
I  may  so  say,  absent ;  breathing  la¬ 
boriously,  and  having  aleaden-coloured 
countenance.  There  was  some  torpor, 
but  no  confusion  of  intellect,  and  his 
urine  was  secreted  in  a  small  quantity. 
I  prescribed  the  bark  in  large  doses  ;  a 
gentle  heat  soon  pervaded  his  entire 
frame;  the  pulse  gradually  returned; 
the  respiration  became  natural ;  the 
face  lost  its  leaden  hue ;  the  urine  was 
secreted  in  its  ordinary  quantity;  and 
in  three  days  he  was  quite  recovered.” 

Now,  it  has  been  pretty  generally  re¬ 
marked  by  those  medical  men  who 
have  seen  much  of  this  concentrated 


Principles  of  Human  Physiology,  p.  443-4. 


DR.  MILROY  ON  THE  USE  OF  EMETICS  IN  CHOLERA. 


883 


form  of  fever,  as  it  is  every  now  and 
then  met  with  in  the  malarious  districts 
of  hot  climates,  that  one  of  the  most 
effectual  means  of  relieving  the  prostra¬ 
tion  in  the  cold  stage  of  the  attack — 
whether  this  prostration  be  indicated 
by  a  sudden  collapse  of  the  vital 
powers,  or  by  an  apoplectiform  stupor 
— is  the  operation  of  vomiting  ;  and  it  is 
not  unworthy  of  notice,  that,  when  the 
great  epidemic  of  the  cholera  broke 
out  in  India,  in  1817-18,  many  of  the 
medical  men,  to  whom  the  disease  was 
comparatively  new,  upon  being  called 
to  a  case  before  the  vomiting  and  purg¬ 
ing  had  fairly  set  in,  mistook  the  attack 
for  one  of  malignant  ague,  and  treated 
it  with  success  by  administering  an 
emetic  at  first.  Dr.  Hartley  Kennedy 
alludes  to  some  instances  of  this  sort 
that  occurred  in  his  own  practice.*  1 
need  scarcely  remark,  that  the  modus 
operandi  of  the  remedy  in  such  circum¬ 
stances  is  almost  entirely  by  equalising 
the  circulation,  relieving  internal  con¬ 
gestion,  and  determining  the  blood  to 
the  surface  of  the  body.  “The  relief, 
which  the  act  of  vomiting  affords, 
in  febrile  disorders,  does  not  arise  ( so 
much)  from  the  evacuation  of  any 
noxious  contents  from  the  stomach,  but 
(as)  by  producing  an  almost  immediate 
change  in  the  action  of  the  heart  and 
capillary  system.”t 

There  is  another  set  of  cases  in 
which  the  action  of  powerful  vomiting 
has  been  found  of  unquestionable 
utility,  and  doubtless  upon  the  very 
same  principle,  in  recovering  a  pa¬ 
tient  from  sudden  and  alarming  col¬ 
lapse  :  1  allude  to  the  bites  of  poison¬ 
ous  reptiles  and  insects.  Take  the 
following  instance  from  an  author 
already  quoted  : — “  I  was  once  called,” 
says  Dr.  H.  Kennedy,  “  to  an  officer, 
who  had  been  stung  in  two  places  by  a 
scorpion.  .  .  .  About  two  hours 

after  the  accident,  the  sepoys  of  the 
piquet  came  running  to  me  to  say  the 
‘  sahib’  (the  gentleman)  was  dying.  I 
hastened  to  the  place,  where  I  found 
the  officer  barely  sensible.  What  we 
now  call  the  collapse,  was  completely 
formed  ;  the  extremities  were  deathly 
cold,  and  a  cold  sweat  streamed  from 
him  ;  whilst  rigor  succeeded  rigor  with 
scarcely  five  minutes’  rest  between  the 

*  Notes  on  Epidemic  Cholera,  2nd  edition,  1846, 
p.  218.  The  first  edition  was  published  at  Cal¬ 
cutta,  in  1826. 

f  Wardrop,  op.  cit.  p.  78. 


convulsive  shudderings.  I  adminis¬ 
tered,  as  soon  as  I  could  procure  it, 
three  grains  of  tartar  emetic,  followed 
by  hot  water.  The  vomiting  was  no 
sooner  established  than  he  became  self- 
collected,  and  said  the  pain  was  abated; 
the  warmth  returned ,  followed  by  a 

copious  natural  perspiration . 

This  was  the  most  marked  case  of 
collapse  I  ever  saw  following  a  sting 
not  fatally  venomous.”* 

The  use  of  emetics  has  been  very 
generally  recommended  in  cases  of 
serpent  poisoning.  Dr.  Mead  expressly 
advises  a  full  dose  of  ipecacuan  to  be 
administered  when  alarming  symptoms 
supervene  upon  the  bite  of  a  viper;  and 
most  of  the  remedies  that  have  at 
different  times  been  used  with  advan¬ 
tage  in  similar  cases,  will  be  found  to 
be  such  as  are  apt  to  induce  vomiting, 
as  well  as  profuse  perspiration.  The 
volatile  alkali,  eau-de-luce  or  spiritus 
ammonise  succinatus,  a  decoction  of 
rue,  a  hot  infusion  of  the  aristolochia 
or  snake-wood,  &c.,all  act  more  or  less 
powerfully  as  emetics  and  sudorifics. 
The  ineffectual  vomiting  that  is  fre¬ 
quently  present  in  such  cases,  appears 
to  be  truly  a  medicative  effort  on  the 
part  of  Nature  to  maintain  and  equalize 
the  circulation,  that  so  rapidly  becomes 
arrested  under  the  paralyzing  action  of 
the  venom. 

In  my  next  communication,  I  shall 
proceed  to  examine  whether  the  the¬ 
rapeutic  principles,  explained  above, 
be  applicable  to  the  treatment  of 
malignant  cholera,  and  whether  the 
application  of  them  in  practice  be 
justified  by  the  results  of  experience. 

London,  Fitzroy  Square, 

October  28,  1848. 

[To  be  continued.] 


ON  THE 

BLOOD-VESSELS  OF  THE  NERVES 
OF  THE  HEART. 

By  Joseph  Swan,  F.R.C.S:  &c. 
[Continued  from  page  751.] 

Part  III. 

In  my  two  preceding  papers  I  have 
stated  that  in  each  nerve  there  is  an 
artery  which  runs  down  the  nerve  and 
communicates  with  several  subjacent 


*  Op.  cit.  p.  260. 


884  ON  THE  BLOOD-VESSELS  OF  THE  NERVES  OF  THE  HEART. 


arteries  in  its  course  ;  that  there  are 
two  veins,  one  on  each  side,  communi¬ 
cating  by  transverse  branches  with 
adjoining  ones,  and  a  large  absorbent 
vessel.  I  also  mentioned  the  general 
distribution  of  the  coronary  arteries, 
except  that  the  two  largest  branches 
of  the  left,  which  run  down  externally 
on  either  side  of  the  edge  of  the  sep¬ 
tum,  as  they  descend,  send  branches 
nearly  in  the  middle  between  its  two 
surfaces,  and  direct  smaller  branches 
towards  each  surface  for  the  supply  of 
the  muscle  and  lining  membrane.  The 
communicating  single  branch  spring¬ 
ing  up  at  intervals  from  the  subjacent 
artery,  and  ramifying  on  the  nerve, 
may  be  very  conveniently  seen  by 
carefully  raising  one  edge  of  the  nerve 
throughout  its  whole  length :  at  the 
same  time  it  will  appear  how  it  may 
form  a  convenient  mode  of  conduct  for 
nervous  filaments  to  the  deeper  muscle. 

By  crossing  the  muscular  fibres  and 
arteries,  the  artery  of  every  nerve  in 
its  course  becomes  replenished  with 
blood  from  branches  of  different  sub¬ 
jacent  arteries ;  and,  at  the  same  time, 
each  descending  portion  of  muscle  de¬ 
rives  its  supply  from  several  nerves, 
and  not  from  the  same,  as  it  would 
have  done  if  the  arteries,  nerves,  and 
muscles  had  taken  one  direction,  and 
such  arteries  and  nerves  had  supplied 
the  same  set  of  muscular  fibres  through 
its  whole  extent.  By  the  adopted 
mode  of  crossing,  every  nerve  will  not 
fail  of  having  its  due  quantity  of  blood 
through  the  failure  of  any  particular 
artery,  nor  any  considerable  portion  of 
muscle  suffer  by  the  failure  of  any 
particular  nerve. 

As  the  heart  consists  almost  entirely 
of  muscle  and  vessels,  the  nerves  are 
principally  designed  for  their  use, 
whilst  a  minute  portion  only  is  re¬ 
quired  for  the  pericardium  and  lining 
membrane.  Aslife,  in  adult  mammalia 
at  least,  almost  instantly  depends  on 
the  activity  of  the  heart,  the  great 
object  in  the  disposal  of  the  nerves  is, 
their  safe  conduct  to  every  portion  of 
the  arteries  and  muscular  fibres,  for 
regulating  and  sustaining  their  power, 
and  combining  them  in  action  with 
other  organs.  The  nerves  placed  on 
the  surface  of  the  heart  are  not  only 
free  from  pressure  during  muscular 
action,  but  can  from  thence  be  con¬ 
veniently  disposed  of.  This  arrange¬ 
ment  may  at  first  sight  appear  calcu¬ 


lated  for  producing  perceptibility,  as  it 
in  some  respects  resembles  the  distri¬ 
bution  of  nerves  on  sensitive  organs  ; 
but  a  little  reflection  will  show  that 
the  correspondence,  if  any,  is  illusory ; 
for  the  sentient  nerves  terminate  on 
the  sensitive  surfaces,  whilst  the  car¬ 
diac  nerves  are  almost  wholly  expended 
on  the  arteries  and  muscular  fibres  in 
their  descent  towards  the  apex.  Any 
excitement  produced  by  ever  so  slight 
a  friction  of  one  portion  of  the  peri¬ 
cardium  on  another,  could  not  fail  of 
being  a  frequent  source  of  irritation 
and  of  disturbance  to  the  circulation  ; 
and,  therefore,  the  possibility  of  such 
an  occurrence  is  prevented  by  the 
quality  of  the  structure  of  the  pericar¬ 
dium,  and  its  serous  exhalations.  The 
nerves  are  further  protected  by  the 
general  distribution  of  the  numerous 
veins  and  absorbents  placed  just  under¬ 
neath  the  pericardium,  so  that  any 
external  impression  is  received  by 
these,  filled  with  blood  and  lymph, 
and  not  by  the  nerves.  It  is  more 
particularly  effected  by  disposing  each 
nerve  between  two  veins,  and  covering 
it  with  a  capacious  absorbent;  and,  as 
these  vessels  are  capable  of  becoming 
fuller  during  any  excitement,  they  are 
thus  in  a  proportionate  degree  enabled 
to  defend  the  nerve. 

As  for  some  time  I  did  not  succeed 
in  injecting  fully  the  blood-vessels  and 
absorbents  of  the  heart,  and  as  several 
conflicting  anomalies  arose  in  conse¬ 
quence,  I  determined  to  vary  my  mode 
of  investigation,  and  the  matter  of  the 
injections,  until  I  succeeded;  and  as 
there  is  very  little  information  to  be 
derived  from  books  on  the  subject,  and 
as  a  full  knowledge  of  the  absorbents 
of  the  heart  cannot  be  easily  obtained 
unless  they  have  been  considered  after 
they  have  been  injected  from  the 
coronary  arteries,  and  also  in  conjunc¬ 
tion  with  the  capillary  blood-vessels, 
it  appeared  to  me  that  the  following 
communication  might  be  acceptable  to 
many  who  are  engaged  in  practical 
anatomical  inquiries  : — 

in  injecting  the  coronary  arteries  of 
ten  ox’s  hearts,  the  injection  generally 
passed  rather  freely  into  the  veins,  but 
the  only  portions  of  it  which  ever 
entered  the  exhalants  and  absorbents 
was  spirit  varnish  diluted  with  one- 
fifth  part  of  alcohol,  mastich  varnish,, 
mastich  varnish  to  which  one-fourth 
part  of  copal  varnish  had  been  added, 


ON  THE  BLOOD-VESSELS  OF  THE  NERVES  OF  THE  HEART.  885 


- — - - — -  ~  - -  -  - - - - - -  • 

a  slight  portion  of  the  colouring  matter 
of  lake,  and  a  solution  of  asphaltum. 
I  have  not  included  alcohol  or  spirits 
of  turpentine,  as  I  consider  these  as 
mere  diluents  or  abstersive  appendages. 
Vermilion,  chrome,  ultra-marine,  and 
the  heavier  parts  of  lake  combined 
with  the  preceding  fluids  or  size,  were 
prevented  from  passing,  except  when 
there  had  been  an  extravasation  or  the 
employment  of  inordinate  force;  and 
in  one  instance  in  which  several  ab¬ 
sorbent  vessels  had  been  filled  with 
size  and  vermilion,  there  was  a  decided 
rupture  of  many  capillary  blood¬ 
vessels.  Besides  the  slight  portion  of 
lake  and  asphaltum,  I  believe  other 
colouring  ingredients,  such  as  gamboge 
and  dragon’s  blood,  which  are  capable 
of  solution  in  varnish  or  other  vehicles, 
would  enter  the  exhalants  and  ab¬ 
sorbents.  The  solution  of  asphaltum, 
which  is  prepared,  in  the  best  kinds  of 
the  black  varnish,  called  Brunswick 
black,  diluted  with  an  equal  portion  of 
spirits  of  turpentine,  readily  fills  the 
blood-vessels,  the  exhalants  and  ab¬ 
sorbents;  and,  if  still  more  spirits  of 
turpentine  be  added,  I  believe  there  is 
not  a  vessel,  however  minute,  that  it 
will  not  enter ;  and  as  putrefaction 
does  not  alter  it,  and  the  subject  does 
not  require  to  be  heated,  it  may  be 
employed  as  a  most  useful  means  for 
detecting  vessels  in  parts  in  which 
their  presence  or  distribution  are  doubt¬ 
ful,  and  it  probably  may  fill  the  con¬ 
nections  of  the  blood-vessels  and  ab¬ 
sorbents  in  every  part  of  the  body. 
When  it  is  diluted  with  mastich  var¬ 
nish,  instead  of  spirits  of  turpentine,  it 
is  less  exposed  to  extravasation ;  but 
its  capability  of  minute  penetration  is 
somewhat  lessened.  It  becomes  still 
less  penetrating  if  one-third  of  it  be 
mixed  with  two-thirds  of  spirit  var¬ 
nish  ;  but  it  then  fills  the  arteries,  and 
also  enters  the  veins,  but  not  the  ab¬ 
sorbents. 

If  vermilion  mixed  with  varnish  be 
put  in  one  bottle,  and  lake  mixed  with 
the  same  varnish,  in  another,  the  ver¬ 
milion  is  seen  to  subside  very  quickly, 
but  much  of  the  lake  to  be  suspended 
for  several  hours.  It  may  therefore  be 
presumed  that  the  quick  subsidence  in 
the  vessels  does  not  altogether  prevent 
the  vermilion  from  passing,  as  nearly 
all  the  lake  is  also  impeded,  but  that 
the  particles  of  both  are  too  gross  to  be 
carried  into  the  beginning  of  the  ex¬ 


halants  from  the  capillary  blood¬ 
vessels,  as  well  as  into  the  beginning 
of  the  absorbents.  The  whole  of  the 
asphaltum,  being  in  solution,  is  capable 
of  admission  whenever,  through  the 
quantity  of  fluid  containing  it,  it  is 
made  of  sufficient  tenuity. 

As  the  colouring  matter  of  many 
kinds  of  injection,  or  even  the  fluids 
only,  if  they  are  too  thick,  do  not  enter 
the  origins  of  the  exhalants  from  the 
capillary  arteries,  it  is  clear  that  the 
exhalants  must  be  the  most  minute, 
and  that  the  beginning  of  the  ab¬ 
sorbents  must  also  be  smaller  than  the 
capillary  arteries,  or  they  must  begin 
entirely  from  the  exhalants  and  other 
structures.  When  the  capillary  blood¬ 
vessels  are  ruptured,  the  commence¬ 
ment  of  the  exhalants  and  absorbents 
is  broken  through,  and  the  injection 
enters  the  larger  absorbents  without 
any  regularity. 

If  there  was  not  a  vascular  commu¬ 
nication  or  other  defined  means  for 
directing  the  fluids,  their  entrance  into 
many  of  the  absorbents  would  not  be 
effected  so  quickly  and  readily  in  the 
dead  subject,  in  which  everything 
must  be  governed  by  mechanical  prin¬ 
ciples,  but  that,  on  the  continuance 
of  pressure  on  the  piston  of  the 
syringe,  scattered  injected  absorbents 
and  misshapen  accumulations  of  ex¬ 
haled  fluids  in  the  interstices  beneath 
the  pericardium  would  alone  be  ob¬ 
served. 

Bichat  says* — “  Do  the  absorbents 
arise  from  the  capillary  system  ?  If 
we  may  judge  from  injections,  it  seems 
they  do  ;  for  many  distinguished  ana¬ 
tomists,  in  forcing  fine  injection 
through  the  arteries,  have  filled  the 
neighbouring  absorbents.  I  have  not 
seen  anything  like  this;  yet  I  am  far 
from  denying  a  fact  attested  by  Meckel. 
If  many  other  experiments  confirm 
this,  it  is  evident  that  it  would  incon- 
testibly  establish  the  origin  of  the 
absorbents  in  the  capillary  system,  as 
it  proves  the  origin  of  the  exhalants 
from  the  same  system.” 

For  arteries  I  have  used  two  ounces 
of  vermilion  to  a  pint  of  size  ;  or  half 
an  ounce  of  chrome  to  the  pint ;  or 
four  ounces  of  vermilion  to  a  pint  of 
white  spirit  varnish.  For  blood¬ 
vessels  and  absorbents  I  have  used 
equal  parts  of  Brunswick  black  and 


*  Anatomie  Generate,  t.  2,  p.  587- 


886  CASE  OF  RHEUMATIC  INFLAMMATION  OF  THE  TESTICLE. 


spirits  of  turpentine,  or  mastich  var¬ 
nish  instead  of  the  spirits  of  turpen¬ 
tine.  Rather  more  spirits  of  turpentine 
may  be  required,  if  the  weather  is  cold. 
I  have  also  used,  for  blood-vessels  and 
absorbents,  mastich  varnish  eighteen 
ounces,  copal  varnish  six  ounces,  lake 
half  an  ounce,  vermilion  one  ounce. 
The  lake  must  be  powdered  in  a  mortar, 
and  then  the  vermilion  added  :  both 
must  be  rubbed  to  a  smooth  paste  with 
some  of  the  copal  varnish,  and  then 
the  rest  of  the  varnish  must  be  added. 
Dumeril,  in  his  small  book  entitled 
“L’Art  de  l’Anatomiste,”  insists  on 
the  propriety  of  carefully  mixing  the 
colours ;  and  he  thinks,  therefore,  the 
bladders  of  paint  ground  in  oil,  and 
sold  in  shops,  are  best  for  mixing  with 
varnish,  and  that  the  cakes  of  colour 
used  for  water-colours  are  to  be  pre¬ 
ferred,  when  size  is  adopted. 

As  there  is  some  difficulty  in  fixing 
the  pipes  in  the  coronary  arteries,  it 
may  save  others  much  trouble  if  I  in¬ 
form  them  that  the  aorta  must  be  slit 
down  to  within  half  an  inch  of  the 
semilunar  valves  ;  then  the  point  of  a 
finger  must  be  inserted  in  each  coro¬ 
nary  artery;  the  pericardium  over  this 
must  be  removed,  and  the  fat  carefully 
scraped  away  with  the  end  of  the 
handle  of  the  scalpel,  so  that  a  needle 
and  ligature  may  be  carried  safely 
underneath,  and  the  pipe  be  effectually 
secured.  The  needle  may  be  carried 
under  when  the  point  of  the  finger 
raises  the  left  coronary  artery :  but  as 
the  right  artery  is  so  much  smaller, 
the  pipe  is  best  introduced  for  raising 
the  artery  :  for  the  like  purpose,  the 
nozzle  of  the  pipe  should  be  intro¬ 
duced  just  far  enough  for  effectually 
securing  it,  but  not  too  far,  as  it  will 
reach  to  the  division  of  the  vessel. 
The  beginning  of  the  artery  forms 
something  of  a  pouch,  and  unless  the 
ligature  be  well  tightened,  the  pipe  is 
apt  to  slip  out.  A  pipe  of  the  size  of 
the  largest  swan’s  quill  is  necessary 
for  the  left  coronary  artery,  one  not 
quite  half  the  size  for  the  right.  From 
one  to  two  pints  of  injection  are  re¬ 
quired. 


REPORTS  OF  SURGICAL  CASES. 

By  Henry  Smith,  M.R.C.S. 

Formerly  House-Surgeon  to  King’s  College  Hos¬ 
pital. 


Rheumatic  (?)  inflammation  of  the 
testicle. 

Mr.  S.,  aetat.  23,  sent  for  me  on  the 
evening  of  October  9th:  he  had  only 
just  arrived  from  Liverpool,  having 
travelled  all  day  on  the  railway.  He 
was  complaining  of  being  very  ill,  and 
told  me  that  he  had  a  swelling  in  the 
testicle.  On  examination,  I  found  this 
organ  on  the  left  side  greatly  swollen, 
very  hard,  and  not  very  painful,  except 
when  it  was  pressed.  There  was  at  the 
same  time  considerable  constitutional 
disturbance.  I  ordered  him  to  bed 
directly,  to  take  ten  grains  of  extract 
of  henbane,  and  foment  the  inflamed 
part.  I  learnt  the  following  history 
from  him  He  had  been  travelling  for 
his  pleasure  for  the  last  month  in  the 
nort  h ;  and  about  three  weeks  since,  he 
exposed  himself  the  greater  part  of  a 
night  on  the  deck  of  a  steamer,  lying 
down.  At  the  same  time  he  noticed 
that  he  had  a  discharge  from  the 
urethra,  having  exposed  himself  a  few 
days  before  to  infection.  From  this 
time  he  felt  unwell,  complained  of 
lassitude,  feverishness,  restlessness  at 
night,  and  he  noticed  that  his  urine 
was  very  dark,  and  he  perspired  a  great 
deal.  The  discharge  from  the  urethra 
was  mild,  unattended  by  scalding  or 
chordee.  He  had  suffered  from  several 
attacks  of  gonorrhoea  before,  and  had 
twice  laboured  under  inflammation  of 
the  testicle.  He  used  an  injection  of  sul¬ 
phate  of  zinc,  which  soon  diminished 
the  discharge.  Four  days  ago,  whilst 
at  Liverpool,  having  felt  very  unwell 
during  the  previous  fortnight,  he  found 
some  tenderness  in  the  testicle ;  and, 
as  it  rapidly  increased,  and  he  began  to 
feel  very  ill,  he  came  to  town  to  put 
himself  under  my  care. 

Oct.  10. — He  complains  of  much  pain 
in  the  loins,  and  the  testicle  being 
much  more  painful  when  he  became 
warm  in  bed.  The  urine  is  very  high- 
coloured  ;  tongue  covered  with  a  white 
fur  ;  bowels  costive.  As  the  testicle  was 
very  hard,  and  not  very  painful,  I  re¬ 
commended  strapping  to  be  applied, 
and  a  dose  of  sulphate  of  magnesia  and 
henbane  to  be  taken  three  times  daily. 


CASE  OF  RHEUMATIC  INFLAMMATION  OF  THE  TESTICLE.  887 


Oct.  11. — The  testicle  became  very 
painful  when  he  got  warm  in  bed,  and 
it  was  evident  the  strapping  was  doing 
harm.  I  therefore  removed  it  at  night, 
and  gave  the  patientone  grain  of  opium. 
Ifound  the  organ  very  acutely  inflamed, 
very  hot  and  swollen,  and  the  cord 
deeply  involved. 

Oct.  12.  — He  found  relief  from  the 
removal  of  the  strapping,  but  there  is 
an  aggravation  of  all  the  symptoms 
to-day.  The  testicle  is  swollen, 
tense,  and  painful  ;  the  cord,  as  far  as 
the  external  abdominal  ring,  is  also 
much  swollen,  and  very  painful  ;  there 
is  considerable  febrile  disturbance,  a 
furred  tongue,  quick  pulse,  and  hot 
skin.  I  ordered  six  leeches  to  be  ap¬ 
plied,  and  the  following  pill  every  four 
hours  ft.  Calomel,  gr.  ij. ;  Ant.  Tart, 
gr.  £;  P.  Opii,  gr.  |. 

Oct.  13. — Much  relief  was  ex¬ 
perienced  from  the  leeches,  which  bled 
for  four  hours ;  the  patient  feels  no 
pain  in  the  testicle,  except  when  it  is 
handled ;  but  a  new  symptom  has 
arisen, — he  has  had  most  profuse  per¬ 
spiration  for  some  hours,  of  a  strong 
acid  odour,  exactly  similar  to  that  aris¬ 
ing  from  a  patient  in  rheumatic  fever  ; 
the  urine  is  also  very  high-coloured  ; 
the  tongue  covered  with  a  white  fur. 
I  ordered  the  patient  to  keep  in  bed, 
well  wrapped  up,  and  applied  the 
strong  tincture  of  iodine  over  the 
affected  part.— Repeat  the  pill. 

Oct.  14. — The  perspirations  have 
been  most  profuse,  and  the  acid  odour 
is  strongly  marked,  causing  a  most  un¬ 
pleasant  smell  in  the  room.  The  tes¬ 
ticle  itself  is  smaller,  softer,  and  much 
less  painful ;  the  cord,  however,  is  still 
much  swollen  and  tender;  tongue 
cleaner;  bowels  open;  mouth  not 
affected  by  mercury.  As  there  is  great 
depression,  he  is  to  continue  the  pill, 
omitting  the  antimony,  and  to  drink 
freely  of  a  solution  of  carbonate  of 
soda. 

Oct.  15. — Much  better;  he  has 
passed  a  good  night,  and  is  quite  free 
from  pain  ;  the  testicle  is  much  smaller 
in  size,  and  softer;  perspiration  less; 
urine  still  high-coloured ;  bowels  con¬ 
fined.  To  take  a  black  draught,  and  to 
continue  the  pills  twice  daily. 

From  this  date  this  gentleman  went 
on  improving,  and  in  a  few  days  was 
convalescent.  He  still,  however,  per¬ 
spired  a  great  deal  occasionally,  and 
when  this  occurred  it  presented  the 


remarkably  acid  odour  so  percepti¬ 
ble  at  first.  Some  hardness  of  the 
testicle  and  cord  remained,  for  which 
he  has  been  using  an  ointment  of 
mercury  and  camphor. 

When  I  w7as  first  called  to  this  gen¬ 
tleman,  and  found  he  had  a  discharge 
upon  him,  I  concluded  that  he  was 
labouring  under  a  simple  attack  of 
gonorrhoeal  orchitis,  andtherefore  began 
to  treat  him  in  the  manner  I  had  em¬ 
ployed  with  him  on  two  previous  occa¬ 
sions  when  suffering  from  the  same 
complaint,  wrhich  had  each  time  been 
remedied  in  two  or  three  days  ;  but  the 
means  failed  this  time,  and  even,  I 
believe,  aggravated  the  mischief,  and 
the  inflammation  came  to  a  height 
greater  than  I  have  usually  seen 
in  that  produced  by  gonorrhoea.  The 
cause  of  this,  I  have  every  reason  to 
suppose,  was  the  existence  of  a  poison 
in  the  blood  far  different  from  that 
which  I  at  first  suspected  ;  and  I  found 
this  opinion  upon  the  circumstance  of 
his  having  first  fell  ill  about  the  time 
that  he  had  exposed  himself  to  cold, 
and  his  having  had  symptoms  for  a 
fortnight  before  the  attack  commenced, 
which  clearly  indicated  the  presence 
of  some  noxious  agent  in  the  system, 
which  symptoms  were — languor,  fe¬ 
verishness,  want  of  sleep,  and  particu¬ 
larly  perspirations  at  night,  and  high- 
coloured  urine.  The  moststrikingsymp- 
tom,  however,  which  existed  after  he 
was  under  my  care,  and  which  first  led 
me  to  suspect  that  the  poison  of  rheu¬ 
matism  was  in  the  blood,  was  the 
occurrence  of  the  profuse  and  acid 
perspirations :  this  condition  was  as 
well  marked  as  1  have  ever  noticed  in 
acute  rheumatism  ;  the  patient  literally 
steamed  with  it,  and  the  odour  was  so 
acid  as  to  make  it  quite  uncomfortable 
to  enter  his  room.  The  existence, 
also,  of  the  high-coloured  urine,  and 
the  fact  of  the  pain  being  much  worse 
as  soon  as  the  patient  got  warm  in  bed, 
go  to  strengthen  my  opinion  that  this 
was  a  case  of  rheumatic  inflammation 
of  the  testicle ;  at  all  events,  I  was 
induced  by  these  various  symptoms  to 
treat  the  patient  as  one  labouring 
under  rheumatism.  It  may  be  said 
that  there  was  already  one  sufficient 
cause  existing  for  the  affection,  and 
why  trouble  myself  about  another  ? 
True,  the  patient  had  a  discharge  from 
him  at  the  time,  but  we  may  look  upon 
that  merely  as  an  exciting  cause  of 


888 


THE  DISPENSING  OF  POISONS  FOR  MEDICINES 


the  poison  being  determined  especially 
to  the  testicle,  and  not  to  the  other 
parts  of  the  body  which  we  know 
rheumatism  generally  attacks.  In¬ 
stances  of  morbid  poisons  being  deter¬ 
mined  to  a  particular  locality  which 
has  been  injured,  or  is  in  a  weak 
condition,  are  frequently  seen  :  if  this 
patient  had  hurt  his  knee  instead  of 
having  got  a  discharge,  should  we  not 
have  seen  that  joint  affected,  and  the 
same  general  symptoms  exist?  I  do 
not  mean  to  assert  positively  that  this 
was  a  case  of  rheumatic  orchitis, — I 
leave  the  question  open  for  the  consi¬ 
deration  of  your  readers.  I  am  aware 
that  this  disease  is  very  rare  ;  there  is 
no  doubt,  however,  that  it  does  occur 
occasionally:  my  friend,  Dr.  Hensley, 
had  a  very  well-marked  case  of  it  some 
time  ago. 

13,  Caroline  Street,  Bedford  Square, 

October,  1848. 

SINGULAR  DEFORMITY  OF  THE  HAND.  BY 
DR.  MARCUS. 

A  student  of  the  Elementary  School 
showed  Dr.  Marcus  a  remarkable  appear¬ 
ance  on  his  left  hand.  The  middle  bone 
of  the  ring  finger  had  entirely  dwindled 
away,  and  become  absorbed  ;  the  distal  joint, 
with  its  nail,  was  joined  to  the  proximal 
joint  next  the  metacarpus.  This  change  had 
taken  place  in  about  a  year.  The  patient 
could  move  the  joint  simultaneously  with 
the  other  fingers. 

Dr.  Marcus  thinks  that  inflammation  of 
the  internal  structure  had  originally  existed 
in  the  bone,  associated  with  softening  of 
the  osseous  structure,  and  contraction  of 
the  ligamentous  and  cutaneous  structures. 
Slight  suppuration  was  still  present. —  Cas¬ 
per’s  Wochenschri/t.  X 

MEDICAL  STATISTICS. 

Any  instance  which  may  be  selected  will 
almost  certainly  fail  to  be  the  average  of  its 
class,  or  will  be  a  deserter  from  its  law;  yet 
there  is  such  a  combination  among  these 
erring  individuals,  to  produce,  by  their  joint 
operation,  the  same  average  from  year  to 
year,  or  from  group  to  group  (if  large 
enough),  that  the  masses  exhibit  indications 
of  the  prevalence  of  law,  where  individuals 
exhibit  nothing  but  successions  of  inexplica¬ 
ble  caprice.  Mr.  Finlaison  calculated,  from 
the  events  of  preceding  years,  what  ought  to 
be  the  number  of  deaths  which  the  Registrar 
General  would  be  called  on  to  record  in  the 
first  year  of  his  operations  ;  his  result  was 
355,968 — the  observed  fact  was  355,956. 
This  excessive  closeness  of  agreement  was, 
of  course,  a  remarkable  coincidence,  which 
might  not  occur  again  in  many  trials. — 
Athenaum. 


MEDICAL  GAZETTE. 


FRIDAY,  NOVEMBER  24,  1848. 

In  some  remarks  on  the  dispensing  of 
poisons  for  medicines,  made  in  our  last 
number,  we  adverted  to  the  fact,  that 
unless  the  whole  of  the  circumstances 
were  well  sifted,  a  false  accusation  of 
murder  might  be  easily  made  against 
innocent  persons.  Thus,  to  take  the 
case  which  occurred  at  York,*  where 
arsenic  was  served  for  magnesia, — sup¬ 
posing  the  child  had  laboured  under  in¬ 
tussusception  of  thebowels,  andhadhad 
vomiting  with  discharge  of  blood  from 
the  bowels  before  it  swallowed  the 
powder, — that  no  portion  of  this  powder 
had  remained  for  analysis ;  and  that 
the  youth,  instead  of  admitting  the  pos¬ 
sibility  of  a  mistake,  had  persisted  in 
the  assertion,  that,  although  powdered 
arsenic  was  kept  in  the  shop,  he  was 
quite  sure  he  did  not  supply  it  for 
magnesia, — the  parents  who  had  the 
custody  of  the  child  during  the  time  of 
its  illness,  might  have  been  charged 
with  the  criminal  •  administration  of 
poison.  Such  a  fearful  accusation 
would  derive  support  from  the  actual 
discovery  of  arsenic  in  the  stomach,  and 
from  the  entire  absence  of  this  poison 
in  all  the  other  medicines  taken  by  the 
deceased  during  its  illness,  and  would 
appear  to  be  most  strongly  confirmed,  if 
any  medical  witness  could  be  found  to 
swear  that,  from  the  appearance  of  the 
stomach,  the  arsenic  must  have  been 
swallowed  by  the  child  at  a  period  long 
anterior  to  the  administration  of  any 
medicine.  Our  readers  will,  perhaps, 
consider  that  we  are  putting  an  im¬ 
possible  case :  it  may  be  said  the  dis¬ 
covery  of  intussusception  of  the  bowels 
would  at  once  account  for  the  death  of 
the  child,  unless  there  were  anything 

*  Page  848. 


A  FALSE  CHARGE  OF  MURDER — REMARKS  ON  THE  CASE.  889 


specially  indicative  of  the  effects  of 
arsenic  in  the  symptoms  and  post¬ 
mortem  appearances;  that  no  well-in¬ 
formed  practitioner  could  mistake  the 
symptoms  of  intussusception  in  infants 
for  those  of  arsenical  poisoning ;  and 
that  at  any  rate  no  charge  of  murder 
could  possibly  be  raised  againstparents, 
merely  on  the  ground  that  they  had 
had  the  infant  in  their  custody  from 
the  commencement  of  its  illness  up  to 
the  time  of  its  death !  It  may  be  said, 
if  arsenic  could  not  be  traced  to  their 
possession— if  there  were  no  assignable 
motive  for  so  foul  an  act — if  they  had 
called  in  three  or  four  medical  men 
during  the  child’s  illness,  and  had 
manifested  the  greatest  anxiety  for  its 
recovery — doing  all  that  was  ordered 
with  the  desire  to  alleviate  its  suffer¬ 
ings,  and  showing  the  deepest  distress 
at  its  death — it  would  be  absurd  to 
suppose  that  a  charge  of  murder  could 
be  by  any  possibility  brought  against 
them.  The  whole  of  the  facts  of  the 
case,  although  perhaps  insufficient  to 
develope  the  origin  of  the  fatal  mistake, 
would  establish  their  innocence.  Such 
would  be  the  natural  inference  dedu- 
cible  from  the  facts ;  but  it  is  with  re¬ 
gret  we  state,  that  a  case  actually  in¬ 
volving  a  series  of  circumstances  like 
those  above  supposed,  has  within  a  very 
recent  period  been  the  subject  of  a  trial 
at  the  Central  Criminal  Court.*  The 
facts  come  home  to  every  man  having 
a  mother,  wife,  or  child.  The  proof  of 
parental  affection,  the  absence  of  all 
motive  for  one  of  the  foulest  crimes 
known  to  our  law — the  murder  of  an 
infant  by  poison, — and  the  fact  that  no 
poison  can  be  traced  to  the  possession 
or  knowledge  of  the  person  charged, 
may  weigh  as  nothing  in  favour  of  in¬ 
nocence  against  a  medical  opinion  ex¬ 
pressed  in  a  very  positive  manner  upon 
insufficient  grounds.  Nay,  the  fact 


*  The  Queen  against  Dore  and  Spry,  August 
28th,  1848. 


that  the  child  has  received  that  un¬ 
ceasing  care  and  attention  from  its  first 
illness  to  the  hour  of  death,  which 
only  fond  parents  would  be  likely  to 
extend  to  it,  may  be  held  one  of  the 
strongest  facts  against  them.  The 
case  of  Dore  and  Spry ,  has  proved 
that  nothing  can  be  more  unsafe  than 
for  parents  to  be  incessantly  in  attend¬ 
ance  on  a  dying  child  !  If  no  medicine 
be  given  to  it  except  by  them,  or  in 
their  presence;  and  by  any  unfortunate 
accident  one  of  these  medicines  should 
be  a  poison,  they  must  be  prepared  to 
take  upon  themselves  the  whole  re¬ 
sponsibility  of  its  administration! 

A  very  brief  outline  will  suffice  to 
put  our  readers  in  possession  of  the 
facts  of  this  case,*  which  is  one  of  the 
most  remarkable  in  the  annals  of 
Medical  Jurisprudence  : — 

An  infant,  of  the  age  of  four  months, 
had  suffered  from  thrush  and  the  usual 
effects  of  dentition,  for  about  two 
months  prior  to  the  commencement  of 
its  fatal  illness.  It  was  put  to  bed  on 
Wednesday  night,  the  12th  July,  at 
11  o’clock:  it  slept  with  its  mother, 
the  accused,  Mrs.  Dore,  and  one  of  her 
sisters.  It  was  then  in  its  usual  state 
of  health.  The  only  food  that  it  had 
taken  was  some  rusk  boiled  in  water, 
prepared  in  the  afternoon  by  the  sister. 
There  was  no  food  or  liquid  in  the  room 
at  the  time  the  child  went  to  bed.  It 
awoke  at  2  o’clock  on  the  morning 
of  Thursday  the  13th  July,  “  and  cried 
rather  as  if  it  had  the  stomach-ache.”f 
The  grandmother,  the  accused  Mrs. 
Spry,  came  and  applied  to  the  child’s 
stomach,  a  flannel  dipped  in  hot  water. 
“  The  child  seemed  to  be  easier  after¬ 
wards,  and  went  to  sleep  again;  no¬ 
thing  was  given  to  it  but  the  breast. 
The  child  did  not  seem  to  be  in  any 
pain  after  that,  until  6  o’clock,  when  it 
screamed  again,”  and  appeared  as  it 
did  at  2  o’clock.  It  did  -not  vomit  dur¬ 
ing  the  night,  but  it  was  purged  about 
7  o’clock,  although  “  not  in  an  unusual 
way.”  Medical  assistance  was  pro¬ 
cured,  and  a  mixture,  containing  cal- 


*  Taken  from  an  office  copy  of  the  depositions 
sworn  at  the  Judges’  Chambers,  and  notes  made 
at  the  trial. 

f  Evidence  of  E.  S.  Spry. 


890 


THE  DISPENSING  OF  POISONS  FOR  MEDICINES - 


cined  magnesia*  and  syrup  of  poppies, 
was  prescribed.  The  accused,  Mrs. 
Dore,  left  London  at  8  o’clock,  in  com¬ 
pany  with  a  friend,  according  to  pre¬ 
vious  arrangement,  to  pass  a  few  days 
at  the  Isle  of  Wight.  By  the  advice  of 
the  medical  attendant,  she  took  the 
child  with  her :  it  then  seemed  easy, 
a  dose  of  the  mixture  having  been 
given  to  it.  During  the  journey,  the 
child  was  in  great  pain,  vomited  occa¬ 
sionally,  and  passed  some  blood  once 
from  the  bowels.  Medical  assistance 
was  again  procured  in  the  Isle  of  Wight. 
The  child  vomited  in  the  presence  of 
the  medical  man  then  called  in,  and 
he  stated  that  there  was  nothing  re¬ 
markable  in  the  matter  vomited,  except 
that  it  contained  a  large  quantity  of 
bile.  He  did  not  perceive  any  blood. 
This  was  about  seven  o’clock  on  the 
evening  of  Thursday  the  13th.  This 
gentleman  prescribed  a  powder  of 
mercury  and  chalk,  an  effervescing 
mixture,  containing  carbonate  of  soda 
with  citric  acid,  and  castor  oil.  He  told 
the  accused,  Mrs.  Dore,  that  the  child 
was  labouring  under  intussusception 
or  obstruction  of  the  bowels,  that 
there  was  but  little  hope  of  its  re¬ 
covery,  and  that  she  had  better 
return  with  it  to  London  as  soon  as 
possible.  The  child  was  very  ill  that 
night,  and  appeared  to  be  dying.  The 
mother  returned  with  it  to  London  at 
about  12  o’clock  on  the  following  day 
(Friday  the  14th),  and  her  companion 
stated  that  the  child  appeared  to  be 
then  gradually  sinking.  She  reached 
home  at  half-past  3  o’clock  on  that 
afternoon,  and  her  sister,  who  saw  her 
on  her  return,  deposed  that  the  child 
then  seemed  to  be  very  ill.  Two 
medical  men,  one  of  them  being  the 
assistant  who  had  prescribed  for  the 
child  in  the  first  instance,  saw  it  about 
half-past  6  o’clock  in  the  evening  of 
Friday  after  its  return.  The  abdomen 
was  then  tympanitic,  and  the  child  is 
described  as  having  been  slightly  con¬ 
vulsed.  Castor  oil  was  prescribed,  and 
a  mustard  cataplasm  was  applied  to 
the  abdomen.  As  the  bowels  were  not 
relieved  at  9  o’clock,  the  assistant  was 
dispatched  to  the  dispensary  for  four 
grains  of  calomel .f  The  powder  thus 
hastily  procured,  and  as  it  was  after¬ 

*  Very  fortun  ately  for  the  accused,  arsenic  had 
not  been  dispensed  for  magnesia,  as  in  the  case 
at  York,  referred  to  in  our  last  number. 

t  At  the  trial  it  was  stated  five  grains. 


wards  proved  by  a  person  who  was 
not  authorized  to  dispense  medicines  in 
this  shop,  was  administered  at  once  by 
the  medical  man  wrho  prescribed  it.  It 
was  mixed  with  a  small  quantity  of 
milk  in  a  teaspoon,  and  put  down  the 
child’s  throat.  The  child  appears  to 
have  been  then  moribund.  Other 
powders  containing  very  small  doses  of 
tartar  emetic  and  sugar,  were  given  to 
it,  but  they  had  no  effect;  there  was 
neither  vomiting  nor  purging.  The 
child  sank,  and  died  at  half-past  4 
o’clock  on  Saturday  morning  the  15th. 
July  ;  the  whole  duration  of  its  illness, 
from  the  first  symptom  of  pain  at  2 
o’clock  on  Thursday  morning,  until  its 
death,  making  up  a  period  of  fifty - 
hours. 

The  body  was  not  inspected  until 
five  days  after  death.  It  was  then 
found  that  there  was  an  intussuscep¬ 
tion  of  the  lower  part  of  the  small 
intestines,  so  that  about  a  foot  of  the 
intestine  was  completely  locked  in 
another  portion  near  the  caecum.  The 
strangled  part  was  highly  inflamed 
downwards  from  this  point,  but  not 
upwards.  The  duodenum,  and  all  the 
small  intestines  above  the  strangulated 
part,  were  quite  healthy — free  from  any 
inflammation,  and  were  full  of  feculent 
matter  of  a  bright  yellow  colour.  The 
disease,  it  was  stated,  had  gone  on  to 
that  degree  that  the  passage  of  the 
intestines  was  completely  obstructed. 
This  was  considered  to  be  a  sufficient 
cause  of  death,  and  certified  accord¬ 
ingly.  The  medical  man  who  made 
the  inspection,  stated  at  the  trial  “  that 
the  disease  wTas  in  such  an  advanced 
state  as  to  be  incurable,  and  it  would 
account  for  all  the  symptoms  that 
were  exhibited  before  death,”  as  wTell 
as  for  the  fatal  result.  In  conse¬ 
quence  of  a  dark  mark,  about  the 
size  of  a  shilling,  observed  on  the 
exterior  of  the  stomach,  this  viscus 
was  sent  to  a  “  Lecturer  on  Chemistry” 
for  analysis.  Arsenic  was  found  in 
the  contents  of  the  stomach  in  the 
quantity  of  about  two  grains;  the 
mucous  membrane  was  not  inflamed 
in  any  part,  but  there  was  a  dark 
patch  on  one  portion  of  the  lining 
membrane,  about  the  size  of  a  shilling, 
described  as  gangrenous  or  sphacelated, 
and  in  a  state  of  disorganization,  and 
immediately  around  this  a  fringe  or 
border  of  a  yellow  substance,  proved  to 
be  arsenic  in  the  state  of  sulphuret,  in. 


A  FALSE  CHARGE  OF  MURDER - REMARKS  ON  THE  CASE.  89  X 


quantity  not  more  than  two  grains. 
It  is  important  to  mention  that  the 
stomach  was  not  opened,  nor  its  con¬ 
tents  examined,  until  a  week  had 
elapsed  from  the  time  of  death,  and 
that  no  trace  of  calomel ,  or  any  mer¬ 
curial  preparation,  was  found  in  it. 
No  analysis  was  made  of  the  intestines 
or  their  contents,  nor  of  the  liver,  or 
any  of  the  tissues  of  the  body. 

Such  are  the  medical  facts  of  this  re¬ 
markable  case,  as  they  were  sworn  to  by 
the  witnesses  at  the  inquest  and  trial. 
The  jury  at  the  inquest  appear  to  have 
been  induced  to  return  a  verdict  of 
wilful  murder  against  the  mother  and 
grandmother  of  the  infant,  chiefly 
upon  the  evidence  of  the  Lecturer  on 
Chemistry.  He  deposed  on  oath  “  that 
the  appearances  which  he  met  with  in 
the  stomach  are  those  that  are  pro¬ 
duced  when  the  deceased  has  lived  at 
least  two  daps  after  taking  the  arsenic. 
The  poison  causing  the  disorganization 
could  not  possibly  have  been  taken  on 
the  day  of  the  death.  The  reason  that 
induced  me  to  believe  that  the  ulcera¬ 
tion  on  the  stomach  was  the  result  of 
poison  before  I  analysed  the  contents 
of  the  stomach,  was  that  the  whole 
texture  of  that  portion  of  the  stomach 
was  destroyed.”* 

The  charge  against  the  mother  and 
grandmother  of  administering  poison 
was  so  improbable  from  the  facts  of 
the  case,  that,  although  committed  for 


*  Office  copy  of  the  depositions.— In  another  part 
of  the  depositions,  this  chemical  witness  states, 
the  stomach  “  presented  an  appearance  which  I 
have  never  seen  except  from  arsenic  ;  it  was  my 
impression  there  was  arsenic  in  the  stomach. 
The  appearance  I  allude  to  was  disorganization : 
there  were  dark  spots  on  the  interior  lining-  of 
the  stomach  :  they  could  not  be  the  result  of  de¬ 
composition /”  We  have  it  on  good  authority 
that  there  was  no  ulceration  of  the  stomach,  that 
there  was  beneath  the  mucous  coat  a  patch, 
arising  from  blood  darkened  by  putrefaction,  the 
effects  of  which  on  the  part  were  already  mani¬ 
fested  by  the  transformation  of  the  arsenic  from 
white  arsenious  acid  to  yellow  sulphuret.  The 
peritoneal  coat  was  not  destroyed.  The  witness 
admittted  at  the  trial  that  the  arsenic  around  the 
patch  could  only  have  become  yellow  by  decom¬ 
position,  which  was  perfectly  true ;  but,  with 
this  plain  proof  to  the  contrary  before  him,  he 
at  the  same  time  swore  that  the  patch  itself  had 
undergone  no  change  or  darkening  from  de¬ 
composition  ! 


murder,  they  were  immediately  bailed 
on  application  to  a  learned  judge,  Mr. 
Baron  Alderson.  The  bill  was  pre¬ 
sented  to  the  Grand  jury,  and,  as  our 
readers  know,  evidence  for  the  prose¬ 
cution  only  is  received  under  these 
circumstances.  In  spite  of  the  appa¬ 
rently  strong  testimony  against  them, 
the  grand  jury  looked  at  the  evidence 
as  men  of  the  world  :  they  put  no  faith 
in  the  “chemical”  opinion,  which 
went  to  fix  the  administration  of 
arsenic  on  persons  who  could  have 
had  no  possible  motive  for  administer¬ 
ing  it,  and  they  ignored  the  bill !  The 
accused  were  then  tried  upon  the  coro¬ 
ner’s  inquisition,  and  as  the  case  had 
gone  thus  far,  it  was  fortunate  for 
them  that  their  innocence  became 
thereby  clearly  proved.*  The  accused, 
without  being  called  upon  for  a  de¬ 
fence,  were  immediately  acquitted 
from  the  evidence  for  the  prosecution, 
— the  learned  judge,  Mr.BaronPlatt, 
indignantly  exclaiming  that  there  did 
not  appear  to  be  the  slightest  ground 
for  the  charge. 

A  case  like  this  must,  to  a  certain 
extent,  bring  discredit  on  medical 
evidence  in  Courts  of  law;  and  it 
therefore  becomes  a  duty  to  trace  out 
the  cause  of  this  most  serious  mistake, 
which  has  led  to  the  trial  of  two 
innocent  persons  for  murder,  and  to 
the  placing  of  their  lives  in  jeopardy. 

Our  readers  will  perceive  that  there 
were  here  two  most  important  questions 
for  solution  :  1,  At  what  time  was  the 
arsenic  given  ?  and  2,  Did  the  child 
die  from  the  effects  of  the  arsenic,  or 
from  that  natural  disease  in  children, 
not  uncommon  during  dentition — in¬ 
tussusception  of  the  bowels  ?  The 
chemical  witness  swore  very  positively 

*  So  strong  was  tbe  suspicion  of  murder 
against  these  unfortunate  persons,  that  another 
child  of  the  accused,  Airs.  Dore,  which  had  died 
two  years  previously,  and  a  child  of  Mrs.  Spry’s, 
which  had  died  in  April  last,  were  actually  ex¬ 
humed,  and  their  bodies  examined  for  poison. 
No  arsenic  was,  of  course,  found. 


892 


THE  DISPENSING  OF  POISONS  FOR  MEDICINES - 


that  the  arsenic  (of  which  about  four 
or  five  grains  only  were  found  in 
the  stomach)  must  have  been  in  the 
body  at  least  two  days;  and  that  the 
poison  could  not  possibly  have  been 
taken  on  the  day  (t.  e.  within  twenty- 
four  hours)  of  the  death.  This  very 
strong  opinion  of  course  did  away 
with  any  necessity  for  the  analysis  of 
medicines  given  to  the  deceased  in  the 
interim ;  because,  even  had  arsenic 
been  detected  in  them,  some  of  the 
poison  must  have  been  given  forty- 
eight  hours  before  death,  and  the  first 
medical  man  only  saw  the  child  within 
forty-five  hours  of  its  death.  There¬ 
fore  this  opinion  was  tantamount  to 
the  declaration  that  there  could  not 
have  been  any  mistake  in  the  medi¬ 
cines  ;  and  as  the  accused  mother  and 
grandmother  were  in  attendance  on 
the  child  before  the  assigned  period  of 
two  days,  they  must  have  either  ad¬ 
ministered  the  arsenic,  or  have  been 
cognisant  of  its  administration.  No 
other  conclusion  can  be  drawn  from 
the  evidence  of  this  gentleman. 

There  were,  however,  some  facts 
rather  adverse  to  this  opinion  which 
did  not  transpire  at  the  inquest.  Ar¬ 
senic,  it  is  well  known,  exerts  a  very 
powerful  action  on  infants :  their  ex¬ 
citable  systems  are  soon  affected  by 
the  poison,  even  in  very  small  doses — 
the  symptoms  of  poisoning  come  on 
speedily,  are  well  marked  in  their 
character,  and  prove  rapidly  fatal.  As 
the  deceased  infant  was  in  its  usual 
health  up  to  within  fifty  hours  of  its 
death,  there  is  no  reason  to  believe 
that  four  or  five  grains  of  arsenic  could 
have  been  then  lying  in  its  empty 
stomach  without  having  produced  some 
symptoms  indicative  of  its  presence ; 
at  any  rate  there  is  no  reason  why 
this  should  be  assumed :  and  as  the 
child  had  manifested  no  symptoms  of 
alvine  irritation  before  2  o’clock  on  the 
Thursday  morning,  it  is  clear  that  if 


the  statements  of  the  chemical  witness 
were  true,  the  poison  must  have  en¬ 
tered  the  stomach  at  or  about  that 
time.  On  turning  to  the  history  of 
the  case,  we  find  that  the  child  was 
fed  by  its  aunt  in  the  afternoon,  that 
it  took  nothing  before  going  to  bed  at 
eleven  o’clock,  that  it  slept  for  three 
hours,  then  awoke  with  the  stomach¬ 
ache,  which  was  relieved  by  fomenta¬ 
tions,  and  it  then  slept  for  four  hours 
more :  there  was  no  vomiting  during 
the  night.  Now,  we  ask  our  readers 
who  know  any  thing  of  the  effects  of 
arsenic  on  infants,  whether  it  is  in  the 
least  degree  probable  that  this  child 
was  then  sleeping  calmly  with  a 
large  dose  of  arsenic  in  its  stomach, 
which,  if  administered  at  all,  on  the 
chemical  theory,  must  have  been  given 
to  it  before  eleven  o’clock,  the  hour  at 
which  it  was  put  to  bed!  If  they 
agree  with  us  that  it  is  not  at  all  pro¬ 
bable,  they  may  then  feel  it  necessary 
to  examine  more  closely  the  grounds 
for  this  opinion  of  the  chemical  witness. 
There  does  not  appear  to  have  been 
any  vomiting  until  about  eight  or  ten 
hours  after  the  period  at  which,  ac¬ 
cording  to  this  theory,  the  arsenic 
must  have  entered  the  stomach.  The 
medical  man  in  the  Isle  of  Wight,  ob¬ 
served  only  bile ,  and  no  blood,  in  the 
matter  vomited,  although,  according  to 
the  theory,  ulceration  and  disorganiza¬ 
tion  must  have  been  then  going  on.  He 
diagnosed  intussusception,  and  his  diag¬ 
nosis  proved  correct.  There  are,  there¬ 
fore,  not  only  no  medical  grounds  for 
the  assertion  that  the  arsenic  had  been 
in  the  body  at  least  two  days,  but  all 
experience  of  the  ordinary  effects  of 
large  doses  of  arsenic  on  tender  infants, 
is  decidedly  adverse  to  it.* 

*  The  symptoms  of  poisoning  by  arsenic  are 
sometimes  retarded,  and  do  not  appear  for  seve¬ 
ral  hours.  This  has  been  noticed  in  the  cases  of 
adults  who  have  taken  opium,  or  who  have  gone 
to  sleep  soon  after  swallowing  the  poisonous  dose. 
Against  this,  we  must  put  the  more  excitable 
state  of  system  in  infants  of  the  age  of  the  de- 


A  FALSE  CHARGE  OF  MURDER - REMARKS  ON  THE  CASE. 


893' 


The  statement  that  the  poison  could 
not  possibly  have  been  taken  within  24 
hours  of  death,  is  as  little  justified  by 
the  facts.  They  who  are  accustomed 
to  inspect  thebodiesof  persons  poisoned 
by  arsenic,  know  that  it  is  scarcely 
possible  in  any  case  to  pronounce  from 
the  appearances,  how  long  the  poison  has 
been  swallowed.  Sometimes  effects  are 
produced  in  a  few  hours,  which  in  other 
cases  are  not  witnessed  until  after  the 
lapse  of  several  days.  If  we  except 
for  the  present  the  assumed  patch  of 
gangrene,  there  was  not  the  least  sign 
to  indicate  that  the  arsenic  had  been 
more  than  a  few  hours  in  the  stomach. 
There  was  no  inflammation  of  the 
stomach,  of  the  duodenum,  nor  of 
any  part  of  the  small  intestines  ; 
and  had  the  vomiting,  observed  during 
the  journey  to  the  Isle  of  Wight, 
really  depended  on  the  action  of  this 
powerful  irritant  poison,  it  is  cer¬ 
tain  that  some  inflammation  or  marks 
of  violent  irritation  of  the  mucous 
membrane  would  have  been  found.  We 
have  it,  however,  on  “  chemical”  au¬ 
thority,  that  there  was  an  isolated  patch 
of  gangrene,  without  any  inflammation 


ceased,  who  are  very  speedily  affected  by  small 
doses  of  arsenic.  To  suppose  that  the  symptoms 
of  arsenic  began  with  a  stomach-ache  after  three 
hours’  sleep,  and  that  these  having  thus  begun, 
then  subsided,  so  that  the  child  slept  again  for 
four  hours,  and  did  not  vomit  for  at  least  ten 
hours  from  the  time  at  which  it  went  to  bed, 
would  be  contrary  to  all  experience  of  the  effects 
of  arsenic  on  children,  as  detailed  by  the  best 
authorities,  while,  on  the  other  h